#219 ‒ Dialectical behavior therapy (DBT): skills for overcoming depression , emotional dysregulation, and more | Shireen Rizvi, Ph.D., ABPP
Shireen Rizvi, Professor of Clinical Psychology and Psychiatry at Rutgers, discusses Dialectical Behavior Therapy (DBT). She explains its origins from CBT, its focus on balancing change and acceptance, and practical skills like "wise mind," "radical acceptance," and "opposite action" for emotional regulation and interpersonal effectiveness.
Deep Dive Analysis
20 Topic Outline
Defining Dialectical Behavior Therapy (DBT)
Understanding Cognitive Behavioral Therapy (CBT) Basics
Marsha Linehan's Journey and DBT's Origins
Borderline Personality Disorder (BPD) Explained
Marsha Linehan's Personal Epiphany and Life's Work
The Dialectic Between Change and Acceptance in Therapy
Understanding Dialectics and the Wise Mind Concept
Radical Acceptance: Applying it to Life's Challenges
Five Domains of DBT Skills Training
Marsha Linehan's Choice of BPD for Research
Benefits of DBT for Non-Pathological Individuals
The DEAR MAN Skill for Interpersonal Effectiveness
DBT Adaptations for Adolescents and Families
Identifying and Addressing Vulnerability Factors
Chain Analysis: Assessing Problem Behaviors
Challenges in Emotion Regulation and Emotional Myths
The Importance of Mindfulness in DBT
Opposite Action: An Emotion Regulation Skill
Exploring DBT: Self-Study vs. Professional Help
Finding a Well-Trained DBT Therapist
10 Key Concepts
Dialectical Behavior Therapy (DBT)
DBT is a form of talk therapy inspired by cognitive behavioral therapy (CBT), designed for individuals with complex mental health problems, originally for those who are suicidal, self-harming, or meet criteria for borderline personality disorder. It focuses on balancing change and acceptance to help people regulate emotions and improve behaviors.
Cognitive Behavioral Therapy (CBT)
CBT is a class of talk therapy that is present-focused, concentrating on current thoughts and behaviors contributing to problems. It is a structured, active problem-solving approach that aims to modify or change thoughts and behaviors to improve mental health outcomes.
Borderline Personality Disorder (BPD)
BPD is a complex mental health disorder characterized by dysregulation across multiple domains, primarily emotion dysregulation. This includes intense, rapidly changing emotions, often leading to behavioral dysregulation like impulsivity, self-injury, and chaotic relationships due to fears of abandonment.
Dialectics
In DBT, dialectics is the understanding that contradiction, opposition, and tension exist in everything. It involves recognizing these tensions, finding validity in opposing sides, and striving to synthesize them into a new argument or statement that incorporates both truths.
Emotion Mind
Emotion mind is a state where an individual is completely controlled by their emotions, leading to impulsive or reactive behaviors. Actions are driven solely by intense feelings, often without consideration for logic or long-term consequences.
Reasonable Mind
Reasonable mind is a state where an an individual is controlled by facts and logic, often without awareness or strong experience of emotion. Decisions are made based on objective analysis and practical considerations, potentially overlooking emotional impact.
Wise Mind
Wise mind is the synthesis of emotion mind and reasonable mind, representing a balanced state where both emotional experience and logical thought are integrated. It's a skill people strive to access more often, allowing for decisions that are both emotionally intelligent and rationally sound.
Radical Acceptance
Radical acceptance is the practice of completely and totally accepting a moment, situation, or oneself exactly as it is, without judgment or resistance. It involves actively and willingly choosing to acknowledge reality, even when it is painful, to reduce suffering caused by fighting against what cannot be changed.
Vulnerability Factors
Vulnerability factors are internal or external conditions that make an individual more susceptible to negative emotions, stress, or distress. These can include physical pain, lack of sleep, overwhelming demands, or other circumstances that reduce one's capacity for emotional regulation and distress tolerance.
