DIALECTICAL BEHAVIOR THERAPY / DBT IN A COUNSELING SETTING: What to Expect & How it Works. Sarah Peterman. Inverness Palatine IL Counselor Specialist


Dialectical Behavior Therapy/ DBT in a Counseling Setting

What to Expect & How it Works

Sarah Peterman, LCSW
Clinical Care Consultants Psychotherapist / Counselor – Inverness IL


 What does DBT mean?

As a counselor / psychotherapist who is passionate about helping clients who self-injure and/or who have a Borderline Personality, Mood, Anxiety or Eating Disorder, I feel compelled to educate others about Dialectical Behavior Therapy (DBT), a scientifically validated psychotherapy / counseling method. The following information should help either the person with one of the above disorders, or their loved ones, to be more informed and confident about the therapist/treatment provider and type of treatment they decide to choose.

DBT, which is short for Dialectical Behavioral Therapy (because that is a mouthful!), is a type of therapy which has gotten some attention in the media in recent years.   It was developed by Marsha Linehan, who is also a prolific/best-selling writer about the topic and professor of Psychology at the University of Washington.  In 2011, Dr. Linehan courageously disclosed that she has struggled with a life-long history of Borderline Personality Disorder.

However, for many people searching for a therapist, they are unsure of what to expect when a therapist, like myself, says they use DBT in therapy. While it’s not important to know ALL the details about DBT, it can be very useful to know “what you are getting into” based on what a therapist says they specialize in. As such, let me break DBT down a little bit.

Firstly, Dialectical Behavior Therapy uses the word dialectic which means being able to hold two opposing views at the same time. The main “dialectic” or opposing views for the DBT therapist are acceptance and change. This means that when I am in therapy with a client I work hard to understand where they are now and validate that they are doing the best that they can with what they know. However, it also means that, even though I am accepting my client and their experience as it is, I am also helping to move them towards changing things which aren’t working for them. I also encourage my clients to approach their problems this way – with a gentle acceptance for their struggles while still identifying potential areas for change and taking active steps towards that change. Long story short, DBT focuses on the fact that once we can accept our current struggles as they are and as a part of our experience we are often more free to make meaningful change.

There are a few more basic assumptions that I have when meeting with a client which resonate from the DBT perspective. These assumptions include the idea that people are doing the best that they can, want to improve, and need to learn new skills in therapy which they can apply and practice in their “real lives.” This impacts how I interact with clients and work with them to move towards and maintain changes in their lives. It means that I focus on my client’s strengths and motivation throughout the therapy process. It also means I typically assign homework so that my clients get a chance to practice what is talked about or worked through in the therapy session in the life situations in which they feel they need to be able to use them.

So, who benefits from DBT therapy?

Initially DBT was developed for people struggled with Borderline Personality Disorder, which is a disorder in which people struggle with intense emotions, feelings of emptiness, fears of abandonment, and sometimes engage in self-destructive behaviors like self-injury, eating disorder, and/or addictive behaviors and/or experience frequent suicidal thoughts.

While DBT continues to be very effective for clients with Borderline Personality Disorder, more recently it has been confirmed that DBT is also effective for adolescent and adult clients who experience other disorders which create intense emotions or in which clients engage in self destructive behaviors. For example, I have worked with clients with depression, Bipolar disorder, anxiety disorders, eating disorders, self-injury, suicidal ideation, personality disorders other than Borderline Personality, and addictive behaviors within this model. Clients with a variety of reasons for coming into treatment have reported to me feeling connected to skills they learn in DBT and finding that it has helped them to move toward recovery.

How does it work then?

First, we start with identifying patterns of thoughts, feelings, or behaviors which are problematic to the person seeking treatment. Sometimes patterns aren’t initially obvious and we practice tracking thoughts, feelings, and behaviors over the course of a few weeks to begin to get a better understanding.  Often this kind of tracking continues over the course of treatment as well to gauge progress being made, identify struggles which continue to need to be addressed, or notice areas which develop over the course of treatment which require attention.

We then begin to look at specific events in which emotions or thoughts and emotions lead to unhelpful behavior and try to identify a place in those series of events in which the person could have made a different choice or used a new skill to change the outcome. Initially we practice this together but with time clients often begin to track this more independently as well.

We also talk a lot about skills that can be learned to help with coping. There are four sets of skills which are focused on in DBT – mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

Mindfulness is an important piece of DBT treatment. Often I start sessions with a mindfulness exercise that I engage in with my client. This can look differently depending on the best fit for the client, but a simple example would be focusing on the breath for a few minutes with the goal of focusing on the present moment in an intentional and non-judgmental way. Additionally, we talk about using mindfulness to stay in the present moment and how being better able to stay in the present (rather than the past or the future where we tend to be focused when struggling with intense emotion) can help us to cope more effectively. We also discuss the benefits of seeing all experiences – thoughts, feelings, situations – as temporary. We can cope with anything, essentially, for a little bit of time but it is harder to cope when we feel like something lasts forever.

