What the Heck is DBT?
When I first heard the term, “Dialectical Behaviour Therapy” the concept of it completely went over my head and had me silently swearing that I was never having anything to do with this form of therapy. Chances are, I am not the only one who feels intimidated by this complex approach. I can definitely empathize with anyone for feeling uncertain or overwhelmed by this theory because there’s certainly a lot to it. If you’re curious about DBT and want to learn more about it, then this post is for you!
The goal of DBT is to learn new skills and techniques to transform negative thinking and unhelpful behaviours into positive outcomes.1,2 This approach started out specifically for those with chronic and severe suicidal ideation and suicide attempts, and later for those living with Borderline Personality Disorder (BPD), but has shown to be useful for individuals who struggle with lower thresholds of self-harming, eating disorders, substance abuse, major depression, and more.3
What is a Dialectic?
Let’s tackle the first part of DBT – the dialectic. In reference to counselling, a dialectic is finding a balance between two opposites. It’s the understanding that two ideas can be correct at the same time, letting go of black and white thinking, and understanding that there’s no universal truth.4 A real-life example of finding a dialectic would be having to opposing thoughts such as: “I can trust everyone,” or, “Nobody can be trusted,” which then the dialectic would be finding that sweet spot in the middle which would be, “I can trust some people, but not everyone I know,” and coming to terms with the fact that those two opposing beliefs, trust and distrust, can exist at the same time.4
In DBT, we encourage clients to ask themselves, “What is missing from my understanding?” instead of accepting a final answer or conclusion. This is a way of expanding our perceptions of things and understanding and validating another person’s perspective.4
What is the Behaviour part of DBT?
The behaviour part of DBT includes learning practical skills and helpful behaviours and letting go of the actions that interfere with our quality of life and personal wellbeing. There are four main modules that are covered in DBT to teach these skills:
- Interpersonal Effectiveness: this module includes being able to ask for what we need, reach our goals, and to cope with difficult interactions or conflicts.
- Distress Tolerance: this module builds the ability to notice situations that evoke a negative emotional response and to be able to see the impact it has on us. The purpose of this is to be able to make rational decisions about how we want to proceed.
- Emotion Regulation: this module encourages noticing our emotional experiences, but not letting the emotion completely take over. Clients learn to use self-soothing techniques to cope with the strong feelings and develop the skills to act mindfully and intentionally while experiencing emotions.
- Mindfulness: this module teaches us how to accept and cope with powerful emotions and to be able to notice the present moment we are experiencing, along with the emotions and sensations that come with it with a non-judgmental mindset.
What is the Therapy part of DBT?
DBT is implemented through a variety of ways, such as skills training group and individual therapy. The group is typically 6-12 months long and is meant to introduce us to skills that are intended to improve our coping and ability to manage powerful feelings. The individual sessions focus on increasing our motivation and skill application. Individual DBT sessions give us a chance to work towards our personal goals and to apply our skills in our day-to-day life.
I hope that this article helps you understand a bit more about DBT. It’s certainly been a big learning curve for me, and I’ve come to appreciate the complexity of issues it’s able to address. While it can still be daunting at times, the beauty of DBT is that it can be broken down into bite-sized, practical skills and steps that help us move forward.
If you think DBT could be helpful to you, or you just have some more questions about it, please feel free to give us a call, we’d love to hear from you!
- Centre for Addiction and Mental Health. (2019). Dialectical Behavioural Therapy, from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/dialectical-behaviour-therapy
- Child Youth Mental Health. (2010, May). DBT Training. Lecture presented at DBT Training, Abbotsford
- Gleissner, G. (2016). What Is DBT? Retrieved March 18, 2019, from https://www.psychologytoday.com/us/blog/hope-eating-disorder-recovery/201609/what-is-dbt
- Miller, A. L., Rathus, J. H., & Linehan, M. (2007). Dialectical behavior therapy with suicidal adolescents. New York: Guilford Press.
Expectations, whether based on fact and experience, or our own assumptions and interpretations, have the tendency to either prepare or disappoint. Because of this, it’s important to understand what differentiates DBT skills groups from other therapeutic groups, so that you can make an informed decision about whether participating in a DBT skills group will be beneficial for you. Joining a DBT skills group is a 24-week commitment and although this experience can prove highly effective, it may not be a good fit for everyone.
