Dialectical Behavior Therapy

Emotional Lability (Frequent Mood Changes)
Problems with Anger
Chaotic Relationships
Fears of Abandonment
Confused sense of self (e.g., not knowing where they fit in)
Sense of Emptiness
Suicidal and Self-Injurious Behaviors/Threats
Impulsive Behavior (e.g., alcohol/drug abuse, binge eating,
Paranoid Thoughts
Dissociative Responses
High Emotion Vulnerability
High Sensitivity
-immediate reactions
-low threshold for emotional reaction
High Reactivity
-extreme reactions
-high arousal dysregulates cognitive processing
Slow return to baseline
-long-lasting reactions
-contributes to high sensitivity to next emotional stimulus
Biological Vulnerability
an Invalidating Environment
INVALIDATION means to DENY another person’s
take on a situation or to JUDGE it.
Examples of INVALIDATION include:
“How can you feel that way?”
“That makes no sense.”
“That is so stupid.”
“You are so selfish.”
“You have no reason to be upset.”
 Thoughts,
feelings, perceptions are met
with inconsistent, inappropriate, and
extreme responses from environment.
 The
individual learns to believe that they
are wrong to have those thoughts,
feelings, perceptions.
 The
consequences of invalidating
environments are severe.
The individual does not learn to:
Label feelings accurately,
Regulate emotion skillfully,
Trust their reactions (Self-invalidation),
Effectively tolerate distress,
Achieve long-term goals,
Form realistic goals and expectations,
Express emotion appropriately.
Dialectical behavior therapy (DBT) is a specialized form of cognitive-behavioral
therapy. It was originally developed to treat adults and adolescents
demonstrating intense mood swings; relationship difficulties ; frantic efforts to
avoid abandonment ; confused thinking; impulsive behavior ; and recurrent
suicidal behaviors including suicidal ideation, intentional self-injury, and history of
multiple suicide attempts.
DBT Includes:
1. Weekly Individual DBT Sessions
In individual DBT, the client and primary therapist begin by establishing a
committed, collaborative working relationship while clearly defining the client’s
treatment goals. A comprehensive behavioral assessment is completed that
includes past and current history of problematic behaviors, prior treatment
experiences and life goals.
2. Weekly DBT Skills Training
In weekly 90-minute DBT Skills Groups, the focus is on learning and mastering four
skills modules which include core mindfulness skills, distress tolerance skills, emotion
regulation skills, and interpersonal effectiveness skills.
3. Between-Sessions Phone Coaching
Phone or e-mail consultation between sessions with the primary therapist is encouraged
in DBT. Calls or e-mails to the primary therapist focus on decreasing suicide crisis
behaviors; increasing skillful behaviors in everyday life; and resolving interpersonal crises,
alienation, or a sense of distance between the client and the therapist
4. DBT Consultation Team
In DBT, there is a strong emphasis on a team-approach to treatment. DBT therapists commit to
obtaining weekly case consultation with colleagues within a treatment team meeting format. The
goal is to maintain adherence to DBT principles and to conduct caring, compassionate, competent
and effective therapy.
Life-threatening behaviors (e.g., overdosing,
cutting, making suicide threats)
Therapy-Interfering behaviors (e.g., not
completing diary cards, missing sessions,
not telling the truth)
Quality-of-Life Interfering behaviors (e.g.,
using drugs & alcohol, binging/restricting
food, risky behaviors)
Increase: Behavioral Skills
Distress Tolerance
Emotion Regulation
Interpersonal Effectiveness
& Middle Path Skills
Being in control of your mind instead of
letting your mind be in control of you.
Controlling what you pay attention to and
how long you pay attention to it.
Focusing on one thing at a time and staying
in the moment.
Just noticing the experience.
Being fully mindful and aware can help you “think before
you act” and avoid impulsive and destructive behaviors you
may later regret.
Mindfulness increases choices. Once you are aware that
you have an impulse, you can decide to act on the impulse
or choose another course of action.
Mindfulness is often the first step towards using skills.
