DBT Made Simple

DBT Made Simple Plot Summary

Introduction

Living with intense emotions can feel like navigating a turbulent ocean without a compass. For those experiencing emotional dysregulation, simple interactions become charged with overwhelming feelings that seem impossible to manage. Relationships suffer, self-destructive behaviors emerge, and the pain of daily existence can become unbearable. But what if there was a way to build a set of skills that could transform this chaotic experience into a life worth living? Dialectical Behavior Therapy offers a profound pathway to emotional balance and interpersonal effectiveness. At its core lies a powerful dialectic: accepting yourself exactly as you are while simultaneously working toward change. This seemingly contradictory stance creates the foundation for transformation. Through mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, even those with the most intense emotional experiences can learn to navigate life's challenges with greater stability and purpose. The journey isn't easy, but with practice and persistence, these skills become powerful tools for creating a more balanced and fulfilling life.

Chapter 1: Understanding the Dialectical Foundations

Dialectical Behavior Therapy (DBT) begins with a fundamental understanding: that seemingly opposite truths can coexist. This dialectical worldview acknowledges that reality isn't static but constantly changing, and that synthesis between contradictory perspectives often reveals deeper truths. The primary dialectic in DBT is the balance between acceptance and change – acknowledging that clients are doing the best they can while recognizing they need to do better, try harder, and be more effective in their lives. Consider Vicki, a 33-year-old woman who was attacked by a dog as a child. Her fear was understandable and served a protective function when she was young. However, decades later, this fear continued to control her life. When she moved to a new neighborhood and discovered a dog park nearby, her anxiety became overwhelming. Not only did she stop taking walks, which she had previously enjoyed, but she eventually stopped leaving her house altogether when alone, terrified she would be attacked. For Vicki, her anxiety had served its purpose – it protected her when she was a child, and it continued to motivate her to protect herself. Yet this same anxiety was now preventing her from living a fulfilling life. The dialectic here involves acknowledging the validity of her fear while recognizing it had become maladaptive. By accepting her anxiety as understandable rather than judging it, Vicki could create space to work on changing her response to it. The biosocial theory at the heart of DBT explains that emotional dysregulation stems from the interaction between biological predisposition and environmental factors. Some individuals are born with heightened emotional sensitivity – they react more intensely to emotional stimuli, experience emotions more strongly, and take longer to return to baseline. When this biological vulnerability interacts with an invalidating environment (where emotional responses are punished, trivialized, or dismissed), the person never learns to understand, label, regulate, or tolerate emotional distress. Working with dialectical thinking means helping clients get unstuck from rigid, either/or thinking. For instance, a client might believe they must either express their anger by lashing out or completely suppress it. The therapist helps them find the synthesis – acknowledging anger while expressing it effectively. Similarly, clients learn that they can love someone and be angry with them simultaneously, or that they can accept themselves as they are while working toward change. To practice dialectical thinking yourself, notice when you're caught in extreme positions. Are you viewing a situation as all-or-nothing? Are you stuck between seemingly contradictory truths? The dialectical approach invites you to look for the kernel of truth in opposing perspectives and find the middle path that honors both sides of the dialectic.

Chapter 2: Mastering Mindfulness as Core Practice

Mindfulness forms the foundation of all other DBT skills. At its essence, mindfulness is about doing one thing at a time, in the present moment, with your full attention, and with acceptance. This practice helps clients take control of their minds rather than letting their minds control them, becoming aware of thoughts, emotions, and urges without being overwhelmed by them. Rebecca, a client struggling with anger management issues, would often find herself in explosive conflicts with her partner that she later regretted. During one session, she described a recent argument: "He forgot to pick up groceries again, and I just lost it. I started screaming about how he never listens, how he doesn't care about me. I called him worthless, and then I slammed the door so hard a picture fell off the wall and broke. Afterward, I felt horrible, but in the moment, I couldn't stop myself." Through mindfulness training, Rebecca learned to create space between her emotions and her reactions. She started practicing counting her breaths when she noticed anger arising. At first, she could only maintain this awareness for seconds before being swept away by emotion. With continued practice, however, she gradually developed what DBT calls "wise mind" – the ability to experience emotions while still maintaining rational thought. After several weeks of consistent practice, Rebecca had a breakthrough. When her partner forgot an important appointment, she noticed the familiar sensations of anger arising – the tightness in her chest, the heat in her face, the urgent thoughts demanding she express her rage. Instead of immediately reacting, she paused, took three mindful breaths, and observed these sensations with curiosity rather than judgment. This brief moment of mindfulness allowed her to respond from her wise mind rather than her emotional mind. To begin practicing mindfulness yourself, start with informal practices incorporated into your daily routines. When washing dishes, focus completely on the sensation of the water, the smell of the soap, the texture of each dish. When walking, notice the feeling of your feet touching the ground, the rhythm of your breathing, the sounds around you. Whenever your mind wanders (which it naturally will), gently bring your attention back to the present moment without judging yourself. For more structured practice, try the "counting breaths" exercise: Sitting quietly, count "one" as you inhale deeply, "two" as you exhale slowly, continuing up to ten before starting over. When your attention wanders, simply notice this without judgment and return to counting. Even just five minutes daily can significantly improve your ability to stay present during emotional challenges. Remember that mindfulness isn't about achieving a perfect state of attention but rather about noticing when your mind has wandered and bringing it back. Like training a puppy to sit and stay, your mind requires patient, consistent practice to develop this essential skill that underlies all emotional regulation.