How Are DBT Groups Different?
A common misunderstanding of DBT skills groups is that they are comparable to other therapeutic groups, such as process groups or support groups. Although the DBT skills group atmosphere often fosters feelings of peer support and understanding, the primary purpose of these groups is to learn effective skills.
The DBT skills group format allows for the sharing of personal information at the discretion of each group member, however, the majority of information shared within the DBT skills group is done in relation to the use of the DBT skills. This practice ensures that any difficulties implementing the skills may be addressed, by both the facilitators and group members. Although DBT skills groups encourage group member interaction and input there is a classroom-like component, as each week a new skill is taught. One of the benefits of participating in a DBT skills group is that each group member brings their own experiences and unique approaches to particular skills and situations. This opportunity the learn together, and from each other’s experiences helps us learn innovative ways to approach the skills.
A DBT skills group is an essential component of Dialectical Behaviour Therapy. While combining individual therapy and the DBT skills group is not mandatory, it is important to recognize that the main goal of a DBT skills group is to teach and support group members in effectively using new skills. The emphasis on teaching new skills – and the very nature of a group setting – allows for less 1-on-1 attention for each group member and is a reason that supplementing DBT skills group with individual therapy is recommended.
What Does a DBT Skills Group Session Look Like?
Each DBT group session will begin with mindfulness practice. Mindfulness can take many forms, ranging from mindful colouring to guided visualization, and is incorporated for both personal practice and group benefit. This practice can help group members become present and ready to engage and learn in a group.
Following mindfulness, each group member is given an opportunity to check-in and let the rest of the group know how their week has been, with an emphasis on skills tried and used. This can be an opportunity for group members to troubleshoot skills that were not as effective as they’d hoped or suggest alternate skills that may have been effective for the given situation or particular struggle. Group interaction and insight can be a particularly helpful addition to check-in. This can also be a time to review any homework or questions from the previous week’s group.
After a short break, the second half of the DBT group session is dedicated to learning a new skill. All DBT skills are separated into four main modules: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. These skills are taught with an emphasis on being effective in everyday life. Oftentimes real-life examples can be used to illustrate how each specific skill can be effective; group members are welcome to present a relevant personal situation where a skill may be useful to see its specific application if they so choose. As the founder of Dialectical Behaviour Therapy, Marsha Linehan would say, the goal of DBT is to create “a life worth living.” Through the learning of skills and the support of the group, clients can be supported in gaining control of their lives and moving toward a life worth living.
Click here to learn more about our youth and adult DBT groups!
One of the questions we get a lot is what are some of the specific Dialectical Behaviour Therapy (DBT) techniques that we teach clients? I think this is a great question and one that we can answer through some blog posts, so here’s the first one – I hope you like it!
Mindfulness is the at the core of dialectical behaviour therapy – it’s the foundation, if you will, that everything else is built upon. Mindfulness is the practice of being present in the moment, without judgement and without attachment to it. It sounds simple, but it is often very difficult for us to practice in our daily lives.
What are the goals of mindfulness, with respect to DBT, you might wonder? According to Dr. Marsha Linehan, the goals are threefold:
- Reduce suffering and increase happiness
- Increase control of your mind
- Experience reality as it is
The mindfulness skills learned through engaging in dialectical behaviour therapy help clients create their own mindfulness practice. A mindfulness practice involves incorporating different skills into a routine practice that is woven into our lives as a foundation for doing life. This can involve any or all of the skills, meditation, contemplation, and mindful movement.
There are three core mindfulness skills in dialectical behaviour therapy and I want to introduce one of my favourites because it’s one of the ones I’ve found most helpful: Wise Mind.
The Wild Mind
You won’t find this terminology in any DBT books, but it’s what I call the dance between the two extreme states of our minds: logic vs. emotion. In DBT terms, we’d call the two polar opposites Reasonable Mind and Emotion Mind.
Often, we tend toward one or the other especially when we’re under stress. Those of us who are more naturally prone to logic will rely on this part of our mind to make everything rational, logical, and pragmatic at the cost of ignoring emotional content. Others more naturally drawn to emotion will rely on this part of the mind to make everything about mood, feelings, and impulses to do or say things.
As you can probably tell, both of these approaches are likely to create problems because they focus on one area at the cost of ignoring the other. So, what’s the alternative?
