Dispelling Misconceptions About Dialectical Behavior Therapy: What Every Therapist Needs to Know

Dialectical Behavior Therapy (DBT) is a type of psychotherapy that was developed in the 1980s by Dr. Marsha Linehan. It was created with the intent to treat severe emotional dysregulation, which can be a common symptom of several mental illnesses. Specifically, it was developed to help individuals with Borderline Personality Disorder (BPD), a mental health condition that can cause intense, unstable emotions, impulsive behaviors, and difficulties in relationships.

DBT has been recognized as the gold standard treatment for BPD. However, despite its proven effectiveness, many therapists have a narrow view of DBT, which limits its application and utility for clients who are suffering. Some may view it as a rigid, manualized treatment that doesn't allow for individualization or flexibility. Others may question its usefulness outside of BPD, believing that it is only helpful for a specific group of clients.

This article attempts to dispel some of those preconceived notions and increase the use of these incredibly helpful skills. While it is true that DBT was originally developed for BPD, it has since been adapted for use in a variety of settings and with different populations. Its core principles - mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness - are relevant to anyone who struggles with managing their emotions or behaviors.

In fact, DBT has been found to be effective in treating a wide range of mental health conditions, including eating disorders, substance use disorders, depression, anxiety, and PTSD. It has also been used in schools, prisons, and other non-clinical settings as a tool for developing emotional intelligence and interpersonal skills.

Despite its versatility, DBT is often underutilized by therapists. This article aims to provide a more comprehensive understanding of DBT and its potential applications. By doing so, it is hoped that more therapists will incorporate DBT into their practice, and more clients will benefit from these life-changing skills.

Myth #1: DBT is Just for Borderline Personality DIsorder

DBT was originally developed with borderline clients in mind, and the initial research focused on treating BPD. However, many therapists incorrectly equate DBT with BPD. In reality, DBT is a set of life skills that is useful for almost everyone. You don't need a diagnosis to benefit from learning how to navigate the world more smoothly and avoid stumbling blocks.

Learning DBT skills can take about six months in a skills group format, but you can also learn them through self-study. The skills are grouped into four different categories or modules:

1. Mindfulness. Mindfulness is a powerful tool for improving our mental health and overall sense of fulfillment in life. It involves staying in the present moment instead of dwelling on the past or worrying about the future. Anyone can benefit from basic mindfulness skills, without needing a formal diagnosis. However, it's important to note that mindfulness is not a path to constant peace and happiness. Sometimes it involves looking clearly and honestly at unpleasant moments. Mindfulness is not a quick fix, but rather a long-term solution to living in harmony with reality, rather than fighting against it.
2. Distress Tolerance. Distress Tolerance skills are used to manage short-term crises, such as being stuck in traffic and being late for a critical meeting, or having a fight with a loved one. Distress tolerance skills can be short-term, used to manage an imminent crisis that will pass, as well as long-term, used when a painful situation is not likely to resolve on its own, such as a significant loss.
3. Interpersonal Effectiveness. Unfortunately, we are often not taught how to communicate effectively. Effective communication involves understanding our own wants and needs, understanding those of the other person, and expressing our wants in a way that the other person is likely to listen. It also includes setting and maintaining boundaries. How many times have you struggled in your life because you didn't set boundaries, or because your boundaries were so rigid that you weren't able to connect with other people?
4. Emotion Regulation. Another class that would be extremely useful in grade school, but is never taught, is helping people understand the emotions they are feeling. Often, someone will know that they are unhappy or upset, but will be unable to identify the specific type of upset feeling they have. Is it angry, sad, ashamed, or scared? Identifying the emotion we are feeling is the first step to working with it. Once we can name the emotion and understand how we experience it, we have tools to shift the emotion or develop a positive relationship with it.

The most common comment I hear from people who have graduated from a DBT program is something along the lines of, "Why wasn't I taught these skills earlier in life? This would've changed everything!" I'll be honest and share that I use these skills regularly in all aspects of my life, and it has made everything better.

Myth #2: DBT is Rigid and Inflexible

The original protocol for Dialectical Behavior Therapy (DBT) was highly manualized and structured. This was necessary to conduct double-blind, randomized controlled trials to test the effectiveness of this therapeutic modality in its early days. However, this perceived rigidity has led some mental health practitioners to refer to programs as either adherent-to-the-model or not-DBT. This “either/or” thinking is not in alignment with DBT, which advocates for a “both/and” mindset. Unfortunately, adherence to the model can feel restrictive and is not actually in the spirit of how DBT was originally conceived. As a result, some therapists have been put off by DBT and did not look deeper. These therapists may have otherwise wanted to learn to adapt the skills and techniques for their practice.

DBT values cognitive and emotional flexibility, as well as the principle of "Doing What Works". Research on adapted models of DBT has surpassed that on the original DBT. This research has shown that life skills taught in DBT can be applied in various settings and with different client demographics, including outpatient and inpatient clinics, jails, schools, and corporations.

DBT is not a one-size-fits-all approach and can be adapted to meet the unique needs of each individual client. It can be adapted for couples therapy, recovery from burnout, and helping individuals without mental health diagnoses develop emotional intelligence and interpersonal skills.

Myth #3: DBT is a standalone modality and I will have to change how I work

Adapted DBT is a highly flexible therapy that pairs well with many other therapeutic modalities. This includes somatic psychotherapy, mindfulness-based cognitive therapy, psychodynamic psychotherapy, narrative therapy, reality therapy, and solution-focused therapy. As someone trained in both DBT and Sensorimotor Psychotherapy, I was surprised to learn that these are highly complementary approaches that work well together, which is contrary to what many people think. I have spoken with other DBT therapy providers who have validated and affirmed this observation as well.

As a somatic psychotherapist, I frequently use body-based interventions in my practice. For example, I might guide a client to connect with a feeling or thought that they struggle to let go of, and then lead them through the process of holding an object and slowly uncurling their fingers to let it fall. This approach is similar to the "Half Smile" technique used in DBT, as both exercises rely on bodily actions to inform underlying mental and emotional processes. By understanding this connection, you can see how DBT can complement other therapeutic modalities rather than necessarily replacing them.

Myth #4: DBT Training is expensive and inaccessible

Comprehensive training and certification in DBT can be expensive, but it is not necessary to incorporate DBT philosophy and skills into therapeutic practice. There are various DBT trainings available through independent practitioners and online training sites that can teach the philosophy, theory, and practical applications of the skills. You can choose which aspects you would like to include in your practice and receive training only on those aspects without needing the full comprehensive DBT package.

In a time of increasing mental health struggles and severity, we need all the available tools and must increase their accessibility. To achieve this, we need to train more therapists in using these tools so that they can help their clients who are suffering. By incorporating DBT skills and philosophy into their practices, therapists can provide life-changing skills to their clients, enabling them to manage their emotions and behaviors more effectively. DBT is a versatile and effective therapeutic modality that is useful for almost everyone. It is not rigid or inflexible, but rather values cognitive and emotional flexibility. Therapists can learn to incorporate these skills to help their clients develop the tools they need to manage their emotions and behaviors more effectively, leading to a more fulfilling life.

Further Reading and Resources:

Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings, edited by Dimeff, Rizvi and Koerner

The Expanded Dialectical Behavior Therapy Skills Training Manual: DBT for Self-Help and Individual & Group Treatment Settings by Lane Pederson

DBT For Professionals: The Skills and How to Teach Them

DBT For Professionals: Fundamentals of Theory and Application

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