Chapter 3: Developing Emotional Regulation Skills

Emotional regulation forms the cornerstone of DBT, focusing on helping clients understand, experience, and manage their emotions effectively rather than being controlled by them. This doesn't mean suppressing or avoiding emotions but rather changing one's relationship with them to reduce vulnerability and increase resilience. Matthew, a 27-year-old client with a history of severe depression, struggled with overwhelming sadness that often led to isolation and suicidal thoughts. During a particularly difficult session, he shared: "I feel like I'm drowning in this darkness. When these feelings come, I can't do anything but crawl into bed and wait for them to pass, which sometimes takes days. I've lost jobs, friends—everything—because I can't function when I'm like this." The first step in Matthew's journey was simply understanding what emotions are and the purpose they serve. He learned that emotions provide information, motivate action, and communicate with others. Even painful emotions serve important functions—sadness signals loss and draws support from others, fear alerts us to potential threats, and anger tells us when boundaries have been crossed. As Matthew became more aware of his emotional patterns, he started using the "Getting to Know Your Emotions" worksheet to track his experiences. He noted how sadness manifested in his body (heaviness in his chest, fatigue), the thoughts that accompanied it ("I'll always be alone," "Nothing will ever change"), the urges it triggered (to isolate, sleep, sometimes self-harm), and the behaviors that followed. This awareness alone created space between his emotions and his reactions. Next, Matthew learned practical skills for reducing emotional vulnerability. He established a consistent sleep schedule, improved his nutrition, began daily walks outside, and reduced his alcohol consumption. These lifestyle changes significantly decreased his baseline emotional vulnerability, making it easier to implement other skills during difficult moments. To practice emotional regulation in your own life, start by simply observing and naming your emotions without judgment. When you notice a strong emotion arising, ask yourself: What am I feeling right now? Where do I feel this in my body? What thoughts are connected to this emotion? What is this emotion trying to tell me? This simple practice of mindful awareness creates space between feeling and action, allowing you to respond rather than react. Remember that accepting emotions doesn't mean approving of them or resigning yourself to suffering. Rather, it's recognizing that fighting against your emotional experience typically intensifies it. As Matthew discovered, the paradox of emotional regulation is that accepting emotions as they are—without judgment—often leads to their natural transformation.

Chapter 4: Building Distress Tolerance Capabilities

Distress tolerance skills function as emotional emergency tools, helping clients survive crisis situations without making things worse through impulsive, harmful behaviors. These skills don't solve the underlying problems or eliminate emotional pain, but they create a bridge to get through intensely painful moments without resorting to self-destructive actions. Jennifer, a 32-year-old dealing with binge eating disorder, would often turn to food whenever she felt overwhelmed by negative emotions. During one session, she described a recent incident: "My team leader at work reprimanded me for something I thought would be helpful. I felt completely demoralized and incompetent. On my way home, I drove through a doughnut shop and ordered a dozen doughnuts. I ate half of them in the car and finished the rest while watching TV. Afterward, I felt physically sick and even more ashamed than before." Together, Jennifer and her therapist completed a cost-benefit analysis of her binge eating behavior. She identified immediate benefits like temporary emotional relief and the pleasurable taste, but the costs were significant: physical discomfort, weight gain, financial strain, and intense shame. This analysis helped Jennifer recognize that while binge eating provided short-term relief, it ultimately increased her suffering. Jennifer then learned the RESISTT skills for distress tolerance: Reframing the situation, mindfully Engaging in activities, doing something for Someone else, generating Intense sensations, Shutting out the crisis temporarily, Thinking neutral thoughts, and Taking a break. When she next felt the urge to binge after a difficult interaction, Jennifer tried reframing: "This is just one moment in my career, not a reflection of my entire worth." She then engaged in an intense 15-minute walk, which helped dissipate the urge enough that she could prepare a healthy meal instead. To practice distress tolerance in your own life, identify your most common self-destructive coping behaviors and create a personalized crisis survival plan. First, set a timer for 15 minutes when an urge arises and commit to not acting on it during that time. Use this period to implement one or more RESISTT skills – perhaps holding an ice cube in your hand to generate an intense sensation, calling a friend to shift your focus to someone else, or engaging in vigorous physical activity. Remember that urges are like waves – they build in intensity, peak, and eventually subside if you don't act on them. By putting time and space between the urge and the action, you create opportunity for your wise mind to emerge. The goal isn't to eliminate distress completely but to survive it without making the situation worse, gradually building confidence in your ability to tolerate discomfort.

