Essential Dialectical Behavior Therapy (DBT): If you’re not in jail, it’s because you’ve used DBT

Dialectical Behavior Therapy may sound clinical and mysterious, but we actually use it every day. It's why we’re not in jail for road rage. It's why we’ve had a disagreement with a boss or a conflict with a coworker and not lost our job. It's why we can have a misunderstanding with a loved one and not say or do something that destroys the relationship. It's why we’re alive and reading this, even though we may have had self-destructive thoughts in the past.

DBT is essential. People who fail to master its fourfold skills fall victim to strong emotions that seize them like a rip tide and pull them into verbal and behavioral reactions that swamp them and those in their wake.

Like someone who is drowning, these impulsive behaviors are self-protective. But self-protection is the opposite of protecting someone else. So, they exact a high toll from nearby swimmers, such as partners, coworkers, children, or other drivers.

DBT helps us to make wise choices, rather than being led by distorted thinking and emotional impulses. DBT skills help us to manage conflicting (dialectical) ideas, interests, truths, falsehoods, self-interest and care for others. It is an approach that helps us slow down impulsive reactions and instead choose wise, effective behaviors that respect and protect ourselves and those with whom we are in relationship.

DBT is a frequently-used therapy in the treatment of conditions ranging from mood disorders to Post-Traumatic Stress Disorder (PTSD), to low self-esteem, to self-sabotage, Borderline Personality Disorder (BPD), impulse control, self-harm and suicidal ideation.

Despite its clinical use, it’s also very pedestrian. Most of us recognize it as the subconscious process we go through when we endure circumstances not to our liking, control our emotions lest they control us, resist childish or selfish reactions, and choose to respond in a way that does not blow up our personal world.

That pretty much sums up DBT. Its skills slow down the chain reaction of feelings, thoughts and actions, helping us back to the shoreline of balanced thoughts, self-control, and helpful, effective, relationship-protective behaviors.

The four parts to DBT are:

• Mindfulness

• Emotion regulation

• Distress tolerance

• Interpersonal effectiveness

Mindfulness:

Mindfulness is the skill of being aware of the “here and now.” It includes focusing our senses on what we are hearing, seeing, touching, smelling, or tasting. It is being aware of our internal state, the changes occurring in the body, the emotions arising within, and aware of the impulse that wants to take over. It is being non-judgmental about what we’re sensing; just noticing it. This is employed so that we don’t get carried away into an altered state triggered by judgments, misperceptions and false conclusions, which spark emotional fires. Rather, we train ourselves to notice what is happening inside and around us. Without judgment, we just notice; we’re mindful, perhaps saying out-loud—if the context allows—the story being created in our head. This brings clarity and postpones our response until we make effective decisions based on reality.

A specific mindful practice is the 5-4-3-2-1 technique. It is naming five things you can see, four things you can touch, three things you can hear, two things you can smell, and one thing you can taste. You can apply a different number to each sense, if you want. The effect of the practice to “ground ourselves” in reality. Being grounded in reality anchors us, lest a cocktail of cortisol & adrenaline poured by our emotional minds activate our muscles or mouth before reason has shown up to bar the door.   

Emotion Regulation:

Emotion Regulation is the skill of recognizing what we’re feeling, without giving emotions full reign over our decisions.  Emotions are clues to something important and should be mined for understanding. However, they are also immature and cannot be allowed to drive without supervision. Dialectical Behavioral Therapy invites the rational mind into the supervisory role, slowing down impulsive reactions, grabbing the wheel before the emotional toddler steers us off a cliff. Remember, we practice this every day; most of us have control over the steering wheel that governs our lives. No one lives by emotions, alone. If we get cut off in traffic by an inconsiderate driver, we may be incensed, righteously indignant, and just old-fashioned mad, but we don’t use our vehicle as an instrument of retribution. We don’t respond to their emotional immaturity by unleashing our own emotional immaturity; we maintain control, lest our inner toddler cost us a ticket or our license or our freedom.

Because DBT invites emotion regulation, it is often used to treat Borderline Personality Disorder (BPD). BPD was originally so-named because its presentation was thought to border on psychosis (trouble discerning reality) and neurosis (feeling anxious). It would sound less mysterious if it were called “Emotion Dysregulation Disorder.” Those who suffer from BPD—or those who demonstrate  borderline traits—often have a sensitive, empathic personality. Many have also endured difficult, neglectful, or abusive backgrounds and life experiences. This combination can create a hyper-vigilant amygdala, quick to misinterpret the meaning of words, looks, incidents or interactions as disrespectful, offensive, dismissing, rejecting, minimizing, or as precursors to abandonment. The problem here, of course, is that interpretations are not facts, and feelings are not facts. Emotion-driven reactions to misinterpretations without the dialectical engagement of the rational mind can lead to  relationship troubles, chaotic lives, shame, self harm or even suicidal ideation or attempts. A BPD self-defensive reaction can go from 0 to 100 almost instantly, unleashing an emotional tantrum of words or actions that may create a self-fulfilling prophecy of pushing away family and friends. The boundaries that others must necessarily erect against Borderline abuse is interpreted by the sufferer as evidence that loved ones are not there for them. Given the above, DBT applies the brakes before emotions stomp on the accelerator.

