Dialectical behavior therapy (DBT) combines cognitive and behavioral therapies with Eastern mindfulness practices. Developed by psychologist Marsha M. Linehan, DBT is useful in treating individuals with a wide variety of issues, including depression, anxiety, bipolar, self-injury, eating disorders, substance abuse, and relationship conflict. The goal is for clients to learn to manage their emotions and develop healthier coping skills, while also practicing self-acceptance.

The term dialectical refers to the goal of synthesizing the rigid “black and white” thinking of many clients who have trouble regulating their emotions. Additionally, a key dialectical within DBT is the principle of accepting the client as he or she is, and offering validation, while also helping him/her learn change strategies. Validation in DBT refers to offering the client verbal and nonverbal support and confirmation.

The emphasis on validation in DBT grew out of observations in the late 1970s that many clients experienced behavioral therapy as invalidating; this led to resistance and sometimes withdrawal from therapy. Clients’ resistance often manifested in behaviors that sabotaged the effectiveness of individual therapy. These observations led to some of the core features of dialectical behavior therapy, including radical acceptance and validation of the client’s current level of emotional and behavioral functioning. This balancing of acceptance and change is important not only within individual therapeutic interactions, but within the overall treatment. While the client learns skills to improve self-acceptance, the therapist employs validation strategies, including the following:

Methods of Validation

1. Focus on listening with empathy and genuine concern, being careful to stay in the moment. Display interest through verbal and nonverbal cues: Nod and maintain eye contact, and use verbal replies such as “Uh-huh” and “What else are you feeling?”
2. Respond with accurate reflection, summarizing what the individual had shared. For example, “It sounds like you are angry that your wife made these plans without consulting you.” Check for accuracy by asking, “Is that right?”
3. Observe and articulate the individual’s unspoken emotions, based on what he or she says and nonverbal cues. Ask if your observations are correct. For example, “So you think it is unreasonable that she expects you to show up at this event without asking you. Is that correct?”
4. Validate and restate the person’s feelings and behaviors in relation to past and present situations and issues. Acknowledge that his or her current emotions are understandable in light of past experiences and/or present circumstances. For example, “Considering that your mother was so controlling when you were growing up, it makes sense that you would feel resentment in this situation.”
5. Focus on destructive behaviors that stem from prior history, and point out why the current response is not constructive. Restate the past experience and link it to the individual’s current issue and behavior choices. For example, “Because your mother tried to control your time and activities, it is understandable that you are feeling angry in this situation. However, refusing to speak to your wife does not help her understand why you are so upset.”
6. Focus on empowering the individual and treating him or her as an equal. While acknowledging the client’s struggles, express hope and optimism that the person is capable of positive change. For example, “I can see that you are working hard on making changes, and I think you are going to see some progress and start feeling better.”

In working with clients, DBT therapists are careful to avoid invalidating behaviors and responses that dismiss, reject, or criticize the client’s emotions and behaviors. Examples of this would include statements that the client should not “feel that way,” that their assessment of the situation is inaccurate, that the issue is not important, or that the client is to blame for the problem.

Dialectical behavior therapy is a support-oriented approach. As clients learn coping skills to better handle intense emotions and distress, they also identify their strengths and are able to make healthier behavior choices. Validation is a critical component in DBT, not only to help clients build their self-esteem, but to encourage their active participation throughout the therapeutic process.

Clients who have completed the mindfulness training module in dialectical behavior therapy (DBT) then move on to the second core skills module, interpersonal effectiveness. These skills are extremely important because the way we communicate with others has a significant impact on the quality of our relationships and on the outcome of our interactions. In order to communicate more effectively, DBT clients are taught skills that help them approach conversations in a more thoughtful and deliberate manner rather than acting and reacting impulsively due to stress or intense emotions. Two key components of interpersonal effectiveness are the ability to ask for things and to say no to requests, when appropriate.

