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By Karen Elbert, LMSW
Clinical Social Worker - Pine Rest Wyoming Clinic, DBT Program Coordinator
Therapist: So, how is it that you have come to see me today?
Client: I don’t know. I was at the hospital and they told me I
had to come and see you for follow-up.
Therapist: Oh. What did they think you needed to follow up on?
Client: They think I need to talk to someone about cutting on my arms.
Therapist: So, they think you need to talk to someone about cutting?
Client: Yeah.
Therapist: What do you think? Do you need to talk to someone about cutting
on your arms?
Client: No….well, I don’t know. Everybody seems to think
it’s a big deal…
Therapist: So, everybody else thinks it’s a big deal and you aren’t
sure if it is or not?
Client: Yeah…my parents, the doctor, they all think it’s
a big deal and I guess, sometimes, when I think about it, it is pretty
gross. I mean, when I do it, it’s great, but then I have to keep
my arms covered up so no one sees. They just freak out when they see
it.
Therapist: So, let me see if I have this straight…when you do
it, it’s helpful, but then it becomes a problem because other people
freak out and…maybe you do too?
Client: Yeah…I guess. It’s just that when I’m really
angry, it just works so well.
Therapist: So, when you are angry, cutting on your arms helps you to
get through it?
Client: Yeah…I guess.
Therapist: And then you do it and then other people freak out and you
kind of do too?
Client: Yeah…I guess.
Therapist: So, what if you had a way to deal with being angry that wouldn’t
involve cutting on yourself…how would that be for you??
Client: I guess that would be good, but……You are going to
tell me I have to stop cutting, too!!!!!!
Therapist: So, you are concerned I will tell you that you have to stop
cutting?
Client: It sounds like you are going to be just like everyone
else who just doesn’t understand!
Therapist: I certainly don’t
want to be another one of those people who don’t understand, so
let me check in here to see if I am getting it. If you had a way to deal
with anger that you wouldn’t have
to cut on yourself, that might be a good thing. But you are not sure
if you want to give up the cutting completely?
Client: It’s just all so confusing…you know? I really don’t
want to do it, but it works so well and I don’t know if that other
stuff they talked about in the hospital will work as well. And the anger,
you know, nobody listens…nobody understands what my life is really
like. They all think I should just be able to “get through it.” They
don’t understand how hard this all is for me.
Thus begins many a DBT Program assessment session.
Dialectical Behavior Therapy, or DBT, was developed by Dr. Marsha Linehan,
Professor of Psychology at University of Washington for clients with
histories of chronic suicide attempts, suicidal thinking, urges to self
harm, and patterns of actual self- harm behaviors. It has at its foundation
Cognitive Behavioral Therapy, which is focused on learning new behaviors
and creating the changes necessary for a ‘life worth living.’
Who is DBT appropriate for?
Clients who most benefit from this treatment are those who have developed
patterns of behaviors to cope with life stresses that, in and of themselves,
end up making life even more stressful. These behaviors may include,
but are not limited to:
- Chronic suicidal thoughts
- Multiple suicide attempts
- Self-mutilation such as cutting, burning,
and piercings for the experience of the piercing
- Disordered eating
- Serial problematic relationships
- Over-spending
- Drug and alcohol abuse
(after a solid period of sobriety)
Often these clients report either feeling chronically empty and alone
or they are always on an “emotional roller coaster.” Because
of these behaviors and experiences, their relationships and self-esteem
suffer collateral damage.
Bio-social Theory
Linehan frames DBT treatment in her “bio-social” theory of
why people resort to these extreme means to solve problems in their lives.
A key assumption in DBT is self-destructive behaviors are learned techniques
for dealing with unbearably intense and negative emotions. Although “negative” emotions
like shame, guilt, sadness, fear, and anger are normal parts of life,
it seems some people are particularly inclined or ‘hard-wired’ to
be more sensitive to stimuli and experience stronger heights of emotional
arousal that also seem to last longer. Severe emotional or physical trauma
can also cause changes in the brain to make it more vulnerable to intense
feeling states. Whether through ‘wiring’ or experience, some
people are just more emotionally vulnerable.
Extreme emotional vulnerability is rarely the sole cause of psychological
problems. An invalidating environment is also a major contributing factor.
Examples of an invalidating environment can range from less than optimally
matched personalities of children and parents (e.g., a very shy child
growing up in a family of extroverts who don’t understand the level
of anxiety present in social interactions) to extremes of physical or
emotional abuse. Linehan’s theory is self-destructive behaviors,
whatever the form, arise from the transaction between the emotionally
vulnerable individual trying to survive in an environment that is not
able to meet these vulnerability-based needs.
