Skills for Trauma Survivors: Dialectical Behavior Therapy (DBT)
Skills for Trauma Survivors: Dialectical Behavior Therapy (DBT)
Today on the blog, we are diving into Dialectical Behavior Therapy, or DBT! Skills for trauma survivors can help calm distress right now. DBT is a very helpful therapy for trauma survivors. Read more to learn about the history of DBT, how DBT works for trauma survivors, and how to find a DBT therapist.
This type of therapy has become much more common as of late. Many celebrities have started endorsing it, or you may have heard about it from your current therapist. Regardless, the traction DBT has received since its development is absolutely warranted.
How effective is DBT?
DBT is incredibly effective!
Current research shows that DBT is effective at resolving symptoms of chronic dysregulation, borderline personality disorder, stabilizing bipolar disorder, depression, and anxiety. DBT is effective at helping people with trauma establish what professionals like to call a “life worth living”.
I have personally been heavily trained in this method and have used it for my patients as well as myself for several years now.
This blog is dedicated to all things DBT: what it is, how it was developed, its core principles, and what happens during a typical session.
If you want the 4-1-1 on Dialectical Behavior Therapy, keep reading!
History of DBT:
Dialectical Behavior Therapy was developed by American psychologist Marsha Linehan in the late 1980s.
Marsha’s approach to developing DBT was very science-based, meaning she properly followed the scientific method (observation, hypothesis, research, experiment, data analysis, report conclusion, and adjustment as needed). This is important to note because this means that she didn’t jump into the experiment based on her own biases and what she personally believed to be working in her own practice.
Marsha went into the experiment with an open mind, letting go of what she thought should work and focusing on what is actually effective in helping people.
We now see that this idea of focusing on what actually works for patients is actually a guiding principle in how therapists perform DBT.
Marsha’s initial observation was that there was a population of clients that were not responding well, if at all, to current treatment methods. A significant portion of people were really struggling with staying in a recovered place.
These individuals experienced high levels of emotional crisis and distress and engaged in persistent and chronic parasuicidal behaviors.
Parasuicidal behaviors = non-suicidal injury and self-harm, suicidal gestures, or even non-lethal attempts.
These symptoms were unfailingly occurring in this population despite being in varying levels of intense therapy, working with psychiatrists, and taking medication.
The most current research available at the time revealed that roughly 50% of people showed remediation of symptoms within 10 years, and 50% of people showed no remediation at all.
The ongoing theory was that the people showing remediation within that 10-year time frame were not a result of an effective intervention but more of a result of simply aging. It doesn’t necessarily mean that these people felt better or their quality of life improved, but they weren't engaging in behaviors that qualified them for a diagnosis anymore.
There’s a whole population of people that, despite having sophisticated methods of intervention, therapy, and medication, are continuing to suffer in huge numbers.
Simply put, this was a severe issue, thus conceiving Marsha’s experiment.
At the time, the most effective intervention for behavior change was Cognitive Behavior Therapy (CBT). It was also the most heavily researched method.
There's a lot of debate in the field about Cognitive Behavior Therapy. This intervention is much simpler to conduct research on due to how it is manualized. With CBT, we measure changes in external behaviors, which are much more observable than internal experiences. Internal experiences are what we observe through more psychodynamic methods.
Psychodynamics is significantly more individualized and more about a principle or guiding approach to how we experience dynamic space with a client. It is challenging to measure because, in a scientific method, we need to control a lot of the variables. When we measure the effectiveness of an intervention, that intervention has to be consistent among all participants in the study.
We do, however, have research that demonstrates - based on outcomes and different measures that measure outcomes - that psychodynamic therapy can be really effective for many people.
What we also found was that psychoanalytic and psychodynamic therapy had a much higher risk for increasing distress in participants who have chronic emotional dysregulation.
Chronic emotional dysregulation = The consistent and persistent experience of emotions is incredibly overwhelming. Someone with chronic emotional dysregulation may feel like their life and behavior are controlled by their emotions. They often feel flooded by emotions and have acute distress that occurs frequently and pervasively.
Research also shows that psychodynamic and psychoanalytic therapy led to people becoming more distressed. The nature of these methods requires therapists to dive deep into the psyche to understand the meaning and origin of specific experiences and enable more experiences of these kinds, thus leading to safety issues.
Marsha started by providing Cognitive Behavior Therapy to the population she was targeting. This meant pushing for many behavior changes in how to use skills, reducing reactivity through practicing coping skills, and challenging problematic; distorted; and black-and-white thinking and replacing that with more accurate thinking.