In the Skills Training Manual for Treating Borderline Personality Disorder, DBT founder Marsha Linehan identifies three types of effectiveness that must be addressed in interpersonal exchanges:

1. Objective effectiveness
2. Relationship effectiveness
3. Self-respect effectiveness

For any given situation, these three factors must be considered and prioritized. The individual is likely to be more satisfied with the interaction and outcome if his or her highest priority has been addressed.

The term objective effectiveness refers to the goal or purpose of the interaction, which often is a tangible outcome. For instance, a woman might want her husband to call her when he will be working late. Relationship effectiveness represents the goal of a conflict-free relationship. In this example, the wife might rank emotional closeness and harmony as her highest priority. Alternately, self-respect effectiveness might be the top priority if this woman feels that his failure to call is disrespectful to her.

Dialectical behavior therapy utilizes acronyms to help clients remember the skills that are tied to each type of effectiveness. For objective effectiveness, the acronym is DEAR MAN, and the skills are as follows:

D – Describe: Describe the situation in concrete terms and without judgment.

E – Express: Express feelings, conveying to the other party how the situation makes you feel.

A – Assert: Assert your wishes, i.e. clearly state what you do or do not want.

R – Reinforce: Reinforce why the desired outcome is desirable, and reward people who respond positively to the request.

M – Mindful: Be mindful and present in the moment, focused on the current goal.

A – Appear: Appear confident, adopting a confident posture and tone, and maintain eye contact.

N – Negotiate: Be willing to negotiate and give in order to get, with the understanding that both parties have valid needs and feelings

Moving on to relationship effectiveness, the DBT acronym is GIVE:

G – Gentle: Approach the other party in a gentle and nonthreatening manner, avoiding attacks and judgmental statements.

 I – Interested: Act interested by listening to the other person and not interrupting.

V – Validate: Validate and acknowledge the other person’s wishes, feelings, and opinions.

E – Easy: Assume an easy manner by smiling and using a light-hearted, humorous tone.

Finally, the DBT acronym for self-respect effectiveness is FAST:

F – Fair: Be fair to yourself and to the other party, to avoid resentment on both sides.

A – Apologize: Apologize less, taking responsibility only when appropriate.

S – Stick: Stick to your values and don’t compromise your integrity to gain an outcome.

T – Truthful: Be truthful and avoid exaggerating or acting helpless to manipulate others.

The interpersonal skills taught in DBT can increase the likelihood of positive outcomes, regardless of how the client prioritizes objective, relationship, and self-respect effectiveness for that particular interaction. When used effectively, the DEAR MAN-GIVE-FAST skills help the individual convey his or her needs and wishes clearly, without the other party having to “read their mind.” It enables the person to ask for what he or she wants respectfully and with integrity, while considering the other person’s feelings and preserving the relationship.

The third module of dialectical behavior therapy (DBT) is emotion regulation, which teaches clients how to manage negative and overwhelming emotions while increasing their positive experiences. This module encompasses three goals:

1. Understand one’s emotions
2. Reduce emotional vulnerability
3. Decrease emotional suffering

An important aspect of emotion regulation is understanding that negative emotions are not bad, or something that must be avoided. They are a normal part of life, but there are ways to acknowledge and then let go of these feelings so that one is not controlled by them.

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Often, clients with extreme emotional sensitivity go through cycles that begin with an event that triggers automatic negative thoughts. These thoughts then prompt an extreme or adverse emotional response, which may subsequently lead to destructive behavioral choices. The detrimental behavior is then followed by more negative emotions, such as shame and self-loathing.

Understanding and Labeling Emotions
The first skill in emotion regulation involves recognizing and naming emotions. Clients are taught to use descriptive labels such as “frustrated” or “anxious,” rather than general terms like “feeling bad,” because vaguely defined feelings are much more difficult to manage.

Another important distinction is that of primary and secondary emotions. A primary emotion is the initial reaction to an event, or to triggers in one’s environment, while a secondary emotion is a reaction to one’s thoughts, i.e., feeling depressed about having gotten angry. Secondary emotions are often destructive, making an individual more vulnerable to unhealthy behaviors. Therefore, in addition to naming both primary and secondary emotions, it is important for clients to learn to accept their primary emotion without judging themselves for experiencing it.

