What is dialectical behavioral therapy?
Mikołaj Wroński - RMF FM: Let's start with the name - DBT, i.e. dialectical behavioral therapy. Sounds complicated, but what does it actually mean?
Magdalena Skuza: DBT is a behavioral therapy, i.e. focused on understanding behaviors that are treated in a broader sense than just what can be seen from the outside, such as talking, shouting or other specific actions. Behavior also includes internal processes, i.e. emotions, thoughts, ways of reacting or dealing with difficulties. Each of them can be a source of suffering or maintain it. In DBT, we try to understand where certain behaviors come from and what a person has learned during his or her experiences. Therefore, it is not about "training" the patient or simply changing visible behaviors, but about recognizing their meaning, even when they are harmful, and gradually modifying them.
The word "dialectical" means taking into account different perspectives. Dialectic says that there is no absolute truth and at the same time there is a grain of truth in every perspective. In this therapy, we assume that even the most difficult behaviors of the patient have their meaning and functions, even if they lead to suffering. The therapist does not impose his vision of what is right, but helps find a balance between acceptance of the current situation and the need for change.
This is the most important axis of DBT - on the one hand, we work on changing behaviors and mechanisms that maintain suffering, and on the other, we recognize and validate human experiences. Another important element is mindfulness, i.e. the ability to be "here and now", noticing your own emotions, thoughts and reactions without automatically judging them. DBT therefore links change with acceptance. Therapy is intended to help overcome suffering, but without questioning what the person has experienced.
You talked about mindfulness. What does it involve in everyday life?
Mindfulness is not so much a goal in itself, but a skill that can be developed. In DBT, we treat it as a way to be more aware of what is happening at a given moment, in us and around us. For people who experience strong emotions or long-term suffering, a natural reaction is to avoid difficult thoughts, stress, confrontation or their own feelings. Mindfulness is the opposite of this avoidance. It allows you to notice what is happening and accept the experience as it is, rather than immediately running away from it. If something unpleasant happens to us, e.g. someone cancels a meeting, we may feel sad. Mindfulness is not about fighting this sadness or convincing ourselves that we don't care at all. Rather, it's about noticing it, experiencing it - and then returning to your current activities. It is also the ability to notice one's own impulses, changes in the body and thoughts, which often automatically comment and evaluate reality. In a mental crisis, these thoughts may be particularly rigid: "this person hates me", "I definitely won't be able to cope", "I'm in danger". Practicing mindfulness helps you take a step back and say: "This is my thought, not necessarily an objective description of reality." Of course, this does not mean that we immediately stop believing in such thoughts. It's about gradually noticing how they affect us and gaining greater freedom in reacting. It's a process that takes time and work.
But it must also mean being willing to accept that we will also experience pain in life.
Yes, this is part of DBT therapy, which is grounded in acceptance and understanding for everyone who comes for help. People who go to therapy often have experienced losses, traumatic experiences, a lot of suffering and the feeling that they have been treated badly and invalidated by those around them. They may also fear that the pain will return. In such a situation, the desire to cut yourself off from emotions is very understandable. “I don't want to feel this, I don't want to go through this again” is a natural starting point. However, acceptance does not mean consent to suffering or harm. The transition from years of avoiding emotions to being ready to experience what life brings is not easy. For many people it may even sound like something impossible. That's why in DBT it's important to meet a person exactly where they are now: recognize their current problems, understand what they're facing, and show how specific therapy can help. So we work on what needs to be solved here and now, but at the same time we look towards the life that the person wants to achieve. No abstract promises that daily mindfulness practice alone will bring peace. Mindfulness may have benefits, including at the neurobiological level, but it is not enough. Therefore, behavioral techniques and learning specific skills also play an important role in therapy. The state we want to reach with each patient is to create a life worth living, i.e. to determine what is important to him, what he wants, what difficulties and traumas hold him back, and then engage all available resources and strategies to get to this place.
What exactly does mindfulness give us?
Developing the skills and attitude of mindfulness can be compared to learning a new language. Everyone has their own native language in which they speak fluently, this language consists of vocabulary and patterns of using them. Our emotional, family and traumatic experiences teach us to speak a certain "language": we judge others, we get angry at failure, we avoid something, we control, we think that we are worthless. It is our automated language for communicating with each other and the world, our patterns. When we start to develop mindfulness, we learn a new language of communicating with ourselves and the world: we observe instead of doing automatically, we describe instead of judging, we notice more, we begin to see our automatisms, "old patterns", thanks to which we can choose whether to follow them or choose new patterns: observing, describing, being present, acting effectively and not impulsively. Regular mindfulness practice helps strengthen this new language, new behavior patterns. Importantly, we know from research that these new reaction patterns are observable at the level of changes in the activity of the brain and the entire nervous system.
When to seek help in this field and how is the therapy carried out?
For what problems is it worth seeking dialectical behavioral therapy?
DBT is especially effective for people who experience significant problems with emotion regulation. These are situations in which they are so strong that they influence thinking, relationships, decisions and everyday functioning. This may apply to people with impulsive behavior, difficulty maintaining stable relationships or life situations, as well as chronic suicidal thoughts and tendencies. The reasons may also include self-aggressive and self-destructive behavior, problems with impulse control, eating disorders, harmful substance use, anxiety or depressive symptoms.
Most often, we associate DBT with therapy for people diagnosed with borderline personality disorder. However, it can be helpful for a variety of other complex disorders.
It is an intensive therapy, so it is usually addressed to people who were not satisfied with previous forms of help. DBT is holistic and helps you work on emotions, behaviors, relationships and safety at the same time.
So, to put it simply, if someone cannot cope with emotions and has suicidal thoughts, is it a signal to consider this form of therapy?