What she found was that some change did happen, but most of the clientele felt deeply invalidated by the experience. They were being told that their thoughts were wrong and their behaviors were inappropriate when this was how they managed to survive.
Marsha went back to square one and decided to develop validation techniques that therapists could use to help enable clients to stay present in the room. These techniques included learning how to validate the valid and invalidate the invalid, how to help clients tolerate appropriate invalidation, and how to use validation to help clients process their emotional experiences to then come back to their newfound skills to make changes toward their goals.
Dialectical Behavior Therapy became so much more effective once we better-equipped therapists with these tools to validate the emotional experience of the client.
Marsha’s findings also revealed frequent moments of clients and therapists getting stuck. There would be situations where this all-or-nothing, black-and-white, or incredibly polarized thinking around specific topics would arise for clients.
The client would get fixated on a limiting belief where they can’t move forward in a situation unless it changes, or they can’t tolerate being in a particular relationship unless that person(s) changes their behavior.
Because these individuals were getting fused to this polarization, Marsha's next step was to design dialectical processes for therapists to use with clients to help them get unstuck in those moments and continue to move forward.
Dialectics = the ability to take what are seemingly opposite mindsets and find a way to synthesize them and move forward.
Acceptance and Change
Acceptance and change is a core dialectic of DBT. Accepting something often feels like you approve of it, but there is a wisdom that comes where you recognize the difference between what we can change and what we cannot change, and that acceptance is stepping away or releasing control of what we can’t change. There are certain things in our lives and the world at large that are simply unchangeable, and the way to live in this world is by accepting them.
Change is essential too. Being able to change the things that we have power over (our behaviors, how we manage our emotions, and the different actions that move us in the direction of our goals) is critical in moving forward.
That also includes holding boundaries and giving people feedback about how their behavior affects us.
It may seem like acceptance and change are in opposition. It may seem like we shouldn’t be pushing for change around things we must accept and vice versa. In reality, these two things work together in the sense that to change anything in our lives, we first have to accept where we are.
Acceptance is not approval or agreement.
It is sometimes just acknowledging “this is what it is.” As soon as we accept something and acknowledge the truth about it, we can make the necessary changes that help us achieve our goals.
Another example of a seemingly polarizing mindset that we must harmonize is conflict and peace. Both components are integral parts of a healthy relationship. Conflict is a time when we get to discuss and experience the ways in which we are two different people. It can be a very empowering, intimate moment in a relationship if done healthily.
This is the primary purpose of these dialectical processes. By teaching people these skills, it teaches them how to balance something that is polarizing. We saw tremendous change in clients after applying dialectics.
Marsha had one last issue. Therapists were consistently getting burnt out and were unable to continue providing therapy for clients in this manner because it was so emotionally and physically exhausting.
Therapists were not getting their needs met with the amount of work that was required of them.
The inclusion and requirement of consultations for DBT therapists was a wise decision on Marsha’s part. Essentially, therapists met with teams to apply DBT intervention skills to themselves.
After this last piece of the puzzle was incorporated, we finally saw the true effectiveness and sustainability of this method.
Magnificently, after years of adjustments and applying these adjustments to practice, studies began reflecting highly positive results.
Those same individuals who had chronic emotional dysregulation, parasuicidal behavior, and traits similar to borderline personality disorder were experiencing a resolution of symptoms.
Nearly 85% of them saw symptom resolution within one year.
We went from 50% of people seeing remediation in 10 years to 85% seeing remediation in 1 year. This is fantastic!
In just one year, people can get massive amounts of relief from their pain and see remarkable changes in their life.
DBT rendered this possible.
I have seen these incredible results firsthand with my own clients. When they engage with the treatment consistently and effectively, within a year (sometimes much less), they see a significant remediation of symptoms.
How Does DBT Work?
DBT as an intervention
Dialectical Behavior Therapy is a skills-based approach. Meaning a lot of this intervention is teaching people skills to be able to:
Change their behavior
Improve their mood
Tolerate distress
Communicate more effectively with other people
Find a sense of centering and grounding in their lives when needed
Assess and understand what's going on within themselves.
The first step is learning how to break down the barriers that come up for people when introducing these skills into their lives. Once this is achieved, therapists can begin teaching the aforementioned skills.
DBT has evolved so that there are three main phases of the method. Those phases are: learning the skills, applying the skills, and living a skillful life.
