What is Dialectical Behavioral Therapy? The Features of DBT, Radical Acceptance, and Coping with Pee

Monday, October 13, 2014 by Meg   •   Filed under Treatment Techniques

Dialectical Behavioral Therapy (DBT) has been a growing phenomenon in the psychotherapy world. And as this movement becomes more popular in the general population, I have been getting more and more questions about it.

“So….DBT is like Cognitive Behavioral Therapy…but it isn’t?”

Pretty much. There are a number of great books on it, including Calming the Emotional Storm: Using Dialectical Behavior Therapy Skills to Manage Your Emotions and Balance Your LifeDBT Made Simple: A Step-by-Step Guide to Dialectical Behavior Therapy, the DBT Skills Training Manual, Doing Dialectical Behavior Therapy: A Practical Guide (Guides to Individualized Evidence-Based Treatment)Dialectical Behavior Therapy for Binge Eating and Bulimia, and, as a clear winner for the longest title on the planet, The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. 

But before you run out and buy those, I invited a friend of mine to tell you all about DBT and illustrate some key concepts for you. Welcome to the world of Dialectical Behavioral Therapy.

By: Dr. Angelica Shiels

I’d like to introduce you to my girl, Marsha Linehan.  Okay, so maybe this stoic, no-nonsense psych guru doesn’t even know who I am, but I know who she is and think of her often.  

Dr. Linehan is the mastermind behind DBT (Dialectical Behavioral Therapy), a type of therapy that is designed to help people manage extremely difficult emotions and/or life circumstances. 

Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT)

DBT is somewhat like the popular Cognitive Behavioral Therapy (CBT) in that it that guides patients to reframe their thoughts to be more realistic and tolerable while also encouraging more effective behaviors. However, DBT incorporates unique skills that are especially useful for those with interpersonal and emotional regulation issues.

A central assumption of DBT is that some people have a tendency to become much more emotional much more quickly than the average person.  The psychological literature calls this “increased arousal,” while I sometimes refer to the behavior as being “fired up.”  Have you ever noticed how one person might shrug her shoulders when her boyfriend forgets to call her back, and another person might become deeply offended and angry?  The second type of person would be an ideal candidate for DBT because DBT teaches skills to manage and tolerate this increased arousal. 

The main features of DBT include: 

  • Interpersonal effectiveness, or improving communication, perspective-talking, appropriate assertiveness, etc. 
  • Distress tolerance, or learning ways to tolerate distressing feelings without making the situation worse by blowing up
  • Emotional regulation skills, such as understanding and calming 
  • Improving mindfulness skills, or observing your experiences with awareness (more on mindfulness and self compassion here
  • Reality acceptance or radical acceptance

My favorite is that last one. So how about some elaboration on radical acceptance?  

DBT and How to Practice Radical Acceptance

One of the central aspects of DBT, “Radical Acceptance,” has gotten me through so many moments of powerless frustration in my life that, last year, I considered sending a Christmas card to Marsha’s office:

Happy Holidays, to the Marshster!  P.S., Thanks! Since you helped me radically accept the reality of pee, this year I managed to refrain from selling even one of my kids to any gypsies. 

What is Radical Acceptance? 

Radical means “complete and total.”  So in order to radically accept something, we have to surrender to  unchangeable circumstances, even the difficult parts.

There are three parts of radical acceptance: The first part is accepting that reality is what it is.  (My kid keeps peeing himself.) The second part is accepting that the event or situation causing you pain has a cause, even if you don’t know the cause. (Umm… maybe developmental issues? medical issues? He just doesn’t want to interrupt his playing to use the potty?  Santa scared the piss out of him?)  The third part is accepting life can be worth living even with painful events in it. (Umm, no, I don’t see a little more laundry as detracting from the enjoyment I get in from watching the Millionaire Matchmaker or dancing to Gangman Style with my kids.)

Sometimes the problems that we face in life are really serious; yes, there are many things that are more painful than having to change the sheets every. single. morning.  Dr. Linehan gives the examples of a family member dying, having a permanent disability, or having experienced a traumatic childhood. Regardless of the severity of the problem, in the event that something unpleasant is not immediately changeable or fixable, what is a person supposed to do?  Well, we have two choices:

1)  Fight it internally. In this case, individuals use emotional energy to become angry, outraged, stuck on wanting the unchangeable to change, focus on it/relive it again and again, etc.