An Empirically-Based Treatment
Research studies have been done comparing the outcomes of DBT treatment
to what is called “treatment as usual.” The results of
these studies have found:
- Clients participating in this treatment for one year had significantly
fewer and less severe self-harm behaviors during the treatment year.
- Clients engaged in DBT treatment had a lower rate of “treatment
drop-out” during the treatment year than the group receiving
other treatment.
- Clients in the DBT treatment group had a tendency to enter psychiatric
inpatient units less often and had fewer inpatient psychiatric days.
How is DBT different from other treatments?
All treatment modalities, including Cognitive Behavioral Therapy, have
the goal of change and improvement in some form. So, what makes DBT
different?
Validation and Acceptance
As is portrayed in the opening scenario, clients often come into treatment
with a history of feeling misunderstood and invalidated in their environments.
This can include their families of origin, their current family and
social relationships, school, work, church, and in treatment with medical
and psychiatric psychotherapeutic providers. Even in our best efforts
to help, treatment providers can set up a situation that invalidates
how hard and hopeless change seems to the client. A basic premise of
DBT is the understanding that clients are acceptable just the way they
are and that their behaviors, including those that are self-harming,
make sense in some way. Acceptance and validation of life as it is
becomes the foundation for the change required to build a life worth
living.
Dialectics
When we validate the client’s pain and suffering and acknowledge
he or she is doing the best he or she can, we are practicing acceptance.
When we add to this “AND it can be different and the client can
do better,” we are working in the “dialectic.” “Dialectic” means ‘weighing
and integrating contradictory facts or ideas with a view to resolving
apparent contradictions.’ In DBT, therapists work hard to balance
change with acceptance, two seemingly contradictory forces or strategies.
Likewise, in life outside therapy, people struggle to have balanced actions,
feelings, and thoughts. We work to integrate both passionate feelings
and logical thoughts. A statement we often use is “Uncomfortable
does not mean unhelpful.” The basic premise of dialectics is to
hold both. A situation may be highly uncomfortable AND greatly helpful!
We may need to accept there are some things we cannot change AND others
we can. In the assess-ment session scenario above, the therapist is beginning
to work in the dialectic…to set the groundwork that another behavior
to deal with anger could be hard to learn AND quite helpful!
DBT Skills Group
Linehan found in her early work with Cognitive Behavioral Therapy, that
when she brought validation and acceptance into her sessions, there
often was not enough time to adequately both address it and develop
the new skills offered by Cognitive Therapy. She designed the Skills
Group component of treatment to address the need for a structured skills
building treatment focus. The therapist is then free to use individual
therapy sessions to work with the specific application of new skills
and learnings to the individual’s specific situation. This provides
the balance of validating current struggles AND the expectation that
the client can do better. The DBT Skills Group is a 24- to 26-week
session of weekly classes and focuses on learning skills in four areas:
Mindfulness — Cultivating the skills to stay focused
and engaged in the present moment, to disconnect from judgmental and
self-defeating
thoughts, and to do what needs to be done to solve problems.
Distress Tolerance — Also called “Crisis
Survival Skills,” this module presents the distinction between
a true crisis and a problem that can be solved. Skills are taught to
survive those
situations in which we truly are not in control or that we just can’t
resolve right now.
Emotional Regulation — Clients are taught the true
nature of emotions and the distinction between emotions and chosen
actions or behaviors. This module focuses on learning to experience
and tolerate
emotions rather than “acting them away,” as well as understanding
the chain of events which prompt emotions. Ultimately, over time, clients
can learn to make choices to avoid unwanted, negative, emotional situations.
Interpersonal Effectiveness —This module focuses on learning
specific skills and strategies for determining both whether or not
to ask for
something and how to best approach the situation. These same skills
are applied to determining whether or not to agree to a request made.
The
skills learned in previous modules are brought forward for integration
in dealing with the disappointment and frustration that may result
from these situations.
Components of the DBT Treatment Program
Some therapists may say they do DBT or work in a DBT style. The empirically-researched
results of DBT treatment versus “treatment as usual” (TAU)
are based upon clients’ par-ticipation in the full “Standard
Model” DBT Program.
To be considered active in the DBT Program, clients commit to complete
a minimum of one full year of treatment which includes:
Weekly DBT Skills Group – Clients are expected to attend the
weekly, two-hour session. The average group is typically eight participants.
