Tag Archives: DBT


REBT: The Elegant Solution

Cognitive Behavior Therapy: REBT, The Elegant Solution

Cognitive Behavioral Therapy (CBT) is a term bandied around a lot in news stories or any conversation about therapy. There is a lot of scientific support for its efficacy in treating issues such as Obsessive Compulsive Disorder (OCD), Post-traumatic Stress Disorder (PTSD), unipolar depression, anger, and bulimia. But there is still not perfect consensus among researchers, theorists, and clinicians about what exactly CBT is and what it isn’t. While some disagreements are about whether or not cognitive changes or learning principles (behavioral) are responsible for someone with depression feeling less depressed, some of the confusion is simply due to the variety of cognitive behavioral treatments.
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Dialectical Behavior Therapy – DBT

What is Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) is an integration of Cognitive Behavior Therapy (CBT), a Western science based psychotherapy, and a Zen Buddhist approach to mindfulness, an Eastern philosophical and mediation practice.  Together these approaches help DBT clients achieve their behavioral goals by learning how to accept and change both feelings and thoughts, and by learning how to control their attention to these internal experiences.

DBT Development

Dialectical Behavior Therapy (DBT) was developed by Dr. Marsha Linehan. She had been using traditional Cognitive Behavior Therapy (CBT) and Behavior Therapy (BT) with chronically depressed women with high levels of suicidal ideation, suicide attempts, and self-injurious behaviors, e.g., cutting.  Unfortunately, while these psychological treatments had been shown to be very effective for many depressed patients, these women were not responsive, and some in fact, became worse during the CBT treatment.

In an attempt to understand how CBT therapy was making these clients worse, she and her colleagues began conducting behavioral analyses of the sessions.  What they discovered was that these patients and therapists were reinforcing and punishing behaviors in the exact opposite direction of the therapeutic goals.  When these patients directed high levels of anger toward the therapist in response to an intervention, the therapists would frequently avoid that intervention and shift to something else.  Rather than helping the client learn to tolerate, understand, assertively communicate, or decrease her anger response, she learned that expressing anger aggressively would allow her to escape from an uncomfortable exchange with the therapist.  Likewise the therapist learned to avoid that topic.  Of course neither may have been aware in session of what was being reinforced, but nonetheless the pattern was being strengthened, leading to more anger and avoidance, and less growth.

Cognitive Behavior Therapy (CBT)

Cognitive Behavior Therapy (CBT) at the time was also ill suited for this population for a few other reasons.  Most CBT therapies, e.g., Cognitive Therapy of Aaron Beck, Rational Emotive Behavior Therapy (REBT) of Albert Ellis, posit that one of the most significant causes of our emotions is our beliefs or interpretations about a situation, ourselves, other people, or the world.  For example, it is not only that someone stepped on my foot as I waited in line at the DMV that leads to my anger, but also that I thought to myself and believed strongly that, “He must be a selfish guy to not look where he is going and should know better given that he is an adult.”   Together the trigger (having my foot stepped on) and my belief about the action and the guy who did it lead to my incredibly strong feeling of anger.  Standard Cognitive Behavior Therapy (CBT) suggests the best way to change that anger is to take responsibility for identifying one’s beliefs and then challenging the accuracy and logic of those interpretations and rehearsing something more rational.  While this technique had been shown to work for many depressed and anxious patients previously, these chronically depressed, suicidal, self-injuring women often experienced this as invalidation.  In fact, challenging their beliefs, may have made them “feel” as though their feelings about the situation were being challenged and therefore that the CBT Therapist didn’t believe the patients’ anger experience was valid.  This often led to an increase in anger or other negative emotions, like shame or guilt for feeling angry, when they shouldn’t have because it wasn’t a valid emotional response.  While the CBT Therapist was attempting to decrease the negative emotional experience, instead through invalidation the CBT technique of disputation of irrational beliefs were making these patients symptoms worse.

Standard CBT sessions are typically held once per week for approximately 45 minutes, and include setting an agenda at the beginning of the session.  Dr. Linehan, and others who have since treated patients like this, discovered that both the high number of crises presented in session and the intensity with which they were often present make it anywhere from challenging to impossible to follow and complete the therapy agenda.  These patients simply appear to present in ways and to be experiencing crises in a way that make one individual 45 minute session suboptimal as an effective treatment.