The Wise Mind
The concept of Wise Mind within the framework of mindfulness involves combining the two minds, Reasonable Mind and Emotion Mind into a new framework – Wise Mind. Wise Mind balances the Reasonable Mind and Emotion Mind and allows us to follow a middle path.
Another description of Wise Mind is something we often call wisdom. In this case, it’s the wisdom within each of us that combines both our more rational, reasonable mind with the emotion-focused part to create a full picture. This focus allows us to see, and value both reason and emotion, bringing the left and right brains together as one.
I was just remarking to a client that someone once described wisdom to me this way:
“Knowledge is knowing that a tomato is a fruit. Wisdom is not putting it in a fruit salad.”
Apparently, this quote came from Miles Kingston, a journalist and musician, and what I like is that it helps explain the difference between wisdom and knowledge. In our case, knowledge is what each of our minds is telling us – our reasonable and our emotion mind. Wisdom is knowing how to combine that information and knowing what to do with it – our Wise Mind.
How Can I Get Started Using Wise Mind?
Mindfulness takes practice, as does listening to Wise Mind. Here’s an example exercise that you can try right now to see if you can listen to your inner wisdom using Wise Mind. It’s taken from the Mindfulness Handouts in the DBT Skills Training Manual from Dr. Marsha Linehan:
Asking is this Wise mind?
Breathing in, ask yourself, “Is this (action, thought, plan, etc.) Wise Mind?”
- Breathing out, listen for the answer.
- Listen, but do not give yourself the answer. Do not tell yourself the answer; listen for it.
- Continue asking on each in-breath for some time. If no answer comes, try again another time.
This may not come naturally to you at first, in fact, it probably won’t. Repeat this exercise and see if you can allow yourself to enter a mindful space where you can notice what your Reasonable Mind and Emotion Mind are telling you, and then listen to your Wise Mind to see how you can trust your inner wisdom and operate out of an effective, mindful place in your decisions.
If you’d like help with this, we’re always happy to help! Please give us a call or contact us for options!
Linehan, M., M., (2014). DBT Training Manual. New York, NY: The Guilford Press.
Linehan, M. M. (2015). DBT® skills training handouts and worksheets (2nd ed.). New York, NY, US: Guilford Press.
“You are richer than you think.” This is the current slogan being used by Scotiabank. When I hear this slogan, I think of the clients who are participating in the various DBT groups here at Alongside You. DBT is the short form of Dialectical Behavioural Therapy, created by Dr. Marsha Linehan, who is a psychologist working at the University of Washington in Seattle. This treatment is the gold standard for clients struggling with unstable identity, risky behaviours, chaotic relationships and an inability to regulate emotions and urges. The DBT skills taught in our groups focus on Distress Tolerance and Crisis Management, Interpersonal Effectiveness, Emotion Regulation and Mindfulness. There has been much research supporting this form of therapy that it is now also designated as the gold standard for Borderline Personality Disorder. The skills are also very helpful for clients trying to manage depression, anxiety and substance misuse.
In addition to skill building, learning and participating in a group format has many other benefits. I have facilitated groups of various kinds for 40 years and have been witness to so much growth in so many clients that I can say with confidence that a group experience is a very rich one. Dr. Irwin Yalom describes in his book, The Theory and Practice of Group Psychotherapy that the following factors occur when participating in group therapy:
- Instillation of Hope
- Imparting of Information
- Corrective recapitulation of the primary family group.
- Development of socializing techniques
- Imitative behaviour
- Interpersonal learning
- Group cohesiveness
- Existential factors
Dr. Roy Mackenzie in his book, Time-Managed Group Psychotherapy, identifies learning factors such as
- Vicarious learning
- Self-revelation and Insight
As the late famous American poet Maya Angelou says, “we are more alike than we are different.” Why then do we sometimes we feel that we are left behind while others live their life without strife? This is certainly how it may appear on the various social media sites. More and more I see young clients who spend hours daily checking up on friends on the various social media platforms on the internet. It seems to me that it would be much more healthy to call a friend and plan to do an activity together. If we parallel play as young adults we are not growing psychologically. Attending a group is a good start to get back in the game of communicating both verbally and nonverbally with other people. People need people as we are social beings by nature. A group is a microcosm of society in general. When clients feel supported in a genuine way they are likely to experience some or all of the healing factors mentioned above.
