Behavioral theory: The behavioral theory seeks to explain human behavior by analyzing the antecedents of the behavior. Antecedents are the events, situations, circumstances, emotions, and thoughts that preceded the behavior — in other words, the events that were happening before the behavior occurred — and the consequences of the behavior are the actions or responses that follow the behavior. It’s in understanding the elements that are causing behaviors to manifest — and then further understanding what keeps the behaviors going — that the behavioral theory is applied in order to reduce maladaptive behaviors and increase adaptive responses.An important element to this theory is that maladaptive behaviors are maintained because a person lacks the skills for more adaptive functioning due to problems in processing emotions and thoughts, which is why there is such an emphasis on teaching helpful emotion regulation skills. We discuss regulating your emotions in Chapter 10.
The philosophy of dialectics: Essentially, dialectical theory states that reality is the tapestry of interconnected and interwoven forces, many of which are opposing one another. It is the continuing synthesis of opposing forces, ideas, or concepts that defines dialectics. Chapter 15 has more information on dialectics.
Checking Out the DBT Stages of Treatment
Pretreatment: This is the period of time when the person is making a direct commitment to themselves and their therapist to do DBT therapy. In this stage of pretreatment, the patient also creates a hierarchical list of problem behaviors that interfere with their living the life they want to live.
Stage 1: In this stage, the main goal is to reduce the most severe behaviors that greatly impact a person’s life. These include life-threatening behaviors such as suicide and self-injury, therapy-interfering behaviors such as being late to therapy or not completing homework assignments, and quality-of-life-interfering behaviors such as substance misuse and hurtful relationships. Finally, they want to increase behavioral skills that are done in the skills-group format.
Stage 2: In this stage, the person focuses on emotional experiencing and attending to the trauma in their life, trauma that has often led to misery and desperation.
Stage 3: In this stage, residual problems such as boredom, emptiness, grieving, and life goals are addressed.
Stage 4: In this final stage, the person works on deepening their self-awareness and their sense of incompleteness, becoming more spiritually fulfilled, and recognizing that most of happiness lies within the self.
Surveying DBT Skills
DBT assumes that many of the problems that people experience occur because they don’t have, or can’t effectively use, the skills to manage emotionally charged situations. More specifically, the failure to use effective behavior when it’s needed is often a result of not knowing skillful behavior or, if known, how to use it. Consistent with this idea of skills deficit, the use of DBT skills during standard treatment — in group, individual therapy, and coaching — has been found to lead to a reduction in suicidal behavior, non-suicidal self-injury, and depression, and to improve emotion regulation and relationship problems. In Part 3, we thoroughly review these skills:
Mindfulness: In part derived from Zen and mystical meditative practices, DBT teaches people the importance of how to be mindful. It involves reflecting on two considerations: “What do I do in order to practice mindfulness?” and “How do I practice these mindfulness skills?”
Interpersonal effectiveness: DBT teaches more effective ways for people to get what they need and what they want, how to reduce interpersonal conflict, how to repair relationships, and how to say “no” to unreasonable requests. The focus is on helping a person build self-respect, improve their self-advocacy, and recognize their needs as valid.
Distress tolerance: Whereas many approaches to mental health treatment focus on changing stressful situations, DBT focuses on teaching people skills that allow them to tolerate these situations, which are often fraught with emotional pain or distress. Within the skills, there is also a recognition of the importance of distinguishing between accepting reality as it is and approving of this reality.
Emotion regulation: Central to many of the problems in which DBT is effective is the finding that people who struggle with regulating their emotions lack the ability to do so effectively. The focus of this skills module is to get people to know what emotion they are experiencing, what the vulnerability factors are to dysregulated emotions, what the functions of emotions are, and then how to deal with the emotions when they are disproportionate to the situation.
Walking through the Mechanics of DBT
As mentioned earlier in this chapter, a comprehensive DBT treatment goes beyond individual therapy and includes group skills training, phone coaching, and a consultation team for the therapists. The group sessions are typically held once per week and run for two-and-a-half hours. In the group, the four skills modules that are mentioned in the preceding section — mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation — are taught. (These are extensively reviewed in Part 3 of this book.)
In the skills-group session, the first part is dedicated to reviewing the previous week’s assigned homework, while the second part is used for learning, teaching, and practicing new skills. In individual therapy, the skills learned in the group are reviewed within the context of the person’s individual treatment needs and goals. One way to think about this is that the skills groups put the skills into the person, while the individual therapy extracts them in the context of the person’s life.
Treating Specific Conditions with DBT
Most studies on the efficacy of DBT have been completed in people who struggle with borderline personality disorder; however, DBT has been studied in many other conditions (which are more fully reviewed in Part 5). DBT has been shown to have a degree of effectiveness, either on its own or in combination with other behavioral therapies, for conditions such as the following:
Post-traumatic stress disorder