Brenda, a woman in her late thirties, had severe anxiety that hadn't gotten better through past therapies. She would have panic attacks on the train that sometimes prevented her from getting to her appointments. She would isolate, not reaching out to friends because she was afraid they might not want to hear from her. Brenda also found that her relationships tended to be rocky. She would break up with her boyfriend one day, then text him non-stop the next, begging him to get back together.

Seeing that the then-current therapy was not working, Brenda's therapist referred her for a more intensive treatment, one that I've frequently had success with. As a therapist, it's common for me to meet people who have tried therapy many times before, sometimes without successful resolution of the problems they're seeking help for. I practice a type of psychotherapy that often works where other modes of therapy have failed: Dialectical Behavior Therapy (DBT). In many cases, DBT has offered my clients great success. So, what is DBT, how does it work, and why does it succeed where other therapy methods don't?

DBT Fills in the Gaps Left by Regular CBT

Dialectical Behavior Therapy was originally developed by psychologist Dr. Marsha Linehan in her work with women who had been hospitalized after attempting suicide or serious self-harm. As a health professional who cares deeply about offering her patients effective treatments, Dr. Linehan initially practiced Cognitive Behavioral Therapy (CBT), a type of treatment that promotes changing thoughts, feelings, and behaviors in order to manage and reduce anxiety.

CBT is typically considered a gold standard in anxiety treatments. However, Dr. Linehan found that standard CBT wasn't working with her clients. CBT's emphasis on changing thoughts and behaviors did not do enough to support her clients in accepting where they are right now. The CBT techniques alone were too invalidating to people, who often found concepts such as cognitive distortions to imply that their thoughts and feelings were wrong. Dr. Linehan found that something different was needed - a method that acknowledges and supports the truth upon which clients' experiences are based.

This is where DBT comes in: Dialectical Behavior Therapy is a type of Cognitive Behavioral Therapy, but what makes it unique is its emphasis on mindfulness and dialectical thinking. Rather than only treating symptoms as problems to be solved, DBT places an equally important emphasis on acceptance of experiences as they are in this moment.

How Dialectical Thinking Plays a Role in Therapy

DBT focuses on dialectical thinking: dialectics refers to a philosophical stance in which two ideas or truths, seemingly opposed to one another, can both exist at the same time. For example, a person coming to therapy may need both acceptance of where they are right now, as well as motivation to change. In other words, they need to recognize that everything is exactly as it should be, and at the same time know that they must do better and try harder to create positive change.

How Does DBT Help with Anxiety?

Emotions serve important functions in our lives. Primary emotions linked to anxiety, such as fear, can at times make perfect sense - when there is a threat to our life, health, or well-being, fear can motivate us to act and protect ourselves. At times, however, emotions like fear arise when they are not helpful or productive. These emotions can be difficult to cope with and manage, leading to anxiety and distress.

DBT works through the process of learning emotional and cognitive skills (acquisition), and subsequently applying those skills to your life (generalization). Generally, DBT tackles difficult and distressing emotions and it can help you improve your capacity for emotional regulation, that is, your ability to control the emotions you have, when you have them, and how you experience and express them.

Training Mindfulness and Distress Tolerance Skills with DBT

Through the DBT skills training group, clients learn skills such as mindfulness and distress tolerance techniques that aid in being able to accept the present moment with willingness, rather than fighting reality. These techniques could include breathing exercises, counting to ten, or holding an ice cube in order to bring awareness and acceptance to the present. Exercises like this encourage us to choose to accept what is happening in the moment.

DBT's emotion regulation skills include observing and describing emotions, along with a systematic toolkit for altering emotions you want to change. These tools include checking the facts of a situation, acting opposite to the action urge of the emotion, and problem solving to change the event prompting a particular emotional reaction.

Changing and influencing emotions is a central goal of DBT, but before you can get to this step it is critical to understand and know where these emotions are coming from and why they arise. The "understanding and acknowledging" step of DBT is one of the main facets that separates it from regular CBT: this approach supports the mindful and non-judgmental observation and description of emotional experiences. The addition of this aspect makes DBT effective across a range of mental health problems, including anxiety disorders, because the skills you learn help you differentiate emotions from facts, allowing you to work with and manage emotions effectively.

Using DBT to Develop Emotional Skills and Alleviate Anxiety

Comprehensive DBT consists of several parts, including individual therapy with a trained therapist, group skills training, skills coaching (often available by telephone), and the therapist's participation in a consultation team. All these parts work together to ensure that DBT offers skills you can put into practice to make you feel more in control and in charge of how you feel and how you live in your surroundings. If you are living with an anxiety disorder, you probably know that feeling in control of yourself is an extremely valuable, validating feeling.

In Brenda's case, emotion regulation skills such as Opposite Action helped her approach, rather than avoid, situations where she felt fearful. Mindfulness skills helped her accept the present moment, and she was able to bring more joy and meaning to her life through healthy relationships.

Best of all, what you learn from DBT can be useful for anyone, even when you're doing well. DBT offers and teaches healthy life skills that will remain with us for years and that we can all infuse into our lives.

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