What is DBT?

As I see it, a perplexing dualism exists within the counselor’s mind while providing therapy.  On the one hand, you have a Rogerian unconditional positive regard as an essential element in the therapeutic relationship.  On the other hand, you have the sort of confrontational style found with addiction counseling’s history.  Where is there a middle ground between these extremes? – Understanding & Handling Resistance

After reading my last post, It occurred to me that more can be said on the matter.  In fact, this issue of change vs. acceptance reminds me of Linehan’s DBT.  My first introduction to it was as a client.  I use many of the DBT coping skills today.   As yet another hectic week of interning comes to a close, the importance of these needs emerge in my interactions with clients.  It also reminds me of my youth as a depressed teen….

I felt hopeless and alone.  Enveloped by an unending well of self-pity, I felt suicidal yet “didn’t have the guts to go through with it”.  My memory of this time sticks with me.  I’m grateful to have survived it.  These feelings can goad you toward seeking a solution – any solution – to making the “hurt stop”.  Reality is worse than a death since the pain you feel is never-ending.  With no solutions available, all I could do is marinate in my misery.

From within this mindset two seemingly counterintuitive needs existed.  I wanted someone who understood my pain without needing to fix things.  My favorite advice to all the bullying: ‘Just Ignore Them’ & Be Yourself”.  It never worked.  I was that teenager with a “you don’t understand me” mental filter.  If you “didn’t understand” you weren’t worth listening to.  If someone had taken time to truly listen, I may have been open to their offering of changed-based solutions…..

Against this personal backdrop, I see a bit of myself in my clients.  Its for this reason, I wish to review DBT’s basic principles….

Linehan’s Biosocial Theory….

DBT is a useful in approach helping individuals “manage overwhelming emotions…[and] strengthens…[their] ability to handle distress without losing control” (McKay, et al, 2011, p. 11).  The coping tools taught within DBT Skills Groups are useful in managing emotional dysregulation, (when an individual’s ability to modulate their responses to life situations is ineffective).  According to Linehan’s biosocial theory, pervasive emotional dysregulation is the result of an interaction between biological vulnerability and an invalidating environment (Koerner, 2012). Biological vulnerability is the result of three individual characteristics: (1) heightened sensitivity, (2) heightened reactivity, and (3) prolonged arousal (Linehan, et al, 1999).

Emotionally invalidating environments provide the second causal component in Linehan’s biosocial theory.  Defined as a failure to show respect for and acknowledgement of someone’s feelings; invalidation makes us feel our emotions are being neglected, mocked, and ignored (Linehan’s, et al, 1999).  Emotionally invalidating environments provide consistently invalidating responses to our maladaptive emotional regulation strategies, thereby reinforcing them, (Koerner, 2012). When these two factors coexist, the result is a poor fit between one’s emotional needs and their environment.

“Let us imagine the following: a child grows up and never experienced any validation of thoughts or feelings. He is an emotionally feral child, but lives within a community of other people who ignore validation. His parents have a radical behaviorist approach…adhering to the strictly behavioral position that emotions and cognitions are meaningless constructs” (Gilbert, 2005, page 199).

DBT’s Unique Solution…

A Dialectical Perspective

The word “dialectic” is defined as a perspective that aims to contend with opposing ideas. When I think of dialectic philosophy, Hegel’s work immediately comes to mind. In a nutshell Hegel’s dialectical perspective can be summed up in the fact that the whole is not equal to the sum of its parts.   Each component part, of this whole, has pieces missing.  Additionally, these component parts, focus only on certain elements of a situation.  Attaining wholeness requires us to see what you’re missing. DBT is based on this insight that reality is comprised of interrelated parts that must be seen holistically for the sake of clarity (Lynch, et al, 2006). Dialectical philosophy sees solutions as arising from opposing viewpoints that can be combined into a holistic perspective. DBT applies this philosophy to its treatment of emotional dysregulation with the use of change strategies, acceptance strategies, and dialectical techniques (Koerner, 2012).

