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Dialectical Behavior Therapy: Building Lives Worth Living
Alec Miller, Psy.D. and Faye Rigogiannis, Psy.D.

What is DBT?

Dialectical Behavior Therapy (DBT) is an outpatient multi-modal therapy meaning it involves individual therapy, group meetings and telephone coaching. Marsha Linehan, Ph.D., originally developed DBT in 1993 for the treatment of suicidal and self-injurious behaviors, and Borderline Personality Disorder. Since its inception, DBT has been adapted for multiple treatment settings, age groups, and presenting problems. In 1997, DBT was adapted for adolescents and their families by Alec Miller, Psy.D, Jill Rathus, Ph.D, and Marsha Linehan, Ph.D. In 2007, Miller and colleagues began adapting DBT for school settings. Since 1991, there have been numerous research studies that show that DBT is effective in treating many problems, such as suicidality, mood and substance use disorders and borderline personality disorders in adults. Most recently, research has shown that DBT is effective for treating suicidality and self-injurious behaviors in adolescents. Other therapies have not been as successful as DBT in treating these difficult problems, which makes the development of DBT extremely important.

DBT is built upon strategies that intend to change behaviors, thoughts and feelings and integrates mindfulness and acceptance strategies as core principles of the treatment. This unique synthesis of change and acceptance principles has proven to be highly effective in reducing and eliminating suicidal and self-injurious behaviors. DBT therapists believe that suicidal and self-injurious behaviors develop as unhealthy coping skills individuals use to manage their emotions. DBT targets five broad problems areas for treatment, which include confusion about self, impulsivity, emotion dysregulation, interpersonal problems, and non-dialectical (unbalanced or extreme) thinking or adolescent and family dilemma, which is characterized by non-dialectical thinking, invalidation, and poor contingency management. The modules that were developed to target these specific problem areas are:

  1. Core mindfulness: teaches participants how to focus the mind, direct attention and nonjudgmentally observe and describe what they are feeling and thinking in the moment 
  2. Distress Tolerance: targets impulsivity by teaching participants to effectively distract and soothe themselves while considering the pros and cons of their actions
  3. Emotion Regulation: addresses extreme emotional sensitivity, rapid mood changes and other unregulated moods
  4. Interpersonal Effectiveness: addresses difficulties in maintaining consistent and rewarding relationships by teaching skills such as how to ask for what you want, and how to maintain your self-respect and independence in the face of peer pressure
  5. Walking the Middle Path: targets extreme and unbalanced thinking and behaviors among teens and family members

What does an individual session look like?

DBT individual sessions are guided by the principles of DBT. This means that individual DBT sessions are tailored to the individual’s needs for that moment in time; however, this is not to suggest that DBT sessions are unstructured. In fact, DBT individual sessions are structured hierarchically in such a way to ensure that, not only primary targets of treatment are consistently addressed (e.g. life threatening behaviors), but also to guarantee efficient and effective use of the session time. In other words, the DBT therapist will first focus on discussing any self-injurious behaviors or suicidal ideation that occurred in the past week. After these behaviors are addressed, the DBT therapist will discuss and address other issues selected by the patient and therapist. A DBT client completes a daily diary card in which they keep daily track of these behaviors in order to discuss them in session.

What is mindfulness in DBT?

Due to the many different components of DBT and the length it would take to delve into each module, our discussion will now focus on what mindfulness is and how it is implemented in the DBT program. (Please refer to Alec Miller’s and Jill Rathus’ “DBT Skills Manual for Adolescents” for further information about the four other modules previously mentioned.) The reason for this is that mindfulness is a core component of the DBT program and there is an emphasis throughout treatment on the development of mindfulness skills, which is not to be confused with meditation or relaxation skills. Meditation is typically associated with clearing one’s mind, while relaxation skills aim to reduce physiological arousal. Although both these things may result from a mindfulness practice, neither are necessarily the goals of engaging in mindfulness or acting mindfully in DBT. To be mindful means to be aware of and to purposefully focus attention on the present moment in a nonjudgmental manner. Mindfulness is a muscle that can be built up through daily practice; any daily action (i.e. driving, eating, brushing your teeth) is an opportunity to practice mindfulness.

