Recently I have had many people asking me on Twitter about DBT and it is really hard to describe it in 140 characters. My DBT folder is a good few inches thick and I’m not even half way through the treatment, there is a lot of information and so I decided to write a blog post about what it is and how it has helped me and could potentially help others.
DBT stands for dialectical behaviour therapy. I started DBT last December and my treatment involves attending a skills group every Monday for two and a half hours and then an individual session each week with my psychologist. I remember when I started DBT I just thought that it would be another treatment that would fail or that I would become too unwell and have to leave the treatment which has often been the case with me. I thought it was nonsense and it wouldn’t help me. Recently I have noticed that DBT is actually changing my life. I am still poorly and I still struggle but life is very different to how it used to be and I finally feel hopeful about the future. Everything has clicked into place, DBT has clicked into place and I’ve gone from thinking it was a waste of time to wishing that everybody had the chance to learn the skills that I am learning because they aren’t just life saving, they are life changing.
There are three modules in DBT, these are distress tolerance, emotion regulation and interpersonal effectiveness. There is also a strong focus on mindfulness with it being the foundation for all three modules.
What Is A Skills Group?
A DBT skills group is different to group therapy because behaviours should only be mentioned if it is to say that skills were used. The focus is on the positives, the times where skills were used and the skills there are to learn rather than focusing on the illness and behaviours. Many DBT groups are for those with personality disorders but I am extremely lucky that my Tier 3 eating disorder service offer a DBT group specifically for those with eating disorders.
At the beginning of every session we have skills feedback where each member of the group is given up to 5 minutes to talk about their effective skills use over the course of the previous week. For example coping with a stressful situation such as going out for a meal. We are supposed to have folders but being stubborn and hopeless I didn’t have one up until this weekend when I realised that actually DBT is doing something and the information I am being given is important.
The goals of skills training are to decrease relationship difficulties, intense and unstable emotions, acting on impulse and confusion about self and troubling thoughts whilst increasing interpersonal effectiveness, emotion regulation and distress tolerance as well as using mindfulness.
This is my DBT folder:
Mindfulness is all about being in the present moment. It’s about being aware of what is happening and what you are doing as well as observing what is going on internally and externally.
Mindfulness is not about your mind never wandering, mindfulness is about recoginsing that it is.
Mindfulness includes two sets of core skills. These are the ‘what’ and ‘how’ skills. ‘What’ skills are all about observing, describing and participating. ‘How’ skills are all about doing things effectively, non-judgementally and doing one thing at a time.
You can do almost anything mindfully including driving, eating, brushing your teeth, colouring and cleaning.
States Of Mind
The three states of mind that DBT focuses on are emotional mind, reasonable mind and wise mind.
Emotional mind is probably where most of us spend our time. In emotional mind our thoughts and behaviours are controlled by our emotions and therefore we can get thoughts that are unhelpful and distressing. It can be difficult to think logically and rationally when in emotional mind and facts are often distorted to fit with the current distress. In Harry Potter terms emotional mind would be Ron Weasley.
Reasonable mind is intellectual and scientific as it includes logical and rational thinking. Thoughts are based on facts and evidence and the person is able to plan how to respond. In Harry Potter terms reasonable mind would be Hermione Granger.
Wise mind combines both emotional and reasonable mind, it is the calm which follows the storm. Wise mind grasps the bigger picture rather than just parts. It ensures emotional mind is soothed whilst knowing that reasonable mind is correct. In Harry Potter terms wise mind would be Harry Potter.
The aims of DBT are to recognise emotional and reasonable mind and find wise mind to then appropriately address problems. Finding wise mind is not an easy thing to do and can take a long time to achieve. It is possible though. 100%.
Distress tolerance was the first module I did. It is all about getting through a difficult moment when you cannot make it better but without making it worse. For example if I am feeling upset about a situation in my life then I might restrict my intake in order to cope but that doesn’t get rid of the problem. In fact if we look at the bigger picture it has made the situation worse because not only am I upset about that situation but I now have to deal with the impact anorexia has on my life. Distress tolerance skills are crisis survival skills aiming to reduce suffering, not to get rid of the pain.
Wise mind ACCEPTS was the first skill we were taught. It’s all about distraction which is excellent but should only be used in the short-term. Wise mind ACCEPTS can be helpful to divert your attention from distressing thoughts. Choose things that grab your attention and keep you absorbed.
Activities: Such as baking, writing, journaling, nail painting, making an amazon wishlist, dancing, playing a game, collaging, colouring, reading etc.
Contibuting: For example blogging, tweeting, volunteering, making something for someone, look after a pet, smiling at someone etc
Comparisons: Be careful with this one, don’t make unhelpful comparisons. Perhaps compare yourself to a worse time and look at how far you have come.
Emotions (opposite): Create a different emotion by watching a comedy or fails on YouTube. Look at cute animals or baby photos. Find positive quotes.