Another factor involved in a group setting is the undercurrent explained by the psychoanalyst, Wilfred Bion, in his book Experiences in Groups. Bion says that there are three basic assumptions working alongside any working group. These are mostly unconscious but are helpful for facilitators to consider if a group they are running is starting to struggle. The first basic assumption is the dependency and this happens when leaders are dialectically idealized and devalued. The second basic assumption is pairing in which two group members bond in an attempt to overthrow the leader. The third basic assumption is fight or flight, which happens when the group has a common enemy. It can be a taxing job to be teaching skills as well as observing the group process and the underlying basic assumptions all at the same time. Extra training on group skills is highly recommended when moving from individual therapist role to a group therapist role. I believe that this is one of the reasons our groups are so effective here at Alongside You. We work diligently to create the best atmosphere for people to learn and to grow.
Groups are a dynamic force and when change happens to the individual group members this impacts and creates a vibration which results in changes to the whole group. Systems theory suggests that groups over time tend to develop a self-organizing nature which works to maintain stability and minimize threats. Through this, clients can experience a safe space to explore their challenges and their successes, and learn from, and encourage each other.
My goal when I co-facilitate our Dialectical Behavioural Therapy group is to have clients leave after 24 weeks being even richer than they think they are, as they carry their new tools to help them achieve a “Life Worth Living.” Feel free to contact us to learn more about Dialectical Behavioural Therapy.
When I meet with clients, I often remark that of the 168 hours in their week, I get 1 if I’m lucky. That’s assuming that I get to see them once per week, which is not necessarily the case. Most often I see clients every other week, or even further between sessions. In this case, the hours I don’t get to be with them becomes multiples of the 168. I highlight this because I want to encourage clients that as important as the work we do in-session is, it is truly what they do between sessions that promotes lasting change. It’s not that I discount the importance of what I do, I simply recognize the importance of what my client does day in and day out between our times together.
One thing that I love about Dialectical Behaviour Therapy (DBT) is the emphasis on skill development. In our DBT groups, we focus on both skills and process, but the homework in between groups is heavily focused on skill development. Whether it’s Mindfulness, Distress Tolerance, Emotion Regulation, or Interpersonal Effectiveness they’re working on, there are concrete activities and worksheets clients can follow in between sessions to work on these areas. Clients get all of these resources in a book as a part of the group and the clients who really work at this, come back each week with a well-worn book! It’s wonderful to see clients invested in their process.
One of the questions I am asked a lot is, “Why do you have so many different things at your clinic?” The answer to this is because we believe in a holistic approach to recovery. I’d like to highlight three things you can access in our clinic between counselling sessions that will promote your wellbeing and recovery in those in-between times. The great thing is that all of these also promote things you can do on your own at home that don’t cost more money!
Open Studio Sessions
One of the things people are most curious about in our clinic is our art studio. People regularly wonder why we have an art studio, but the answer is very simple: because it helps people recover. We do this both through 1:1 sessions, and our Open Studio Sessions. There is a large body of evidence showing the power of creativity and art to help people recover from mental health, chronic conditions, chronic pain, and more; it also helps people connect inter-generationally and with family members and friends. All of these are great things! In our studio, you can learn Mindfulness-Based Art Therapy (MBAT) techniques that you can use at home, and we can even help you figure out what materials you’ll need and give advice on where to source supplies for reasonable prices. Many of our clients come to the studio sessions to learn new techniques and then go home and use them in their daily life. You can come to connect or learn new things, and then work on them on your own at home!
Trauma Sensitive Yoga and Yoga Therapy
The second most surprising thing to people about our clinic is that we have a yoga studio. We have a yoga studio because we saw a need that people had that wasn’t being filled. As you might imagine, not everyone is comfortable with large studio yoga, particularly if they’re struggling with trauma, anxiety, depression, or other difficulties. Further, as wonderful as larger studio yoga is, it’s not specifically designed for people struggling with trauma and mental health, or physical health challenges. Our Trauma Sensitive Yoga (TSY) programs and Yoga Therapy programs are specifically geared toward helping people recover from these things. The techniques are evidence-based and the programs are designed specifically to each client’s unique needs. Once again, the goal is to help you recover and work on your own, in-between sessions. Our certified yoga therapist will work with you individually in our safe, trauma-informed space to design a program specifically for you that once you learn, can be done safely at home on your own. When you want to learn more or brush up on techniques, you can come back in for some sessions. It’s flexible, safe, and geared specifically to you and your unique needs.