Opposite Action
Opposite action is an emotion regulation skill used to change an unwanted emotion by engaging in behaviors that are the opposite of the urges associated with that emotion. For example, if feeling sad and having an urge to withdraw, the opposite action would be to activate and engage.
8 Questions Answered
DBT is a form of talk therapy, inspired by CBT, specifically designed for individuals with complex mental health problems, such as those with suicidal or self-harming behaviors, or borderline personality disorder. It focuses on a skills-based approach to emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness.
CBT is a present-focused, structured approach that works on modifying thoughts and behaviors to solve current problems. DBT builds upon CBT by adding a crucial element of acceptance, addressing the dialectic between change and acceptance, and providing specific skills for more complex emotional and behavioral dysregulation.
BPD is defined by dysregulation across several domains, primarily emotion dysregulation, leading to intense and rapidly changing emotions. This often results in behavioral dysregulation (impulsivity, self-injury), unstable relationships due to fears of abandonment, and a lack of a stable sense of self.
Wise Mind is a state of integrated awareness that combines both emotional experience (emotion mind) and logical thought (reasonable mind). It represents a balanced approach to decision-making and problem-solving, allowing individuals to act effectively by acknowledging both their feelings and factual reality.
Practicing radical acceptance involves actively and willingly turning one's mind towards accepting the current moment and situation exactly as it is, without trying to change what cannot be changed. This helps reduce suffering that arises from fighting against reality, even if the situation itself is painful.
Yes, anyone can benefit from learning DBT skills, as they address common human challenges in emotional regulation, interpersonal effectiveness, mindfulness, and distress tolerance. The skills, originally developed for severe pathology, have broad applicability for improving daily life and relationships.
Emotion regulation can be challenging due to biological differences, a lack of learned skills, reinforcement of emotional behaviors in certain contexts, current mood, emotional overload from external pressures, and emotional myths or mistaken beliefs about emotions.
One can start by looking for therapists certified by the Linehan Board of Certification (LBC), as they meet rigorous standards. Additionally, a good indicator of adherence to DBT principles is asking if the therapist is part of a weekly DBT consultation team, which supports their ongoing skill development and model fidelity.
41 Actionable Insights
1. Embrace Change and Acceptance Dialectic
Recognize that both solving life’s problems and accepting what cannot be changed are crucial for reducing distress and misery. Strive to synthesize these two seemingly opposing forces.
2. Cultivate Wise Mind for Decisions
Avoid being solely controlled by emotions (emotion mind) or facts/logic (reasonable mind). Instead, strive to synthesize both, finding what is valid in each, to make decisions that are effective and aligned with your values.
3. Employ Opposite Action for Emotions
When an emotion is intense or doesn’t fit the situation, act contrary to the urges associated with that emotion (e.g., activate when sad, approach when fearful, disclose when ashamed). This sends feedback to your brain to change how you feel.
4. Practice Radical Acceptance of Moment
Fully accept yourself, situations, and the present moment exactly as they are, without judgment or resistance. This practice can reduce suffering and potentially allow you to experience joy.
5. Actively ‘Turn the Mind’ Towards Acceptance
Radical acceptance is an active, continuous process of choosing to move towards acceptance, often multiple times a minute. When faced with a choice between acceptance and refusal, willingly choose the path of acceptance.
6. Reduce Suffering by Focusing Present
Recognize that much suffering comes from ruminating on the past or worrying about the future. Actively let go of these thoughts and experience the current moment to significantly reduce distress.
7. Acceptance Doesn’t Eliminate Pain
Understand that life inherently involves pain (emotional and physical), and acceptance is not about eradicating it. Instead, it’s about not adding to suffering by trying to escape or deny that pain.
8. Consider Cost of Non-Acceptance
When struggling with radical acceptance, ask yourself, ‘What’s the alternative?’ Recognize that refusing to accept reality often consumes more mental resources and leads to greater long-term suffering.
9. Separate Acceptance from Problem-Solving
In a moment of crisis or high distress, focus on accepting the current reality rather than trying to problem-solve for the future. Effective problem-solving is difficult when emotions are overwhelming.