Borderline Personality Disorder (BPD)

Although Dr. Linehan was unaware at the time, the symptoms presented by these women seem to fit quite well under the diagnosis of Borderline Personality Disorder (BPD).  BPD involves at least five of nine possible symptoms.  This, of course, means that many different presentations are possible as some clients will present with very different symptoms.

BPD Symptoms include:

  • extreme fears and other feelings about abandonment
  • intense and often volatile interpersonal relationships with lovers, parents, siblings, friends, and co-workers
  • unstable and poor self-concept, impulsive and risky behaviors that could include unsafe sex, overspending, overeating
  • frequent suicidal ideation and/or urges to self-injure
  • intense and often rapidly shifting emotional states
  • chronic feelings of emptiness
  • anger management problems, often involving intense emotional experiences and self-defeating ways of expressing the anger
  • dissociative symptoms

When she began this work, no effective treatment for Borderline Personality Disorder (BPD) existed.  Therefore, her work to first conduct a thorough assessment of why standard Cognitive Behavior Therapy (CBT) was making these women suffering from BPD worse, was the beginning of the development of Dialectical Behavior Therapy (DBT).

Dialectical Behavior Therapy (DBT)

Dr. Linehan had some experience with Christian contemplative prayer and also Zen Buddhism.  And she had already been well trained as a behaviorist, i.e., the scientific and clinical approach to psychotherapy based on learning principles such as classical and operant conditioning.  The challenges to treating women with BPD were numerous and complex.  They were experiencing high levels of emotional suffering, had few healthy and stable interpersonal relationships, had difficulty inhibiting impulsive urges that were self-defeating, and were not benefitting from standard CBT Therapy.

Therefore Linehan’s new approach had to provide tools for CBT Therapists that did not invalidate the emotional suffering of clients, provided enough time and a format that could facilitate addressing a multitude of crises, provide BPD patients with tools to better communicate in interpersonal conflicts and to initiate, nurture, and maintain relationships.  And that was just for the BPD patients.  What she and her colleagues also learned during this time is that the CBT Therapists who were treating this group were also experiencing high levels of stress.  Therapy sessions with BPD patients are incredibly intense, often involve high levels of anger, high potential for suicide, and so many presenting problems- there is never a sense of completion.  These therapists were at risk for burnout.

A new CBT Therapy for BPD would need to include high levels of validation to BPD patients, a way to provide patients with a lot of tools while not triggering emotional upset, and more support for both BPD patients and the CBT Therapists providing treatment.  Dialectical Behavior Therapy (DBT) has developed to address these issues.

Dialectical Behavior Therapy (DBT) Comprehensive Program

Dialectical Behavior Therapy as a comprehensive treatment involves four components.  There is weekly individual therapy, weekly DBT Skills Group, coaching calls between the BPD client and individual CBT Therapist, and weekly Consultation Group for DBT Therapists.  Together these components allow greater support for everyone involved in the therapeutic process and a number of scientific studies have demonstrated that comprehensive DBT results in fewer days of hospitalization, self-injuries, and suicides.  It also requires a 12-month commitment from the BPD patient.  Shorter treatment is believed to be less effective.

A DBT patient therefore would see her individual therapist to learn how to better handle the current problems in her life.  And also, once enough fluency with her new DBT Skills are present, more significant symptoms, like those of Post-traumatic Stress Disorder (PTSD) may be treated with exposure therapy in individual therapy sessions.  Problems that came up during the week are often understood by conducting a chain analysis, which is a DBT term for doing a behavioral analysis of the event. The DBT client with her therapist identifies all of the links in the chain of the episode from beginning to end.  This helps both of them understand what likely predicts future episodes and how to best intervene.  For example, after conducting a number of chain analyses on anger episodes with her co-workers, it may become clear that a common pattern is a link in the chain that involves going to bed late and not getting enough sleep.  Problem solving skills are then implemented to efficiently test new ways of handling the situation moving forward while practicing self-compassion.