Skills will work better when you use them in a mindful way
and focus all your attention on them
Reasonable Wise
Emotional Mind
How do you know you’re in Emotional Mind?
• You may be experiencing intense emotions such as
anger, sadness, fear, frustration, guilt, envy, or joy.
• It may take very little to trigger an emotional
• You may be quick to react to emotional triggers.
• Your reactions may be extreme.
• It may take a long time for your intense emotion to
• Cool, rational, task-focused, fact-focused.
• Reason based on intellect.
• Reasonable Mind sometimes tries to squash Emotion
Mind with facts and reason (e.g., “Just figure it out.
Get over it.”). In this way, it can be invalidating to
emotional responses.
• Reasonable Mind decisions may be practical, but may
make you feel like you’re “settling” for something
you don’t completely want.
A Wise Mind Involves:
Taking in the whole of a situation – including
observable facts, your emotions and values,
other people’s feelings and points of view, and
possible consequences of behavior.
Using this information to make a wise or
effective decision about what you should do,
how you can view the circumstances, and how
to take care of your emotions.
“What” Skills & “How” Skills
“What” skills
(Observe, Describe, Participate)
“How” skills
(Non-judgmentally, One-mindfully, Effectively)
“What” skills tells us what kinds of things
we need to do during mindfulness practice
to help us reach our wise mind.
These behaviors also describe what we do
when we are actually in Wise Mind.
 Observe
 Describe
 Participate
Put words to
pure sensation
Observe your
experience at
the level of
getting caught
in it and
putting words
to it.
Take part in an activity
with awareness.
Stay in the moment and
notice what you are doing,
feeling, thinking, etc.
After noticing these
things, don’t increase,
decrease, or change the
behavior. Continue to
carry on with (participate
in) what you are doing.
Participation involves:
Spontaneity and flow
Letting go of selfconsciousness
Becoming “one” with
the activity
“How” skills tells us how to accomplish the
“What” skills.
In other words, “How” skills provide us
with tips as to how we should attempt to
observe, describe, and participate when
we are practicing mindfulness and when we
are in Wise Mind.
 Non-judgmentally
 One-mindfully
 Effectively
Don’t evaluate.
Unglue opinions from facts.
Just acknowledge what’s
Accept each moment as is.
Avoid using judgment
words as a short-hand for
descriptions. Instead of
saying “stupid”, “bad”, or
“weird”, ask yourself,
“What do I mean by that
When you find yourself
judging, don’t judge your
Non-judgmentally does not
mean approval.
Doing one thing at a time
with awareness by
bringing your entire
attention to this moment.
Doing what you need to do
to accomplish your goals.
Acting based on what will
work best in the long run,
rather than what will make
you feel better in the short
Acting as skillfully as you
can in the situation you’re
actually in, not the one you
wish you were in.
Asking yourself, “Would I
rather be ‘right’ or get what
I want?”
Acting with your Wise Mind,
rather than your Emotion
Letting go of anger,
vengeance, and ego.
Playing by the rules.
If other actions,
thoughts, or strong
feelings distract you, let
go of these distractions
and return to what you
are doing again and again.
“It’s a crisis!
What do I do ?”
What is it?
Learning to use skills to increase the ability to
tolerate/accept distress and
to bear pain more effectively.
Distress Tolerance skills work toward
tolerating and surviving crises and with
accepting life as it is in the moment
because pain and distress are part of life.
Activities: I might walk my dog to distract myself so with time I will calm down
and let my emotional distress pass.
Contributing: Doing something nice for someone else. Cooking dinner for the
family. Sending a card to a friend that might need a “pick me up.”
Comparisons: Comparing yourself to those less fortunate than you. Some
people are misdiagnosed and need DBT and are in therapy that is
ineffective. Comparing yourself to others whose family does not support
them and refuse to attend the family group.
Emotions: Creating emotions that are opposite to your current emotional
state. If you are very angry, listening to calming music or watching a funny
Pushing Away: To put intense emotions or difficult situations “on a shelf” for a
little while… until you can think and problem-solve more calmly.