Chapter 5: Enhancing Interpersonal Effectiveness

Interpersonal effectiveness skills help clients navigate relationships more successfully, addressing the interpersonal chaos that often accompanies emotional dysregulation. These skills focus on how to ask for what you need, set boundaries, and maintain self-respect while preserving relationships. Carmen, a 20-year-old with anxiety and depression who had been using drugs to cope, struggled with asserting herself in relationships. During one session, she described a pattern of giving in to others' demands even when they conflicted with her own needs: "My boyfriend keeps pressuring me to use drugs with him, even though I'm trying to stay clean. I know I should say no, but I'm afraid he'll leave me if I don't go along with what he wants. I end up using just to keep the peace, then I hate myself afterward." Through DBT, Carmen learned that communication typically falls into four styles: passive (not expressing needs), aggressive (demanding without respect for others), passive-aggressive (indirect expressions of anger), and assertive (clearly expressing needs while respecting others). She completed the Communication Styles Quiz and discovered her predominantly passive style, which helped explain why her needs were consistently unmet. Carmen began practicing assertiveness using a structured approach: first describing the situation factually, then expressing her thoughts and feelings about it, and finally clearly stating what she wanted. In role-play exercises, she practiced saying to her boyfriend: "When you ask me to use drugs with you, I feel anxious and conflicted because staying clean is important for my probation and my health. I need you to stop asking me to use with you, and I'd like your support in staying clean." To develop your own interpersonal effectiveness, first identify your communication style and the patterns that aren't serving you. Practice the assertive formula: "When you [describe behavior factually], I feel [emotion] because [explanation]. I would like [clear request]." Remember that being assertive doesn't guarantee you'll get what you want, but it significantly increases the chances while preserving both the relationship and your self-respect. Begin with lower-stakes situations to build confidence. For example, if you're typically passive, practice sending back an incorrect order at a restaurant or expressing a preference about weekend plans with friends. Pay attention to your body language and tone of voice, which should match your words – speak clearly and make appropriate eye contact without becoming aggressive. The balance of priorities is essential in interpersonal effectiveness. Sometimes your goal takes priority, other times the relationship is most important, and sometimes maintaining your self-respect must come first. Learning to identify your priority in each situation allows you to choose the most effective approach, creating relationships that are balanced and fulfilling rather than sources of ongoing distress.

Chapter 6: Implementing DBT in Various Clinical Settings

While DBT was originally developed as a comprehensive treatment for borderline personality disorder, it has been successfully adapted for numerous settings and populations, making it one of the most versatile evidence-based therapies available today. Mathew was a mental health therapist who worked in a community clinic with limited resources. Though he recognized the value of DBT for his clients with emotion regulation difficulties, he initially felt overwhelmed by the complexity of the full model, which traditionally includes individual therapy, skills training groups, phone coaching, and a consultation team for therapists. "We don't have the staff or funding to implement all four components," he explained to his supervisor. "Does that mean we can't offer DBT at all?" Through additional training, Mathew discovered that DBT could be flexibly adapted while maintaining its core principles. He began by focusing on the skills component, organizing a weekly DBT skills group while continuing to see clients individually. Though he couldn't offer 24-hour phone coaching, he arranged for clients to have access to a crisis line where staff were trained in basic DBT skills coaching. As Mathew became more comfortable with the model, he gradually incorporated more DBT strategies into his individual sessions. He introduced behavior tracking sheets to structure sessions and taught clients to complete behavior analyses when problem behaviors occurred. He also formed a small consultation group with colleagues from neighboring clinics who were similarly interested in DBT, meeting monthly to discuss cases and ensure fidelity to the model. If you're considering implementing DBT in your practice, start with what Linehan calls "DBT-informed therapy." Begin by learning and practicing the skills yourself, then teaching them to clients. Gradually incorporate DBT strategies like validation, dialectical thinking, and behavioral analysis as you become more comfortable with the model. Remember that some DBT is better than no DBT – you don't need to implement the entire model to see significant benefits. For organizational implementation, consider starting with a single component, such as a skills training group, and gradually add additional elements as resources allow. Identify champions within your organization who can help advocate for the necessary training and supervision. Document outcomes to demonstrate effectiveness, which can help secure additional resources for full implementation. Remember that DBT is principle-driven rather than protocol-driven, allowing for flexibility while maintaining the essential dialectical balance between acceptance and change. This adaptability has contributed to its successful application across diverse settings including inpatient units, partial hospitalization programs, schools, correctional facilities, and even primary care practices.