  1. CHANGE STRATEGIES include the utilization of techniques to encourage change and behavioral modification (Koerner, 2012). DBT skills such as distress tolerance, chain analysis, and opposite action are useful in addressing pervasive emotional dysregulation (McKay, et al, 2010).

  2. VALIDATION STRATEGIES exist as a useful counterpoint to these techniques and emphasize acceptance and empathy (Koerner, 2012). These strategies are based on the fact that deep emotional wounds can’t be healed with logic (Lynch, et al, 2006). Validation reduces physiological responses to dysregulated emotion and allows a therapeutic alliance to develop (Linehan, et al, 1999).

  3. DIALECTICAL STRATEGIES address a “tension between the need to accept a client’s…vulnerabilities [while encouraging] them to make necessary change[s]” (Koerner, 2012, p15). DBT skills such as wise-mindedness and radical acceptance provide clients with the insight that underlies this dialectical balance. (McKay, et al, 2010)

Treatment objectives.

Initially, DBT was developed as a treatment for Borderline Personality Disorder, however research has shown it as effective in a wider array of clinical situations (Dimeff & Koerner, 2007). As an empirically supported approach, it is used in inpatient as well as outpatient settings.  It is also effective in group therapy, individual therapy and family therapy (McKay, et al, 2010).

In order to standardize DBT across all these contexts Linehan states that DBT should address five key objectives (Koerner, 2012).

  1. DBT provides clients with skills training to regulate emotions (Koerner, 2012).
  2. DBT strengthens a client’s motivation for change (Koerner, 2012).
  3. DBT helps clients apply skills in their daily lives (Koerner, 2012).
  4. DBT provides therapists with the skills needed to assist clients (Koerner, 2012).
  5. DBT provides a nonjudgmental, structured, and safe environment that allows both therapist and client to function effectively (Koerner, 2012).

Validation & Acceptance

When it’s missing….

While treating chronically suicidal patients with BPD, Linehan noted a critical shortcoming in traditional behavioral and cognitive approaches (Lynch, et al, 2006).   In particular she states the following:

“Focusing on client change, either of motivation or by enhancing capabilities, is often experienced as invalidating by clients who are in intense emotional pain.  In many clients it precipitates noncompliance, withdrawal, and at times, early drop from treatment”  (Linehan, 1997, p. 354).

Traditional behavioral approaches fail to address certain critical needs: validation and acceptance of how one feels.  Admittedly, from a pragmatic viewpoint, the idea of validating a suicidal patient’s feelings might seem idiotic.  After all, doesn’t validating a suicidal patient’s feelings mean we implicitly approve of their actions??? This attitude is quite prevalent in the hospital settings I work in.  Fortunately I’ve have the benefit of seeing things from both “sides of the fence”.

The other side of the fence…

All actions to save my life, however well-intended, resulted me feeling like a prisoner.  (This was after I left “it”.) I did a bad and needed to be constantly reminded of this.   It didn’t matter why I was doing it.  It didn’t matter what I felt or what I was going through.  I did a bad thing….

My mind is now flooded with fuzzy images of that event.  Medical personnel hovered around me as I remain strapped to the gurney.  One tech called me crazy nut and started cursing at me.  Strange hands started grabbing me all over as a tube with black crap was shoved down my throat. I screaming silently inside.  I was scared, hurt and alone.  Didn’t they understand?  Why wasn’t my family there?

After a period of rest, a student doctor sat down briefly to talk.  He was different.  He sat next to me, grabbed my hand and listened.  HE LISTENED.  He didn’t tell me I was bad or wrong.  He didn’t rush to judgment. I didn’t get a lecture. Instead he listened to how I was feeling and told me he was here if I needed to talk.  Just to ask for him…..

It’s been 20+ years since I attempted suicide. Right now I work as a CNA for a large hospital system.  Consequently, I often see patients like this – ALL THE TIME.  On occasion I am assigned as a “Safety Advocate”, for one.  This means staying within an arms reach of them at all times, to ensure safety.  My own experiences on the other side of the fence remain with me.   I witness as hospital personnel work fulfill their list of duties.  They are stressed & have lots on their mind as they attempt to stablize the patient.  They act with the best of intentions, and are guided by a strick moral code.   However, one thing is often missing: counseling experience.

