Dialectical Behaviour Therapy For Self-Harm

Introduction

Overview

Dialectical behaviour therapy (DBT) is a programme of treatment that can be used to address the issues of self-harming thoughts and behaviours in children, adolescents, and adults. Extreme negative emotions can drive self-harming thoughts and behaviours. DBT is an evidence-based treatment for people affected with such intense emotions by helping them to learn to manage their emotions.¹

DBT is a programme of talk therapy adapted to focus on helping you navigate extreme negative emotions that could lead to self-harm. The programme of treatment includes individual therapy, group skills therapy, telephone coaching, and therapist consultation teams to help you regulate your emotions. DBT also helps your family to develop supportive skills such as behavioural management, emotional regulation, and validation.

• Individual therapy: one-on-one weekly sessions with a therapist (approximately 1 hour)
• Group skills therapy: weekly group sessions focused on learning the skills of mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation (approximately 1.5–2.5 hours)
• Telephone coaching: this allows you to call your therapist outside sessions as needed for support, such as when wanting to self-harm
• Therapist consultation teams: this is a team of professionals that may include psychologists, social workers, counsellors, and psychiatrists, who help maintain effective treatment through the course of the programme²

Through an extensive approach, DBT is a programme that can help you and your family gain the skills to tackle your struggles with self-harm. Read on to learn more about DBT as a treatment for self-harm.

What is DBT?

Dialectical behaviour therapy (DBT) is a programme of treatment designed for people who have intensely negative emotions. It comes from Marsha Linehan’s work on cognitive behavior therapy (CBT) for patients with borderline personality disorder (BPD), who are likely to self-harm. Acceptance and change are the two concepts that govern DBT as a practice to help cope with intense emotions.³

DBT has been found to be effective for mental health conditions associated with extreme emotions,such as: borderline personality disorder, self-harm, suicidal behaviour, post-traumatic stress disorder (PTSD), substance abuse, eating disorders, depression, and anxiety.

Urgency of seeking help

It is important to seek help if you or someone you know is practising or thinking of self-harm. Reach out to friends and family for support. Speak to your healthcare provider if you are harming yourself or thinking about it. They can provide medical care and refer you to mental health experts.

Understanding self-harm

Definition and manifestations

Self-harm is a serious issue where a person intentionally causes physical harm to themselves as a response to mental and emotional distress. Some reasons why people self-harm are:

• To cope with their intense emotions
• To express or relieve their distress
• To feel in control
• To punish themselves
• As a cry for help

Self-harm and suicide are strongly linked with a history of self-harm being a key risk factor for suicide. However, not all those who self-harm have suicidal thoughts.⁴

Common triggers for self-harm

The cause of mental and emotional distress can vary and may be from bad experiences in the past or present such as:

• Performative pressures at school, work, home
• Relationship and family problems
• Being bullied
• Traumatic experience
• Physical or sexual abuse
• Financial struggles
• Experience with the criminal justice system
• Low self-esteem
• Stress, anxiety, or depression
• Grief

The transformative power of DBT

Dialectics: balancing acceptance and change

The two concepts that DBT focuses on are:

• Radical acceptance of your reality – past, present, and future
• Change as a necessity for progress to manage emotional distress³

Through DBT, skills inspired from both Western and Eastern practices are taught to help apply these two concepts in your life. These skills are trained during group skills therapy, while individual therapy tackles your current problems and encourages the application of these skills.⁴

The four skills are divided into: 

• Acceptance skills: mindfulness and distress tolerance 
• Change skills: emotion regulation and interpersonal effectiveness³

Core mindfulness: embracing the present

Mindfulness skills are core to DBT. These help you address the present by learning behavioural skills such as:

• Wordless observing
• Describing what is observed
• Participating
• Being non-judgmental
• One mindfulness
• Going within to wise mind
• Effectiveness³

Mindfulness helps with reality acceptance through nonjudgmental experience of what is happening in the moment.

Distress tolerance: tools for survival

Distress tolerance is temporarily tolerating the situations that distress you. This module focuses on accepting the circumstances by teaching delayed gratification and self-soothing techniques to effectively survive through the distressing crisis without further harming yourself. One such strategy learnt in this module is the TIPP method for decreasing stress by activating the body’s nervous system through:

• Tipping your face into cold water
• Intense exercise
• Paced breathing, and 
• Paired muscle relaxation³

These skills help with reality acceptance by reducing distress when current circumstances cannot be immediately changed.

