Dialectical Behavior Therapy (DBT)

Lineham came to mindfulness after observing that clients with borderline personality disorder as well as non motivated chronically suicidal clients of therapists who refused to cooperate in traditional therapy techniques would show a better response to treatment when unconditionally accepted. (We recommend people suffering from this condition to visit www.australianbpdsupport.org for more information). She also realised that for her clients to change for the better they had to come to accept their level of emotional dysfunction and show commitment to therapy.
She developed a therapy based on the concept that ‘thesis plus antithesis leads to synthesis’ and included assertiveness training and CBT as well as Buddhist mindfulness into the mix.
Lineham’s approach is very structured and based on an interaction between therapist and client in which the therapist’s role is to validate the feelings and emotions of the client, while at the same time informing the client that some of the thoughts and feelings they experience are unhelpful. Once accepted, the therapist would now be in the position to proposing better alternatives.
There are 2 components to DBT

Individual – Client and therapist discuss how DBT skills can be applied or improved. Applying learned DBT skills, a client is required to record his or her experiences on diary cards during the week. Therapist and client meet on a regular basis to discuss these experiences and validate the thoughts and feelings that came up. Using a prioritised approach, together they identify which thoughts, feelings or behaviours weren’t helpful in achieving the goals they have been aiming to achieve.
1. First priority is focused on suicidal and self harming.
2. Second priority focuses on behaviours that interfere with therapy
3. Third priority focuses on quality of life skills
4. Forth priority is on general life improvements
Group– meets regularly for 2-3 hours where participants learn how to use specific skills based on 4 modules.
1. Core mindfulness skills
2. Interpersonal effectiveness skills
3. Emotion regulation skills
4. Distress tolerance skills

DBT Core Mindfulness Skills
Observe-
Non-judgmentally observe the environment internally or externally. Understand what is happening in any given situation.
Describe-
Without using judgment, describe to others what has been observed
Participate-
Focus and become fully involved in the activity you are doing
Non-Judgmentally
Describe the facts, without evaluating whether these are good, bad, fair or unfair (as this would constitute ‘judgement’). Being factual in this manner provides an objective way to communicate your point of view across to others without having to worry that others might disagree.
One-Mindfully
Be mindfully – keep focusing on one thing at a time without straying away into emotion mind.
Effectively
Do what works best for you.
How Skills
Interpersonal Effectiveness
Interpersonal effectiveness skills taught in DBT include strategies for asking for what one needs in a particular situation, the ability to saying no, and coping with interpersonal conflict.
DBT’s interpersonal effectiveness skills have the objective to change something in one’s usual behavioural patterns when dealing with others, for example requesting that someone do something for you that you feel is required but in the past you may have been unable to express such request, or to learn how to resist changes that someone else is trying to make that you don’t agree with.
The skills aim to maximize that your goals are met in a way that retains self respect and without damaging your relationship with others.
Interpersonal effectiveness Skills

DEARMAN – the acronym to get something
Describe the situation you find yourself in.
Express to the other person why this situation is an issue and your feelings about it.
Assert yourself – ask clearly for what you want.
Reinforce your position -offer a positive consequence on your behalf if you were to get what you want.
Mindful be mindful and focus on the situation by focusing on the aim and ignoring distractions.
Appear confident even though you may not be it.
Negotiate with hesitant people and achieve a comfortable compromise based on your request.
GIVE – giving something
These are skills that can aid in the maintenance of relationships and is to be used in conversations. The acronym stands for the following:
Gentle: be gentle and use the appropriate language, no put downs, no sarcasm (unless you are sure the person is alright with it), be courteous, be non-judgmental.
Interested: act interested in what is said, maintain eye contact and ask questions, when the person you are speaking with is talking about something.
Validate: through words, body language and facial expressions show that you understand a person’s point of view situation
Easy Manner: endeavour to be calm and comfortable when conversing with others, smile and show a sense of humour.
FAST – keeping your self-respect
This skill aids in maintaining self-respect. used in combination with the other Interpersonal Effectiveness skills, the acronym stands for:
Fair: Be fair to yourself and others.
Apologies (few): apologise for something that was not effective, however, don’t apologize more than once.
Stick to Your Values: stand by and stay true to what you believe and don’t allow others to manipulate you to do something that doesn’t agree with your value.
Truthful: Endeavour not to lie. Lying erodes trust in yourself and others and can damage relationships and self respect.
DBT uses tools such as specially formatted cards to identify therapy interfering behaviours that distract from progress. It uses chain analysis in order to identify the cause and effect relationship of behaviour and it views the cultural heritage and upbringing of an individual as key to their behaviour.
Emotion Regulation
Due to the emotional intensity (anger, depression, frustration, anxiety) that individuals with borderline personality disorder and suicidal individuals typically experience, DBT teaches skills aimed to regulate emotions based on the following strategy:

