Dialectical Behaviour Therapy (DBT) Exercises and Techniques

‍Content warning: Discussion of DBT treatment in this article includes mention of suicidality and self-harm. If you or someone you know may be in danger of self harm or suicide, please get help. Call 911 for emergencies or contact the Canada Suicide Prevention Service hotline at 1-833-456-4566 (24 / 7) or text 45645 (4pm to 12am ET).

History of Dialectical Behaviour Therapy (DBT)

Dialectical Behaviour Therapy (DBT), a cognitive-behavioural based psychotherapy, was the brainchild of psychologist Dr. Marsha M. Linehan, developed in the late 1970s. Initially tailored for individuals who faced intense emotional turmoil and were at risk for self-harm and suicidal ideation, DBT originated as an attempt to adapt cognitive-behavioural strategies for a group CBT struggled to assist. Dr. Linehan observed that direct attempts to alter thoughts and behaviors without addressing the unique needs of these individuals were frequently counterproductive and, in some cases, invalidating.

Dr. Linehan's unique contribution was the  inclusion of validation and acceptance strategies alongside change-oriented techniques. DBT's philosophy hinges on two key elements: acceptance of the patient's experiences as real and valid, and the simultaneous pursuit of positive change. This dialectical viewpoint allows patients to develop a deeper trust in themselves and their ability to cope with challenging situations.

She initially focused her work with adult women with histories of self-harm or suicidal ideation. At the time, CBT was gaining in credibility and popularity, so she decided to apply that behavioural approach to her patients. However, she found key elements of CBT were not effective for her patients for the following three reasons:

1. The focus on changing thoughts in CBT was invalidating her patients' experiences and reality.
2. Because these patients tended to be dealing with more extreme emotional dysregulation, therapists were unknowingly changing their approach when the patient became angry, or they threatened self-harm.
3. The severity of the patients’ struggles were beyond the scope of the standard CBT model—it did not provide time to help with severe symptoms of anxiety and depression or to develop new skills
4. This prompted Linehan and her team to change the model. They started to ensure that their patients knew their behaviours were accepted (validated), so they grew to know they could trust themselves. Acceptance fueled the ability for change. Adding in dialectics helped both the therapist and patient move forward instead of getting stuck in extreme emotions or fixed thinking.

Over time, DBT has broadened its scope beyond borderline personality disorder. Today, it's a comprehensive treatment for a multitude of disorders, including substance dependency, depression, eating disorders, and PTSD.

How DBT Works 

At its core, DBT is a structured program often lasting around a year, designed to help individuals gain mastery over their emotional and behavioral patterns. The process is broken down into four main stages:

1. Stabilization: The initial stage aims at curbing hazardous behaviors, such as self-harm or substance abuse, to obtain behavioral control.
   
   
2. Emotional Experiencing: Individuals begin addressing suppressed emotions, moving towards healthier emotional processes by learning skills like emotional regulation and distress tolerance.
   
   
3. Navigating Life: Here, participants focus on living an everyday life, developing self-respect, setting goals, and maintaining an equilibrium throughout life's highs and lows.
   
   
4. Pursuit of Fulfillment: The final stage encourages individuals to attach meaning to their lives through spiritual pursuits or a resounding connection with the broader world, helping to establish a sense of contentment.
   

Training in four critical skill areas goes hand-in-hand with these stages:

• Mindfulness: This involves learning to exist in the current moment, accepting thoughts and emotions without judgment.
  
  
• Distress Tolerance: Skills teach navigating life's obstacles without resorting to self-destructive actions, acknowledging the impossibility of changing certain aspects of life.
  
  
• Interpersonal Effectiveness: Strategies for improved communication are taught, including articulating needs, saying no, and maintaining individuality in relationships.
  
  
• Emotion Regulation: Individuals learn to recognize and name emotions without being ruled by them, lessening the emotional influence over their actions.
  