Thoughts: Creating other thoughts to fill up your mind rather than ruminating
which can lead to escalation of a distressing situation. Play a word game like
Scrabble, crossword puzzles, or just counting anything .
Sensations: Create other sensations rather than acting on a behavior. Hold
an ice cube until it melts. Put a cold cloth on your forehead or a very warm
cloth. Have emergency breakable hot or cold packs in your car. Jump into
an ice-cold shower.
Vision: Go outside and look at the stars, pick a pretty
flower, decorate your room, look at beautiful scenic
pictures, paint your nails.
Hearing: Listen to music that is soothing or that lifts your
mood. Go outside and hear your chimes on your porch,
or the wind blowing.
Smell: Light some scented candles, spray your favorite
perfume, put on scented lotion, or bake some cookies
just for the aroma!
Taste: Make a cup of tea, or have a piece of
peppermint candy.
Touch: Change your sheets, take a bubble bath, put
on comfy pajamas, blow bubbles & run and catch
Imagery: Imagine yourself well. Make up a fantasy
world where all is peaceful and beautiful.
Meaning: Making lemonade out of lemons.
Prayer: Ask for strength
Relaxation: Muscle relaxation, yoga, calming music,
deep breathing, half-smile.
One thing in the moment: Focus your entire attention
on what you are doing right now. When washing
dishes, focus all your attention on the task.
With a brief Vacation: Taking a nap, or turning your
cell phone off for a day.
With Encouragement: “I know I can get through this.”
Pros and Cons
Thinking of the advantages and disadvantages of doing a harmful behavior.
Focus on the light at the end of the tunnel. Remember times when you felt better.
Goal is to do what works in the short-term and long-term!
Radical Acceptance
Freedom from suffering requires acceptance from deep within of what is.
Pain creates suffering only when you refuse to accept the pain.
To accept something does not mean to acknowledge it as good.
Deciding to tolerate the moment is Acceptance
Turning the mind
An Act of Choice”-you have to turn your mind toward the acceptance road and away from
the rejecting road.
The commitment to accept does not equal acceptance- it just turns you towards the path.
Willingness is doing just what is needed.
It is focusing on being “effective.”
Willingness is listening to your Wise mind, acting from your inner self.
The Goal of Emotion Regulation is to
Reduce Suffering
Increase Happiness
Myths About Emotions
There is a right way to feel in every situation.
Negative feelings are bad and destructive.
Other people are the best judge of how I am feeling.
Painful emotions are not important and should just be ignored.
Staying out of “Emotion Mind”
Remember the ABC’s
Do pleasant things that are possible now.
Make changes in your life so that positive events will occur more often.
Build a “Life Worth Living.”
Do at least one thing each day to build a sense of accomplishment.
Plan for success, not failure. Do something difficult, BUT possible. Gradually,
increase the difficulty over time.
Rehearse a plan ahead of time so that you are prepared to cope skillfully with
emotional situations.
Decide what coping skills you want to use in the situation. Be specific.
Imagine the situation in your mind as vividly as possible. Imagine yourself IN the
situation and rehearse in your mind coping effectively.
The emotion or the intensity or the
duration of the emotion is NOT JUSTIFIED
by the facts of the situation (the emotion
does not fit the situation).
The emotion or the intensity or the
duration of the emotion is NOT EFFECTIVE
for the situation.
CHECK THE FACTS to be sure your
emotional reaction in not justified or is not
effective for the situation.
your emotion.
ACT OPPOSITE to your urges—do opposite
action ALL THE WAY.
CONTINUE opposite action until your
emotion goes down.
REPEAT…over and over, every chance you
Getting the “thing” I want
When it’s your legitimate right.
Getting another to do something for you.
Refusing an unwanted or unreasonable request.
Resolving an interpersonal conflict.
Getting your opinion or point of view taken seriously.
Getting and Keeping a Good Relationship
Acting in such a way that the other person keeps liking and respecting you.
Balancing immediate goals with the good of the long-term relationship.
Remembering why the relationship is important to you now and in the future.
Keeping or Improving Self-Respect and Liking for Yourself
Respecting your own values and beliefs: acting in a way that makes you feel moral.
