Dialectical Behavioural Therapy, or DBT, was developed in the early 1970s by Dr Marsha Linehan to treat a group of patients long forsaken by mental health professionals: chronically suicidal people, often suffering from Borderline Personality Disorder (BPD). Linehan saw how these patients often went from one crisis to another. Characterised by overwhelming mood-swings, which can occur several times per day, and self-destructive behaviour, mainstream psychology had declared such patients untreatable.
Unlike bipolar disorder, another mental health condition characterised by (usually lengthier) mood swings, prescription drugs seemed unhelpful for the BPD patients. The dominant psychological approach at the time, behaviourism, made them feel criticised as they dealt with histories and circumstances out of their control (trauma was a common underlying factor), while humanistic treatment had almost as little success.
Linehan, who later revealed that she herself has BPD, saw a desperate need for an alternative treatment. She believed that, with the right tools, people suffering from intense emotions and destructive coping strategies could learn to live free of the suffering that seemed to plague them. She decided to try an approach that attempted to synthesise the need for change with the need for acceptance, validation of emotional pain, arriving at the idea of ‘dialectical thinking’. From there, she established four core skill groups: distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness. The results were startling – inpatient admissions plummeted, while life satisfaction increased substantially.
Nowadays, DBT is also used to treat depression, anxiety, eating disorders, bipolar, and other people whose lives are limited by extreme, distressing emotions. As mental health remains an important topic for us all, with 68% of young people reporting a decrease in mental wellbeing over lockdown (Mind UK), I have become increasingly convinced that everyone can benefit from the lessons DBT teaches. Full courses of DBT involve regular group and individual therapy and are frustratingly difficult to access, but if you feel that your own emotions are seriously impacting your daily life, you’ll be glad to know that Bangor university offers intensive DBT treatment for those in need! As a BPD sufferer myself, I will be starting Bangor’s DBT programme in September, and look forward to sharing my experience. Until then, here are 4 ways you can use DBT skills to survive & thrive today.
Distress tolerance is about accepting that difficult feelings and situations are an unavoidable part of life and finding healthy ways to cope. One of the core skills based on this concept is called Radical Acceptance. This is a technique that you can use when you’re actively experiencing strong emotions and might be inclined to try and push the sensations away in some way. Radical Acceptance uses coping statements such as the Serenity Prayer: Grant me the serenity to accept the things I can’t change, the courage to change the things I can, and the wisdom to know the difference.
It means looking at the situation without judging yourself or others and letting go of the things that you can’t control. It doesn’t mean you like or condone what is happening or what has happened in the past, and it is not meant for times when you’re in any real danger – you must be in a safe place to practice this skill. However, it is meant to make you stop and allow yourself to truly experience whatever you’re feeling, rather than pushing it down and inevitably making it worse later. This is the first step of getting better: you must accept yourself as you are now.
Another one of my favourite Distress Tolerance skills is called Self-Soothe. This is so important, especially for people who habitually rely on others to feel better or never really learned to self-soothe as a child. One way of practising this is to create a soothe box. You can use an old shoebox or any other container, and fill it with things that make you feel better when you’re upset. It’s a good idea to focus on the senses. For example, a soothe box could include a bar of soap that smells really good, a bar of chocolate, some bubble wrap, a face mask, or some nice body lotion. You could even add a comforting book or photographs. The most important thing is that everything in the box represents a way you can take care of, and soothe, yourself in a pinch. It doesn’t have to be much – I made mine into a mini soothe bag to bring to and from uni.
DBT was the first therapy to include mindfulness, owing to Linehan’s experience with the practice (she is now considered a Zen master, by the way). I’m sure you’ve all heard of mindfulness by now, it’s kind of a big deal. But, practised regularly, the hype is warranted. Mindfulness meditation, similarly to Radical Acceptance, is a way to slow down and experience the present moment fully. This is particularly important for people who find themselves relentlessly living in the past or worrying about the future. This can result in heightened anxiety, depression, and feeling out of control.