Chapter 7: Overcoming Common Treatment Challenges

Implementing DBT effectively inevitably involves navigating various challenges, both for therapists and clients. Understanding these common obstacles and developing strategies to address them increases the likelihood of successful treatment outcomes. Jessica, an experienced therapist new to DBT, found herself struggling with a particularly challenging client named Rob. During a consultation team meeting, she expressed her frustration: "No matter what I do, Rob seems to push back. He says he wants help, but he never completes his diary cards, frequently cancels sessions, and when we do meet, he spends most of the time criticizing the treatment. I feel like I'm failing him, and honestly, I'm starting to dread our sessions." The consultation team helped Jessica recognize that she had fallen into a common trap – taking responsibility for Rob's progress and feeling personally affected by his resistance. They reminded her of the DBT principle that clients cannot fail in therapy; if therapy isn't working, it's the therapy (not the client or therapist) that has failed. This perspective shift helped Jessica approach Rob with renewed curiosity rather than frustration. Jessica implemented several strategies to address the challenges. First, she revisited commitment strategies with Rob, collaboratively identifying his goals and linking DBT skills to those specific goals. She also addressed therapy-interfering behaviors directly, using behavioral analysis to understand what was maintaining Rob's pattern of non-compliance. Additionally, she increased her use of validation while still pushing for change – acknowledging how difficult it was for Rob to trust the process while maintaining clear expectations about homework completion. If you're facing challenges in implementing DBT, first ensure you're practicing adequate self-care. Compassion fatigue is real, especially when working with highly dysregulated clients. Use your own support network, including consultation teams or supervision, to process difficult interactions and maintain perspective. Remember that observing your limits (rather than rigidly setting boundaries) helps prevent burnout while modeling healthy relationship dynamics. For clients struggling with skills practice, break tasks down into smaller, more achievable steps. If mindfulness for five minutes feels overwhelming, start with one minute. If completing a full diary card is too much, begin with tracking just one target behavior. Celebrate small successes and use shaping strategies to gradually increase expectations as clients build confidence. The most effective DBT therapists maintain flexibility while adhering to core principles. They balance unwavering acceptance of clients with an equally unwavering push toward more effective behavior. As Linehan herself notes, therapists are fallible too – approach challenges with the same dialectical stance you encourage in clients, accepting difficulties while continuously working toward more effective therapeutic interactions.

Summary

The journey through Dialectical Behavior Therapy reveals a powerful truth: seemingly opposite realities can coexist, creating space for transformation. By embracing the fundamental dialectic of accepting ourselves exactly as we are while working toward change, we develop the capacity to navigate life's challenges with greater balance and purpose. As Linehan eloquently states, "The therapist's task is to help the patient find the synthesis between self-acceptance and change in order to achieve freedom from the dialectical dilemmas that otherwise entrap and immobilize." Your path forward begins with a single dialectical step: acknowledge where you are today with compassion and acceptance, while simultaneously committing to practice one skill that moves you toward the life you envision. Whether it's pausing to take three mindful breaths during a moment of emotional intensity, validating your experience without judgment, or clearly expressing a need in an important relationship, each skillful action builds your capacity for a life worth living. The skills of DBT aren't merely therapeutic techniques—they represent universal human capacities for awareness, connection, and growth available to anyone willing to practice them with patience and persistence.

About Author

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Sheri Van Dijk

I am a psychotherapist working at Southlake Regional Health Centre and in private practice. I have a Master's degree in social work, and specialize in treating psychiatric disorders using dialectical behavior therapy and mindfulness practice. I have written several books that help readers use DBT skills to treat emotional problems, including The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder, The Bipolar Workbook for Teens (co-author), Don’t Let Your Emotions Run Your Life for Teens, and Calming the Emotional Storm; and am the author of DBT Made Simple, a book that aims to teach clinicians how to use DBT with their clients diagnosed with a variety of emotional problems. I'm just putting the finishing touches on my sixth book, which teaches teens DBT skills to help them be more effective in their relationships; look for this book to be published early in 2015.In 2010 I won the R.O. Jones Award at the Canadian Psychiatric Association Annual Conference for my research on using DBT skills in a bipolar disorder group, published in the Journal of Affective Disorders in March, 2013.Visit me at www.sherivandijk.com.

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