Many of these skills were based on what we already understood about CBT and behavior change models. Behavior change is all about how our behaviors are shaped over time in our minds through a series of reinforcements, rewards, or punishments. These rewards or punishments are communication from our environment, telling us what is appropriate behavior and what is not.
People who need DBT, or people showing chronic dysregulation, have been shaped by a lot of reinforcers showing them that the only way to get their needs met is through intense distress. Because of this, their brains became habituated to engage in this high level of distress.
This meant that these individuals were suffering from stress and emotional pain, but the only time they received any help was when they finally crossed over into acute, high-level anguish.
Their brain shifted to constant firings of high-level distress in order to get help.
The skills created to combat emotional dysregulation were something that Marsha built upon from her own personal experience. She herself faced intense chronic emotional dysregulation, parasuicidal behavior, and multiple hospitalizations as a young adult.
Martha has also discussed openly how connecting to Taoist and Buddhist principles around mindfulness, presence, and acceptance had significant impacts on her mental state. Many of these components come into play with concrete behavioral skills to shape the skillful wheelhouse we present to clients over time.
The Core Components of DBT skills
DBT Mindfulness Skills
This is where people learn skills to stay grounded and present in the moment.
This doesn’t just include traditional meditation. It also includes how to be present when doing everyday tasks such as taking a walk or washing the dishes; how to assess your body sensations, thoughts, and emotions; and how to assess external factors to understand what's going on and what the practical approach is to address an issue.
Additionally, mindfulness helps individuals address feeling fragile, unstable, or like they don’t know themselves.
DBT Distress Tolerance skills
DBT Distress Tolerance skills are concrete coping skills for being able to regulate times of acute distress or emotional crisis.
The skills that fall under this umbrella include how to soothe and regulate our senses, how to effectively distract our mind so we don’t engage in problem behaviors, how to tolerate and get through a painful moment, and how to connect to a bigger picture and get perspective.
Problem behaviors can be self-harm, substance abuse, rage episodes, or anything that we do when we’re in high distress that we know interferes with our lives.
Part of distress tolerance skills is also radical acceptance skills.
How do we learn to practice acceptance for things that are really hard to accept? How do we move toward willingness when all we really want to do is just dig in our heels and refuse to move forward?
Distress tolerance skills are how we find answers to those overhanging questions.
DBT Emotion Regulation skills
DBT Emotion regulation skills are when we learn to understand our emotions and discover what our day-to-day, moderated emotions feel like.
This period is where we learn about our broad range of emotions as well as find the answer to
What do emotions do?
What is their purpose?
How do they happen to us?
What are the different things we can observe through our mindfulness skills that tell us what emotions we’re having?
What can we do with those emotions?
How do we engage our long-term goals to shape how we interact with our emotions right now?
Other emotion regulation skills include problem-solving, acting opposite to emotions that aren’t effective to act on, and being able to sit with our emotions while they are happening.
DBT Life-worth-living skills
Life-worth-living skills are precisely what the name suggests. These are skills that help us feel like our lives are worth living!
These skills include:
How to experience more joy.
How to connect to things that matter to our personal values.
How to set long-term goals to build a life that matters to us and activates our values.
How to take care of ourselves - physically and emotionally.
How to prepare for difficult moments moving forward.
What is so valuable about this set of skills is how we connect even further to our sense of self by utilizing them. Through these skills, we move past the feeling of just surviving and into creating something that really matters to us and towards building a life that really truly is ours.
DBT Interpersonal Effectiveness skills -
The skills in this module include
How we manage and address relationships.
How we express ourselves and communicate.
How we set boundaries.
How we deepen relationships that we want to get closer to.
How we open up to new relationships.
How we end relationships that we need to let go of.
How to gauge how to ask for something or say “no” effectively.
How we manage the behaviors of other people.
How we give feedback.
How we set up practical consequences when someone crosses a boundary.
Altogether, these skills work really well for helping people connect to regulating themselves, being present in their lives in the things that matter, and accessing the social support that we know is one of the main predictors of a successful recovery.
How to Find a DBT therapist
Luckily there are a number of ways to work with and find a DBT therapist!
Adherent DBT or Comprehensive DBT is when you and your DBT therapist are doing DBT precisely according to the model and the way that it is designed. It means that a client is engaging in individual DBT - 1:1 sessions with a DBT therapist that typically involve a diary card where you monitor your day-to-day emotions, what skills you're practicing, how you’re working towards your goals, and what behaviors are coming up as well as phone coaching.
