Dialectical Behavioral Therapy


Last winter, I was in the psych ward for the 4th time in two months, attending the same stupid groups they made me go to every other time, feeling very negative and bored. And then I heard one sentence that made sense, "suicide is not chosen, it happens when pain exceeds resources for coping with pain." It didn't say suicide is selfish or suicide is a permanent solution to a temporary problem. It said something entirely new and concrete, like a math formula. Suicide happens when you have more stress than skills. I thought about this sentence a lot. I thought about all the other things that happen when my pain exceeds my ability to cope: self-injury, dangerous rage, destroyed relationships, and disordered eating.

I have tried things on the first half of the equation. Medication helps the mood swings, and my therapist gives me an open ear and some insightful comments; but after 9 years of "treatment", I am still in a cycle I don't know how to get out of. I discussed this with my caseworker and she suggested I work on the second half of the equation by taking DBT, a coping skills class.

Dialectical Behavior Therapy (DBT) was first designed for borderline personality disorder and has recently been used with bipolar, depression and substance addiction. DBT classes are based on the Skills Training Manual for Borderline Disorder by Marsha Linehan. The manual contains 4 learning modules (Mindfulness, Interpersonal Skills, Emotion Regulation, Distress Tolerance) with about a dozen specific techniques in each. At each meeting, the therapist teaches one skill and the group does some written and verbal exercises to understand it better. Members share their progress by giving examples of skills they have used in recent conflicts. There is no discussion of patient history-- this is not like group therapy. Each group member keeps a diary card tracking food, exercise, medication, moods, conflicts, and skills practiced. The goal is to practice DBT in every day life, when you are feeling good. Then, when you are in crisis, the skills come more naturally to you.


Mindfulness is becoming aware of what is Real Right Now. Not thinking about the past or the future, just of the exact moment you are in. Mindfulness is relaxation, grounding, and accepting your thoughts and emotions without judgment. Mindfulness is also getting in touch with your "Wise Mind." The Wise Mind is intuitive and can make choices based on truth and what is needed (not emotional whim). Mindfulness exercises are great when my thoughts are racing and I can't focus or fall asleep. I also use them when I catch myself in an obsession with a negative thought/urge that won't go away. (See Tool Kit section for two Mindfulness exercises.)

Interpersonal/Relationship Skills

The techniques give step-by-step instructions for assertive communication, setting boundaries, asking for what you want, dealing with conflicts, using "I" statements to take responsibility for your feelings, mirroring and active listening. I've always had intense, drama filled, relationships and it's really exciting to find that such small changes in my vocabulary can make such a big difference in my life.

Emotion Regulation

Emotion Regulation teaches that your emotions are valid and important but they are not FACTS and you do not have to ACT on them. You still have choices. And one of those choices is to CHANGE your emotional state. This module offers about a dozen skills to modify what you are feeling. Today I am using "Act Opposite." I've been feeling low, which usually means I stay in bed feeling miserable. Acting Opposite means I pretend I don't feel like crap, and DO something Anyway. So I got dressed and came down to the coffee shop to write this article. It's very hard to get motivated, but once I'm out of the house, I really do start to feel better.

Distress Tolerance

If Emotion Regulation isn't working, Distress Tolerance skills are the crisis back-up plan. Distress Tolerance includes finding ways to distract oneself, learning to self-soothe, and practicing radical acceptance. To do this, you make a Crisis Survival Plan with emergency phone numbers, contracts for safety, a list of things you will do before hurting yourself, and a Safety Kit. (Building a Safety Kit information in the Tool Kit section.)

My first DBT course was 5 days a week for several weeks. My experience was great, I was using skills every day, I thought I really "got it." Than class ended, my notebook got put away and I started slipping back into old patterns. After a couple frustrated months, I joined a once-weekly group. I like having people to talk to about the process, and I like to be reminded that this IS a process. You don't just learn DBT once-- these skills need to be practiced and incorporated into your life.

For More Information:

Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan. Guilford Press- ISBN 0898620341

http://www.dbtselfhelp.com/ has free, downloadable versions of the worksheets from Linehan's book.

To find a DBT class in your area, check out the Behavioral Tech Clinical Resource Directory- http://behavioraltech.org/crd/index.cfm