Have you ever come across “dialectical behaviour therapy”, and wondered what it entails, the various coping skills, and how you can harness the skills to improve your mental health? If yes, read on; this article is just what you need.

Introduction

Dialectical behaviour therapy (DBT) is a complete evidence-centered treatment for borderline personality disorder which was developed from Marsha Linehan’s determination to create a treatment for multi-problematic suicidal women.¹

Developed in the late 1980s, DBT was originally for parasuicidal patients which later extended to patients with borderline personality disorder. Dr Linehan defined Para-suicidal behaviour as any plan, acute self-harmful action with or without suicidal intention, as well as suicide efforts and self-mutilative behaviours.

Borderline personality disorder (BPD), is a long-lasting disorder with symptoms such as anxious efforts to evade actual or imaginary desertion, insecure relationships, identity disturbance, spontaneous and perilous behaviours, repeated suicidal threats or self-mutilating behaviours, emotional instability, feelings of emptiness, difficulties managing anger, and/or stress-related paranoid thoughts or dissociation.²

The goal of DBT is to treat the symptoms of borderline personality disorder by substituting maladaptive behaviours with healthy coping skills and strategies, such as mental alertness, interpersonal effectiveness, and relationship regulation, and it is currently the only empirically supported treatment for BPD.³ In its standard form, DBT is a one-year intervention comprising four modes of treatment: individual therapy, group skills training, phone coaching, and team consultation.⁴

Although DBT has many similarities with other cognitive-behavioural approaches, many critical and unique features must be in place for the treatment to model DBT. Some of these features are

• serving the five purposes of treatment
• the biosocial theory and centring on emotions in treatment
• consistent dialectical beliefs
• and mindfulness and acceptance-oriented interventions¹

Coping skills

Coping refers to thoughts and conducts used to manage internal and external stressful states.⁵

Coping strategies are defined as the skills required to manage and adjust to stressful situations, representing an important element for the adaptation process to stressful and distressing situations in addition to the process of recovery of patients with severe mental disorders.⁶

Coping skills can help improve self-efficacy and increase positive behaviour which can reduce their problem with psychosocial health.⁷ Coping can be generally categorized into four categories: 

1. Problem-focused or behavioraul-focused strategy which addresses the problem causing the distress aims to manage or modify the problem that is causing discomfort, and dealing with the stressor in different ways, such as planning actions or seeking information⁸
2. Emotion-focused, this coping strategy attempts to regulate the emotional response to the problem, through methods like looking for support⁸
3. Meaning-focused, also known as cognitive-focused, in which an individual uses cognitive strategies to derive and manage the meaning of the situation⁵
4. Social coping (interpersonal) is when an individual reduces stress by finding emotional or instrumental support from their community⁵

The Integration of DBT and coping skills

Emotional intelligence is the ability to recognize one’s feelings. It is an important element of resilience and understanding one’s own emotions contributes to general well-being and effective emotional regulation. Gaining an understanding of one’s emotions relies on the identification of those emotions and may be an essential step before emotional regulation can be enacted.⁹

Mindfulness in DBT 

Mindfulness means being in the moment with everything that is now, without judging and without remarking on what is happening, it means helping the person to understand that pleasant and unpleasant emotions can occur.¹⁰ Mindfulness in DBT is taught as a set of skills within the context of synthesizing acceptance and change; by using the ‘What’ skills of Observe, Describe and Participate, the individual is invited to be aware of their experiences.

By using the ‘How’ skills of non-judgmentally, one-mindfully and effectively the individual learns to change their reaction to their experiences. These skills are used to improve the ability of the individual to be mindful of their state of mind and to use their ‘wise mind’ to guide their actions.¹¹

Balancing acceptance and change 

The dialectics of acceptance and change is one of the main features of DBT. The therapist, on one hand, accepts patients for who they are and provides validation for their thoughts, emotions, and actions, while on the other hand, the therapist acknowledges the need for change and nurtures the learning of new skills to deal with the problem and reach personal goals.¹²

Dialectical philosophy is the fuel that powers much of what is unique about DBT in comparison to other cognitive-behavioural treatments Dialectical philosophy also poses that each opposing force is incomplete on its own and that these forces continually are balanced and synthesized. This also is the case in DBT. From a point, focusing completely on change-oriented efforts was an incomplete strategy, as it lacked the essential ingredient of acceptance.