10. Practice Dialectical Thinking
Acknowledge contradictions and tensions, find validity in opposing viewpoints, and seek a synthesis that integrates both perspectives. This approach helps avoid conflict and fosters a more nuanced understanding.
11. Synthesis Is Not Compromise
When seeking a ‘wise mind’ solution, aim for a new perspective that validates and integrates both opposing sides. This is more profound than simply meeting in the middle.
12. Identify Personal Vulnerability Factors
Recognize what makes you susceptible to negative emotions, stress, or distress (e.g., lack of sleep, excessive commitments). Proactively manage these factors to improve emotional regulation and overall well-being.
13. Conduct Chain Analysis for Behaviors
To change undesirable behaviors, systematically analyze the chain of events, thoughts, and actions that lead up to the behavior, as well as its consequences. This helps identify precise points for intervention.
14. Develop Skills in Five Domains
Focus on improving mindfulness (present moment awareness), interpersonal effectiveness (asking/saying no), emotion regulation (managing emotions), distress tolerance (handling stress without worsening it), and self-management (doing what you need to do).
15. Use DEAR MAN for Communication
Employ the DEAR MAN (Describe, Express, Assert, Reinforce; Mindful, Appear confident, Negotiate) framework to effectively ask for what you want or say no. This increases the likelihood of a positive outcome in interpersonal interactions.
16. Directly Assert Needs or Desires
Overcome the challenge of indirect communication by clearly and directly stating what you want or need. Avoid expecting others to infer your wishes.
17. Reinforce Desired Outcomes for Others
When making a request, explicitly state the benefits or rewards for the other person if they comply. This reinforcement can be tangible or simply your appreciation.
18. Describe Situations Concisely, Without Judgment
When using DEAR MAN, state the facts of the situation briefly and objectively. Avoid interpretations or judgments to maintain the other person’s engagement and clarity.
19. Clearly Express Your Feelings
In interpersonal interactions, explicitly state your emotions related to the situation. Do so without adding judgments or accusations to foster clearer communication.
20. Counter Emotional Urges with Opposite Actions
If sad, activate instead of withdrawing. If fearful, approach instead of running. If ashamed, disclose or confront instead of hiding. These specific opposite actions help shift your emotional state.
21. Combat Isolation by Engaging Family
When feeling the desire to withdraw, actively force yourself to engage with loved ones. This opposite action can lead to improved mood and connection, counteracting the urge to isolate.
22. Commit Fully to Opposite Action
When performing an opposite action, engage not just physically but also mentally. Fully immerse yourself in the activity to effectively change your emotional state.
23. Practice Mindfulness to Separate Thoughts
Engage in mindfulness to identify thoughts and create a distance between yourself and those thoughts. This practice prevents thoughts from overwhelming you.
24. Cultivate Personal Mindfulness Practice
Engage in any form of mindfulness (e.g., yoga, mindful walking, formal meditation) to strengthen your ‘mindfulness muscle’. This enhances present moment awareness and emotional regulation.
25. Practice Self-Validation for Pain
Instead of questioning or rejecting your pain (‘Why am I feeling this way?’), validate your experience by acknowledging, ‘Of course, I feel this way; it’s okay to feel this way.’ This reduces secondary suffering.
26. Use ‘It’s Okay to Feel This’
When experiencing any emotion or pain, simply tell yourself, ‘It’s okay to feel this.’ This simple phrase can be a powerful experience for self-validation and reducing resistance to your current experience.
27. Manage Physical Pain as Vulnerability
Acknowledge that physical pain can increase irritability and reduce patience. During such times, reduce demands on yourself, practice self-kindness, and explicitly communicate your needs to others.
28. Communicate Internal Pain to Others
Since physical pain is often internal, practice interpersonal effectiveness by explicitly verbalizing your suffering to others. This allows you to set boundaries or request space to manage your emotional state.
