Summary
Combining dialectical behavior therapy (DBT) skills with cognitive behavioral therapy (CBT) offers a powerful approach to managing anxiety. While CBT focuses on identifying and challenging anxious thoughts, DBT enhances this process by teaching skills in mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. Together, these therapies provide a comprehensive framework for navigating intense emotions, building resilience, and fostering meaningful behavior change. This post explores how integrating DBT and CBT can empower individuals to manage anxiety more effectively and live with greater confidence.
Cognitive behavioral therapy (CBT) is a widely used approach to treating anxiety disorders. It helps individuals recognize and challenge distorted thoughts contributing to their anxiety, and replace them with more balanced perspectives. Broadly, CBT targets the “cognitive triad” of thoughts, feelings, and behaviors to break the cycle of negative thinking and reduce symptoms of anxiety.
When it comes to treating anxiety, however, it is more accurate to describe CBT as an umbrella of approaches, rather than just one modality. Many of the treatments used to target specific anxiety disorders, such as exposure and response prevention (ERP) for OCD, were born out of CBT. And since these modalities are sometimes inconvenient and highly specific, many clinicians have elected to supplement these CBT approaches with specific skills from dialectical behavior therapy (DBT).
Understanding DBT in the Context of CBT for Anxiety
DBT is itself an offshoot of CBT, initially developed nearly 4 decades ago by Dr. Marsha Linehan to treat borderline personality disorder (BPD). At its core, DBT emphasizes balancing acceptance with change, and includes a robust set of highly adaptable skills for achieving this balance. Today, clinicians use DBT for treating a myriad of disorders beyond BPD, including the anxiety disorders, due in large part to these effective skills. Over time, clinicians have begun carefully documenting how DBT skills might be used in conjunction with CBT-focused treatments (i.e., see The Unwanted Thoughts & Intense Emotions Workbook by Jon Hershfield, MFT and Blaise Aguirre, MD for more information).
DBT skills focus on four key areas: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. For those with anxiety, these skills offer valuable strategies to manage intense emotions, practice acceptance, and embrace uncertainty:
1. Mindfulness Skills as a Prerequisite to Challenge Anxious Thoughts
Mindfulness skills from DBT offer valuable techniques for observing thoughts nonjudgmentally and without becoming attached to them. Ultimately, these skills help individuals cultivate the view that thoughts are separate from oneself and are temporary mental events rather than absolute truths, helping them effectively manage anxiety through DBT and CBT.
For example, one effective DBT mindfulness skill for noticing thoughts is Observing, which encourages individuals to simply notice a thought without engaging with it. By labeling a thought as just a thought, they can create mental space, allowing them to observe it without letting it drive behavior. Another skill is practicing observing thoughts through a non-judgmental stance, which involves acknowledging thoughts without labeling them as “good” or “bad.” This helps in reducing the emotional attachment to certain thoughts. Finally, skills like visualizing thoughts floating by as leaves on a stream or clouds in the sky can reinforce the radical idea that you are not your thoughts.
These skills support anxiety treatment because observing thoughts is a prerequisite to changing them. By learning to engage with thoughts more flexibly, rather than feeling controlled by them, individuals are well suited to take the next step in most CBT approaches, which is to evaluate the accuracy of a thought.
2. Distress Tolerance Skills to Approach Behavioral Experiments with Greater Ease
Distress tolerance skills are skills designed to help manage intense emotions and endure crisis situations without the use of any unwanted behaviors. In anxiety treatment, unwanted behaviors are behaviors that serve to reinforce the anxiety rather than dismantle it, such as engaging in avoidance or safety behaviors that can interfere with new learning brought about by behavioral experiments. Distress tolerance skills achieve this goal by helping individuals to tolerate discomfort brought about by anxiety. For example, the “TIPP” skills are a set of four distress tolerance skills that serve to reduce physiological arousal by reducing body temperature and heart rate through application of cold water, intense brief exercise, paced breathing, and progressive muscle relaxation.
Through these skills that encourage managing intense emotions rather than avoiding them, individuals may find they can more easily approach behavioral experiments that are the core of many CBT approaches.For instance, someone with panic disorder may escape a situation when they feel a panic attack coming on. Distress tolerance skills like TIPP skills can help nudge someone away from complete avoidance and instead engage in a brief, adaptive exercise that helps them to reduce their arousal enough to remain in the situation. Ultimately, this facilitates the new learning that panic attacks may be uncomfortable but they can pass without debilitating consequences.
3. Emotional Regulation and effectively anxiety management through DBT and CBT
The emotional regulation skills in DBT teach individuals not only how to manage intense emotions, but also to reduce their vulnerability to them. This can be particularly helpful in treating anxiety disorders, as managing one’s baseline propensity to experience emotional volatility can reduce their sensitivity to triggers for anxiety and promote effectively anxiety management through DBT and CBT.
