Using Dialectical Behavior Therapy (DBT) to Treat Anxiety Disorders


By Dr. Alison Alden


Dialectical Behavior Therapy (DBT) is form of cognitive behavioral therapy that combines mindfulness, ideas from Zen Buddhism, and behavioral principles to help people better ride out and regulate their own emotions. Although it was originally developed to treat individuals with personality disorders, it includes many concepts and tools that are also extremely useful to people suffering from anxiety disorders. In my practice at the Anxiety Treatment Center, I use many elements of DBT to enhance the more traditional exposure work that I do.

DBT includes four major sets of skills: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness, and as needed, I draw on all of these skill sets in my work with anxious patients.

When people think of mindfulness, they imagine that it means practicing meditation, but in DBT, it actually means much more than this. An important component of it is training your “attentional muscle” so that you can better focus on what is going on in the present moment rather than living in the past or thinking ahead to the future. This is extremely relevant to many people with anxiety disorders who find themselves constantly worrying about what’s to come! Although my colleagues at ATC and I primarily take an exposure approach to treating worry (helping people sit with their worries until they no longer trigger anxiety or fear), I also introduce mindfulness to many of my patients to help them stay more present in their lives. Another important mindfulness concept that I like to introduce to patients is the idea of wise mind—acting and making decisions from a place that considers and balances both what is logical and one’s own emotions. For people who are anxious, this often means owning their fears and being sensitive to where they are at emotionally while at the same time pushing forward with their lives.

Emotion regulation skills largely focus on doing things to reduce your vulnerability to negative emotions and employing strategies to change negative emotions that arise. I work with patients to help them incorporate sleep, healthy eating, exercise, and other healthful behaviors into their lives to reduce their emotional vulnerability. I also introduce many patients to an important DBT concept for changing negative emotions—acting opposite to emotions that are not justified by the present situation (even if they feel justified). The idea of acting opposite to fear and anxiety is very much in line with the way that we typically treat anxiety—by encouraging people to face thoughts, feelings, and situations that frighten them rather than going with their urges to avoid them. Acting opposite also means doing things like approaching people and being active instead of withdrawing and staying in bed when you’re depressed, and treating people with compassion or doing something nice for others when you’re angry. Many patients are surprised to find that when they act opposite to their negative emotions, their emotions actually change for the better!

Interpersonal effectiveness means being assertive, asking other people to make changes in their behavior or saying no to unwanted requests. It also means being able to gauge how strongly to commit to a position and knowing how to maintain your position in the face of challenging responses and reactions from others. This can be an important skill for individuals who are either socially anxious or who are simply stressed as a result of challenging interpersonal situations. I’ve personally found that DBT interpersonal effectiveness skills benefit a wide range of patient—from teens dealing with tough situations with friends to businessmen navigating high pressure situations at work.

Finally, distress tolerance skills involve doing things to ride out your emotions so that you don’t make the situation that you are in worse. They are not intended to make people feel better but are rather intended to help people refrain from acting in haste. In essence, they are distraction tools, and since sitting with and not distracting from their emotions is so important for anxious individuals, I introduce these skills to my anxious patients a bit more sparingly than other DBT skills. However, distress tolerance can be extremely useful to people with anxiety who tend to jump the gun because they can’t tolerate sitting with their own uncertainty about anxiety provoking situations.

In summary, the key components of DBT can be used to enhance traditional cognitive behavioral therapy for anxiety disorders. I tailor my use of them with patients to each patient’s individual needs and many of my patients have found these skills to be invaluable.

Alison Alden, PhD, is a Clinical Psychologist with the Anxiety Treatment Center of Greater Chicago, with offices in Deerfield, Chicago, and Oakbrook. Dr. Alden is located in our Deerfield office and can be reached at 847-559-0001.