DBT: embrace a life worth living
Dialectics is the idea that two seemingly-opposite truths can be held together as valid at the same time. It is the enemy of “black and white thinking” and has been integrated into behavioural therapy to help people in early recovery. Jancey Wickstrom introduces it to readers.
Download Intervene2-148-Dialectical behaviour therapy
“I love DBT,” a new resident at our rehab said as she settled into a chair for her first group. “Wonderful,” I replied, “Why?”
“It helps me to not feel anything.”
Inwardly I both grimaced and felt a bit excited – here again is someone who thinks she knows a little about DBT, and I get to show her what real DBT is: how she can use the skills and approach to experience and fully be present with whatever emotion shows up – all of them, even the ones she wants to avoid.
DBT, or dialectical behaviour therapy, was initially developed, by psychologist Marsha Linehan, to treat people struggling with suicidal ideation and parasuicidal behaviours. It has since been proven to effectively treat substance abuse, bulimia and anxiety, among other issues. And while DBT comes in a neatly packaged manual, it is far from a manualised treatment. Instead, the power of DBT lies in the philosophy of “dialectics”.
Dialectics is the idea that two seemingly opposite truths can be held together as valid at the same time. For example, early recovery is filled with the discomfort of living in the dialectic every day. Recovery would be much easier if, once a person wanted sobriety, all urges to engage in old behaviours immediately stop. But, as anyone in recovery will tell you, the urges do not stop the minute a commitment to sobriety occurs.
Dialectics is the natural enemy of black and white thinking; and it would be more comfortable if the world were black and white but it is not. For example, most relationships have built-in dialectical understandings: I love my partner AND he or she drives me crazy sometimes. The relationship would be easier to tolerate if there was only love and none of this crazy-making behaviour. But the reality is that we must tolerate both positive and negative emotions when embracing the full range of life’s experiences.
Everyone can relate to the idea that it is easier to be in black and white thinking: ignoring annoying or harmful things a partner does so that we can also ignore the difficult emotions of confrontation. This type of rigid thinking leads directly to psychological suffering.
DBT is grounded in the dialectic of embracing acceptance and change. This means we accept current life as it is, all its successes, failures, highs and lows. In tandem with acceptance, we embrace an attitude of change – a desire to live more closely to values and create meaning every day. Embracing this balance of acceptance and change underlies every part of the path to a meaningful life, which is the goal of people participating in DBT.
Sadly, the dialectic is what can get easily lost when working a DBT programme. Many people, therapists and clients alike, view DBT as a programme to stop an unwanted behaviour such as drinking, substance abuse, self-harm, eating disorders or other maladaptive coping techniques. This is not the case. Instead, the only goal of DBT is to create a life worth living.
For example, for a client struggling with alcoholism, the goal of a DBT programme is not cessation of drinking. Instead, the therapist and client work together to develop the client’s definition of a meaningful life. Goals in areas such as relationships, family, education and career are formulated. The client and therapist then utilise skills to begin to accomplish those goals, and soon enough the client discovers that drinking and other old negative coping techniques are not compatible with this new and highly desirable meaningful life.
The four skill areas of DBT are organised by the acceptance and change dialectic. Mindfulness and distress tolerance skills help people to acknowledge and be present with life as it is. Emotion regulation and interpersonal effectiveness are the skill areas that teach participants how to improve their abilities in relating to themselves and other people.
1 Mindfulness is the skill that sets the stage for all other skills in DBT. Clients who struggle with impulsive urges and actions learn mindfulness to help better become aware of what automatic thoughts show up in their daily lives. Because such thoughts have become so prevalent, to be successful in beginning to recognise those thoughts as thoughts (and not as true directives or imperatives), daily mindfulness practice is vital.
2 As an acceptance skill, distress tolerance does not fix problems or make people “feel better”. Instead, these skills help people get through a crisis moment without making matters worse by acting on old impulses and reverting to maladaptive coping techniques.
3 The change skill set of emotion regulation mainly helps people learn how to understand their emotions and how they can be helpful in life.
4 Finally, interpersonal effectiveness helps people to learn how to get their needs met (make requests or say ‘no’ to others) in ways which align with their values. The skills teach concrete steps on how to approach others, how intensely to communicate, how to state needs, and gracefully handle the response.
To have a fully effective DBT programme, four elements must be present: individual sessions, skills group, telephone consultation and a consultation group for the therapists. The skills group is where clients actually learn the skills. The group leader is intensively trained in DBT and teaches the four skill areas to members, using the group dynamics as a place to implement and practice new skills. Skills are taught, homework is assigned and reviewed, and mindfulness practice is conducted during these groups. In individual sessions, the client and therapist work on applying the skills learned during group to the client’s particular circumstances.
Telephone consultation is a vital aspect of a DBT approach. DBT therapists are available to clients as skill coaches for difficult situations that occur outside of a session or skills group. After all, most difficult situations usually happen while the person is not actually sitting in therapy. This availability is essential, allowing the client to practice newly gained skills in real-world settings.
Consultation group is the part of a DBT programme that is designated for the therapists. This weekly meeting of DBT providers allows for case consultation, support and feedback. Sometimes called “therapy for the therapists”, consultation group is how therapists can successfully keep working in the DBT philosophy while effectively helping people in chronic distress.
A comprehensive DBT programme builds the avenue to recovery needed for people in extreme emotional dysregulation and struggling with impulsive addictions of all types. While a great by-product of working a DBT programme is cessation of old behaviours, the true win is for the clients who learn to use the skills in order to live in the full dialectic of everyday life – even the client mentioned at the beginning of this article who thought DBT was a tool to avoid emotion came to embrace her meaningful life, with all its ups and downs, twists and turns – in other words, a typical life in our non-black and white world.
Jancey Wickstrom AM, LCSW is an intensively-trained dialectic behavioural therapy and ACT therapist, providing group and individual therapy in these formats for over seven years. She is the director of clinical training and the DBT programme at Timberline Knolls rehab, and provides both clinical training and supervision to graduate students at both master’s and doctoral levels.