In DBT skills sessions, group leaders also discuss myths about emotions, such as the misconception that there are “right” and “wrong” ways to feel in certain situations. An additional topic is the purpose that emotions serve—which is to alert us that something in our environment is either beneficial or problematic. These emotional responses are stored in memory, and we are then more prepared when encountering similar situations in the future. Additionally, our emotions communicate messages to others through our words, facial expressions, and body language.

Reducing Emotional Vulnerability
The acronym for the first skill set in reducing emotional vulnerability is PLEASE MASTER:

PL – represents taking care of our physical health and treating pain and/or illness.

E – is for eating a balanced diet and avoiding excess sugar, fat, and caffeine.

A – stands for avoiding alcohol and drugs, which only exacerbate emotional instability.

S – represents getting regular and adequate sleep.

E – is for getting regular exercise.

MASTER – refers to doing daily activities that build confidence and competency.

The second skill designed to reduce emotional vulnerability is the building of positive experiences in order to balance life’s negative incidents and feelings. To accomplish this, clients are encouraged to plan one or more daily experiences that they can look forward to and enjoy. This might be participating in a hobby or sport, reading a book, spending time with a friend, or anything that brings the individual contentment. It is important to engage in these activities mindfully, centering attention on what one is currently doing. If an individual has difficulty focusing on the activity, he or she is advised to try something different. The client is also encouraged to identify long-term goals that will bring increased positive experiences into his or her life, such as learning a new skill or making a job change.

Decreasing Emotional Suffering
The last component of this module, decreasing emotional suffering, is comprised of two skills:

1. Letting go
2. Taking opposite action

Letting go refers to being aware of the current emotion through mindfulness, naming it, and then letting it go—rather than avoiding, dwelling on, or fighting it. This might involve taking a breath and visualizing the thought or feeling floating away, or picturing the emotion as a wave that comes and goes.

Taking opposite action means to engage in behaviors that would be typical when one is experiencing the emotion that is in direct contrast to the current feeling. For example, if a client is sad, he or she might try being active, standing straight, and speaking confidently—as the person would if he or she was happy. When an individual is experiencing anger, the person behaves as if he or she were calm by speaking in a soft voice and doing something nice for someone. This skill is not aimed at denying the current emotion; the individual should still name the emotion and let it go. However, acting opposite will likely lessen the length and severity of the negative feelings.

Some of the emotion-regulation skills may sound a bit vague to those unfamiliar with dialectical behavior therapy. In group sessions, DBT leaders cover these skills with clients in more detail, incorporating role playing so that the clients can transfer the new skills to situations in their own lives. Ultimately, these skills empower people to manage their emotions, rather than being managed by them.

As discussed in the overview of dialectical behavior therapy (DBT), the first of the four primary DBT modules is core mindfulness. Derived largely from Eastern zen philosophies and Western contemplative practices, mindfulness forms the foundation for the other three DBT modules of interpersonal effectiveness, distress tolerance, and emotion regulation.

Mindfulness is the practice of observing one’s emotions and environment, describing feelings and experiences, and fully participating in the moment. By learning and incorporating mindfulness skills, clients become more aware of their feelings, thoughts, impulses, and behaviors. This awareness empowers the individual to better regulate his or her emotions and choose more appropriate actions.

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Three States of Mind
A central concept of core mindfulness in DBT is that there are three states of mind: the logical mind, the emotional mind, and the wise mind. In Cognitive-Behavioral Treatment of Borderline Personality Disorder, DBT founder Dr. Marsha Linehan explains that mindfulness helps achieve the wise mind state, which is a balance between the logical (or “cool”) state of mind and the emotional (or “hot”) state of mind. In the wise mind, the individual considers things rationally while factoring in his or her feelings. This enables the person to acknowledge intense emotions in a nonjudgmental manner while making healthier behavioral choices.