On the other end, focusing entirely on the acceptance of the patient also may be incomplete and ineffective, as multiproblematic, suicidal patients require extensive changes to create lives that are worth living. Dialectical thinking influences many aspects of the therapist’s approach and style.¹

Specific coping skills within DBT

Distress tolerance skills

These skills are meant to help distract us and get us through tough emotional situations one moment at a time. A way to remember this skill is with the acronym ACCEPTS:¹³

• Activities- do something that requires focus and attention
• Contributing-do an activity that allows you to concentrate on the other person
• Comparisons- compare your situation to something more traumatizing and painful
• Emotions-do something to create new emotions that will compete with your distressing emotion
• Pushing to avoid a painful situation
• Thoughts- use a mental strategy to shift your thoughts to something neutral
• Sensation- find the safe physical sensation to distract you from your distressing emotions

Improve skills

This aims to improve the moment by inter-changing the immediate situation that has triggered unpleasant emotions, with a more positive act, thereby making the moment more pleasant and easier to tolerate:¹⁴

• Imagery
• Meaning
• Prayer
• Relaxation
• One 
• Vacation
• Encourage 

Emotional regulation skills

Identifying and labeling emotions

Emotional regulation is very crucial for mental health and behavioural regulation. It is the process by which individuals may control their feelings and the different strategies used by the individuals to do so, including emotional reappraisal and emotional suppression. Emotional identification is very vital for proper emotional regulation. Individuals with significant difficulty identifying or naming their emotions may increase distress and preclude them from applying beneficial emotional regulation strategies.⁹

Opposite action 

All emotions trigger us to respond; the type of trigger is biologically wired. The Opposite Action Skill allows us to react opposite to what our biological response would trigger us to do. They get us ready to act. Opposite action does not intend to “give in” to contentious problems but it opens the individual up to new possibilities for solving interpersonal conflicts.¹²

Interpersonal effectiveness

This teaches how to gain objectives skillfully and how to act effectively concerning objectives, relationships, and self-respect.¹²

The DEARMAN skill is intended to help us develop effective interpersonal communication that will help us get our needs met and develop healthy relationships with others:¹⁵

• Describe
• Express
• Assert
• Reinforce
• Mindfully ask
• Appear
• Negotiate 

The GIVE skill is especially important for maintaining healthy relationships through effective communications:¹⁶

• Gentle- be kind and polite
• Interested- pay attention and appear interested in the other person
• Validate- view the world from the other person’s standpoint, and then say or act on what you see
• Easy manner-  be light-hearted

The application of DBT and coping skills

A study was done by Kells et al. to examine the effectiveness of a 24-week DBT-ST program for individuals with BPD or emerging emotion regulation difficulties, who were not routinely engaging in suicidal or self-harm behaviours. The results of the study suggest that a standalone 24-week DBT-ST intervention may be beneficial for individuals with BPD/ emerging BPD who are not actively self-harming or engaging in other suicidal behaviours. A reduction in emotion dysregulation and dysfunctional coping, in addition to an increase in mindfulness and DBT skills use was observed from pre- to post-intervention.⁴

Challenges and limitations includes

• DBT needs highly skilled therapists  who have to be under regular supervision by attending 2‑h consultation team meetings weekly for learning skills and supervision
• DBT has a demanding model of therapy. A patient has to attend two separate sessions including 1 h of personal therapy and 2 h of group skills training weekly along with regular assignments for the one-year duration of treatment
• DBT can be very expensive because of numerous sessions and the involvement of highly qualified therapists if it is not delivered through the public healthcare system
• DBT, when compared to other structured therapies, does not fare well concerning fundamental features of borderline personality disorder except for showing similarities in progress in suicide attempts¹⁷

Summary

DBT is an extensive approach incorporating coping skills to address mental health challenges, emphasising acceptance and change through mindfulness and emotional regulation.