The good news is that nothing lasts forever, and we capitalize on this in DBT to feel more able to cope. Lastly, we focus on non-judgmentally noticing our thoughts, feelings and behaviors. It feels very different to just notice without judgment than it does to be aware that something is happening and have shame, guilt, disgust, fear, or resentment towards what we are aware of. With practice, clients report feeling surprised at how they are able to stay more present and be more gentle with themselves.

Interpersonal effectiveness speaks to the fact that often, when we struggle with emotions, we also struggle in relationships. We all have had the experience of being angry about something that happened earlier in the day and taking it out on friends or family. Or snapping at somebody because we are anxious about what is coming next. In DBT, we learn skills for identifying our intention in interactions with others and then acting accordingly. This often involves discussing ways to be more assertive, set boundaries and limits with others, ask for what we need, say no when we want or need to do so, or maintain our sense of self-respect when someone is being disrespectful or abusive to us.

Since the relationship between therapist and client is also a relationship, I also use the therapeutic relationship as a way for clients to practice interacting in these new ways before taking on these challenges in other relationships in their lives. Building stronger relationships through DBT can help to support us in recovery and eliminate unnecessary stress and pain from our lives.

Emotion regulation skills in DBT focus on ways to stabilize your mood or change your mood when it is not feeling helpful. Some of the skills are more preventative – looking at how our diet, exercise, sleep, physical health, etc impact our emotional health or increasing the amount of positive events in your life. Other skills are more “in the moment” skills including learning how to identify if thoughts or feelings fit the facts of a situation, acting opposite to how our emotion tells us to act – for example approaching something we are tempted to avoid, or learning to be mindful of emotions (sitting with the emotion in a way which reduces our suffering.) One of the features of DBT which I focus on in this area is the idea that there are no good or bad emotions. Emotions are just emotions. They are information. When we begin to relate to them in this way it helps us to feel less controlled by our emotions and more capable of identifying the cause and finding a solution rather than getting stuck. These skills may help change how likely we are to feel emotionally overwhelmed or may help us to cope when we do feel overwhelmed.

Lastly, distress tolerance skills are intended to help in moments of crisis. When experiencing intense emotions one of the most common things I hear as a therapist is that at a certain point it is “impossible” to use skills. Sometimes when that happens it is a sign that distress tolerance skills will be more helpful. In those situations, we discuss skills like distraction, relaxation/soothing activities, use of imagery, ways to reduce physical symptoms of intense emotions, and ways to sit with the emotion without making things worse.

Another important distress tolerance skill is radical acceptance – or the idea of accepting what we cannot change rather than fighting reality and experiencing more suffering as a result. This is a big concept, and one that requires revisiting many times, in my experience, before clients begin to feel comfortable with it. However, clients often report that this is a concept and practice which helps them relate to their problems in a different way and has, in turn, lead them down a more positive path.

I can do all that?

Absolutely! I have worked with many clients who stated that, while it does take some time to learn DBT and a commitment to practicing the new skills at home over time, DBT has significantly changed their outlook on their struggles and has allowed them to move forward in a new direction in their lives from a more confident and capable place. In fact, many clients who come for DBT therapy have been through many other types of therapy before and have not found the relief they were looking for but find DBT to be more effective.

I personally believe that DBT skills are life skills. Some of us learned these skills at some point along the way while others of us weren’t able to learn those skills. I believe that everyone is capable of learning DBT skills and has the potential to benefit from improved mental health through use of these skills.

In my practice, I blend DBT treatment with other models depending on the best fit for the person. Some clients may not benefit most from DBT in which case it may be less of a focus. Other clients benefit from an increased focus on DBT. It just depends. I work closely with clients to identify the best use of DBT skills for their specific situation and needs.

If you are interested in finding out more about DBT therapy and how it might be helpful to you, please reach out to me to see about scheduling an appointment. Whether it is with me or one of my trusted colleagues at Clinical Care Consultants’ Inverness or Arlington Heights IL office, someone will be there for you (or your loved one) to help you resolve the problems that are causing so much suffering.
Sarah Peterman, MSW, LCSW

Clinical Care Consultants
1642 W. Colonial Parkway
Inverness, IL 60067

3325 N. Arlington Heights Rd., Suite 400B
Arlington Heights, IL 60004



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