2)  RADICALLY ACCEPT the reality.  Say, “It is what it is, it has a cause (even if I don’t know the cause), and my life is worth living even though this has happened.”

Here are some examples of common unchangeable scenarios that are often difficult to accept (I chose these as examples because  of how often they come up in therapy, and how relatable I believe they are to everyone.):

- A personal limitation within yourself.  I can radically accept the fact that I am often disorganized and haphazard. The sooner I acknowledge that this affects my husband’s life, the sooner he will feel validated and we will stop fighting. (That’s just a made-up example totally unrelated to my real life.  Yup, that’s my story and I’m sticking to it.)

- A limitation in someone else.  I can obsessively think about how mortally wounded I am by my friend’s lack of giving any shits about my birthday. Or I can radically accept that she’s just not into acknowledging another person’s anniversary of birth.  I can chose to be enraged by the fact that my distractible six-year-old takes an hour to read a seventeen page book, or I can surrender to the reality of his abilities. I can radically accept that my husband has a different, less-detail-oriented, more linear/rational way of thinking OR I can be outraged and butt-hurt that he doesn’t think to pick up milk and dismisses my irritation with my friend who forgets my birthday.

- A certain thought or emotion.  I could chose not to accept many of my thoughts and emotions. I could tell myself that there’s something wrong with me for feeling overwhelmed with grief that the DVR messed up and didn’t record the last Millionaire Matchmaker, or that I fantasize about squishing my annoying coworker’s head with my thumb and forefingers fingers across the room (You know you do it too). OR I can radically accept that my thoughts and emotions are what they are without fighting them. (People with anxiety would do well to accept/ride-out/distract themselves from their fear instead of fighting it. Telling yourself you shouldn’t be upset or afraid will only make it worse.  In fact, telling yourself you shouldn’t feel or think anything is a sure-fire way to get you to feel worse.)

But there is a difference between acceptance and approval:  You may accept a circumstance or behavior is as it is, but not necessarily approve of it.  If you have accepted that your boyfriend is not going to change his defensive and selfish ways, but you don’t have to approve of those characteristics. In other words, it might be time to break up with him.  If you have accepted that you are the selfish, hot-headed one, you could decide to manage your anger and do some things for the other person once in a while. Just because I accept that my four-year-old still has accidents in his pants does not mean that I don’t make him go potty several times a day and reinforce using the toilet.  Because, no, I don’t approve of pee puddles all over the house.  And finally, accepting that something terrible has happened, or that you were wronged or traumatized by someone, does NOT mean that you enjoy the situation or the perpetrator’s behavior.  It simply means that you accept that it has happened and there is nothing you can do to change the fact that it happened.

Marsha Linehan says that pain in life is inevitable, but suffering can be avoided.  The only difference between pain and suffering is that with suffering, there is refusal to accept realities for what they are. So the next time you experience something that is frustrating, painful, uncomfortable, or upsetting, and you can’t change it, remind yourself that you have a choice.  You can radically accept that the situation or you can add insult to injury and make a painful situation into suffering.  

I hope you chose radical acceptance.

Dr. Angelica Shiels is a wife, a mom of three young boys, and a therapist in private practice in the Annapolis, Maryland area.  She blogs shamelessly about psychology, relationships, and parenting adventures at On the Yellow Couch. You can also find her on her brand new Faceboook page and Twitter.

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Topic-Relevant Resources

The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & ... Tolerance (New Harbinger Self-Help Workbook)
Easy to read and complete worksheets to practice and perfect DBT skills.

DBT® Skills Training Manual, Second Edition
Everything you ever wanted to know about the skills embraced by those using Dialectical Behavioral Therapy.

DBT Made Simple: A Step-by-Step Guide to Dialectical Behavior Therapy
This book is exactly what it says: step by step practices to incorporate DBT into your daily life.

Calming the Emotional Storm: Using Dialectical Behavior Therapy Skills to Manage Your Emotions and Balance Your Life
A guide to using DBT to decrease arousal, manage emotions and decrease difficulties.

Dialectical Behavior Therapy for Binge Eating and Bulimia
A great guide for using DBT to challenge eating disordered behaviors and the thoughts that go with them.

Mindsight: The New Science of Personal Transformation
New techniques for mindfully altering the wiring of your own brain, leading to increased happiness.

The Mindfulness Solution
Meditative and cognitive techniques for everyday use