Identification and labelling of your emotions
Identification of obstacles that stop you from changing your emotions
Reduction of vulnerability to your emotion mind
Increasing awareness of your positive emotional events
Increasing your mindfulness to the emotions currently experienced
Taking of opposite action to counteract your current unwanted emotion
Application of distress tolerance techniques

Skills within Emotion regulation
Story of Emotion
This strategy is used to understand what kind of emotion you are feeling. List the following:

What prompted the event?
How do you interpret the event?
What does your body feel like – where do you feel it?
What is your body language like?
What is the action you would want to take (impulsive)
What is the action you did take?
Name the emotion that you feel (based on items 1-6)

PLEASE MASTER
Unhealthy habits are likely to make you more vulnerable to emotion mind. To maintain a healthy body and with it healthy emotions, you need to do the following:
Physica
L Illness (treat): get proper treatment if you are sick, injured or ill.
Eating (balanced): Eat a healthy balanced diet.
Avoid Mood-Altering Drugs: In order to avoid unpredictable mood swings ensure that you do not take non prescribed drugs
Sleep (balanced): Ensure you sleep enough – not too much and not too little – 8 hours is recommended per night for adults.
Exercise: get exercise to improve your body image and increase endorphine production
MASTERy (build): focus on doing one thing a day to build up your competence levels and control.
Opposite Action
When faced with an unjustified emotion do the opposite of your urges that you feel at the moment. This skill enables you to replace unwanted emotions with emotions that are opposite (i.e. wanted).
Problem Solving
When experiencing justified emotions use this skill in combination with other skills to overcome problems.
Letting Go of Emotional Suffering
Stay in the observer mode and allow yourself to experience your emotions, accept them and let them go.
Distress Tolerance
When compared to many current mental health treatment approaches that are focusing primarily on changing distressing events and circumstances Lineham’s DBT approach focuses on acceptance of the current situation and the finding of meaning in the experienced distress.
This in turn will increase distress and pain tolerance in the practitioner of DBT. It is pointed out that this does not mean that the practitioner of DBT is to develop an attitude of approval and resignation, but rather is encouraged to recognize distressing situations and their impact instead of hiding from them or becoming overwhelmed by negativity.
The state of mind achieved this way gives practitioners the ability to make better decisions about what action to take rather than engaging into destructive and unhelpful thoughts and behaviours.

Skills within the Distress Module
ACCEPTS is the acronym of skills within the tolerance model and is used to temporally distract a practitioner from unwanted thoughts and feelings
Activities: Engage in positive enjoyable activities
Contribute: by helping out others.
Comparisons: make comparisons between yourself and people that are less fortunate or compare yourself to a previous situation in which you felt worse than now.
Emotions (other): make yourself feel something different right now by engaging in activities that bring out your sense of humour or feelings of happiness.
Push away: put what is bothering you to the back of your mind for a while and temporarily concentrate on something else.
Thoughts (other): redirect your thoughts and force yourself to think about something else.
Sensations (other) – Do something other than what you are doing right now that has an intense feeling, like taking an ice cold shower or eating a spicy candy.
Self Soothe
In moments of distress or agitation behave gently, comforting, soothing, nurturing and kind to yourself.
IMPROVE the Moment
In moments of distress use the following skills to relax:
Imagery: imagine images of success, or relaxation, pleasing things.
Meaning: finding meaning and purpose in the experience
Prayer: pray to the object of your belief
Relaxation: Relax and breathe deeply
One thing in the moment: Stay in the present and focus your attention on what it is that you are doing right now.
Vacation (brief): turn your attention to something else – take a short break.
Encouragement: develop some positive self talk – yes I can
Pros and Cons
Think about the positives and negatives consequences of not tolerating distress.
Radical Acceptance
Letting go of fighting against reality (letting go) and accept the situation the way it presents itself.
Turning the Mind
Turn your mind towards accepting the situation (used with Radical Acceptance)
Willingness versus Willfulness
Be willing and open towards what is effective. Let go of a willful stance as it counteracts acceptance. Keep your focus on the goal you have set for yourself.