Dialectical Behavior Therapy (DBT) but First a Disclaimer

The following post is entirely my own interpretation of DBT, and I am solely responsible for the content. I am in no way authorized as a spokesperson for the field of DBT.

In the immediately preceding post, I listed ten mental health skills areas, five derived from emotional intelligence and five derived from dialectical behavior therapy (DBT). That post focused on emotional intelligence and this one on DBT. However, this post is not about providing or consuming DBT. Instead I introduce the four skill sets of DBT along with dialectical thinking teased out as an additional skill set. To be sure, dialectical thinking is the sauce that permeates the four skill sets of DBT, and its separation is not authorized. I do so to highlight it as a mental health skill.

Marsha Linehan is the architect of DBT. She conceived the intervention as a manualized intervention for persons who live with borderline personality disorder. DBT, however, can enhance the mental health of everyone. In my own practice, I present the principles of DBT in psychoeducational doses to my patients as part of individual therapy.

Dr. Linehan’s principles can be found in her seminal book, Cognitive-Behavioral Treatment of Borderline Personality Disorder. As extraordinary as that book is, the one I recommend for beginners is DBT Made Simple by Sheri Van Dijk. You can use this post as an introduction to DBT vocabulary and then turn to Van Dijk for an in-depth look. After that, please get Linehan’s original book. Read it and keep it for reference.

Five Mental Health Skill Sets Gleaned from DBT

1. Dialectical thinking

Dialectical thinking is the ability to see validity on all sides of issues, including controversial ones, and simultaneously accept the contradictions.

Dialectical thinking asks us not to judge the intrinsic worth of people, situation, and objects. We are, however, allowed to judge whether we like or don’t like certain people, situations, and objects. Caveat: Our likes and dislikes are usually best kept to ourselves.

Dialectical thinking is a tough sell because we humans have evolved to prefer negativity and its attendant divisiveness. Social media and much of traditional media make fortunes with snarkiness, trolling, condemnation, and AI programmed polarization.

After noticing the negative, mentally healthy people immediately seek all relevant sources of data before concluding anything. These highly functioning people have cultivated the ability to tolerate ambiguity and to be patient with complexity.

(Dialectical thinking is not one of the four sanctioned DBT skill sets. Instead it is the foundation of DBT, just look at the name, dialectical. For the purpose of this post, I discuss it as a skill to help newcomers to DBT.)

2. (1) Mindfulness

Traditionally, mindfulness is the ability to be in the moment while suspending judgment about external and internal stimuli.

My preference, however, is to define mindfulness as the ability to return immediately to the present as necessary. Mindfulness allows sojourns to the past and to the future while keeping the path clear to the present. Mindfulness should be largely joyful, not a prison sentence to present time.

The measure of mindfulness is willful, focused attention. We scan the environment and then proactively choose what to observe.

Lack of mindfulness has three traps. Ironically, the first is getting stuck in the present. This can be a form of dissociation called depersonalization/derealization disorder (DDD). The real problem with DDD is not the surreality or the outside observer perspective but the being stuck. The second trap is getting stuck in the past and is called rumination, a core component of depression. ((Note: The rumination in depression can be so severe that the future is often blank, i.e. hopeless.)) The third trap is getting stuck in the future and is called catastrophizing, a core component of clinically significant anxiety.

Therefore, the skill set of mindfulness is essential for modulating anxiety and depression and keeping them within healthy bounds. ((The concept of anxiety and depression as health promoting may surprise you. A topic for a future post.))

Pointers on achieving mindfulness

• Mindfulness is predicated on a physically and mentally healthy lifestyle and is not a standalone skill. Competence in mindfulness comes as one develops all the skills of DBT and emotional intelligence.
• Managing the consumption of media, both social and traditional, is basic to mindfulness.
• Mindfulness operates in the background but requires frequent conscious daily doses of a few seconds to a few minutes.
• There are many mindfulness skill building exercises. The one I recommend for beginners is physiological coherence breathing (PCB).

