I just finished watching an MSNBC Morning Joe episode on Dialectical Behavioral Therapy and had to write about it.  The authors of the book, Dialectical Behavioral Training for Dummies, Gillian Galen and Blaise Aguirre [1], highly credentialed and obviously very knowledgeable, with bonafide’s from the likes of Harvard, were interviewed by Mika Brzezinski and Joe Scarborough. As a former media maiven myself in another life, I can say, it wasn’t good.

I hope the book does a better job of breaking it down than the authors did in the interview.  In fairness, this is not an easy thing to explain and I am sure it is even harder to explain on air in real time.  Still, for people writing a book for dummies, this was a confusing and not very helpful explanation of DBT. At a time when so many people are struggling with anxiety, it is really important that we get it right as DBT has much to offer those in need.

I am a trained DBT therapist certified to train other therapists and have been doing DBT training for more than 20 years.  Here is how I explain what it is: 

DBT therapeutically (Therapy part) addresses the role that judging words or black and white thinking (Dialectical part) play in causing emotional responses that prevent us from being able to solve a problem (Behavioral part.) It is a move away from either/or and all or nothing thinking toward both/and thinking when it comes to understanding what causes a problem and how to solve it effectively. We have Marsha Linehan to thank for DBT training as it was her brain-child in the 1970’s.

I am a systems theory person when it comes to causality.  In systems theory, Linear causality says that A causes B.  Mutual causality says that A plus B causes C.  Multiple/ Cyclical causality says that A + B + C + (infinity) cycle together and change each other to cause X.  I believe that understanding eating disorders is best done when using the Multiple/Cyclical model of causality. In the majority of the cases that I treat, eating disorders are the result of many things (an illness such as COVID, weight gain, fear of the future, anxiety, a leaky gut, etc.) that interact making the problem worse and worse.  So while it may start out as one thing, it often takes on a life of it’s own and becomes self-perpetuating. 

DBT is an especially effective tool at treating problems with multiple causes and as such is  an excellent tool for the treatment of eating disorders.

DBT has broad-based appeal. Besides being used in treatment, I can still remember being a part of the team of consultants that taught the both/and principals at Proctor & Gamble to improve the problem-solving skills of upper level management many years ago. 

Specifically, dialectical refers to the ability to view an issue from multiple perspectives where each side has previously been locked into an opposing point of view, with the goal of arriving at an agreement that seems reasonable irrespective of one’s original position. 

For example, a dialectical approach is the difference between saying “You are always unfair to me.” and saying “Sometimes you are fair and other times I feel as if I am not being treated fairly.” Another example would be “I hate really hot weather.” Vs “Sometimes I am ok with hot weather and other times I do not enjoy it.”  Or if you are very sensitive to heat, you might say “I have to plan ahead when it gets hot in order to stay comfortable.” 

The goal is to be descriptive instead of being absolute and/or judging.  When we use absolutes like “never” and “always”, or we use judging terms like fat or ugly, we eliminate all of the exceptions that can occur in between. We risk having a very rigid frame of reference, which can make problem solving difficult if not impossible. In other words, in teaching DBT, I try to help people avoid words like “never” and “always” as they leave no room for other options or hope.

Here is a story I love to tell.

I was working with a group of upper level executives in a fortune 10 company. They were frustrated about a government regulation that generated a great deal of paperwork and, from their perspective, slowed down their research efforts.  They recognized that they were not problem-solving well and that they seemed to be in a state of constant irritation so they asked for a DBT crash course.

After giving a very short description of DBT, I directed their attention to two blank charts.  On the first chart, I recorded all of the words they used to describe the process and on the second chart I recorded all of the words they used to describe their feelings about the words on the first chart. 

On the list describing the process I got words like this from them:

List #  1

Time suck
Waste of time
Mind numbingly stupid

And so on, almost 30 similar words. 

On the second chart I asked them to give me the feelings they associated with these words. 

Feeling List

Checked out
Burnt out
Nails on chalkboard

I then asked what the feeling level in the room was from 1 to 100 and they said 150. Wow.

At this point I put two new blank charts up and said “Now I’d like you to forget the first two charts, the words and the feelings, and use non-judging, neutral words only to describe the process.” Dead silence.  They could not think of a single non-judging word.

I said how about numerical, analytical and they got the idea and came up with:

New List

Numbers driven
Data based
A tool

And so on, although a much shorter list this time.