Mindfulness has become something of a buzz-word in pop psychology, but that is not a bad thing! Mindfulness is the practice of focusing on the present, allowing your brain and body to calm and be in the here and now. We’ve written previously about it on our blog, and you can look forward to more articles on this in future. It’s a vital practice that supports holistic health in body, mind, and soul. We can approach mindfulness training in a number of ways here: individual sessions with our DBT therapists and the curriculum from the dialectical behaviour therapy programs, one on one sessions in the art studio with Meg Neufeld to learn Mindfulness-Based Art Therapy techniques, or with our yoga instructors using breathwork and yoga techniques. Once again, all of these are skills you can learn and take home with you and practice on your own!
At Alongside You, our goal is to support you both in-session as we provide counselling, and outside of sessions to help you cope, grow, and thrive using holistic methods. This not only increases the effectiveness of your counselling, it also promotes autonomy, choice, and increases the chances of your recovery. Our belief is that all of our clients possess unique strengths and gifts that can be used to journey toward wholeness and resilience, and our job is to help identify these, support them, and encourage you. I hope this article gives you some ideas on how you can support yourself along the journey! If you are interested, feel free to contact us!
One of the most common questions I get from people when I give talks on Borderline Personality Disorder (BPD) and Dialectical Behaviour Therapy (DBT) is the question of how to support someone with BPD? So many individuals, couples, and families are struggling with how to love, care for, and support someone in the midst of what often feels like total chaos and painful experiences.
Shari Y. Manning, former President and CEO of Behavioral Tech and Behavioral Tech Research, the research organizations founded by Marsha Linehan to provide training in BPD, wrote a book on just this, titled “Loving Someone with Borderline Personality Disorder” and in it she focuses on how to keep the out of control emotions from destroying relationships between individuals with BPD and their families and other supports. She highlights the difficulty of balancing compassion for the person, while still wanting to help them find ways to change their behaviour and managing their emotions.
I’ll admit that it’s not easy to help someone struggling with BPD. It may seem that they are manipulative, egocentric, and focused on their own needs exclusively. The reality is that it’s not actually too far from the truth. The key to supporting someone with BPD without losing our own sanity, in my mind, is in our approach and how we frame what we’re observing. This is where Dialectical Behaviour Therapy (DBT) skills come in handy for us as well.
Interpersonal Effectiveness and Manipulation
Let’s talk for a minute about the idea that people with BPD are manipulative. It’s common to hear, both amongst clients with BPD, support systems, and yes, even professionals. I remember years ago that I used to get very angry when I heard this because I felt very compassionate toward clients with the borderline personality disorder and their need for help. Then it dawned on me – that is, they are being manipulative. And so are we.
See, manipulation is nothing new in relationships. We do it all the time – in fact, as I said to my intern John this week in supervision, we’re all in relationships to get what we need from the other person. None of us would be in relationships if this weren’t true. The difference is, we do it in a mutually beneficial way that serves everyone involved. The fact remains, however, that we’re all trying to get what we need from others, we just have more ability to do so effectively. This is what interpersonal effectiveness skills in DBT do for clients and for members of support systems; they teach us how to get what we need from others in an effective way.
Why Individuals with BPD Behave the Way That They Do
I remember back many years ago when I began working with individuals with developmental disabilities, we often repeated the phrase with staff and caregivers, “All behaviour is communication.” This is a very important concept and applies just as much to kids and adults alike, as well as individuals with BPD. When we can’t use words to communicate, we use actions. Further, when we see the often extreme behaviours of individuals with BPD, it’s important we remember what is happening to them at that moment, and how it got that way.
We’ve learned from research that individuals with BPD have reasons for interacting with the world in the way they do, just as we all do! Linehan’s theory from 1993 is the most substantiated, and it suggests that BPD can be the result of the interaction between biological and psychosocial factors, including adverse childhood experiences. One of the predominant factors is invalidating developmental contexts where emotional expression is invalidated in childhood. Further research suggests that between 30%-90% of individuals have experienced abuse and neglect in their lifetime. This has a significant impact on the developing brain.