“What” and “How” Mindfulness Skills
In DBT, the practice of core mindfulness is taught through “what” skills and “how” skills, i.e., what can we do to become mindful and how should we do it? The three “what” skills are observing, describing, and participating. The observing skill refers to observing the current environment and events, as well as the client’s own sensations, thoughts, and feelings—without describing or judging him or her. This process helps prevent impulsive reactions and the triggering of negative emotions and internal dialogues.

The second step is to describe what has been observed and experienced, being careful to express facts rather than interpretations. For example, the client might say, “I am feeling frustrated with the complexity of this project,” rather than, “I am too stupid to complete this project.”

The third “what” skill is participation, wherein the individual is fully engaged in the present moment. The focus is on the discussion one is engaged in, or the event he or she is attending, rather than allowing the mind to wander about past incidents or future possibilities—which generally increases feelings of agitation.

In practicing the “what” skills, it is critical to employ the “how” skills, which explain how to perform the “what” skills: nonjudgmentally, one-mindfully, and effectively. The nonjudgmental skill helps neutralize the common tendency to label experiences and feelings as “good” or “bad.” In applying this skill, the individual describes the key facts of the experience rather than his or her feelings and judgments about it.

The second “how” skill, one-mindfulness, refers to focusing 100% attention on the present situation rather than multitasking—in other words, participating mindfully as opposed to mindlessly. This skill is helpful in breaking the habit of dwelling on negative thought patterns, which tends to prolong and aggravate distressing emotions.

Finally, the effectiveness skill enhances the capability to select behaviors that are consistent with achieving goals rather than deliberating on what is fair or unfair, and how things “should be.” The idea is to take productive and goal-oriented actions instead of being caught up in a cycle of negative thinking and behaviors.

Mindfulness can be a challenging skill for some people to develop. Many of us have become accustomed to focusing on something that has already happened or may occur in the future, rather than what is happening right in front of us. With training and practice, however, core mindfulness enables clients to become more flexible in their thinking and avoid being controlled by their emotions. It can help reduce the tendency to react negatively based on internal triggers, allowing clients to be fully present in the moment and engage in more productive behaviors.

Dialectical behavior therapy (DBT) distress tolerance skills address the tendency of some individuals to experience negative emotions as overwhelming and unbearable. People with a low tolerance for distress can become overwhelmed at relatively mild levels of stress, and may react with negative behaviors. Many traditional treatment approaches focus on avoiding painful situations, but in the distress tolerance module of DBT, clients learn that there will be times when pain is unavoidable and the best course is to learn to accept and tolerate distress.

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A key ingredient of distress tolerance is the concept of radical acceptance. This refers to experiencing the situation and accepting the reality of it when it is something the person cannot change. By practicing radical acceptance without being judgmental or trying to fight reality, the client will be less vulnerable to intense and prolonged negative feelings. Within the distress tolerance module, there are four skill categories:

1. Distracting
2. Self-soothing
3. Improving the moment
4. Focusing on pros and cons

These skills are aimed at helping individuals cope with crisis and experience distress without avoiding it or making it worse.

Skill No. 1: Distracting
The first skill, distracting, helps clients change their focus from upsetting thoughts and emotions to more enjoyable or neutral activities. This skill is taught with the acronym ACCEPTS:

A – is for activities and distracting oneself with healthy, enjoyable pursuits such as hobbies, exercise, and visiting with friends.

C – is for contributing and doing things to help others, through volunteering or just a thoughtful gesture.

C – is for comparing oneself to those less fortunate, finding reasons to be grateful.

E – is for emotion; identifying the current negative emotion and acting in an opposite manner, such as dancing or singing when one is feeling sad.

P – is for pushing away, by mentally leaving the current situation and focusing on something pleasant and unconnected to the present circumstances.

T – is for thoughts; diverting one’s attention from the negative feelings with unrelated and neural thoughts, such as counting items or doing a puzzle.

