What is DBT?
DBT is short for “Dialectical Behavior Therapy.” This is a type of psychotherapy that increases peoples’ ability to live life well. DBT was developed by Marsha Linnehan, PhD, from the University of Washington in Seattle. She wanted to develop a treatment for Borderline Personality Disorder (BPD), a disorder that had proven to be notoriously difficult to treat. As it turns out, DBT is very effective, not only for BPD, but for a wide variety of problems, including depression, eating disorders, substance abuse and “multi-diagnostic, difficult-to-treat” patients. Research studies comparing DBT to standard cognitive behavioral therapy (CBT) or to psychodynamic therapy have shown DBT to be more effective. Clients get better faster and retain gains made. Further, follow-up measures of symptoms conducted at 6, 12 and 18 months post treatment show clients become even more effective/less symptomatic after discharge. Here’s why:
Simply put, DBT teaches people how to live well. It doesn’t matter the diagnosis, or even if there is no diagnosis. If one has a model of strategies and skills to deal effectively with the inevitable stress that is part and parcel to the human experience, one is better equipped to manage their life more effectively. One can learn to create “a life worth living”. Here are some details:
“Full fidelity DBT” includes four component parts: Individual Therapy, Skills Group, Phone Coaching, and Consultation for the therapist.
Individual therapy begins with a comprehensive assessment of the client to identify problems, strengths, history and former treatment. Treatment goals are collaboratively established. We use diary cards to track one’s emotions, problem behaviors, behaviors one wants to develop (e.g. conflict resolution, assertiveness), the skills the person has been using and if they are working. When a problem behavior shows up, we conduct an analysis to identify what is influencing that behavior to occur and what skills and strategies one might use to avoid the problem behavior. Consequently, in future situations one can more easily identify when they are heading toward problem behaviors and how to avoid them.
This is the manner in which various skills and strategies are taught. There are four skills sets: 1) Core Mindfulness; 2) Distress Tolerance; 3) Emotion Regulation and 4) Interpersonal Effectiveness.
Core Mindfulness is a set of ancient skills that help increase awareness, support living in the moment without judgement, to participate fully in the moments of our lives and to respond to situations in service of long-term goals.
Distress Tolerance provides tools to use when one is feeling impulsive or reactive. When we are overwhelmed with intense, usually negative, emotions, we may react in ways that provide some modicum of relief in the short term, but create more problems long term. It’s not very useful to just say “stop that!” unless alternatives are provided. Distress tolerance provides alternative responses that don’t have longer-term problems.
In the DBT model, the heart of the problem, the thing that drives us to react ineffectively, is “emotions run amok”. In other words, our emotions get the better of us. They overwhelm our effective coping skills If we can learn to regulate our emotional world more effectively, we don’t get so easily overwhelmed and are thus less reactive or impulsive. The need for Distress Tolerance diminishes.
Many emotional problems occur in the context of our relationships with others. This module teaches skills in getting your needs met in relationships with others. One learns skills to set limits, ask for change from others, express one’s opinions in a manner others take seriously, resolve conflict and stand up for one’s legitimate rights. Further one learns skills to see others’ point of view, validate their perspective and attempt to find solutions that are “win-win”, where both parties feel their concerns are addressed. Finally, all this is done with another skill set that supports mastery and self-respect.
Especially early in DBT treatment, clients don’t have the skills needed to avoid the problem behaviors in which they engage. It takes time to learn and become proficient at all the skills and strategies that are offered in DBT. So, part of the therapy includes providing phone coaching as needed. When one is having difficulty, they can call their therapist to get advice on skills use in that situation.
In the event of a crisis, defined and suicidal thoughts or impulses one is having difficulty managing or, when one is at risk for engaging in tissue-damaging self-harm (e.g. cutting, burning self), they can call their individual DBT therapist 24/7. The therapist will evaluate for risk and the possible need to hospitalization and will provide crisis coaching to help the client deal with the crisis effectively. If one can’t stay safe, hospitalization is imperative. However, to develop a life worth living, we need to develop the ability to deal with difficulties effectively and become less reliant on, or not need at all, psychiatric hospitalizations to stay safe.
An essential element in DBT therapy is that the therapist is meeting weekly with other DBT therapists to discuss cases and get support for doing this kind of work. We call it “therapy for the therapist”. Sometimes, in this model of therapy, the therapist might get rewarded by clients for veering away from the model of treatment and punished for adhering to it. Weekly consultation helps us stay faithful to the treatment model and provides us the support needed to work with a “higher risk” population. Research on this part of the therapy shows that client drop out rates become much higher when the therapist is not attending a consultation group.
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