DBT Skills: The Go-To Treatment for ADD?
Dialectical behavior therapy teaches people to manage their ADHD symptoms using four basic DBT skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Learn how here.
What are DBT Skills?
Dialectical behavioral therapy (DBT) training teaches DBT skills in four key areas: mindfulness; distress tolerance; emotional regulation; and interpersonal effectiveness. DBT is an effective treatment for many conditions marked by an inability to control emotions, including ADHD and mood and anxiety disorders.
You’ve probably heard of mindfulness meditation and cognitive behavioral therapy (CBT) as evidence-based treatments for managing ADHD symptoms. Dialectical behavior therapy (DBT), a type of CBT, combines elements of both. I see DBT as a new and improved form of CBT.
Dialectical behavior therapy was originally developed by Marsha Linehan, Ph.D., a psychologist in Seattle, Washington, in the 1980s, to treat borderline personality disorder (BPD). BPD primarily involves emotional dysregulation. Because many conditions are marked by an inability to control emotions — attention deficit disorder (ADHD or ADD), mood and anxiety disorders, substance use disorders — DBT has been found to be an effective treatment for all of them. It has become a go-to treatment for ADHD.
What Is DBT for ADHD?
Thinking “dialectically” means taking a more balanced perspective on your thoughts, emotions, and life situations. It is recognizing that we don’t own the truth, and that doing our best to see what we’re missing helps us bring a different, more balanced viewpoint of life. It helps us move away from black-and-white thinking, and to get unstuck from the power struggles that often arise from such thinking.
A central tenet of DBT is validation — accepting uncomfortable emotions and situations before trying to change them. By coming to terms with troubling thoughts and emotions, change appears possible, and patients can work with their therapists to create a plan for recovery. One of my clients couldn’t focus when studying. We talked about being flexible in her thinking, and making some changes in her study routine. Instead of studying for one hour without a break, she studied for 30 minutes, took a 10-minute break, and returned to studying for another 30 minutes. She found that she was able to accomplish a lot more in two shorter time periods.
Another client was having a problem with her mother, who was pushing her to do online course work as soon as she got up in the morning. The daughter recognized that she did not do her best work so early in the day, so we came up with a compromise: Mom and daughter agreed that she had to be out of bed doing something by 9 A.M. — showering, having breakfast, going out for a walk. Schoolwork could come later, when her brain was online.
DBT Skills: Four Key Areas
- Mindfulness. Mindfulness meditation for ADHD focuses on doing one thing at a time, in the present moment, with one’s full attention and with acceptance. This is challenging for most people, and especially for the racing minds of people with ADHD. Acceptance is also difficult, but when you can accept something — yourself or the fact that you have ADHD — it helps to reduce emotional suffering.
- Distress Tolerance. These skills help people tolerate negative emotions instead of trying to run away from them.
- Emotion Regulation. These skills help decrease the intensity of feelings without acting on them. Some skills include naming emotions accurately (people often mix up anger with fear/anxiety); checking the facts by asking yourself if the emotion you’re feeling is warranted by the situation; and acting in a way that is opposed to the problematic emotion — for instance, smiling during an upsetting situation — in order to reduce it.
- Interpersonal Effectiveness. These skills help a person understand his needs in relationships and develop ways of dealing with friends and family. A client learns techniques that enable her to communicate with others in ways that are assertive, maintain self-respect, and strengthen relationships.
How DBT Skills Help with ADHD Symptoms
Some of the ways DBT skills help people regulate their emotions include:
> Inhibiting behaviors, rather than impulsively reacting when experiencing an emotion (by practicing mindfulness)
> Refocusing attention through self-soothing and distracting skills, in order to prevent negative emotions from escalating
> Deciding on value-based action to help solve a problem (perhaps through asserting oneself), or managing the emotion effectively in other ways (through acceptance).
DBT Skills: Inattention
When you engage in mindfulness, you are practicing concentration. The more you practice something, the better you get at it. As the ability to concentrate improves, so will your memory, as you’re more focused on the one thing you’re doing in the present moment.
DBT Skills: Hyperactivity/Impulsivity
DBT skills help people learn to tolerate the moment, which means tolerating internal experiences (such as emotions), physical sensations (such as agitation and restlessness), and urges to fidget or interrupt others. By learning to tolerate these uncomfortable experiences, and learning to make more effective choices, people see that they can change.
Committing to DBT Skills Treatment
DBT is a skills-focused treatment, requiring a commitment to learn the skills and put them into practice. Individual sessions are highly structured, with an agenda set for each session to keep therapy on track. The role of the DBT therapist is to teach skills; this happens through practice in one-on-one sessions, and by doing homework assignments to practice skills outside of sessions.
DBT is a behaviorally focused therapy. The goal is to over-learn the skills, so that these new ways of thinking become second nature. A client of mine realized that she interrupts others a lot, which has gotten in the way of relationships in the past. By taking a dialectical perspective, she was able to see that her interruptions make it seem that she doesn’t value what the other person is saying. Mindfulness has made her more aware of the urge to interrupt. In sessions we work on not acting when the urge to interrupt arises. Her weekly homework assignments require her to be mindful of these urges in interactions with her best friend and her mother. The good news is that her behavior is slowly changing.
The DBT treatment process Marsha Linehan developed can be costly and lengthy, usually taking a year. The program consists of one-on-one sessions with a therapist, outpatient group skills therapy, skills coaching (in which the client can talk with a DBT therapist 24 hours a day, seven days a week), and meetings with a DBT consultation team.
Individuals can benefit from modified versions of the full program. Many therapists provide “DBT-informed therapy.” In my own practice, for example, I teach DBT skills in individual sessions, rather than requiring clients to attend both individual and group sessions. I also offer a shorter (12-week) group that teaches some of the DBT skills central to emotion regulation, rather than having a client attend group sessions for a year.