S – is for sensations, and distracting oneself with physical sensations using multiple senses, like holding an ice cube, drinking a hot beverage, or enjoying a warm foot soak.

Skill No. 2: Self-Soothing
The second skill in distress tolerance is self-soothing; clients can use the five senses to nurture themselves in a variety of ways:

1. Vision: Look at beautiful things such as flowers, art, a landscape, or an artistic performance.
2. Hearing: Listen to music, lively or soft, or enjoy the sounds of nature such as birds chirping and waves crashing. Savor the voice of a relative or friend.
3. Smell: Use a favorite lotion or perfume, light a scented candle, notice the scents of nature, or bake an aromatic recipe.
4. Taste: Enjoy a hearty meal or indulge in decadent dessert. Experiment with a new flavor or texture, and focus on the food’s flavors.
5. Touch: Pet an animal or give someone a hug. Have a massage, rub on lotion, or snuggle up in a soft blanket.

Skill No. 3: Improving the Moment
In the third distress tolerance skill, the goal is to use positive mental imagery to improve one’s current situation. The acronym for this skill is IMPROVE:

I – is for imagery, such as visualizing a relaxing scene or a successful interaction. Imagine negative feelings melting away.

M – is for creating meaning or purpose from a difficult situation or from pain, i.e., finding the silver lining.

P – is for prayer—to God or a higher power—for strength and to be open in the moment.

R – is for relaxation, by breathing deeply and progressively relaxing the large muscle groups. Listen to music, watch a funny television show, drink warm milk, or enjoy a neck or foot massage.

O – is for one thing in the moment, meaning the individual strives to remain mindful and focus on a neutral activity in the present moment.

V – is for vacation, as in taking a mental break from a challenging situation by imagining or doing something pleasant. This could also be taking a day trip, or ignoring calls and emails for a few hours.

E – is for encouragement, by talking to oneself in a positive and supportive manner to help cope with a stressful situation.

Skill No. 4: Focusing on Pros and Cons
In focusing on pros and cons, the individual is asked to list the pros and cons of tolerating the distress and of not tolerating the stress (i.e., coping through self-destructive behaviors). It can be helpful to remember the past consequences of not tolerating distress, and to imagine how it will feel to successfully tolerate the current distress and avoid negative behaviors. Through evaluating the short-term and long-term pros and cons, clients can understand the benefits of tolerating pain and distress, and thereby reduce impulsive reactions.

The distress tolerance skills are valuable tools in helping individuals maintain balance in the face of crises, teaching them to accept the distress and cope with it in healthier ways. By practicing the skills of distracting, self-soothing, improving the moment, and focusing on pros and cons, clients can weather stressful circumstances and decrease painful feelings and destructive impulses.

Dialectical behavior therapy (DBT) is a comprehensive, evidence-based treatment approach used to treat individuals with a wide variety of issues, including relationship conflict, anxiety, depression, bipolar, self-injury, eating issues, and substance abuse. Developed in the 1980s by psychologist Marsha M. Linehan for the treatment of borderline personality disorder and chronic suicidality, this method has since been adapted and utilized to help clients with much less severe issues. The therapy can help clients who exhibit extreme emotional reactions, helping them develop self-acceptance while also learning coping skills to better regulate their emotions and handle distress. DBT uses both individual therapy sessions and group skills training, as well as telephone coaching between sessions.

The DBT model combines a behavioral therapy approach with eastern mindfulness practices. In one sense, the term dialectical refers to the goal of synthesizing the extreme opposites inherent in the rigid “black and white” thinking of many clients who have trouble regulating their emotions. “Dialectical” also applies to the core DBT principle of practicing acceptance strategies while implementing change strategies, in the process of reducing and modifying self-destructive behaviors.

This type of therapy is very support-oriented; it helps clients identify their strengths, build new skills, and increase their self-esteem. DBT focuses on cognitive issues by indentifying destructive thought patterns and replacing them with more neutral and accepting internal dialogues. It is designed to be a nonjudgmental collaboration, with the therapist and client working together to increase emotional awareness and understanding, minimize negative thought patterns and behaviors, and develop new coping and problem-solving skills.