They forget the human being sitting next to them is simply in pain.  They don’t take time to listen to their story.  It doesn’t occur them to ask: “How is it, that this patient’s emotional state can be understood from within the context of their life situation?”

Encouraging Change

When Acceptance Alone is Inadequate….

When a person validates your feelings, they acknowledge the reality of your lived experience “[as] understandable within [your] current life context or situation (Linehan, 1993, p. 222-223).”   You feel an implicit empathetic acknowledgement of who you are as a human being in pain.  You notice your emotional responses are taken seriously and not discounted, trivialized or mocked.  However, despite its vital importance alone it is inadequate as an approach to therapy…

“focusing treatment [of suicidal patients] on exploration and understanding, in the absence of a clear focus of efforts to help the client change, is often experienced by these same clients as invalidating because it does not recognize the ‘unendurability’ and therefore the necessity for immediate change (Linehan, 1997, p. 354).”

This statement resonates with another personal experience of mine.  As a high school student, I was depressed and alone.  I had no friends and only my school counselor to talk to.  A comment made during one of our sessions sticks with me to this day.  I shared with her the bullying I was dealing with.  She expressed sympathy and added that its just a matter of waiting it out.  “Once you graduate you’re out of here”.  When I asked her what she meant by this, she noted this small school was very cliquey & that finding friends would be difficult for me.  My reputation was pretty much cemented in the minds of my classmates and there was no changing opinions at this point. Her solution: Just wait it out.  I was already half way through high school and in the grand scheme of things, two years was nothing.

While I don’t recall my exact response to this explanation an inescapable sense of hopelessness fell over me like a foreboding and dark cloud.  It then occurred to me that my parent’s advice had a similar message to it: “They’re in cahoots!”

In retrospect, I remember my first experiences with dissociation in this moment.   This out-of-body “unreal-ness” was my only coping tool to the emotional traumas of bullying.  With no other solution at hand, this was my only coping mechanism.  It has taken much of my life to work through…..

The need for “a way out”

As I noted earlier, DBT provides a balanced solution that includes both acceptance and change-based strategies.   Based on the idea that the whole doesn’t equate to the sum of its components, the solution is to see those things you’re missing.  Hegel describes a process of transformation much like this in his philosophy,  It is a perspective that’s applicable to mental health, fields of study, and even society as a whole.

Hegel’s dialectical stages of growth begin with a THESIS, (another fancy word for idea, i.e. change is bad).
Change happens when this THESIS encounters an ANTITHESIS, (a fancy word for a contradictory idea, i.e. change is good).
When an individual resolves two conflicting ideas, (THESIS vs ANTITHESIS), the result is SYNTHESIS...(change can be scary but isn’t always a bad thing).

Wrestling with seemingly counterintuitive ideas like, leads to a cognitive dissonance, that urges us towards resolution. Using my example above, I’ve learned that my fear of change isn’t always warranted. While its not bad to move forward with caution, avoiding change at all costs results in stuckness. Sometimes a unique approach to things can create new solutions and positive transformation.

“The most fundamental dialectic is the necessity of accepting clients just as they are within a context of trying to help them change (Linehan, 1997, p. 354).”

It is a goal of mine to learn more about this method, and utilize it as a key approach in my future practice….

References

Koerner, K (2012). Doing dialectical behavior therapy: A practical guide. New York, NY: Guilford Press.
Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
Linehan, M. M. (1997). Validation and psychotherapy. Empathy reconsidered: New directions in psychotherapy, 353-392.
Lynch, T.R., Chapman, A.L, Rosenthal, M.Z., Kuo, J.R., & Linehan, M.M. (2006). Mechanism of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology. 62(4), 459-480
Mckay, M., Wood, J., & Brantley, J. (2007). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. New Harbinger: Oakland, CA.

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