Acting in a way that makes you feel capable and effective.
Tell the person exactly what you are reacting to…..stick to the facts.
Express your feelings and opinions about the situation. Use phrases such as
“I want” and “I don’t want,” instead of “I need,” “you should,” or “I can’t.”
Assert yourself by asking for what you want or Saying No clearly. Assume that others will not figure it out
or do what you want unless you ask. Assume that others cannot read your mind. Don’t expect others
to know how hard it is for you to ask directly for what you want.
Reinforce or reward the person ahead of time by explaining the consequences. Tell the person the positive
effects of getting what you want or need. Tell him or her (if necessary) the negative effects of your not
getting it. Help the person feel good ahead of time for doing or accepting what you want. Reward
him or her afterwards.
(stay) Mindful:
Keep your focus ON YOUR OBJECTIVES. Maintain your position. Don’t be distracted.
Appear confident:
Appear EFFECTIVE and competent.
Use a confident voice tone and physical manner; make good eye contact. No stammering, whispering,
staring at the floor, retreating, saying, “I’m not sure,” etc.
Be willing to give to get. Offer and ask for alternative solutions to the problem. Reduce your request.
Maintain no, but offer to do something else or to solve the problem another way. Focus on what will
(Be) Gentle
Be courteous and temperate in your approach. No attacks, No threats,
No judging
(Act) Interested
LISTEN and be interested in the other person.
Validate or ACKNOWLEDGE the other person’s feelings, wants,
difficulties and opinions about the situation.
Be nonjudgmental out loud: I can understand how you feel, but…”,
“I see that you are busy, and…”
(Use an) Easy manner
Use a little humor. SMILE. Ease the person along. Be light-hearted.
Wheedle. Use a “soft sell” over a “hard sell.” Be political.
(Be) Fair
Be fair to YOURSELF and to the OTHER person.
(NO) Apologies
No OVERLY apologetic behavior. No apologizing for being
alive, for making a request at all. No apologizing for
having an opinion, for disagreeing.
Stick to Values
Stick to YOUR OWN values.
(Be) Truthful
DON’T LIE, ACT HELPLESS when you are not. Don’t
EXAGGERATE. Don’t make up excuses.
The goals of this module are to help group members
effectively manage family dilemmas by using:
Balancing Acceptance and change, and
“walking the middle path”
Working on acceptance
Working on change
Dialectics teaches us that:
There is always more than one way to see a situation, and
more than one way to solve a problem.
All people have unique qualities and different points of view.
It is important not to see the world in “black-and-white,” “allor-nothing” ways.
Two things that seem like (or are) opposites can both be true.
Change is the only constant.
Meaning and truth evolve over time.
Change is transactional.
A “life worth living” has both comfortable and uncomfortable
aspects (happiness AND sadness; anger AND peace; hope
AND discouragement; fear AND ease; etc).
Validation communicates to another person
that his or her feelings, thoughts, and
actions make sense and are
understandable to you in a particular
REMEMBER: Validation ≠ Agreement
Self-validation involves perceiving your own
feelings, thoughts, and actions as accurate
and acceptable in a particular situation.
When you validate another person:
• It shows that you are listening.
• It shows that you are trying to understand them.
• It can decrease the intensity of conflicts.
• It communicates respect.
When you validate yourself:
• It helps you get out of Emotion Mind and into Wise
• It helps you take your own point of view seriously.
Behaviorism is a set of strategies
or principles used to increase
behaviors we do want and
reduce behaviors we don’t want
(in our selves and others).
Reinforcers: Consequences that result in more of a
behavior. Reinforcers provide information to a person
about what you want that person to do.
Positive reinforcement: Increases the frequency of a
behavior by providing a rewarding consequence
(e.g., praise, a compliment, or an A on an exam).
Negative reinforcement: Increases the frequency of a
behavior by removing a negative consequence.
Examples: taking aspirin to get rid of a headache,
doing homework to get Mom to stop nagging, or selfcutting to decrease or avoid negative feelings
(although DBT teaches skills to manage this better).
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