How to be mindful

Mindfulness consists of two components fittingly named the “What” and “How” skills, which describe what to do and how to do it in order to be mindful. “What” skills consist of observing, describing, and participating. Observing entails simply noticing an experience and having a “Teflon mind,” in which you allow thoughts and feelings to come in and out of your mind without holding on to them. Describing is labeling the experience without interpretations; simply put, sticking to the facts. Participating is throwing yourself into the present moment fully with no worries about the past or future.
Mindfulness “How” skills describe how to attain a mindful state of mind. “How” skills entail not judging an experience as good or bad, staying focused or being “one-mindful,” and doing what works. Avoiding judgments or evaluation of an experience as positive or negative and replacing them with descriptions allows one to have more control over his or her emotions. Acting one-mindfully means focusing and refocusing attention on one thing in the moment, which prevents past, future, and current distractions from getting in the way (this is the opposite of multitasking). Lastly, doing what works means being effective and skillful in order to achieve your goals. Minimally, this involves letting go of negative feelings, not letting emotions control behavior and playing by the rules.

Individuals new to mindfulness often worry that because they are easily distractible and find that their minds often wander that they will be unable to practice mindfulness. However, mindfulness requires a mind to wander in order to be practiced; catching one’s thoughts drifting and bringing awareness back to the present moment is exactly what mindfulness is. An easily distractible mind has countless opportunities to practice mindfulness and should not be a deterrent to developing one’s mindful muscle. 

How can mindfulness help me?

Individuals receive a module on mindfulness at the beginning of each of the four skills modules (distress tolerance, emotion regulation, interpersonal effectiveness and walking the middle path) because well-developed mindfulness skills allows for the ability to implement the other skill sets. According to Alec Miller and Jill Rathus (2015), mindfulness is especially valuable to individuals with difficulty regulating their emotions because being mindful can:

  1. Help one slow down and notice emotions, thoughts and urges, which can reduce impulsivity and increase one’s control over their behavior
  2. Reduce one’s emotional suffering and increase one’s pleasure and sense of well-being
  3. Help one make important decisions and balance overly emotional or overly logical decisions
  4. Help focus one’s attention in order to increase one’s effectiveness and productivity
  5. Increase compassion for self and others
  6. Lessen one’s pain, tension, and stress, which can in turn even improve one’s health

Those not familiar with DBT often harbor the misconception that DBT is an adjunct to “talk” therapy in which clients are provided with a set of skills, while actual treatment is provided by their other community therapist; this myth could not be further from the truth. DBT is a comprehensive treatment in which one attends weekly individual therapy sessions and skills class. The client is also provided with access to his or her individual therapist in between sessions for coaching calls to ensure generalization and implementation of the DBT skills. In Miller, Rathus, and Linehan’s adaptation for adolescents, weekly skills class requires consistent caregiver participation in which caregivers are expected to learn and use the DBT skills as well. Additionally, one leader of the client’s multi-family skills class coaches parents in between classes to ensure they too are skillfully managing their child or teen’s behaviors or crises as they may arise. Weekly individual therapy sessions serve to assist the client in developing personal short and long term goals and developing insight into how his or her behavior is interfering with achievement of these goals. DBT is much more than simply reducing problem behaviors and increasing skillful behavior; DBT instills hope and, considered the overarching goal of DBT, helps clients build lives worth living.

Miller, A. & Rathus, J. (2015). DBT skills manual for adolescents. New York, NY: Guilford Publications.

Alec Miller, Psy.D.
Co-Founder and Clinical Director of Cognitive & Behavioral Consultants, LLP (Westchester & Manhattan)
Clinical Professor of Psychiatry and Behavioral Sciences
Montefiore Medical Center/Albert Einstein College of Medicine

Faye Rigogiannis, Psy.D.
Cognitive & Behavioral Consultants, LLP (Westchester & Manhattan)

Disclaimer: The views in this article are those of the authors and not the views of WCPA. Statements contained in the authored articles on the Westchester County Psychological Association (WCPA) website are the personal views of the authors and do not constitute WCPA policy unless so indicated. The information in the articles on the WCPA website is for educational purposes only. The information contained in the articles is not intended for diagnosis, psychological advice or medical advice.  It is not intended to be treatment and is not a replacement for psychotherapy. If you are in need of psychological treatment, you can utilize our clinician database which can be accessed by clicking on the link, "Find a Psychologist." WCPA and its directors and employees are not liable for any damages resulting from the utilization of information contained in articles posted on the WCPA website.


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