Most people have never heard the word ‘dialectical’ when learning of Dialectical Behavior Therapy (DBT). When I first started studying DBT in graduate school, I remember thinking, “This must be a really complicated treatment, because I don’t know what dialectical even means.”
When I start DBT therapy groups or DBT trainings, I like to start with the question, “What does dialectical mean?” I often hear, “a discussion between two people,” “a dialogue,” “the way people talk, like the word dialect,” and finally “maybe something related to two things?” The last guess is the closest. Google and Wikipedia aren’t so helpful either; each defines dialectical with other big words!
Marsha Linehan, the creator of DBT, defines dialectical as a synthesis or integration of opposites. That’s kind of confusing, right? In simpler terms, dialectical means two opposing things being true at once. But even that is still kind of confusing!
Let’s break this down.
Think about someone you care about. Now, think of a time they upset you. Here’s an example from my own life. I love my brother dearly. He’s very busy, essentially working two full time jobs right now. I’ve been trying to reach him on the phone for weeks to ask him a simple question, and either he answers and has to go within a minute or doesn’t even pick up the phone. This really irks me. I care about my brother and think he’s great, AND him being hard to reach is something I don’t like about him. This is a dialectical situation. These two, seemingly opposing facts about the way I feel about my brother, are both true at the same time.
DBT is comprised of many dialectics, two simultaneous yet opposing truths. My favorite DBT dialectic? “I’m doing the best I can AND I want to be doing better.” This can apply to many situations. On the surface, doing the best I can and I want to do better seem quite opposite. Yet, I can imagine many times both can exist right next to each other in someone’s life. Have you ever seen a parent juggling a few kids out in public, and they just won’t all listen at once, so this parent gets angry? This parent is likely doing the best they can to manage their kids, given who the parent is, who their kids are, and the situation they are in. At the same time, I can imagine that parent wishing they had more resources, or that they did not get angry as quickly. That’s the want to be doing better part of the dialectic.
Notice when describing these dialectical situations I’m using the word AND, not BUT! That’s intentional. If I wrote, “I’m doing the best I can BUT I want to be doing better,” the first part of that sentence doesn’t matter anymore. You’re left only with I want to be doing better, and that’s not a dialectical statement.
DBT as a whole is centered on one main, overarching dialectic: acceptance AND change. For the treatment to work, providers and patients need to balance the two strategies, not focusing too much on either side. There are some other key dialectics as well, that I’ll be mentioning later in this DBT 101 blog series.
Do you have a favorite dialectic or dialectical situation? Let us know!
Andrea Barrocas Gottlieb, PhD, is the DBT Program Coordinator at Sheppard Pratt. She completed her psychology internship and postdoctoral training at McLean Hospital/Harvard Medical School in Massachusetts, where she learned to implement Dialectical Behavior Therapy (DBT) with youth and adults. She has studied and published research on nonsuicidal self-injury and mood disorders in youth. Dr. Gottlieb helps Sheppard Pratt implement DBT more widely through program development and staff training.
What is Dialectical Behaviour Therapy (DBT)?
Dialectical means “the existence of opposites.” In DBT, people are taught two seemingly opposite strategies: acceptance (i.e., that their experiences and behaviours are valid), and change (i.e., that they have to make positive changes to manage emotions and move forward).
DBT is divided into four stages of treatment. The stages are defined by how severe a person’s behaviours are.
- In Stage 1, the person is often miserable and their behaviour is out of control. The goal is for the person to move from being out of control to achieving behavioural control.
- In Stage 2, the person may feel they are living a life of quiet desperation: their life-threatening behaviour is under control, but they continue to suffer. The goal is to help the person move from quiet desperation to full emotional experiencing.
- In Stage 3, the challenge is to learn to live: to define life goals, build self-respect and find peace and happiness. The goal is for the person to lead a life of ordinary happiness and unhappiness.
- For some people, Stage 4 is needed. The goal is to find a deeper meaning through a spiritual existence.
How does Dialectical Behaviour Therapy (DBT) work?
A standard DBT program requires a one-year commitment. Shorter programs, sometimes called “DBT-informed programs,” use some methods or structure of DBT and can be very helpful for certain people.