DBT Skills Group are conducted weekly.  These are typically led by a therapist other than the individual DBT therapist.  While this is part of the comprehensive DBT program, it is largely seen as psychoeducational.  Four modules of skills are taught to clients in a warm, supportive, and efficient manner.  DBT Group Leaders provide structure so that the content can be discussed without unnecessarily triggering and emotionally dysregulating group members.  For instance, DBT Group members are prohibited from discussing self-injury in ways that would trigger another member.  The DBT Group is begun with a mindfulness exercise, which is one of the four content modules that is taught during the 12-month program.  Similarly to CBT individual therapy homework is checked at the beginning of sessions and assigned at the end of sessions.  The four modules that are taught during DBT Group are Core Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation.

DBT Coaching Calls are another component that typically sets it apart from other Cognitive Behavioral Therapies (CBT).  Many CBT Therapists are concerned that coaching calls between sessions can lead to dependency and prevent CBT clients from developing self-efficacy skills by practicing their newly developed skills in between sessions.  However DBT believes that properly conducted DBT Coaching Calls facilitate the generalization of skills learned in session into the real world for BPD patients who may otherwise fall back on older more reliable ways of managing interpersonal conflicts and emotional suffering, strategies like self-injury or substance use.
Targets for coaching calls can include:

  • Decreasing suicidal and self-injury behaviors
  • Increasing the generalization of DBT skills into the real world setting
  • Decreasing conflict or “feelings” of distance from the individual therapist

DBT Coaching Calls need to be conducted properly though, or like standard CBT Therapy they can in fact exacerbate the symptoms of a BPD client and lead to burnout for the individual therapist.

DBT Consultation Teams meet weekly as well.  During these meetings DBT Therapists who provide both individual DBT Therapy sessions and DBT Skills Group meet to improve their own DBT Skills as therapists and group leaders. DBT Team Members share information about DBT patients and do so in a non-judgmental manner.  They work to utilize dialectical philosophy, e.g., acknowledging that there is no absolute truth.  And as such, accepting that and moving forward through synthesis can best support all of the members of the team.  This support allows the DBT Therapists to prevent themselves from burnout, hone their skills, receive technical guidance from other team members who may have a different perspective on a problem that has yet to be successfully addressed by a particular DBT Therapist.

BPD clients clearly face very serious challenges given the number of ways they suffer.  It is also clear though that comprehensive DBT, is just that comprehensive.  It provides very specific content, format, and clear parameters for how each is to be conducted.  It also provides DBT Therapists with the training and support necessary to effectively treat these courageous people diagnosed with BPD who through this process can dramatically reduce their suffering and create lives worth living.

Ben-Porath, D.D., Koons, C.R. Telephone coaching in dialectical behavior therapy: A decision-tree model for managing inter-session contact with clients. Cognitive and Behavioral Practice, Volume 12, Issue 4, Autumn 2005, Pages 448–460.

Employment and mental health

Which is worse- A Bad Job or No Job? – by Staff

Common wisdom says that being employed is much better for one’s mental health than being unemployed. Right? It makes sense that the former might lead to loss of self-esteem and self confidence and, in consequence, depression. However, according to the results of a national survey conducted regularly in Australia, it really depends a lot on the job.

Employment that is unfavorable in terms of important conditions and aspects may not improve one’s mental health at all; in fact, it might just be harmful to psychological and emotional health. In other words, if your new job provides little monetary compensation and few benefits, offers little control over what you have to do, and/or is very demanding, you may see a decline in your wellbeing. And if you stay in the poor quality job a long time, your mental health is more likely to continue deteriorating.

These findings seem to create a serious dilemma. Obviously, there are advantages of having a job, regardless of how bad it is, over not having one. Besides getting some measure of wages to at least help pay the bills, a job usually affords one the social benefits of companionship or friendships, as well as psychological benefits, such as structure, maintaining a work ethic, and feelings of accomplishment. What other benefits does a job potentially offer?

Nevertheless, if a poor job is worse than no job, as the research indicates, what does it mean we should do? Turn down a lousy job to avoid worsening our mental health? Or take the job, even though we know the working conditions may make us “sick?”

I can’t imagine with unemployment where it is, any of us plan to turn down the Plan B job offer if we get the call.