What we also know from brain science, and certainly I’ve observed this in my clinical work, is that individuals who have histories of abuse, neglect, invalidating emotional environments, and other traumas, have brains that are more sensitive to danger. The limbic system is designed to keep us safe and also regulate our emotions. At its’ best, it keeps us safe when we’re in danger, and regulates our emotions to keep us at an even keel. At its’ worst, it’s being triggered in situations that aren’t dangerous and causing us to react in ways that would make sense if we’re in danger but make no sense when we’re not. It’s also important to remember that when this system is acutely active, it shuts down our frontal cortex, which is where our rational thought mechanisms are housed. So, when we’re in danger, as I often say to clients, we can’t think to save our lives. This is the brain state that individuals with BPD are in when they react in extreme ways. Their brains are in full-blown fight or flight mode and simply reacting, trying to do anything they can to be safe. Most often, they turn to their closest relationships.
Relationships as Safety
Ever heard the idea that we hurt the ones we love the most? This is often the case with individuals with BPD when they react in extreme ways. But why is this? Many people with BPD have a very externalized locus of control, meaning, they don’t believe they can contain their own emotions, especially when they’re overwhelmed. You know what? They’re right. When they’re in fight or flight the mechanisms in their brain responsible for regulating emotions and behaviour are not rational, and are just reacting and they can’t contain it. This is simply a more extreme version of what happens to all of us. So then, what’s the difference?
I believe the difference is the level of fear experienced in these moments. The idea of not being able to contain extreme emotions would be, I imagine, quite terrifying. Coupled with the fear of being left by the people they are closest to, the proverbial pot boils over and they have to do something extreme to get attention. I often hear, “Oh they’re just attention-seeking,” to which I reply with an emphatic, “Yes, of course, they are!”
Remember the idea that all behaviour is communication? When people with BPD are at this heightened state they are unable to communicate effectively and are doing their darndest to communicate their pain and fear to us, asking us to help them contain it. What may look to us like someone simply showing out of control behaviour, I believe, is a desperate attempt at seeking safety and containment.
Can you imagine what it would be like to be in this position? Having BPD, feeling so unsafe and so in pain that you have to go to such extreme lengths to try to get help? I can’t. The idea of being there is far too terrifying to me. Quite frankly, I don’t want to know what it feels like to be in that place, but it gives me a great deal of compassion for those who are.
What Do We Do To Help?
One of the best ways to be supportive is to help those struggling with BPD to get the help they need. Dialectical Behaviour Therapy (DBT), on an individual basis as well as in skills groups, is very effective in helping those with BPD manage their symptoms. With the right help, individuals with BPD can learn the skills they need to manage their emotions and relationships and ultimately, have a life worth living! This was Marsha Linehan’s goal in developing DBT, to help those struggling with suicidal thoughts have a life worth living. We’re proud to say that our DBT programs have been effective at doing just that for our clients, and we’d love to help even more people this way.
We have often been asked if we run groups for family members and other supports who are trying to help someone with BPD. Unfortunately, we don’t at the moment but it’s on our radar. We are looking into doing exactly this in the future. What we can do, however, is teach DBT skills on an individual or family basis for those supporting someone with BPD. We have a number of counsellors available for this, and you can talk to Doug, Share, or Kelly about this if it would be helpful.
Education is also very important as once we understand what is happening, it gets less scary. There are many books that can be very helpful. Here are a few ideas to get you started:
Stop Walking on Eggshells by Paul Mason
Loving Someone with Borderline Personality Disorder by Shari Y. Manning
DBT Made Simple: A Step-by-Step Guide to Dialectical Behavior Therapy by Sheri Van Dijk
Finally, self-care is absolutely paramount to your survival for yourself and the person struggling with BPD. As the airlines often remind us, we need to put our mask on before we can help anyone else! If we don’t take care of ourselves, we will flip our lids and react in much the same way as those we’re trying to help.
I hope this has been helpful – if our team can be of any help to you as you support someone with BPD please feel free to give us a shout. Our Dialectical Behaviour Therapy program is comprehensive, and we would love to teach you the skills needed to be a solid support, for yourself and your loved ones with BPD!