How to Add Dialectical Behavioral Therapy to Your Practice

As a therapist or a mental health professional, the success of your work output depends on your patient's progress. Even if sometimes the progress is out of your control, this might be a metric you use to gauge whether you're making a difference in someone's life or not. It is difficult dealing with patients that have a tough time accepting treatment. Sometimes, even advanced and heavily researched techniques such as plain Cognitive Behavioral Therapy (CBT) may not be enough. Luckily for you and your patient, an extensive version of CBT called Dialectical Behavioral Therapy (DBT) has shown success in treating a myriad of disorders and mental health issues. 

Dialectical Behavioral Therapy was introduced first in the 1980s by American psychologist Dr. Marsha Linehan as an intersection between behavioral therapy and elements of acceptance and change. Dialectic means acting through opposing forces. This definition is evidenced by the stark contrast between the psychology behind behaviorism and acceptance of that behavior. Dr. Linehan first used this technique to treat problematic women afflicted with suicidal tendencies. Eventually, this treatment was introduced for patients suffering from Borderline Personality Disorder (BPD). DBT focuses on helping the patient reach a place of acceptance of themselves, their behavior, and their situation. 

The Theory Behind DBT

Mental health disorders such as personality disorders can cause instability in a person's mood or actions. They may find themselves unable to regulate their emotions and trauma. It results in risky behavior, volatile and impulsive actions, and a tarnished self-image. Considering all of that, DBT helps by enabling the patient to accept two opposing pools of thought. Therapists that treat patients with DBT allow them to accept their situation and help them move toward getting better. DBT enables the patient to have a different approach to handling life, despite being told differently for years. The affirmation may go something like, "I am this way, but I also know that I can change for the better."

DBT is an intense form of therapy that covers a variety of trauma. Hence it is not for the faint-hearted. At some point during treatment, you will need to ask difficult questions that may trigger your patient. Similarly, your patient may disclose their feelings and emotions, at which point you will need to guide them accordingly. If done right, DBT is a wonderful source of healing that can make the lives of both the therapist and patient easier. DBT requires skills and training. Hence it is essential for you as a therapist to be learned in this technique.

Different Techniques Used for DBT 

For DBT, there are different modes of training the patient to develop specific skills that can help them regulate and understand their behavior. 

 These modes of training or therapy involve:

• Group Therapy - where patients are taught how to control their behavior in a group setting 
• Individual Therapy - one-on-one sessions with patients to help them understand and regulate their emotions, feelings, and actions. 
• Phone Coaching - this may come in handy in case a patient needs spot-on advice regarding a difficult 

There are four skills taught to patients to help them take charge of their behavior, including:

• Mindfulness
• Distress Tolerance
• Interpersonal Effectiveness
• Emotion Regulation

Core Mindfulness

Mindfulness practices include being present in the moment. It allows your patients to be self-aware and take inventory of their feelings, emotions, fears, and anxieties. If a person may find themselves in a triggering situation, staying mindful can help calm them down and regulate their impulsive tendencies. As their therapist, you can start with simple exercises to give your patients to test their reactions to small stressful situations and eventually build up this practice to suit highly intensive ones.

Typical exercises include closing your eyes and focusing on breathing. Becoming aware of each intake of air and back out again can help center a person.

Distress Tolerance

Knowing how to handle yourself in stressful situations is critical to living a healthy and happy life. People that can't handle even most minute situations cannot hope to live everyday life. They would be too busy overthinking and overanalyzing actually to get anything done. Distress tolerance provides patients with skills and learned behaviors that can help them through a distressing time. This is a skill they can build on overtime. That is, they can improve their tolerance. 

Distress tolerance techniques include:

• Distracting yourself from the current situation by thinking about more positive things
• Improving the moment by changing your reaction or behavior towards the situation
• Self-soothing which includes repeating affirmations and focusing on yourself
• Tallying up pros and cons of the situation

By acting more composedly, one can navigate through distressing emotions and come out on the other side feeling better or relieved. 

Interpersonal Effectiveness

Learning to communicate with people in different relationship settings is an essential part of healing from any trauma. Likewise, under DBT, this can enable the patient to be assertive to get what they want out of it. Usually, people who have personality disorders have difficulty choosing a stance in their relationships. They may behave in various ways, not putting themselves first and not always mindful of their situation. To be in a positive and healthy relationship with someone, we need to voice our needs and keep lines of communication open. If not, it can lead to hurt or manipulation. 

As a therapist, you can provide your patients with several following points to maintain that healthy balance. These points can be in the form of easy-to-remember acronyms such as GIVE. 

Gentle - be kind, non-judgemental 

Interest - take an interest in other people's lives 

Validate - make sure to acknowledge what the other person is feeling 

Easy - do not stress about situations, not in your control

Emotion Regulation 

Emotion Regulation is an important skill, as it can help you anticipate the on-set of overwhelming emotions like anger, stress before they even arrive. This skill set can help your patient identify their feelings and behave oppositely, giving them a little control over their behavior. For example, if something makes you angry, you can anticipate it and think with a clear head instead of lashing out. We are constantly adapting to different situations in life. Our emotions must do the same. This also means that you need to engage in behaviors that you usually want to change what you're feeling. If you're sad, it's a good idea to visit friends or family that can uplift your mood. 

How Can Journaling Help

Like in all CBT psychotherapies, journaling can also be advised to patients in conjunction with DBT. DBT practices mindfulness, and so does journaling. The process of keeping a diary to write in daily has done wonders for people suffering from anxiety disorders, depression, PTSD and even has implications here. It helps you stay centered and on target. Writing your thoughts down and making sense of them is therapeutic and enables you to regulate your emotions better. 

Regarding DBT, you can ask your patients to note down their daily exercises in skill learning. They can write down what they felt, if anything went wrong, or what they see in their progress. They can write about what emotions or triggers they face most often and how they respond to them daily. All of this data in one daily journal can help them navigate the lanes in their minds better. It can provide them with an excellent mental map. 

The skills DBT offers are ones that a patient mainly has to practice independently when they are out and interacting with the world. You may not always be there for them, or they may not always ask for help. Keeping a journal can give them something concrete to look forward to each day. It can be treated as minute therapy sessions and hence keep them consistent. 

Your Role as a Therapist

Suppose you're new to DBT and want to use the technique to help your patients. In that case, it is essential that you are adequately trained through an organization like BehaviouralTech, founded by Dr. Marsha Linehan for teaching mental health professionals in DBT. You can even join a team of other therapists on the same path as you. DBT also requires a considerable commitment of time and energy. It consists of any sessions and also remaining online for any calls that come your way from patients. It is an intensive program but can work wonders for people if done right. It is also necessary to remain patient, as learning a new mindset and behavior can be challenging for people in their early stages of recovery. Being a therapist is not an easy task. However, if you remain invested in your patients and work towards their progress, they will eventually respond to you as well.