Last week, we put up a post introducing the basics of DBT. These basics included what it is, how it works, and who it’s for. This week we’ll go more in-depth into what the 4 domains of DBT are and how they work in sessions.
Distress tolerance
Many individuals who have borderline personality disorder have a difficult time with distress tolerance. That’s why this is such an important aspect of DBT. Distress tolerance refers to how able someone is to experience and manage difficult or intense emotions. These emotions can often increase stress. Chronic stress can then be potentially harmful in the long term, resulting in immune system damage, depression, and anxiety. It can even impact your heart health.
Being able to tolerate stress and difficulty is an important skill that everyone needs in order to successfully thrive and grow as a person. Not being able to do so can result in destructive or problematic coping skills to try and reduce or avoid distress. While these may work in the short-term, they often make the individual worse over time.
Clinicians can use a variety of techniques to help an individual increase distress tolerance and learn healthier coping skills. A common method used is called TIPP – Temperature change, intense exercise, paced breathing, and paired muscle relaxation. Temperature refers to a quick and sudden change in temperature. It can be done by either splashing cold water on your face or holding a cold item, such as an ice pack, in your hands. This sudden change in sensation can help distract from intense emotions. Intense exercise relates to a short burst of exercise, such as running in place or jumping jacks. This is another technique that can help an individual distract themselves from their emotions or thoughts. Some clients with mobility difficulties may not be able to partake in intense exercise, so this can be left out or modified for them. Paced breathing is using a breathing technique, such as box breathing, to help calm an individual. By slowing and calming the breathing, it helps send signals to trigger the parasympathetic nervous system, which helps calm the body after a “fight or flight” response. Paired muscle relaxation is a type of meditation practice that involves systematically tensing and releasing tension in muscles. This helps bring awareness to the body and be in the present moment. This is another method that may not be suitable for some people, such as individuals with severe PTSD or some medical conditions. Instead, have them press their hands together or hold onto an object tightly, if able. Or this can be skipped, if needed.
Emotional regulation
Emotional regulation is a client’s ability to not just tolerate distress but to manage their emotions through psychological changes. This involves a level of psychological flexibility and means that someone can bring themselves back to their emotional baseline after experiencing something distressing. Many people who have mental health disorders struggle with emotional regulation. DBT helps clients work on these skills by allowing them to accept their emotions without placing judgements on them. They can see their emotions as a “right now” feeling and reduce potential secondary responses to their emotions, such as shame or guilt.
A common technique that many clinicians employ in DBT is S.O.S.: Stop, Observe, Shift. This skill asks the client to take a pause so they don’t act on impulse. They then are asked to just observe what’s going on inside of themselves and into what triggered their response. Finally, the client would then shift to a new response that is more adaptive than their previous patterns of responses.
Interpersonal skills
Interpersonal skills revolve around being able to communicate with other people and establish and maintain relationships. These relationships can be friends, family, colleagues, romantic partners, etc. Many individuals who seek out therapy struggle with interpersonal skills. This is usually due to some previous adverse event that has resulted in them having difficulty trusting people or communicating effectively. These events could be abuse, neglect, abandonment, or betrayal and could have been a one-time event or could have been a chronic, on-going problem for years.
DBT can help individuals recognize this communication style and make changes to it if this is contributing to their interpersonal problems. It can also help people with active listening, which is something many people struggle with. Not being able to engage in active listening can have a strong negative impact on people’s relationships. Many clinicians will utilize worksheets in order to help teach clients these skills and help them use them outside of session.
Mindfulness
Many people have heard of mindfulness but aren’t really sure of exactly what it is or how it works. The act of mindfulness involves being able to be present in the moment and observing thoughts, feelings, and events without judgement. It can help clients to be able to tolerate distress more effectively by taking that judgement that we so naturally attach to events out of the picture. Mindfulness is a core component of DBT and is taught to clients through many different means.
Clinicians will often introduce mindfulness to clients through guided meditation or teaching them mindful breathing. They can also send clients home with homework that would have them do exercises such as going on a mindful walk, doing some kind of writing exercise, or doing a guided meditation at home on their own. Guided meditations can either be found on YouTube or other sources online that a clinician will recommend or clinicians may even make their own recordings for clients.
It’s important to remember that mindfulness needs to be individualized for the clients. Some clients struggle with visual mindfulness exercises. Some clients with severe PTSD may have a hard time being in a room with other people and closing their eyes. Keeping in mind what your client needs allows for a more successful introduction to mindfulness, making it more likely that they will use the skill outside of session.