3. (2) Distress Tolerance

• Distress tolerance is the ability to acknowledge our upsetting emotional reactions to negative people, objects, and situations while acknowledging the positive and neutral aspects of our current context.
• Distress tolerance is the ability to withstand emotional reactions and delaying responding until all appropriate data are in.
• Distress tolerance is recognizing that the present is not our future or our past.
• Distress tolerance is mindfulness in action: Experiencing the moment without attempting escape unless unacceptable harm could result.

Opportunities for developing distress tolerance

• Physical exercise for 30 minutes a day in addition to routine labor such as household chores, shopping, etc. The 30 minutes can be divided into exercise snacks as short as 2 minutes.
• Twenty minutes three times a week of physical exercise harder than you want such as running, swimming, spinning (not leisurely bike riding), stair climbing, wheelchair workouts, rowing, etc. according to the limbs available to you.
• Not automatically looking at your digital devices when standing in a queue, stopped for a traffic light, or in a waiting room. ((The waiting room is a tough situation. If alone, I will refrain from my phone for five minutes. If others are present, I will look at my phone right away to avoid becoming a distraction to others.))

4. (3) Emotional Regulation

Our emotional reactions serve as suggested default responses. Emotional regulation is the ability to respond to challenges, big or small, in pro-self and prosocial ways whether or not they are in agreement with our emotional reactions.

This is a tall order because evolution by natural selection (EBNS) has selected for obeying emotional reactions without question. What had worked in the wild is now an obstacle to self-actualization in civilization.

Emotional regulation is a proactive effort to be aware of our emotional urges and their triggers. Our mental health demands that we study these urges, accept them as part of ourselves, and carefully choose our responses to the challenges of life while taking our emotional reactions into account as only one source of information.

Our individual schemas of reality begin in our heads and cause us to have expectations: Expectations of ourselves, of others, and of the physical world. When our expectations are contradicted, emotional reactions automatically flood our thinking, our desires, our central and peripheral nervous systems, and our internal organs and glands with the result of blinding us to context.

So, emotionally regulated people deal with challenges by thoughtful, analytic responding after considering all the available data beyond the restricted context of emotional reactions. Often the best solution to a challenge is the one suggested by an emotional reaction, but only after considering the range of responses available. All important decisions of life (partners, living arrangements, careers, significant purchases, etc.) should be rooted in emotional reactions but carried out only after analyzing the consequences.

5. (4) Interpersonal Effectiveness

Interpersonal effectiveness is the ability to cooperate with others so that all parties get more from the cooperation. In my experience, the ability to compromise is the essential skill of interpersonal effectiveness. Let me explain: Compromise has dual outcomes, gain and loss. Mentally healthy people are grateful for the gain, and their gratitude overcomes the loss. On the other hand, those people who have growth edges in interpersonal effectiveness are determined never to lose anything, tangible or intangible. The obsession of never relinquishing is just that, an obsession which interferes with mental health.

The willingness to compromise is in line with recent findings that people older than 65 with dispositional gratitude and without a single-minded attitude of loss avoidance are more satisfied.

Please look at the section on Sociability in Part One of this two-part post for more ideas on interpersonal effectiveness.

Endnotes

• Writing this post has given me new appreciation into Dr. Linehan’s formulation of DBT. Specifically, interpersonal effectiveness rests on emotional regulation, which rests on distress tolerance, which rests on mindfulness, and all that combined rests on dialectical thinking.
• We can use the skills in this post and in Part One prophylactically, similarly to daily physical workouts. Will power and healthy practices cultivated daily are a rehearsal for the inevitable violations of our naïve expectations. If we do not exercise our will power and healthy habits daily, they will not be available to us in the throes of urgent situations and temptations.
• Consult a therapist as needed. Life is so complicated that we can’t see everything. The best of parents and schools cannot prepare us for everything. Psychotherapy is an opportunity for lifelong learning, although working with a therapist need not be lifelong.

Good mental health,

Dr. Michael DeCaria

(The featured image is a clematis growing through an wooden fence a few blocks from my house. I was thrilled that Millcreek City chose this photo for inclusion in its 2022 calendar. Photograph by the author)