Each week a new skill is offered and explained, and homework is assigned
to practice the skill. Clients are urged to practice skills in their
daily life to build mastery which also bolsters self-respect. When
clients
try to apply skills in times of crisis without the practice and mastery,
they become frustrated and disillusioned. Clients are expected to
attend two full sessions. Family members are invited to attend skill
building
sessions to enhance their capabilities to coach in the home environment.
Individual DBT Therapy – Clients are required to be in regular
(weekly or bi-weekly) individual therapy with a DBT primary therapist.
The purpose of individual therapy is to apply the skills learned to the
client’s specific situation. The client may be asked to track behaviors
and skill usage. The therapist is considered the ‘primary provider’ for
the client and is responsible for coordinating care across the treatment
team, including: providers of psychotropic medications, Skills Group
leaders, and other treatments the client may be involved in.
Phone Coaching – Clients are expected to call their primary
therapist for skills coaching before engaging in any self-harm behavior.
The primary
therapist is expected to authorize any decision to seek inpatient
hospitalization.
Clients are asked to participate in activities to measure changes in
behaviors and attitudes before and after each session of Skills Group.
Targets of Treatment
The overall goal of DBT is to help clients create “lives worth
living.” What makes life worth living varies from client to client.
For some, it may be completing a college degree and working in the field
of their choice. For others, it may mean sustaining a solid, long term
relationship. For still others, it could mean becoming grounded in a
spiritual tradition and practice. While the goals will differ, the commonality
all clients share is the task of bringing problem behaviors, especially
behaviors that could result in death, under control. For this reason,
DBT organizes treatment into four stages with targets in each. Stages
I and II are generally the targets of the one-year, intensive treatment
commitment and will be addressed here. Stages III and IV focus on the ‘ordinary’ and
expected issues of life, and may be addressed in or out of therapy. These
stages will not be addressed here.
Stage I: Moving from Being Out of Control of One’s Behavior
to Being in Control.
Target 1: Reduce and then eliminate life-threatening behaviors, such
as suicide attempts, suicidal thinking, and intentional self harm.
Target 2: Reduce and then eliminate behaviors that interfere with
treatment. For example, behavior that “burns out” people
who try to help, sporadic completion of homework assignments, non-attendance
at
sessions, or non-collaboration with therapists. This target includes
reducing and then eliminating the use of hospitalization as a way to
handle crisis.
Target 3: Decreasing behaviors that destroy the quality of life. These
may include depression, phobias, eating disorders, non-attendance at
work or school, neglect of medical problems, lack of money, substandard
housing, or lack of friends. Increased focus is placed on behaviors that
support a life worth living, such as going to school or having a satisfying
job, having friends, having enough money to live on, not feeling anxious
and depressed all the time.
Stage II – Moving from Being Emotionally Shut Down to Experiencing
Emotions Fully.
The main target of this stage of treatment is to help clients experience
feeling without having to shut down by dissociating or avoiding life.
In this stage, the client learns to experience, appropriately name, and
tolerate emotions.
Summary
In summary, DBT is a problem-solving, acceptance, and change based treatment
which has as its foundation learning the appropriate skills to manage
emotions and address the issues of life. The treatment is most effective
with clients who are tired of their life being a series of upheavals
and crises, and are ready to commit to a year of intensive treatment
in a “Standard Model” DBT Program of individual therapy,
weekly skills groups, and telephone coaching. Clients who have had
previous counseling under other models are often successful in DBT
due to its integration of both acceptance and validation models along
with the expectation and support for change.
To learn more
This article is a compilation from the resources listed below and Pine
Rest Christian Mental Health Services’ experiences in imple-menting
a “Standard Model” DBT Program.
• Behavioraltech.org – the web site of Marsha Linehan’s
organization for research and clinical application of Dialectical Behavior
Therapy.
•
Gunderson MD, J. and Murphy, PhD, E.: “A Promising Treatment for
Borderline Personality Disorder,” McLean Hospital Psychiatric Update,
January 1999, Vol.1, Issue 3
•
Hartstein, J.: “The Use of Validation in Family Adolescent Dialectical
Behavior Therapy,” Behavioral Emergencies Update, Section on Clinical
Emergencies and Crises, American Psychological Association, Vol. 4, Issue
2, Spring 2003
•
Linehan, M.: Cognitive-Behavioral Treatment of Borderline Personality
Disorder, 1993, Guilford Press, New York
•
Linehan, M.: Skills Training Manual for Treating Borderline Personality
Disorder, 1993, Guilford Press, New York
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