One key set of emotion regulation skills are the PLEASE skills (taking care of physical illness, eating balanced meals, avoiding mood-altering substances, sleeping well, and exercising regularly). When any one of these areas is not met, the likelihood of experiencing an emotion more intensely goes up. Think of it like this – you may normally find a very bright light slightly aversive but if you have a migraine, you will find it intolerable! The PLEASE skills help individuals to stabilize their physical and mental health, which reduces their likelihood of experiencing intense anxiety. Regular practice of these emotional regulation skills can help individuals develop the capacity for more flexible, balanced thinking, making CBT’s cognitive interventions more effective.
4. Interpersonal Effectiveness Skills for Improved Problem-Solving
DBT’s interpersonal effectiveness skills provide a structure for navigating interactions in a way that helps individuals get their needs met without compromising their self-esteem or their relationship with the other person. Perhaps the most well-known interpersonal effectiveness skill is DEAR MAN, which encourages individuals to make requests by first Describing a situation using the facts, Expressing how they feel, Asserting their request, and Reinforcing the benefits of cooperation. They should make this request while staying Mindful, Appearing Confident, and being willing to Negotiate where needed.
DEAR MAN is effective in its own right, but offers specific benefits when coupled with CBT for anxiety. The steps in DEAR MAN serve as a framework for stepping away from ruminative thinking and engaging instead in problem-solving. Many individuals with anxiety describe having difficulty with assertiveness and setting appropriate boundaries. Accordingly, they may approach conversations with others ineffectively or avoid opportunities for these conversations entirely, which only reinforces the difficulty. The step-by-step structure of DEAR MAN can make interpersonal interactions feel far more approachable, thereby providing opportunities to experience success.
Applying DBT Skills in CBT for Anxiety
At the Center for Anxiety, OCD, and Cognitive Behavioral Therapy, we employ behavioral experiments to treat a range of anxiety disorders. Unlike exposures that involve approaching a feared stimulus in hopes of habituating to it, behavioral experiments are used to test the accuracy of anxiety-related beliefs or predictions. The example below illustrates how these experiments are conducted:
Peter is a 33 year old man with social anxiety. He often avoids communicating with his colleagues at work, unless it is absolutely necessary, for fear of rejection or humiliation. In treatment, he and his therapist design a behavioral experiment in which he will ask his coworker to collaborate with him on a project. Peter’s prediction for this experiment is that he will become overwhelmed with anxiety such that his hands will shake and face will be red, which will cause his coworker to think Peter is a “weirdo”. Peter will know if his prediction came true because his coworker will decline, give him a funny look, ask if he’s OK, and avoid talking to him for the rest of the day.
DBT Skills Demonstrated
In a traditional CBT framework, Peter would go about the experiment and record his results to process with his therapist at their next visit. But, here’s an example of how it might look to use DBT skills to bolster this experiment and maximize its efficacy:
Prior to the experiment, Peter uses his PLEASE skills to ensure he gets sufficient sleep, eats breakfast, and exercises in the morning before work as he always does. By controlling these variables, Peter is ensuring the experiment is as rigorous as possible. Just prior to approaching his colleague, Peter uses the Observe skill to notice his thoughts without automatically judging or even believing in them. During the experiment, Peter relies on the DEAR MAN skill to make his request. He notices himself getting anxious as he’s speaking, so he silently engages in progressive muscle relaxation instead of giving in to his urge to abandon the conversation entirely. All of these skills together result in Peter’s predictions not coming true and his colleague agrees to collaborate. Peter learns that he has the capacity to act skillfully despite feeling anxious.
Conclusion
Integrating DBT skills with CBT provides a comprehensive toolkit for treating anxiety disorders. They allow individuals to engage more easily and effectively in the behavior changes that lead to cognitive modification. DBT’s focus on mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness can strengthen the cognitive restructuring process. It offers ways to tolerate intense emotions, stay grounded in the moment, and navigate relationships. In combining the best of both approaches, anxious individuals can develop resilience, gain control over their thoughts, and manage emotions more effectively, empowering them to live a life that is not controlled by anxiety.
At The Center for Anxiety, OCD, and Cognitive Behavioral Therapy, we’re dedicated to helping you cope with and overcome your social anxiety. For more information on effectively managing anxiety through DBT and CBT, and to explore our comprehensive approach, we invite you to read more about our Social Anxiety Treatment services and Overcome Your anxiety: Enhancing Exposure Therapy with DBT Distress Tolerance Skills, and to learn about the type of specialized CBT for social anxiety disorder offered at our Center. We also have a number of additional blog posts that discuss topics related to social anxiety such as dating, enhancing exposure therapy with distress tolerance skills, empowering anxious children through play, guiding anxious children through fear, and embracing supportive statements for anxious kids.
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