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Dialectical behavioral therapy is a modified form of cognitive behavioral therapy that may be used in the treatment of anxiety. Learning to tolerate intense emotions and develop interpersonal skills, combined with mindfulness practices, are central.

What is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT) is a modified form of cognitive behavioral therapy (CBT), which was originally developed for people with borderline personality disorder, severe self-harm and suicidality. In borderline personality disorder (BPD), people typically experience mood dysregulation, which triggers impulsivity and increased interpersonal conflict. As a result, people with BPD often feel misunderstood and resentful towards those around them.

The psychology researcher who developed dialectical behavior therapy, Marsha Linehan, had initially employed CBT to treat her patients with borderline personality disorder but found this was unsuccessful, in part because people experienced the core tenets of CBT as critical. Linehan then tried an acceptance-based perspective which employed meditation, Zen Buddism and mindfulness ideas, but this also proved fruitless. She therefore decided to merge mindfulness and CBT change strategies, and dialectical behavioral therapy was born.

A key difference between cognitive behavioral therapy and and dialectical behavioral therapy is that:

  • CBT is premised on the idea that thoughts, feelings, and behavior all influence each other. It looks to arm people with skills to identify dysfunctional thoughts and feelings and learn how to respond to them differently.
  • DBT, in contrast, aims to help people to regulate their emotions better while also teaching them to tolerate emotional distress. The goal is to enable people to achieve self-acceptance, a feeling of safety, and to help them find ways to manage their emotions so that they do not engage in self-destructive or otherwise harmful behaviors.
The "dialectical" in DBT means embracing the somewhat contradictory elements of accepting feelings while also learning strategies to change them. Understanding and acknowledging emotional experiences in DBT encourages people to be more "present" in the moment and to observe their environments in a non-judgmental manner.

DBT aims to help people acquire emotional and cognitive skills and, at the same time, enable them to "generalize" those skills – that is, apply them to their lives. Emotional regulation is an important goal of DBT: being able to control emotions and regulate when and how they are experienced and expressed is key. DBT describes the mind as having three parts: the emotional mind, the reasonable mind, and the wise mind. DBT holds that blending and balancing the messages that come from the emotional mind and reasonable mind leads to a wise-mind outcome.

Applications and techniques

Although dialectical behavior therapy was originally designed for use with those with personality disorders, it has since been applied to the treatment of many other disorders, including anxiety.

DBT combines individual therapy with skills training group-work. The focus is on helping people to better manage intense emotions, interpersonal relationships, and emotional crises. Dialectical behavior therapy helps people manage those conflicts in life that are concerned with dialectics or polar opposites (usually to do with change and acceptance) and finding a balance in those situations, so avoiding the “all or nothing” script.

Four Ways to Manage Thoughts and Behaviors

DBT skills training has four key aspects:

  • Core Mindfulness looks to help someone focus mind and attention. These skills enable people to focus on the “here and now” rather than ruminating on the past or worrying about the future.
  • Distress tolerance is about accepting the current situation alongside developing crisis management skills so that reverting to problematic behavior is less likely. It helps people to learn skills to calm and reassure themselves in functional ways rather than avoiding distress or allowing emotions to overwhelm them.
  • Interpersonal effectiveness skills are about learning to be assertive, ask for help and better traverse interpersonal conflict. DBT aims to support people to understand relationship needs and wants and to find constructive ways to getting those needs and wants met.
  • Emotion regulation skills are about being able to identify emotions, any issues that prevent changing those emotions, lessening the tendency to be emotionally reactive, and aiming to increase the presence of positive emotions. Working on emotion-regulation skills enables people to change emotional intensity, and reducing the drive to act upon difficult feelings.

DBT also has a number of mnemonics or acronyms that are used to help people remember different approaches or skills to manage different situations. Some common ones include:

ACCEPTS - This helps develop tolerance to distress by self-distraction:

  • Activities: Engaging in positive and enjoyable activities
  • Contribute: Supporting others in some way
  • Comparisons: Considering yourself in relation to those less fortunate
  • Emotions: Changing the feeling by, for example, making yourself laugh
  • Push away: Change your focus temporarily
  • Thoughts: Make yourself think about something else
  • Sensations: Engage in an alternate activity that is also a strong sensation.

IMPROVE This is a relaxation/distraction technique to improve the moment:

  • Imagery: Visualizing a relaxing environment
  • Meaning: Looking for intrinsic meaning or personal purpose
  • Prayer: Using some religious ritual or prayer to relax you
  • Relaxation: Physical relaxation such as breathing or muscle relaxation
  • One thing in the moment: Bringing your attention fully to the here and now but focusing on a specific activity
  • Vacation: Taking a short break from the situation
  • Encouragement: Build yourself up by using encouraging and supportive self-talk.

PLEASE – this is about emotion-regulation - looking after the physical self to support the emotional self:

  • Physical Illness: Ensure you take care of your physical health by treating problems as necessary
  • Eating: A healthy balanced diet
  • Avoid mood-altering drugs:
  • Sleep: Getting a good balance in sleep
  • Exercise: Ensuring you get exercise

DEARMAN – This is about increasing interpersonal effectiveness to enable people to better achieve goals:

  • Describe your situation
  • Express your problem and how it makes you feel
  • Assertiveness - ask for what you want or need
  • Reinforcement – why the other person should agree to your request
  • Mindful – stay mindful of the situation and ignore attempts to be distracted or diverted by defensiveness
  • Appear Confident even when you don't feel confident
  • Negotiate your request, acknowledging you many need to persuade or compromise if necessary

GIVE – this is to support and maintain interpersonal relationships:

  • Gentle: Use appropriate and constructive language
  • Interested: Try to appear interested through eye contact, interacting with questions, and trying to avoid distractions
  • Validate: Try to be understanding and sympathetic to other's problems
  • Easy Manner: being relaxed and calm in interactions

FAST – this is about self-respect:

  • Fair: Ensuring fairness both to yourself and others – be assertive but not aggressive
  • Apologies: Do not feel the need to apologize repeatedly – once is enough
  • Stick to values: Honor your beliefs – don't abandon them to please others or fit in
  • Truthful: Veracity and accuracy are key

DBT for Anxiety

So having explored the basic ideas in DBT, how can this be applied to anxiety?

1. The idea of training your “attentional muscle” is useful to people with anxiety. As DBT builds skills to live in the “here and now”, it can help people to focus less on the past or worries about the future, and put their energy into managing the intensity of the feelings in that moment.

2. Learning to tolerate intense emotions and sensations and change established behaviors can help people to “rewrite the scenario” and change established patterns of reacting and responding. This, for example, could help someone change avoidance or safety-seeking behaviors and habituate themselves to situations that would normally elicit the stress response.

3. Anxiety is often generated by interpersonal reactions and so the emphasis on building interpersonal effectiveness is likely to have a positive impact on worries. Learning to be assertive and articulate your needs and wants is a prime way to avoid worries.

4. Mindfulness encourages acknowledgement of thoughts and feelings without allowing them to dictate or dominate. It promotes compassion, especially towards the self and being non-judgmental about your thoughts and feelings. This is likely to help with shame and guilt which can so often reinforce many mental disorders.

4. DBT skills are essentially about enabling people to feel more control over themselves and their lives. Research has shown that “control” or fear of the unknown is a key element in the development and maintenance of all anxiety disorders therefore increasing a sense of competence can only help to drive down fear-based disorders.

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