A specific DBT Emotion Regulation skill is called, “Taking Opposite Action.” This is the skill of doing opposite of what we feel like doing. For instance, instead of yelling at one's partner and accusing them, taking opposite action might be to draw close and ask, “Help me understand,” (wanting to understand rather than to argue). Instead of taking revenge on someone, it is doing something kind for them. Instead of leaving a scathing review, it is commending what we can. When taking opposite action, take note of how much better you wind up feeling than you would have, had you given in to an aggressive, self-serving impulse born of a negative feeling.

Distress Tolerance:

Distress Tolerance is the skill of tolerating unpleasant situations—disappointment, frustration, stress, a crisis, rejection, or a relationship rupture. Distress tolerance includes challenging the incomplete story we are telling ourselves about a situation. It is often this negative interpretation of an incident that triggers a maladaptive self-defensive response. Consistent with Mindfulness and Emotion Regulation above, DBT skills apply the brakes. They challenge the idea that the situation, or what someone said or did, “made us” respond in a certain way. Distress tolerance reclaims our personal agency—our ability to choose our response—from the thief of a victim mindset.

Rather than quitting a job, verbally assailing a partner, damaging property, cutting ourselves, or blowing up a situation, we learn “radical acceptance.” That is, we make the radical, brave decision to accept what is; to accept what is not ours to control (the weather, an awful circumstance, someone else’s words or behavior) and instead decide our response.

Distress tolerance buys some time instead of reacting instantly. The skill might include employing the five senses for self-soothing; aroma therapy, listening to soothing music, watching the clouds roll by, wrapping up in something cozy, or drinking something flavorful and non-alcoholic. It might include praying for the person who is the object of your emotions. It might include deep breathing: close your eyes, take a deep breath and hold it, then let it go longer than you inhaled. It might include going  for a walk, splashing cold water on your face, or holding an ice cube.

Another tool is “radical acceptance,” which is making the radical decision to accept what is—to acknowledge that it is unpleasant, but that “It is what it is…”  This challenges black and white thinking (all-good or all-bad), invites comparison to people whose situations far worse, leaves room for the benefit of the doubt, and notes that the disappointing factor is only one factor among a myriad of factors that are not bad.

Another tool for tolerating distress is to distract ourselves. This is the opposite of rumination, which is a gateway to depression. Distraction is consistent with acting-opposite-of-feeling. We apply our thoughts and efforts to something else; we do something consistent with our values, interests, and self-care. This is not eternal avoidance, but is getting out of Kamikaze mode until we are regulated enough to make protective decisions.

All of the above, and others listed in the resources at the end of the article, are ways to tolerate what is, rather than punish it in ways that ultimately only punish ourselves, those we love, and the things we care about.

Interpersonal Effectiveness:

This final movement in DBT is the point of it all. It is the skill of preemptively challenging ourselves on the relationship effectiveness of an impulse that is about to be released by our hair trigger. What is occurring at this moment is that the right brain—drunk on emotions— is telling us that the tempting impulse will protect us, will make us feel better, or will help us get our way. The dialectical opportunity here is to engage the left brain, which processes if-then statements to determine their logical outcome. The most relationally-effective decisions are those that consider both our emotions—what they are pointing to that is important to us—and the effects of planned behavior.

Interpersonal Effectiveness is pausing to consider the outcome of our words before they leave our mouth and the results of our actions before we employ our muscles. Remember, we’re talking about the difference between losing a relationship or not, losing a job or not, getting a ticket or not, being evicted or not, even losing our kids or not.

Interpersonal Effectiveness, like the other skills, is a way of slowing things down and taking stock of the future before we create it. It’s playing the movie through to the end, asking whether that’s the outcome we want.

Interpersonal effectiveness recognizes that relationships live within a constant tension that balances self-interest with the interests of others; self-protection with the protection of others. Emotional effectiveness is deciding—in the midst of our emotional and physical dysregulation—to handle things in a way that won’t harm relationships. In fact, we might even muster the strength and love to respond in a way that may improve a relationship.

DBT theory speaks of the “wise mind,” and Interpersonal Effectiveness if proof of its engagement. The wise mind is the combination of the emotional mind and the rational mind; the combining of thinking and feeling in deciding a measured response that, at the end of the day, will be effective in the grander scheme of life and relationships.