Pushing away: Leave the situation behind for a while. Put it in a box and decide not to think about it.
Thoughts (changing): Change your thoughts by playing word games, doing a puzzle book, counting in 3s backwards, speaking another language or learning song lyrics.
Sensations: Focus on the five senses (taste, smell, touch, sound and sight) by using a stress ball, having a bath, using hand cream, listening to loud music etc.
Distress tolerance has a huge focus on pros and cons. What are the pros and cons of tolerating the distress? What are the pros and cons of not tolerating the distress? So basically what is good and what is bad about using skills compared to using behaviours?
Other distress tolerance skills include radical acceptance which is accepting what is happening at the time without making it worse or doing anything. There is also turning the mind which is all about turning your mind towards acceptance and willingness rather than willfulness.
I think for me the key parts I got from distress tolerance were self-soothing and distraction when distressed rather than getting angry or upset with people or harming myself.
Emotion regulation helped me to understand and name my emotions. Emotion regulation also decreases unwanted emotions and emotional vulnerability. These skills are important because they quieten the body, quieten behaviour, help to find wise mind and improve self-respect.
Emotion regulation takes a healthy perspective on emotions. We need to accept that we are emotional beings and that emotions are neither good or bad. It isn’t helpful to judge your emotions. Whilst it is okay to have an emotion, there is a difference between having an emotion and acting on an emotion. For example, it is okay to feel angry with your partner for lying to you but it is not okay to punch your partner in the face repeatedly because of it. Emotions are pretty good at convincing us they are permanent but they are not. Emotions come and go and get replaced by another emotion regularly. Emotions may feel like the truth but feelings are not facts.
Emotion regulation taught us to describe emotions. It gave us words that related to the emotion for example other words for anger are fury, rage, wrath and frustration. It also gave us prompting events for the emotion, for example seeing blood may make you feel disgust. It also focused on the biological changes relating to the emotion as well as expressions and actions and the after affect of the emotion.
Emotion regulation focuses on changing the emotion. Firstly it is important to check the facts. To notice and observe the emotion you are feeling and want to change, what event prompted the emotion, what your interpretations, thoughts and assumptions are. You should also ask yourself whether you are assuming a threat and/or a catastrophe and then think about whether your emotion fits the facts. If it doesn’t or if acting on the emotion is not effective then opposite action can be helpful.
Opposite action is acting opposite to your action urge. For example, the other day I had my sunglasses on because I wanted to hide from the world but realised this was coming from a place of emotional mind so then I took the sunglasses off. If the urge is to avoid then don’t avoid. If the urge is to attack then avoid or be nice.
Certain things in life can make us more vulnerable to emotional mind but there are ways to reduce vulnerability. The acronym ABC PLEASE can be used to remember these skills.
Accumalate positive emotions: In the short-term do pleasant activities that are possible in the moment. In the long-term make changes to your life so that positive events will happen in the future. Build a life worth living.
Build mastery: Do things that make you feel competent and effective to combat any helplessness or hopelessness you may be feeling.
Cope ahead of time with emotional situations: Rehearse a plan and prepare to cope skillfully with emotional situations.
PLEASE: Treat PhysicaL illness. Balance Eating. Avoid mood-Altering substances. Balance Sleep. Get Exercise.
I am only beginning the interpersonal effectiveness module now so I don’t have a huge amount of information on it. The aims of interpersonal effectiveness are to be skillful in getting what you want and need from others, for example getting others to take your opinions seriously or being able to say no to unwanted requests. Interpersonal effectiveness also aims to build relationships that are healthy, strengthen current relationships whilst also ending any destructive ones.
The three parts of interpersonal effectiveness are objective effectiveness which is about being effective in asserting your rights and wishes, relationship effectiveness which is about acting in a way that you maintain positive relationships and finally self-respect effectiveness which is about acting in a way that keeps your self-respect.
Myths can get in the way of interpersonal effectiveness, for example feeling like I don’t deserve to get what I want or need might make me not bother asking but interpersonal effectiveness gives challenges to these such as, ‘we are all equal and we all have the right to ask for what we want and need’. It is okay to ask for what you want and need and it is also okay for that person to say no but the person saying no doesn’t mean that you shouldn’t have asked in the first place.
Everyday I have to fill in several diary sheets. I started off just filling in the standard DBT diary sheet which gets you to rate emotions, urges and behaviours from 0-5. However this has now been tailored to me so as well as filling in that sheet I fill in a mood and food diary and write down how much time I spend on myself in that day and what I have been avoiding that day. It is a lot to do every day and I spend the majority of my time thinking about it or recording things but that is a good thing because DBT is not one of those therapies where you only have to do it in the session, it can be applied to everything and should be used every day.
I understand that DBT may not work for everyone, the same as any other therapy or medication but I can honestly say with my hand on my heart that after a very lengthy battle with no signs of recovery or improvement I am on the road to recovery. DBT is changing my life.