My favourite DBT Mindfulness exercise is called Wise Mind. For this, I usually picture an owl with a mortarboard on for some reason. Essentially, Wise Mind is finding a state in between your rational and emotional mind in order to make healthy decisions. For example, if you are feeling anxious about doing a presentation for uni, your rational mind could be telling you there’s absolutely nothing to be afraid of and you’re being ridiculous, while your emotional mind is telling you to hide under the covers and miss the presentation entirely. Your wise mind, on the other hand, is somewhere in between: it’s not ridiculous to feel anxious about a presentation, our brain doesn’t know the difference between anxiety caused by a bear chasing you and anxiety caused by fear of stumbling over your words in front of the class. In this case, Wise Mind validates the fear while reminding you that you’re safe, and nothing bad will happen if you say ‘organism’ wrong again.
This is a cornerstone of DBT (and life) because Emotional Regulation is all about taking care of yourself and understanding your emotions, so that life’s ups and downs don’t hit you so hard. It’s all about building yourself up until you feel safer in your own company. Unlike Distress Tolerance, Emotional Regulation focuses on things that we can control. For example, a core principle is Physical Regulation, summed up by one of DBT’s many acronyms, ABC PLEASE:
Accumulate Positive Experiences – regularly do things that make you happy and record them; whether you take pictures, write about it, or just make a mental note.
Build Mastery – likewise, take time every day to do something that gives you a sense of accomplishment, no matter how small.
Cope Ahead – plan strategies ahead of time if you know something difficult is coming up.
Treat Physical iLlness – This acronym is horrible, but it’s important enough that I’ll let that slide. Don’t avoid that doctor’s appointment!
Balanced Eating – a healthy relationship with food makes such a difference: good food, good mood.
Avoid mood-altering substances – this can even include avoiding caffeine if you’re sensitive to it, or at least avoiding it in the evening.
Balanced Sleep – creating a good evening routine and trying to stick to a consistent sleep/wake schedule helps your body and mind to regulate themselves, which sets you up for a better mood.
Exercise – if exercise isn’t your thing, you can think of this as movement. You don’t need to get on a treadmill, just make sure you get plenty of movement in your day – even if that just means dancing while you get ready in the morning.
It takes time to build the positive habits ABC PLEASE represents, and many people require some outside support with one or more of them, so take it one step at a time knowing that each is a step towards a healthier, happier life.
I chose to put this skill last, as it often appears last in the programme. It’s easy to see why. Working on yourself is one thing, dealing with others is another. There are many reasons people can struggle in their interpersonal relationships, but they can all result in misunderstandings, hurt feelings, and unnecessary suffering. You can’t change other people, but you can change how you respond to them.
A key part of Interpersonal Effectiveness is about developing your ability to be assertive. To be assertive means to be confident without putting other people down. One of the most important aspects of this is saying no and asking for what you want assertively. Healthy relationships start with choice. You need to feel able to choose whether you want to spend time with someone, and then be able to advocate for yourself with that person. To do this, you need to know what you want. This can be tricky for some people who have spent years trying to please other people rather than themselves, but it can be done. Recall difficult feelings you’ve recently had in a relationship, visualise the situation, then try to name it. Some examples could include hurt, hopeless, insecure, overwhelmed, anxious, or unappreciated. You can phrase it simply like this: “when_____ happened, I felt _____.” Now you know what you want to change. Some people may not expect you to be assertive, and some will resist it. It’s important to stick to your guns on matters that are essential to your health and wellbeing. If the other person can’t accept that, it may be time to move on.
As for the people who are willing to listen to you, practice validating their emotions (this does not mean excusing bad behaviour but understanding why they act in a certain way) and listening non-judgmentally. This means letting go of the urge to plan your next argument, interrupt, or belittle them. Interpersonal effectiveness is most successful when two people are in it together – it’s give-and-take. When you find people willing to treat you with this respect, you’ll find that good, healthy relationships with others (and yourself!) are not so impossible after all. And, with that, DBT has fulfilled its purpose.