Reading: Have You Practiced Your DBT Today?

Hell. 

That’s where Dr. Marsha Linehan went as a psychologically troubled, distraught and suicidal 18-year-old. She had come completely undone during her senior year of high school, a deterioration that seemingly came out of nowhere. Since her recovery, she has devoted her education and practice as a psychologist to get people, notably suicidal patients, out of their own similar hell. Her most effective solution is the practice she developed of Dialectical Behavioral Therapy.

Better known as DBT, this therapy, in its most simplistic terms, helps patients develop skills to manage what has been unmanageable and to replace unskillful actions with effective ones. The tools of DBT can work for people not in therapy too, like those of us struggling to reconcile the chaos of COVID-19. 

Psychologist Dr. Marsha Linehan

While Linehan originally constructed this treatment to address suicidal behaviors, DBT is now considered “the gold-standard treatment for borderline personality disorder, a condition characterized by pervasive and difficult-to-manage emotion dysregulation,” according to Linehan’s profile as Professor Emeritus of Psychology, and Director Emeritus of the Behavioral Research and Therapy Clinics at the University of Washington. This evidence-based treatment also effectively works on a wide range of other psychological problems including depression, bulimia, post-traumatic stress disorder, and substance abuse. Dr. Linehan began teaching at University of Washington in 1977, and in 1991 she published her first strictly controlled clinical trial that established the effectiveness of DBT on suicidal patients. 

While DBT takes behavior modeling cues from the more widely known Cognitive Behavioral Therapy, DBT has more facets to its therapy. It’s broken down into four distinct areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. For each, the patient is taught different skills with the goal of making them habits. Individual and group therapies are also used, so that a patient can practice these skills on their own and learn from others’ experiences. Therapists have to be DBT-certified and part of a kind of continuing-ed team of fellow DBT psychologists. Linehan proudly notes that DBT is the only kind of psychological therapy where mindfulness has a proven clinically successful role.

The “dialectic” in “dialectical” Linehan describes as the “synthesis or integration of opposites.” As a young therapist practicing behavior therapy, she saw that when she suggested behavior changes to her patients, they would get insulted, feeling that she was being judgmental. Traditional individual listening therapy wasn’t working either, because patients wanted concrete help. Linehan’s solution was to combine the problem-solving techniques of behavior therapy with the validating technique of acceptance strategy. This is where the patient radically accepts, rather than fights, their own feelings. 

What also makes DBT unique are the assumptions it has about the patient: the patient has trouble regulating emotions; the patient may or may not have caused their own problems, but it is up to them to solve them; and the patient has to define their own goals and keep working toward them. In DBT, the assumption is that the patient cannot fail. 

To be honest, the techniques that Linehan helps her most troubled patients master can work for all of us, as illustrated by the title of Linehan’s recent memoir, Building a Life Worth Living. This writer has stepped into the calming waters of DBT, notably to manage anger. In group therapy, I received photocopies of lessons and handouts from the Linehan-authored DBT Skills Training Manual and its accompanying book of worksheets. I felt like a football player trying to learn the contents of a National Football League team playbook, which contains tons of diagrams illustrating particular plays and differing responses. As the patient, I’m the quarterback. I have four 300-pound defensive linemen in front of me and various options to move the ball forward. Some of them will work and others will fail. And just like a quarterback, I have to practice.

Illustration by Jesse Finkelstein

A look at the manual’s pages on mindfulness, which many people practice outside of formal therapy, shows how being mindful can lead to “wise mind.” Wise mind is a more neutral, peaceful space of thought that allows you to behave or make decisions based on facts, not all the noise around the facts. Practicing mindfulness can get a patient from “emotional mind,” where thoughts or often rash decisions are based on feelings, or “reasonable mind,” where thoughts are based around logic or task-oriented decisions, to “wise mind.” And as one therapist recently told me, “wise mind” helps us follow all the “new and inconvenient protocols [for COVID-19] without losing it.”

DBT also emphasizes the notion of walking the middle path, which is based on the idea that there is always “more than one way to see a situation and more than one way to solve a problem.” In this middle ground, one should avoid using all-or-nothing adverbs such as “always” or “never,” which can put you in a corner or make the person you are speaking with feel defensive. Instead, DBT suggests you use “I feel” statements that describe how you feel about something, instead of telling someone “you are,” which is attacking and often judgmental. 

A huge part of the middle path is practicing validation, which involves actively listening to someone without judgement and responding with tolerance and empathy. An example given in one of my handouts is that you can validate your child about being upset about getting a low grade on a test — even though you know they didn’t study — while not validating the lack of preparation that led to the low grade. Wrap your head around that one!

DBT, with its accompanying toolbox of techniques, can also help you manage the distress and anxiety resulting from our new way of life during the COVID-19 pandemic. One of these techniques is called “TIPP” (DBT relies on acronyms as mnemonic devices to help patients remember the plays in their playbook). Here’s how it breaks down:

• T stands for temperature, literally cooling yourself down by holding ice cubes or putting a cold cloth on your neck. 
• I stands for intense exercise, which can help let off steam. 
• P is for paced breathing, where you regulate your breathing pattern to encourage calm. 
• The final P is for paired muscle relaxation, also called progressive muscle relaxation, where you tighten and relax muscle groups throughout your body to relieve tension. 

You can also take a look at the “ACCEPTS” acronym below with additional thoughts from Dr. Shireen Rizvi, a clinical psychologist and associate professor at Rutgers Graduate School of Applied and Professional Psychology. Rizvi, a mentee of Dr. Linehan, has created some wonderfully relatable webinars on how to use DBT skills to cope during the COVID crisis; she plans to post more over the coming weeks.

DBT has many other tools and corresponding acronyms for most of life’s situations. This somewhat wiser mind thinks we would all be better off using them daily.