Summary

Those are the four components of Dialectical Behavioral Therapy. As I said at the beginning, they’re not mysterious. You recognize them from everyday use in your better moments. The reason they have been collected into a coherent system is to provide a roadmap for moments when emotions want to respond to a distressing situation in mindless way that threatens to blow up your world. If we commit these steps to memory—including reflexive muscle memory—we have something to hold onto until the roller coaster has dropped and leveled off.

As promised, there are print, video, and linked resources below. But before closing, let me provide in more detail a DBT skills that incorporates all that has been mentioned above: “From Feeling to Acting.”  It is a roadmap for moving from impulsive reaction to intentional response.

From Feeling to Acting

It starts with identifying that impulse and action are different things. They may seem to cooccur, but they are two separate steps. We experience an impulse, but then engage in a behavior.

The practice of “feeling to acting” helps us identify a feeling, separate it from an  impulse that will be experienced by others as selfish, and choose instead to act with caring toward others.

The key is to slow down the process, identify its steps, and deliberately choose a wise, relationally helpful response to a feeling. The process looks like this:

• Pause — Unless acting urgently to protect someone else, rarely is immediate action the best action.

• Breathe — A deep inhale, followed by holding your breath, followed by releasing the breath

slowly for two to three times longer than the breath was drawn in, activates the

parasympathetic nervous system, which is the body’s calming response.

• Give voice to your feelings — Whether talking out loud, or clearly inside your head, identify your

feelings without blaming someone; just name them and voice them. Don’t settle for

distancing secondary emotions like frustration, irritation, jealousy, or anger; rather dig

deeper for vulnerable primary emotions such as hurt, fear, sadness, shame, or loneliness.

• Separate facts from feelings. Feelings are not facts. Challenge your interpretation.

• Give voice to your impulse —Tell yourself (out-loud if the context allows) what you feel the

urge to say or do.

• “Ride the roller coaster” — Keep your hands, feet, and voice inside the cart until the ride

has come to a complete stop and you have activated a wise mind to control your mind, body, and mouth.

• Change the atmosphere — Smile, speak softly, hug, offer comfort, serve food, get fresh air,

pray for the other, stimulate endorphins, go to a happy place, rest.

• Consult with counsel — Contact someone in your support system who knows your swings

and can “talk you down.”

• Counsel yourself — What will be the realistic outcome of the impulse? Consider not just the

short term, but the long term effect for yourself and for others (especially partners and

children). Picture the desired outcome for the relationship; what next step does that

suggest? (The impulse is the movie trailer; play the whole movie to the end.)

• Control yourself — Control what you can (yourself), and accept what you cannot control

(others’ words and behavior, the weather, time, traffic, the economy…). Acceptance does

not mean approval, but focus. Focus on being your best self—who you want to be and want others to see—no matter what. Live your highest values.

• Act responsibly — Choose an intentional response from a calm place; decide on a

behavior that will protect others and yourself based on what is real. “Take opposite action.” That is, if you feel hurt, angry, sad, unloved, not prioritized, abandoned, or another negative emotion, don’t justify retaliating in-kind. Instead, take action that will protect others.

• Celebrate — Congratulate yourself when you resist an emotional impulse and choose instead effective, relationally responsible behavior. Reward yourself.

Worksheets:

MINDFULNESS:

Components, Practices and Benefits:

https://www.therapistaid.com/therapy-worksheet/what-is-mindfulness

EMOTION REGULATION:

IMPROVE: Improving your actual moment (the next minute, hour, afternoon, etc…)

https://www.therapistaid.com/worksheets/dbt-improve

DISTRESS TOLERANCE:

ACCEPTS and Engaging the Senses:

https://www.therapistaid.com/worksheets/dbt-distress-tolerance-skills

INTERPERSONAL EFFECTIVENESS:

The “Dear Man,“ GIVE and FAST strategies help us engage in respectful dialog when our needs conflict with others’ needs:

https://www.therapistaid.com/therapy-worksheet/dbt-interpersonal-effectiveness-skills

Resources:

• DBT Skills Training: Handouts and Worksheets, by Dr. Marsha Linehan

• DBT Skills Training Manual, Dr. Marsha Linehan

• Building a Life Worth Living, by Dr. Marsha Linehan

• Dialectical Behavior Therapy, Vol. II - The Worksheets, by Cathy Moonshine, PhD

• You Untangled: Practical tools to manage your emotions and improve your life, by Amy Tibbitts

• Stop Self-Sabotage, by Judy Ho, PhD

• Video featuring Dr. Ho:

https://www.youtube.com/live/IFnDyxu0ZRY?si=Qq44O5cl0VMME9UW