Phone coaching is where a client can connect with their therapist via phone call or text, and your therapist can help you practice skills outside of session. Phone coaching is brief. It is a quick space (10mins or fewer) where you check in about a specific issue or skill you're trying to practice, and you can do so in real time.
With Adherent or Comprehensive DBT, the client is also engaging in some sort of official skills training. Typically, this is attending a group therapy session where group skills are learned and facilitated by DBT-trained group leaders. This can also be done in individual sessions if the client is uncomfortable in a group setting. There just has to be a component of the therapy where concrete skills practice is happening.
In addition to this official skills training, therapists are required to be in a group consultation team, addressing any issues that come up with the therapy, making sure they're sticking to effective approaches, being innovative and creative in designing interventions, and addressing their own behaviors.
DBT Target Hierarchy
The DBT approach also adheres to a hierarchy of priorities. The way that we organize the focus of therapy in DBT is through three different levels.
Level 1 = addressing life-threatening behaviors.
Any behavior that puts a client’s life or body at risk: suicidal behaviors, homicidal behaviors, self-harm, etc.
There’s also room here for other behaviors (substance abuse or eating disorder behaviors) that are likely to lead to a life-threatening situation. Not all substance abuse or eating disorder behaviors are life-threatening, so it is something that we evaluate on a case-by-case basis.
The idea behind this level is that if a client’s life is at risk, or if a client takes their own life, therapy is no longer going to work (obviously), so this will always be the number one priority.
Level 2 = addressing therapy-interfering behaviors.
These are things that we do as clients that interfere with therapy being effective.
Examples include showing up late to sessions, not doing the homework, not practicing skills, not completing diary cards and worksheets, not calling for phone coaching when needed, getting into verbal altercations, or getting emotionally overwhelmed during sessions and not being able to continue.
A nice aspect of DBT is that these behaviors are classified only as resistance on the part of the client. When these behaviors arise, DBT moves to a non-judgemental/non-pejorative space where we acknowledge them.
We address them as if they are another target of something that we want to problem-solve. The client is here showing up, they want to improve, so we can help them address the things that interfere with that.
When we are able to address these interfering behaviors, get to the bottom of them, and help move through them, then we can move on to level 3.
Level 3 = understanding the origins of behaviors.
During level 3, we work with our other symptoms (depression, anxiety, trauma, etc.) or diagnoses while using the skills we’ve learned, CBT interventions, and exposure techniques to help repair and remediate these symptoms.
DBT Informed Therapy
Another way that many DBT-trained therapists use this intervention is by incorporating specific components of it without adhering strictly to the model.
This method is called DBT-Informed therapy, meaning the therapist is doing a blend of talk-based therapy and skills training.
DBT-Informed therapy allows for more flexibility if people don’t necessarily want to do the considerable amount of work involved in true DBT.
Regardless of which approach you and your therapist choose, you will typically begin with a pre-treatment stage prior to starting. This is where a therapist assesses your goals and informs you on what DBT looks like and the commitment level required.
Pretreatment is a great time to build skills around willingness and commitment to stay motivated toward your goals.
DBT does require a lot of work! It is a very powerful intervention when implemented, but it is also a significant change. Pretreatment is when someone can decide if they really want to commit to that change.
DBT is a Lifestyle!
Ultimately, Dialectical Behavior Therapy is a lifestyle. It is a way of living and engaging in the world. It is not just an intervention that once it’s done, you never do it again. The idea is that these skills and principles become a part of how you interact with life moving forward.
DBT is focused not only on making things better/less painful but also on the goal of making a life worth living. The end goal is not being able to survive without wanting to die. That does not truly help sustain people.
We were not put on this earth simply to exist and not die.
A purposeful part of the treatment is figuring out what makes life worth living and how to get to that point and continue living in that space.
We are all entitled to a life that we are proud to live, and we all deserve to experience joy.
If you want to learn more about Dialectical Behavior Therapy, stay tuned for the next blog! I will follow up with a post all about how DBT can be used to help people through trauma recovery.
Want to learn more about YOUR specific trauma recovery style? Take the QUIZ and get unique skills specific to you!
You can listen to this episode on my Podcast, “Initiated Survivor.” The episode is titled “DBT” and is available on Apple Podcasts and Spotify!
If you want to start your DBT with me today, sign up to work with me here. I offer DBT informed therapy to best meet the needs of trauma survivors. You can sign up for my mailing list to get tips for trauma recovery right to your mailbox. You can also listen to my podcast, Initiated Survivor, anywhere you hear podcasts. Follow me on Instagram, TikTok, Facebook, and Youtube to get awesome survivor content.
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