The four modules of dialectical behavior therapy:

• Core mindfulness: The first of the four primary modules of DBT, this concept involves learning to observe one’s emotions, describe those emotions, and fully participate in present experiences. This skill forms the foundation for the other three modules, and is derived largely from eastern practices of living in the moment.
• Interpersonal effectiveness: The second core component of DBT teaches clients assertiveness skills and strategies to ask for what they need, set boundaries and say no when appropriate, and deal more effectively with interpersonal conflict.
• Distress tolerance: The third module entails clients developing nonjudgmental acceptance of themselves as well as their current situation. The focus is on learning to accept the present reality and to tolerate crises, and making use of strategies such as distraction, self-soothing, and improving the moment. Practicing these skills will increase the client’s ability to tolerate challenging events and environments.
• Emotion regulation: The final module of DBT consists of three main goals: to understand one’s emotions, reduce emotional vulnerability, and decrease emotional suffering. With this in mind, some of the specific skills taught in DBT include identifying and labeling emotions as well as evaluating: events that prompt the emotion, interpretations that trigger the emotion, how the emotion is experienced, how the emotion is expressed behaviorally, and the aftereffects of the emotion.

In the case of adolescent treatment, Dr. Alec Miller has adapted Dr. Linehan’s model to incorporate parents attending skills training groups with their teens. There is an additional module, “walking the middle path,” which focuses on helping parents and their children understand each other’s viewpoints and reduce conflict and invalidation.

The five functions:

Dialectical behavioral therapy was designed to fulfill five primary functions:

• Enhance behavioral capabilities: DBT helps clients develop important life skills that help them regulate emotions, experience the present moment, improve interpersonal interactions, and better tolerate distressing situations.
• Improve motivation to changes: DBT supports clients’ motivation to change by tracking and reducing detrimental behaviors, thereby increasing quality of life.
• Generalize capabilities to other environments: In order for the client to make progress, the skills learned in therapy must transfer to a wide variety of situations. This is accomplished through homework assignments and practicing skills. Telephone consultations also can be valuable in helping clients utilize these skills in their daily lives.
• Support client and therapist capabilities: DBT aims to maintain and build the capabilities of therapists through continued training and consultation-team meetings.
• Enhance therapist motivation: The DBT model encourages the use of support, validation, feedback, and encouragement between therapists to avoid burnout and improve their effectiveness.

Stages of treatment:

The course of DBT generally flows through three stages:

• Stage 1: This stage is primarily focused on eliminating or reducing serious behaviors, including self-injury, suicidal thinking, and aggression. Behaviors that interfere with therapy also are addressed, such as missing appointments and not returning phone calls.
• Stage 2: The client strives to increase quality of life and experience emotions in a less intense manner. The client continues to eliminate or decrease destructive behaviors, and address other issues or situations that are interfering with daily life, such as past trauma.
• Stage 3: The client is experiencing increased feelings of completeness, self-respect, and love.

Who can benefit:

Though DBT originally was developed to treat more severe issues, such as borderline personality disorder, suicidal behaviors, and self-harm, the treatment has become a widely respected method for treating clients who exhibit the following, much milder traits and issues:

• Difficulty with emotional regulation
• A high level of reactivity, with a slow return to baseline
• Impulsiveness with a tendency toward self-destructive behaviors
• An inclination toward extreme thinking, unable to perceive a middle ground
• A lack of sense of self, tending to feel incomplete or empty
• A history of instability in relationships, and difficulty with interpersonal interactions
• Extreme sensitivity, accompanied by rapid mood swings, anxiety, and depression
• Fears of abandonment and trouble with intimate relationships

Dialectical behavior therapy has proven to be a very effective tool to help people manage intense emotions, change negative thought patterns, and decrease self-destructive behaviors. Individual therapy sessions focus on current detrimental behaviors in the client’s life, while group sessions involve learning skills from the four modules: mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation.