Lessons in the Art of Living
Dialectical behavior therapy is a formula for effectiveness, perfectly attuned to our times.
By Hara Estroff Marano published September 2, 2013 - last reviewed on April 21, 2017
Mindfulness. Distress tolerance. Emotion regulation. Interpersonal effectiveness. If ever there were a set of psychological skills for negotiating life in the 21st century, this is it.
They just happen to be the skills that are the focus of dialectical behavior therapy, the cognitive-based therapeutic program specifically designed to help those with borderline personality disorder curb their self-destructive impulses and manage their unruly emotions. The more that studies demonstrate the effectiveness of the program, which consists of both group instruction and individual therapy sessions, both conducted weekly for a year, the more it has been applied to other disorders.
Take interpersonal effectiveness. One of its core principles is that learning how to ask directly for what you want diminishes resentment and hurt feelings, reactions that typically emotionally derail borderlines but which are no strangers to the rest of us; just ask the nearest divorce lawyer.
In DBT, the skill is encapsulated in a mnemonic device known as DearMan: Describe what you want; Express yourself in ways that reflect the importance of your request; Assert yourself effectively but not aggressively; Reinforce a request by explaining what good would come from it; stay Mindful and don't get caught up in another's defensiveness or your own intensity; Appear confident; Negotiate, don't demand. Why should a diagnosis be required to acquire such basic relationship skills?
Or to acquire mindfulness? Learning how to stay focused on the present moment, noting the fleeting nature of emotions so as not to get whipsawed by them, not getting mired in regret about the past or overcome with anxiety about the future. It affords us a choice of how we want to respond to experiences.
"When Marsha Linehan first came out with dialectical behavior therapy," says Barry Lubetkin, cofounder and director of New York's Institute for Behavioral Therapy, "most of us looked around and said, 'My God, this is the stuff we have been teaching people for the last 20 years, and this is the way we ourselves want to live our lives. As therapists and as human beings we are always trying to develop more effectiveness.'"
If DBT made sense for a clinical population when it was introduced two decades ago, it makes at least as much sense for the general population in 2013. There's considerable evidence that pathology is increasing among Americans; the prevalence of anxiety, depression, and narcissism is rising, especially among younger cohorts. One in 10 Americans now takes antidepressant medication.
The increasing rates of such conditions may in fact reflect sudden changes in the way we now must live our lives. Depression, argues Brandon Hidaka in the Journal of Affective Disorders, is likely a disease of modernity. In fact, a signal marker of modernization—per capita GDP—correlates with lifetime risk of the disorder, the result of an evolutionary mismatch between longstanding human environments and recent lifestyle shifts. Declining social interaction, increased sedentariness, diminished sun exposure, sleep deprivation—all the products of the way we now function—contribute to depression risk.
The context of all our lives has changed dramatically just within the last two decades. The most obvious change is the advent of the Internet and related technologies.
It's axiomatic that different environments impose differing demands on us. This, after all, is the fundamental dialectic of evolution: Adapt—or wither into ineffectuality.
The Internet, the universe many Americans inhabit much of the time, increasingly enables our livelihoods. But it also offers unlimited opportunities for distraction: View pornography and every other kind of sexual activity at the touch of a button. Prefer to search for that old sweetheart, or a new one? Or just contact friends? Maybe video games are more your thing, made all the more irresistible by instant feedback. Escape and entertainment are often overwhelmingly tempting in the face of difficulty. (Much of the popularity of so-called study drugs can be attributed to the attempt, however misguided, to maintain a focus in the face of easy escape.) Hello, distress tolerance.
Think of digital diversions as add-ons; traditional outlets for frustration have not lost their appeal in the electronic age. In 40 years of practice, Lubetkin notes, "I have never seen so many people having affairs. A man has a fight with his wife or girlfriend and he immediately acts out with someone else, rather than managing the distress and finding alternative ways of controlling a bad reaction or learning better communication skills. "
Adolescent psychologist Carl Pickhardt sees a growing gap between the degree of self-discipline young people now need and the little they acquire. Concerned parents, he contends, typically focus on their kids' academic achievement and on minimizing social risk-taking. "But they're really not preparing their kids for self-management."
As a result, he says, "young people are riddled with procrastination and manage stress in ways that increase the stress they are under." Instead of catching their breath and mindfully thinking about choices, "they often escape into social networking or streaming a movie, or they beat themselves up for not getting things done." He believes the lack of self-management skills is responsible for the high rate of failure to finish college.
The environment most of us inhabit today presents demands and distractions that require an unprecedented mastery of psychological abilities—skills that we might have acquired on a hit-or-miss basis if we acquired them at all, but which are now essential for navigating the changed context of life in the 21st century.
When German psychiatrist Martin Bohus introduced Marsha Linehan at a conference two years ago—at which Linehan made the bombshell revelation that DBT grew out of her own early struggles with borderline personality disorder—he described the arc of DBT's relevance. The therapy, he said, has had three major metamorphoses. It was developed for chronic suicidal patients. It then became the number one treatment for borderline personality disorder. It expanded to become a treatment for emotion dysregulation. And now, he was sure, "it will be extended to an art of living."
In some ways, dialectical behavior therapy is a misnomer. It's much more than a therapy. It's a corrective worldview—as much philosophy as psychology—that sees the relationship between health and understanding, and sees both not as static things but as ongoing processes hammered out through a continuous Socratic dialogue with the self and others. Over the course of a year, DBT trains individuals to balance life's tensions and complexities as a dynamic process that accommodates the constant flux of feelings without getting caught up in them.
The primary dialectic is engaging change strategies in the context of acceptance, but equally rooted in the idea of creative resolution of problems is understanding that living inherently engages contradictory emotions and oppositional thoughts. As therapist-teachers model dialectical patterns—for example, by questioning patients to open up new avenues of behavior—they are also seamlessly shifting patients away from rigidity toward accepting thought as a messy process.
What is so remarkable about dialectical behavior therapy is that it is a veritable instruction manual for avoiding the psychological traps of modern life. It addresses a range of deficits that are increasing most quickly among the young. In acknowledging complexity and contingency, in recognizing pain and distress as facts of life, in reducing confusion about identity, in teaching emotion-regulation techniques and interpersonal effectiveness, in balancing acceptance and change, self versus other, and thoughts versus feelings—in accommodating the nature of modern reality—dialectical behavior therapy aims to develop perspective and coping skills that so many are lacking.
Given its strong instructional approach, DBT is already almost perfectly geared to a world needing updated lessons in the art of living. Why not turn it wholly into a classroom course, at the very least for the young, to ensure they are prepared for the world they are inheriting. A modest proposal: Present a version of classroom-only DBT to all incoming students in America's colleges and universities, where increasing numbers are demonstrating a dearth of coping skills by experiencing significant psychological distress. Basic Life Skills 101.