Understanding Cognitive Behavioral Therapy and Dialectical Behavior Therapy
Updated: Aug 25
Written by Jennifer Perillo, who is the mom of a wonderful daughter who was diagnosed with DMDD. She lives in New Jersey with her family, dog, gerbils, fish, and parakeet.
If you have a child with DMDD, you may wonder if therapy would help them manage their emotions and behavior. Therapy is an essential part of treatment but is only successful once your child is stable. Since there are many types of therapy to choose from, it can be hard to figure out which is the most effective for this disorder. Two popular options are cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT). What’s the difference?
The word cognitive in CBT signifies that it focuses on thoughts (cognitions) and their impact on behavior and emotion. In the 1950s, Psychiatrist Aaron Beck noticed that many of his clients were reciting internal monologues – often negative – that affected their beliefs and behavior. By exploring and challenging these “automatic thoughts” (as he called them), he could help his clients think more positively, which helped them feel better. Dr. Beck’s work, combined with earlier therapeutic techniques, led to what ultimately became known as CBT.
CBT helps people recognize negative self-talk and self-defeating behaviors and change them into something more realistic and positive. For example, a child who believes her teacher doesn’t like her may become withdrawn in class (which can cause her school performance to worsen and become a self-fulfilling prophecy). A cognitive-behavioral therapist might begin by questioning her assumptions. For example, by helping her recognize times that her teacher was warm and supportive or by identifying other explanations for the teacher’s behavior that have nothing to do with her (maybe the teacher hasn’t been feeling well lately). As the child begins to think more positively about her relationship with the teacher, her behavior in class will hopefully improve.
Another example, if a child thinks he is dumb because he is bad at math, the therapist may help the child restructure his thoughts by realizing all the things that he is good at: “Math isn’t my best subject, but I’m excellent at science and art.” Therapists may also help identify instances of black and white thinking or catastrophizing (assuming that the worst will happen) and change those thought patterns.
In the case of DMDD, a therapist might help a child identify common triggers that make her angry and have her practice de-escalation techniques that can prevent an outburst, and relaxation techniques to help her stay calm in stressful moments.
Another CBT technique is exposure therapy, in which a person slowly approaches a situation that causes anxiety in stages until they feel more confident.
With younger children, a cognitive-behavioral therapist may incorporate play therapy (using arts and crafts or dolls, for example) and role-playing or modeling to practice ways to handle difficult situations.
A cognitive-behavioral therapist will often assign homework so clients can work on their issues in between sessions. They may ask clients to keep a journal to track negative and positive self-talk or practice certain techniques (such as anger management or self-calming skills) that they have learned in therapy.
With CBT, generally, the therapist and client choose one issue to work on at a time and create a short-term treatment plan to achieve their goals. CBT has been proven particularly effective for treating depression and anxiety in children. A large body of evidence also suggests that CBT is effective in treating anger and aggression, suggesting that it may be appropriate for children with DMDD.
The articles below demonstrate the use of CBT for children with DMDD:
Dialectical Behavior Therapy
Dialectical behavior therapy is a form of CBT. Like CBT, it is based on talk therapy; however, it places more emphasis on managing emotions and improving interpersonal skills and is recommended for people who have difficulties dealing with intense emotions.
DBT was developed in the 1970s by Psychologist Marsha Linehan, Ph.D.
Dr. Linehan’s own experience with severe mental illness (she was misdiagnosed with schizophrenia as a teenager, and repeatedly hospitalized), her training in Zen mindfulness, and her work with suicidal patients all influenced the creation of DBT. She discovered that CBT’s intense focus on change could aggravate certain clients because they were frustrated by aspects of their lives that they could not control (their parents, partners, or environment, for example). On the other hand, Zen concepts of acceptance were equally distasteful to clients who desperately wanted to get better. In DBT, Dr. Linehan blended concepts of both accepting oneself and wanting to change. (The word dialectical comes from dialectics, the belief that two opposing ideas can both be true.)
DBT works on improving client skills in four key areas or modules. The first is mindfulness, which teaches clients how to stay in the present moment and not let strong emotions dominate their attention; they are taught to observe their emotions neutrally and not label them “good” or “bad.” Distress tolerance teaches clients how to manage negative emotions, for example, with helpful self-soothing techniques, rather than choosing unhealthy behaviors to try and escape them. Emotional regulation helps clients identify their emotions, recognize their impact, and avoid giving into emotional urges. Finally, interpersonal effectiveness helps clients learn effective speaking, listening, and conflict resolution skills so that they can get along better with loved ones. Another key aspect of DBT is validation. Therapists must validate their clients’ feelings and perceptions, rather than dismissing or minimizing them.
A fifth module, referred to as the “middle path,” is specifically developed for parents and teenagers. This skill teaches parents and kids to validate each other, compromise, negotiate, and see each other’s points of view. There is also DBT-C, a form of DBT specifically designed for preadolescent children and their parents. DBT-C may be particularly effective for kids with emotional dysregulation and behavioral issues.
DBT is intensive; it involves weekly individual therapy, skills coaching between sessions, and a weekly skills training group session as well. Unlike the shorter-term duration of CBT, DBT clients may work with their therapist for a year or more. Some studies have found DBT to be useful in helping children with DMDD.
The articles below offer examples of how DBT might be used with children with DMDD:
CBT or DBT for DMDD
So, which method should you choose? Both CBT and DBT have been used to treat children with DMDD, and studies suggest that either method may be successful (either on its own or in conjunction with medication). After reading the descriptions of CBT and DBT in the linked articles above, you may have a better sense of which therapy might work best for your child. Put very simply, CBT tends to be more “logical” and focused on identifying and changing negative thoughts and behaviors, while DBT targets emotional and interpersonal skills. One of the other might be a better fit depending on your child’s temperament. Finding a therapist whose methods and outlook feel useful and supportive to you, and who can develop a strong bond with your child is key to finding a therapy that works.
Dialectical Behavior Therapy
Dialectical Behavior Therapy for Children
Expert on Mental Illness Reveals Her Own Fight
History of DBT: Origins and Foundations
How is Cognitive Behavioral Therapy (CBT) Different For Kids?
How Cognitive Behavior Therapy Can Rewire Your Thoughts
What’s the Difference Between CBT and DBT?