Emotion regulation: rediscovering balance

Emotion regulation skills help manage your emotional responses and reduce these intense emotions. Emotions are brief, instinctive, patterned responses to internal and external cues. Responses to such stimuli can be controlled by understanding your emotions and the factors influencing them. Such behavioural and cognitive skills include:

• Identifying and describing emotions
• Changing emotional responses
• Managing difficult emotions
• Reducing vulnerability to negative emotions
• Adding pleasant events
• Developing value-fitting goals³

Emotion regulation encourages a change in emotional and behavioural response to triggering events.

Interpersonal effectiveness: rebuilding connection

People who struggle with extreme negative emotions tend to struggle in their relationships with others. Feelings of jealousy, anger, fear, shame, or depression can be damaging to their relationships. The interpersonal effectiveness module teaches skills such as:

• How to be assertive with requests
• How and when to say no
• Validation
• Dialectics
• Contingency management
• Strategic positive and negative reinforcement³

Interpersonal effectiveness skills promote healthier relationship dynamics with others. 

How DBT works

Pre-assessment

Before starting the DBT programme, your therapist may assess the suitability of DBT as a treatment for your needs. They will explain the various individualised treatments you will partake in and how long the treatment will last.

Individual therapy

These are weekly one-on-one sessions with your therapist typically lasting 1 hour. These sessions aim to help you talk through your current problems, reduce life-threatening behaviours like self-harm, help you apply learned skills and behaviours into your daily life, modify your environment, and provide motivational support to change.²

You will likely be asked to make a record of your emotions, thoughts, and actions as homework in between sessions by keeping a diary and bringing this with you to share in your individual therapy sessions. This will help you and your therapist to prioritise your session time by targeting the behaviours that need to be addressed.²

Telephone coaching

People dealing with self-harm and suicidal thoughts and behaviors need more support between individual therapy sessions, especially during times of crisis that threatens their safety and life. Telephone coaching with your therapist provides the needed support as necessary and does not replace therapy sessions.³

Group skills therapy

These are weekly therapy sessions focused on acquiring and improving the skills needed to put the concepts of acceptance and change into practice. These usually last for 1.5–2.5 hours.²

Therapist consultation teams

A component of DBT is a consultation team of professionals who usually meet weekly for 1–2 hours to discuss better implementation of treatment, provide encouragement and support, and help with therapist burnout. This ensures that effective treatment is maintained throughout the DBT programme.²

How long does DBT usually take?

DBT treatment usually lasts from 6 months to 1 year. Due to the unique circumstances and mental health conditions of each individual, the length of treatment can vary and can often last for several years for those with borderline personality disorder.

Benefits and considerations for a successful DBT treatment

Benefits of DBT

Several studies on patients with borderline personality disorde have demonstrated that DBT is effective in reducing:

• Suicidal behaviour and suicide attempts
• Self-harm
• Impulsivity 
• Anger
• Depression 
• Substance use
• Hospitalisations²

Considerations in implementing DBT

Some things to consider for a successful DBT programme include:

• Having a commitment to the therapy work and skill learning
• Being consistent in attending sessions and doing the assignments
• Being able to do some sessions in a group setting
• Having a collaborative mindset with your therapist through continuous assessment and adaptation of treatment plans

The road to recovery

Encouraging seeking professional assistance

Self-harm usually is due to intense negative emotions brought about by distressing triggers. You do not have to deal with these extreme emotions alone.

The life-changing potential of DBT

The goal of DBT has been to create a “life worth living” by helping you to reduce self-harming thoughts and behaviours, regulate your emotions to prevent self-harm, and reinforce progress at a pace that suits you. DBT has the potential to improve your way of living and your relationships with others.^2,3

Summary

Dialectical behaviour therapy is a comprehensive treatment programme that helps you tackle the core issues behind the urge to self-harm. It provides you with the necessary tools and skill set that can help you cope with your situation and ultimately control your emotions. This is done through a multi-component approach of individual therapy, group skills therapy, telephone coaching, and therapist consultation teams. DBT emphasises the concepts of radical acceptance and change, teaching you the skills of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. With commitment, DBT can help you through your struggles with self-harm, improve your way of life and your relationships with others.