Now I asked them to give me the feelings they associated with these new words. 

Feelings List #2

In control

And so on.  These were very different words. When I asked where the feeling in the room was now between 1 and 150 they said 15. Ok.

“So we have gone from 150 to 15 in terms of level of feeling. What has changed?” 
“Nothing” they replied.
“Have we solved the problem?” I asked 
“No.” They replied.
“Have we improved upon it?” I asked.
“No.” they replied.
“How did this happen, that the level of feeling in the room, changed so dramatically?” 
“We changed the words.” someone said.

That is it in a nutshell.  By using non-judging words, they changed their emotional reaction to the problem. What happened next was that after I left, they decided to put a jar in the office and every time someone said, or thought,  a judging word, they were required to put $5.00 in the jar.  (I know, right? …definite honor system.)

Three months later they invited me back to report that productivity had improved by nearly 20%, as they had resolved several of the most irritating issues in the process. I wish the jar had been my idea, but it wasn’t, it was all on them. But it is one of my favorite examples because they did such a good job documenting their success.

When it comes to treatment, especially for eating disorders, DBT is a powerful tool.  If you are Anorexic the words you use to describe your body or parts of your body are often very judging, which raises your level of emotional arousal and in some ways helps motivate you to continue restricting. Same with Bulimia, the judging often precedes the bingeing and purging.

Here is the problem with arousal. It is fattening. That’s right. When we get upset cortisol is released, which tells us to find fat and store fat.  This is a mechanism left over from when we were cave dwellers.  If a wooly mammoth was chasing us, we had to throw our spear (fight) or run (flight) and the brain assumed that we might be holed up in a cave for a while so it also sent out a message to find fat and store fat to keep us alive while we waited for the wooly mammoth to go away.  

Back then, the fight or flight response was critical to our survival. Unfortunately, we still have it hard-wired into our brains and it is no longer critical to our survival, i.e. there are no more wooly mammoths chasing us.  Today fight or flight can be triggered by someone on Facebook showing off a picture of their new bikini while vacationing in the Greek Islands because we have FOMO when we see it. Ugh!

The solution today is to catch ourselves when we use a judging word and replace it with a non-judging word. It really works. I was in a DBT workshop and on the second day of a three-day workshop the leader passed out rubber bands to everyone in the audience and told us to put the band on their left wrist.  “Every time you have a judging thought for the rest of the workshop, switch your band to the other wrist” he said. 

Three hundred participants immediately switched the band to the other wrist.  I cannot speak for the rest of the participants, but my first thought was what a pain in the neck that was going to be because I was trying to use my laptop to take notes. For the rest of the workshop we were all switching our bands constantly, especially in the beginning.  It was very difficult to manage the negative thoughts.  Most of mine were of the self-conscious nature:  “Did I say that the way I meant to say it? Did what I just say make sense? Am I taking up too much air-time?” Other people reported similar reactions.  We also found ourselves becoming paranoid when someone switched their band while we were talking…. “Did she just judge me?” 

At first it seemed impossible to control the judging thoughts, they were so well ingrained into our thinking.  But by the end of the day and then the next day, which was the last day of the workshop, it was working, as we were switching our bands far less. (Even now I wrote “blasted” band and had to erase it to take the judgement out, lol.) 

I share this story with you because I think it epitomizes the challenges of staying neutral. This was a group of mental health care workers struggling to stay in neutral.  It was also a life-changing experience for many of us who thought we were good at not judging.  For myself, I am an empath and I assumed that because of that I was not a judger.  Turned out that much of the judging we did was of ourselves, but it was still judging and was having an impact. 

If you would like to learn more about dialectical behavior therapy and how it can help you improve problem-solving and reduce anxiety contact Dr. Norton at 513-205-6543 or fill out our online contact form.

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1. Gillian Galen, PsyD, is an instructor of psychology at Harvard Medical School and the Program Director of the 3East Girls Residential DBT Treatment Program at McLean Hospital in Belmont, Massachusetts. 

Blaise Aguirre, MD, is the Medical Director of 3East, a DBT continuum of care at McLean Hospital in Belmont Massachusetts, and a trainer in dialectical behavior therapy.

Dr. Renae Norton specializes in the treatment of eating disorders. Located in Cincinnati, Ohio. Call 513-205-6543 to schedule an appointment or fill out our online contact form for someone to call you to discuss your concerns. Tele-therapy sessions available. Individual and family sessions also available.

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