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Dialectical Behavior Therapy DBT technique- a Non-addictive Benzodiazepine

Drugs, Rock ‘n’ Roll, & an 80’s Video

I want a new drug
one that won’t spill
one that don’t cost too much
or come in a pill…

one that won’t make me sick
one that won’t make me crash my car
or make me feel three feet thick…
-Huey Lewis & The News . “I want a new drug.”

Dialectical Behavior Therapy (DBT) technique

Don’t we all Huey.

Anxiety and anger problems are both very common in therapy offices (Lachmund, 2005). Insomnia plagues us in this age of longer work hours, Red Bull, Blackberries, and decreased physical activity. But many pharmaceutical interventions for anger, anxiety, and insomnia come with devastating side effects.

For example, Benzodiazepines (Xanax, Klonopin, Valium, etc.) are incredibly effective in the short-term for reducing physiological arousal. But the risk of addiction, paradoxical excitation, and depression, is cause for serious concern by consumers and prescribers alike.

So, the next time you or a client can’t calm down or go to sleep, could you try something that isn’t in the medicine cabinet?

What about shoving your face in a sink full of ice-cold water? Sound as soporific as warm milk? Maybe not, but sleep specialists know that cooler temperatures are typically a good idea in the bedroom. One reason vigorous exercise isn’t recommended hours prior to bedtime is due to the increase in body temperature. But, there may be more to a cold water face plunge than Huey Luis or most of us thought.

French Ducks & Ectoplasm

In 1879, a French physiologist, Paul Bert reported that he had observed a duck survive under water for approximately 20 minutes. Charles Richet, the man who later coined the term “ectoplasm”


and went on to win a Nobel Prize, was then one of his students. After hearing his mentor’s description, he went on to design an experiment to further clarify what had been observed, and established that ducks could hold their breaths longer underwater than above. He proposed that bradycardia was at least one mechanism responsible.

This was some of the earliest scientific work conducted on the diving reflex. The diving reflex can be triggered in reptiles, birds, and mammals (including humans). When the animal’s face gets wet, and the breath is held, oxygen is conserved by slowing the heart, peripheral vasoconstriction, and increasing (at least the ratio) blood supply to vital organs. Obvious evolutionary advantages of this reflex are clear. But what about a client who can’t sleep and wakes with nocturnal rumination?

Diving Reflex’s Practical Implications

Last year I heard Marsha Linehan and a colleague share a story of a physician audience member who introduced them to the concept of the diving reflex.

Many of their patients had used cold water on their faces to calm down. The diving reflex explained why these techniques had been working for their clients. Since learning of the reflex, they had become more confident in the strategy, nicknamed it a “non-pharmacological Benzo,” and may be including it in their upcoming version of the Dialectical Behavior Therapy (DBT) skills workbook. Tolerance and addiction aren’t side effects any clinician should expect from the “non-pharmacological Benzo,” but anyone planning to use it needs to consult his/her physician first (heart problems may be at least one contraindication).

But for those with medical clearance, here are the steps:

Non-pharmacological Benzo Strategy

  1. Pour water in an appropriate sized bowl
  2. Place ice cubes in the water
  3. Inhale and exhale 3 times
  4. Plunge your face into the cold water, hold your breath for as long as you can, without inducing a panic response
  5. Pull your head up

Any approximation of the exercise can be experimented with.  If your coworkers might view you as odd for shoving your face into an ice bucket before a board meeting, even holding a cold soda can to your forehead might have some benefit. But the ideal conditions appear to be about 38 degree Fahrenheit water, bending forward as if diving, and bringing the water up to the temple line. With those recommendations in mind, there may be great variation.

So with medical clearance, experimenting with the parameters is probably a good idea to find what is most effective for you. There appears to be some anecdotal evidence that improvements in the efficacy of the technique may occur with practice according to Dialectical Behavior Therapy (DBT) practitioners. Even more interesting, classical conditioning may even aid in the process as the technique becomes ritualized. So that bradycardia may even occur before your face hits the water.

If you or your clients have already used this or a similar technique, or if you try it, we would love to hear how it goes.  Especially if you find ways to make it more effective- let us know your experience.


Lachmund, E., DiGiuseppe, R., & Fuller, J. R.  (2005).  Clinicians’ diagnosis of a case with anger problems. Journal of Psychiatric Research, 39(4), 439-447.

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