The overarching aim of DBT is to empower the individual to become their own advocate in managing their mental health. This approach has a strong research foundation underscoring its effectiveness—evidence-based therapy—making DBT a respected and sought-after modality for both patients and practitioners. With a focus on practical skills, clients are supported in coping more adaptively with daily stressors, ultimately working towards a life where they can confidently trust in their capacity to face and manage life's challenges.

Common Inquiries on DBT Strategies

Primary DBT Exercises for Emotion Regulation

Dialectical Behaviour Therapy (DBT) introduces several exercises to help you manage strong emotions. Core Mindfulness and Distress Tolerance skills empower you with techniques like deep breathing and mindfulness meditation. These practices encourage you to stay centered and composed during emotional challenges.

Distress Tolerance

• Acceptance of reality as it is
• Crisis survival strategies to endure emotional pain

Emotion Regulation

• Identifying and labeling feelings
• Increasing positive emotional events

The Four Modules of DBT Skills

DBT is structured around four key modules, each with a distinct role in promoting psychological and emotional health.

Mindfulness

• Increases presence and awareness
• Cultivates non-judgmental observation

Interpersonal Effectiveness

• Enhances communication
• Builds assertiveness while maintaining relationships

Emotion Regulation

• Helps in understanding emotions
• Teaches skills to reduce emotional intensity

Distress Tolerance

• Fosters coping with crisis
• Aids in accepting and tolerating distress

Applying DBT for Borderline Personality Disorder

Individuals with Borderline Personality Disorder (BPD) can benefit significantly from DBT by learning to regulate their emotions and improve relationships. The therapy becomes a structure to understand and manage emotional swings, avoid self-harm behaviors, and develop a consistent sense of self.

Emotion Regulation teaches skills for modulating intense feelings. Interpersonal Effectiveness enhances personal relationships. Mindfulness offers grounding techniques.

Enhancing Interpersonal Effectiveness in Group DBT

DBT group therapy sessions foster interpersonal skills through various activities:

• Role-Playing: Practicing assertiveness and conflict resolution
• Feedback Sessions: Developing communication and social interaction

These activities aim to build confidence in social scenarios and amplify your ability to maintain respect for yourself and others.

Mindfulness Exercises in DBT for Better Mental Health

Mindfulness activities in DBT encourage a moment-to-moment awareness.

• Breathing Exercises: Ground yourself in the present
• Observational Tasks: Notice experiences without judgment

These exercises can increase your concentration and reduce impulsive reactions, contributing to overall mental well-being.

Understanding the '24-Hour Rule' in DBT

The 24-Hour Rule in Dialectical Behaviour Therapy (DBT) is a guideline often used in the treatment of self-harm or substance abuse behaviors. This rule suggests that a person should wait for 24 hours before acting on harmful impulses, like self-harm or drug use. 

During this period, individuals are encouraged to use DBT skills like distress tolerance and mindfulness to manage their emotions. This approach allows time for intense emotions to subside, reducing the likelihood of engaging in harmful behaviors. 

Conclusion

One of the main goals of DBT is to help you become your own “case manager''. By focusing on skills building alongside a trained therapist, we eventually become more automatic in how we respond to challenges. It won’t make hard life moments disappear, but we can learn to trust ourselves and the process of working through challenges while coping in a healthier way.

Dialectical behaviour therapy is an evidence based therapy modality. That means there is a lot of scientific research proving it’s effective, and plenty of training available to teach therapists how to work with people using DBT. For that reason, you’ll likely come across DBT on many of First Session’s partner therapist profiles under their modalities.

You might work through a full year-long program, or you might use some of these tools in a “DBT-informed” way. You might focus more on other behavioural therapies like cognitive behavioural therapy (CBT), mindfulness therapy, or more body-focused approaches (somatic therapy) like eye movement desensitization and reprocessing (EMDR) therapy. There are dozens more tools, methods and techniques out there. Feel free to ask your therapist about their specializations and how they might work for you. 

‍You can easily search for therapists and counsellors in Canada who specialize in DBTon First Session.