Yes, especially if the emotions are so strong that they are very difficult to control. Someone may explode, take impulsive actions or, on the contrary, suppress his or her experiences very strongly. Whenever a difficult emotion arises, he immediately does something to drown it out. Chronic difficulties in relationships are also an important signal, e.g. high variability, "ups and downs", thinking in "all or nothing" categories. These are circumstances that are worth consulting and checking whether DBT can be helpful. This does not mean, however, that the patient must decide for himself which therapy is right for him. A DBT therapist does not begin work without a joint, thorough assessment of a person's problems and needs. The responsibility for this qualification does not lie solely with the patient. It is worth adding that there are also DBT programs adapted to work with youth.
Is working with addiction also an option?
DBT-based addiction treatment programs exist, and this form of therapy can be especially helpful for people who use substances or engage in addictive behaviors to cope with strong emotions and discomfort. DBT teaches you to recognize emotions, tolerate tension and regulate it in a way other than using stimulants or addictive behaviors. It also helps to stop established, automatic patterns of reaching for a substance. It is also very important to understand the path that led a given person to addiction, without moralizing or judging him or her as "weak". In therapy we talk about dialectical abstinence. This means that the goal is, of course, abstinence, but its interruption does not invalidate the entire process. They are treated as a signal to analyze the situation and further work on even more effective strategies.
And when is it worth seeking help in another therapeutic field?
When the patient's problems can be explained by a more limited set of symptoms, for example in anxiety disorders, social anxiety disorder, OCD or uncomplicated, non-chronic depression without co-occurrence of other disorders and suicidal tendencies. Similarly, in the case of a single traumatic experience after which specific symptoms appear. For such difficulties, there are other methods that are effective and less complex than DBT.
What happens during therapy?
DBT assumes that many of the patient's difficulties, from lack of emotion regulation to self-destructive behavior, are related to a deficit of specific skills. The standard DBT program consists of several modes.
The first is individual therapy, i.e. regular meetings with a therapist, during which the patient learns to understand his or her behavior, emotions and crisis situations. Suicidal tendencies, self-aggression and other impulsive behaviors are monitored especially at the beginning. However, it is not only about analyzing them, but also about learning new, more effective ways of responding.
However, the patient acquires these skills primarily during group DBT training. It usually takes place once a week and includes, among others: learning mindfulness, tolerating mental discomfort, emotion regulation and interpersonal effectiveness. Participants learn specific tools that help them recognize emotions, reduce arousal, deal with a crisis and stop the impulse to self-harm, aggression or reaching for substances.
The third important element is coaching between sessions, most often by telephone. It is intended to help transfer new skills to everyday life, especially when tension suddenly appears and old habits return. The therapist does not solve the problem for the patient, but helps him apply what he has learned in therapy. Each time you use a new skill, it strengthens the new way of reacting and gradually weakens the old one.
The fourth element of DBT is the therapist consultation team, sometimes called "therapy for therapists." Specialists working in this field meet regularly, usually once a week. Together they discuss difficulties in working with patients, look for solutions and support each other in conducting therapy in accordance with the principles of DBT. All these elements should take place simultaneously.
Telephone coaching means that the patient can simply call the therapist between sessions?
Yes, but such contact always takes place on previously agreed terms. The patient and the therapist discuss when to call, in what situations, how long the conversation can last and what it is intended for.
Costs, duration of therapy and availability in the National Health Fund
Is dialectical behavioral therapy possible under the National Health Fund?
Yes. The full DBT program can be implemented as part of services financed by the National Health Fund, because its individual elements can be billed accordingly. There are already facilities in Poland offering this form of assistance, including: in Warsaw, Kraków, partly in Gdańsk and Greater Poland. However, availability is still limited. For a DBT program to work, the facility needs trained therapists who work as a team and implement all elements of the therapy. There are still relatively few such specialists in Poland, but their number is growing.
How much can one private therapy session cost?
Prices depend on the city and facility, but an individual DBT session itself should not be more expensive than a standard psychotherapy session in another field. In Tricity, where I work, it is usually around PLN 150-250 for an individual meeting. Group DBT skills training takes place separately. A two-hour meeting can cost around PLN 120-180, although rates vary. Telephone coaching between sessions is most often included in the settlement of individual therapy and does not necessarily mean an additional fee.
How long does this therapy last?
In adults with severe emotional dysregulation, chronic suicidal tendencies or self-aggressive behavior, the first phase of therapy, i.e. stabilization and limitation of health- or life-threatening behaviors, usually lasts from one to two years. During this time, the patient learns to regain control over impulses, apply new skills and cope with crises. Some people see significant improvement already at this stage, e.g. hospitalizations related to suicide attempts stop. If other difficulties co-occur, such as addiction or severe post-traumatic symptoms, another year or two of in-depth work may be needed. DBT is therefore usually a medium-term therapy. A very significant change can be made within two to three years, although it is worth remembering that some people, due to the scale of previous experiences and suffering, may need support for longer.
What to expect during your first visit to a DBT therapist?
At the beginning, the therapist asks a lot of questions because the first meetings are primarily aimed at assessing whether DBT will be the best form of help for a given person. The therapist will ask about the difficulties experienced, especially about emotion regulation, impulsive behavior, crises and ways of dealing with tension. It may also use tools, e.g. questionnaires. An important topic will be motivation and readiness to work. DBT requires active participation, including practicing skills between sessions, monitoring difficulties, and engaging in working toward established goals. The therapist explains the rules of the program, its requirements and what individual therapy, group training and possible coaching between sessions look like. The decision does not have to be made in one visit. DBT usually has an orientation phase that lasts about three to five meetings. During this time, the patient and the therapist together set goals and check whether this therapy is appropriate.