29. Improve Self-Management for Effectiveness
Develop the ability to consistently perform necessary tasks, even when undesirable. This includes maintaining routines like waking up early, exercising, and eating healthy.
30. Challenge Emotional Myths
Identify and question mistaken beliefs about emotions that hinder your ability to regulate them. These myths can perpetuate dysregulation and prevent effective coping.
31. Be Aware of Behavioral Reinforcement
Recognize how certain emotional behaviors (e.g., anger, crying) might be subtly reinforced by others’ responses. This awareness helps you understand why these behaviors might increase in specific contexts.
32. Practice Identifying Full Range Emotions
Move beyond basic emotions like anger to recognize and label more nuanced feelings such as helplessness, sadness, hurt, and fear. This is a crucial step in effective emotion regulation.
33. Apply CBT Principles to Problems
Focus on present thoughts and behaviors contributing to issues, then work to modify or change them. For example, with insomnia, identify and modify thoughts/behaviors hindering sleep.
34. Overcome Fears via Exposure, Thoughts
Instead of avoiding feared situations, repeatedly expose yourself to them to learn you can handle it and that the feared outcome won’t occur. Simultaneously practice alternative, competing thoughts.
35. Combat Depression: Change Thoughts, Activity
Work to make negative thoughts more balanced and evidence-based. Counter the tendency to retreat by getting active and systematically solving problems contributing to depression.
36. Model Regulated Behavior for Children
Demonstrate calm and skillful responses to challenges, rather than resorting to authoritarian or dysregulated reactions. This teaches children healthier coping mechanisms through example.
37. Parents Learn DBT Skills with Children
If children are learning DBT, parents and caregivers should also participate in skills training. These skills are beneficial for everyone and can significantly improve family dynamics.
38. Explore DBT Skills Independently First
Start by exposing yourself to DBT skills through videos or workbooks to see if they resonate and if you can apply them on your own. If you struggle, then seek professional help.
39. Consider DBT Skills for Well-being
Even without a formal diagnosis, many individuals can benefit from learning and applying DBT skills. These skills can improve various aspects of their lives and emotional health.
40. Verify DBT Therapist’s Consultation Team
A key indicator of a well-trained DBT therapist is their participation in a weekly consultation team meeting with other DBT therapists. This helps ensure adherence to the model and ongoing professional development.
41. Consider Certified DBT Therapists
When seeking a DBT therapist, look for those certified by the Linehan Board of Certification (LBC) as a strong indicator of adherence to standards. However, note that uncertified therapists can also be effective.
7 Key Quotes
DBT is a form of cognitive behavioral therapy that was designed for more complex people or presentations.
Shireen Rizvi
Change your thoughts and get exposure.
Shireen Rizvi
I want to work my entire life to get other people out of hell.
Marsha Linehan
Humans don't like contradiction.
Shireen Rizvi
What's the alternative? The alternative is refusing to accept. How does that work? How do you do that? And how long can you sustain that for?
Shireen Rizvi
It's okay to feel this.
Shireen Rizvi
When I do act out of anger, I almost always regret it and almost always feel worse about myself afterwards.
Shireen Rizvi
2 Protocols
DEAR MAN Skill for Interpersonal Effectiveness
Shireen Rizvi- Describe the situation without interpretation or judgment.
- Express your feelings about the situation.
- Assert directly what you want or need.
- Reinforce by explaining what's in it for the other person or the positive outcomes of your request.
- Stay Mindful of your objective, avoiding distractions or changing the subject.
- Appear Confident in your request or refusal.
- Negotiate or be willing to negotiate, finding a solution that works for both parties without compromising your core objective.
DBT Chain Analysis for Problem Behaviors
Shireen Rizvi- Identify a recent occasion where the problem behavior occurred.
- Assess all the factors, events, thoughts, and behaviors that led up to that behavior (the chain).
- Identify the vulnerability factors that made the person susceptible.
- Assess the consequences of that behavior.
- Determine what elements in the chain can be modified to prevent the problem behavior from recurring.