A standard DBT program usually has five components, each serving a specific function:
- A DBT skills training group is facilitated by a skills therapist in a group format similar to a class. Tasks are provided for people to practice between sessions. The purpose is to help people introduce effective and practical skills into their lives, which they can use when they are distressed. These skills are meant to replace other unhealthy and negative behaviours. The class usually meets once per week for 2.5 hours. It takes 24 weeks to get through the full skills curriculum, which is often repeated to create a one-year program. In the class, four skills are taught:
- mindfulness: the practice of being in the present and acknowledging thoughts, feelings and behaviours as they happen, without trying to control them
- distress tolerance: the process of learning how to cope during a crisis, especially when it is impossible to change, and accepting a situation as it is, rather than how it should be
- interpersonal effectiveness: the ability to ask for what a person needs and to say no when necessary, while still maintaining self-respect and relationships with others
- emotion regulation: the ability to manage emotions so that they do not control thoughts and behaviours.
- Individual psychotherapy focuses on enhancing motivation and helping people apply the skills to specific challenges and events in their lives. These sessions provide opportunities for the person and the therapist to come together and discuss their individual goals. Sessions are usually held on a weekly basis for 60 to 90 minutes.
- In-the-moment coaching uses telephone coaching and other real-life (“in vivo”) coaching to provide in-the-moment support. The therapist will coach a person through a stressful event and encourage them to use their DBT skills. The goal is to ensure that skills are generalized and applied to a person’s day-to-day life.
- Case management strategies empower the person to take control of their lives and care. The therapist applies the learned strategies to teach the person how to be autonomous and how to be their own case manager.
- The DBT consultation team is focused on supporting the people who provide DBT, including therapists, skills therapists, case managers and others. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. The team helps one another by managing burnout and sharing knowledge.
The goal of all of these elements is to help the person build a life they feel is worth living.
Skills Training
This is intended for individuals with Borderline Personality Disorder who have a therapist in the community whom they see at least bi-weekly.
Individuals in this program will attend a weekly DBT Skills training group that is facilitated by a skills therapist in a group format similar to a class. Exercises are provided for people to practice skills between sessions. The purpose is to help people introduce effective and practical skills into their lives, which they can use when they are distressed. These skills are meant to replace other unhealthy and negative behaviours. The class usually meets once per week for 2 hours. It takes 24 weeks to get through the full skills curriculum. In the class, four skills are taught:
-
Mindfulness:
the practice of being in the present and acknowledging thoughts, feelings and behaviours as they happen, without trying to control them
-
Distress tolerance:
the process of learning how to cope during a crisis, especially when it is impossible to change, and accepting a situation as it is, rather than how it should be
-
Interpersonal effectiveness:
the ability to ask for what a person needs and to say no when necessary, while still maintaining self-respect and relationships with others
-
Emotion regulation:
the ability to manage emotions so that they do not control thoughts and behaviours.
Who can Dialectical Behaviour Therapy (DBT) benefit?
DBT was developed for people with borderline personality disorder. But it can help people with other mental health problems, including suicidal behaviour, self-harm, substance use, posttraumatic stress disorder (PTSD), depression and eating disorders.
Frequently asked questions
How is DBT different than cognitive behavioural therapy (CBT)?
Both DBT and CBT are forms of psychotherapy. In these therapies, a person talks to a mental health professional about their challenges and learns skills to help them cope. However, CBT primarily focuses on learning ways to change unhelpful thoughts and behaviours. DBT teaches people to accept their thoughts, feelings and behaviours, and the techniques to change them. Not only are personal skills taught in DBT, but skills for interpersonal relationships are also emphasized.
DBT is based on CBT, but it focuses more on the emotional and social aspects of living. In fact, DBT was created to help people manage their intense emotions.
Sources:
What is dialectical behavior therapy (DBT)? © 2017 Behavioral Tech
What’s the difference between CBT and DBT? © 2015 Canadian Mental Health Association, BC Division
Dialectical behaviour therapy (DBT) © 2017 Mind
Dialectical behaviour therapy (DBT) © 2017 SANE Australia
