Greg Thorkelson, MD with Ryan Reagan, PhD, LPC

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This week the Nexus blog is going to return to the familiar subject of cognitive psychotherapy. At this point we will start to delineate between some of the popular psychotherapies. This is why we elected to use the term “cognitive psychotherapy” as opposed to CBT. If you have read some of the previous posts leading up to this one, you will notice that there was quite a lot of talk about CBT, its historical context, why it is valuable, and its acknowledged shortcomings.

The shortcoming(s) of CBT is where we will be picking up. First, it should be stressed that CBT is a very good psychotherapy. The critique that was often heard when clinicians of my age came into the field was “yes, but it does not work on everything.”  Interestingly enough, this was also a critique that would later be leveled at DBT (Dialectical Behavioral Therapy), which emerged under the CBT umbrella. At some point it would be fair to ask whether it makes any sense to think someone is going to deliver a universal psychotherapy that works on everything. The field of physics is still searching for a grand unified theory.  I wouldn’t hold my breath on psychology getting there first.

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It might serve us better to think of the modalities of therapy in the way that we think of medications. You might take 2-3 medications for symptom management, likewise a couple of different modalities might be key in managing symptoms. One of those modalities is the subject of this post.  As mentioned, above DBT emerged under the CBT umbrella. It’s creator, Marsha Linehan originally published her work as an extension of CBT. Consequently, there are still books in circulation entitled Cognitive Behavioral Therapy for Borderline Personality Disorder. CBT has been a powerfully dominant paradigm for decades.

There is an argument that has emerged within the field of psychotherapy that aims to resolve questions of differentiation by classifying new therapies as “third wave CBT” with DBT and a few others acknowledged as the “second wave.” This feels appropriate. A good case could be made that any therapy that operates on cognition is a version or extension of CBT. Henceforth, we should consider any critique of CBT, fair or unfair, as referring to the traditional CBT which was the bread and butter of most psychotherapy training going back 50 years.

DBT was one of the second wave of cognitive therapies that addressed some of the shortcoming of traditional CBT.  For one, CBT focuses specifically on cognition which often gets conflated with thinking. Thus, the CBT interventions target “cognitive distortions” which unfortunately have also been referred to as “thinking errors.” This is unfortunate, because we human beings do not like it pointed out that we are thinking wrong.  We especially don’t like this when feelings are involved.

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This is the main problem that DBT sought to address. We have to remember that CBT still emerges under a model of the mind that was less informed by advances that would be brought by neuroscience. CBT emerges in a very Western paradigm that has thought of reason and emotion as to separate spheres, and if we just got rid of the problematic emotions, we would all be better off. This is nonsense. The brain is not organized this way. We don’t have a specific area dedicated to emotion that we could simply eliminate.

DBT helps to remedy this problem by giving weight to the emotional experience of life. In fact, the earliest modules in DBT stress the balance of emotional mind and rational mind. This balance is referred to as wise mind. In philosophy dialectics are opposing forces that synthesize. This is also represented in the familiar yin and yang symbol in Taoism. These are two opposing forces that are inseparable, much like reason and emotion which arise in the same mind. The goal of DBT therapy is to help patients hold both realities simultaneously—that we can be a reasonable human who also happens to be experiencing intense emotions.

The other important contribution of DBT was its extensive focus on coping skills. DBT is also heavily indebted to several existing streams of thought that pulled heavily from Eastern religion and philosophy. Indeed, Linihan remarked that there is nothing original in DBT other than the packing of the ideas. Taken together they represent a balanced approach to navigating a world that can easily elicit strong and intense emotions.

DBT achieves this by a combination of psychoeducation (skills training) and therapeutic process (psychotherapy).  Unfortunately, this is a lot of work, and this is the reason it is often taught in Intensive Outpatient (IOP) settings.  The amount of material in DBT exceeds what can be handled in this post.  None of the concepts in DBT are particularly difficult to grasp, but there are an extensive array of specific coping strategies (24—off the top of the head). It simply takes time and patience to learn all of this.  

To simplify, we will focus on the four core modules of DBT. If you wish to go further with DBT there are plenty of readings, resources, and workbooks that can serve the purposes of psychoeducation. Additionally, it is not entirely necessary to learn DBT through IOP.  IOP is a level of service that is traditional offered when symptom acuity reaches a point that daily functioning begins to deteriorate and there is a risk of hospitalization.  It should be noted however that DBT leaned outside of the traditional model is not necessarily a DBT program, but rather DBT informed therapy.

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The DBT modules can be valuable as a complement to any therapy, and as mentioned previously, the concepts exist in other literature that DBT built on. The core modules of DBT include Mindfulness, Radical Acceptance, Emotion Regulation, and Distress Tolerance. Under each of these modules are specific coping skills that pertain to their respective domain. In some ways the language of Buddhism is so pervasive now that it is easily lost how novel these ideas were when they were first introduced.

Mindfulness, for example, is so pervasive and conflated with meditation that it can be challenging to know if we are discussing the same concept. DBT teaches the concept of mindfulness through the dialectic model mentioned previously, an awareness of emotion and reason that achieves one-mindedness through balance.  The concept of mindfulness existed independently before being incorporated with DBT. Two of the distinctive features associated with mindfulness are awareness of our thoughts, feelings, and sensations in the present moment.  To paraphrase a mentor, “you don’t need to do meditation, you can mindfully wash the dishes, but you need to be present, immerse yourself in it, the water, the soap, the sounds, and don’t be off in your head thinking about bills.”

Radical Acceptance is tough. But it is a necessary skill in life. We are sometimes faced with situations that we do not want to accept. The loss of a loved one or a relationship, any variety of unfortunate events. We have a lot of protective mechanisms that shield us from reality, and for good reason. Reality can be brutal. There are things that we simply cannot accept in totality at the time the present. An important distinction that is often emphasized: radical acceptance is not saying it is “ok.” There are events that we experience that are never “ok.” Radical acceptance is saying that I acknowledge that this has taken place.

The emotion regulation module supplies coping skills that can be helpful in managing intense emotions. Like the other modules, Linehan offers some incredibly sharp insights that capture the importance of subject. “You are not your emotion.” This is easily forgotten. Emotions are visceral and intense. It is also true that they are fleeting. Sure, they can get stuck and they can be painfully intense, but they are not you. You are always a bigger story than any emotional moment.

Distress tolerance is pretty straight forward, although like the other modules there are specific coping skills aimed at tolerating stress. As mentioned above, emotions can be painfully overwhelming. In fact, Brene Brown has built a career on pointing out how deeply painful the emotion shame is.  Research shows that human beings will opt for physical pain to avoid experiencing shame. Again, DBT to is too elaborate to sufficient address in this post. Some of the important contributions of the distress tolerance module are using the senses to engage in pleasurable activities (self-soothing), using visceral experiences to ground us in the moment (holding an ice cube, cold shower), and acting opposite to emotion (leaning in to fear as opposed to running).

To summarize, DBT emerged to fill some of the gaps that traditional CBT had not addressed. It has made a valuable contribution to the field of psychotherapy and it is highly regarded as an effective evidence-based modality for the treatment of mood and anxiety symptoms, and even substance use disorders. The value of the coping strategies in DBT extend beyond psychotherapy. This is fitting since the model draws heavily from different sources and traditions. To paraphrase a mentor—“these are skills everyone should know, sometimes we just miss a lesson.”

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