In the late 1980s, early in my career as a psychologist, I was challenged in a unique manner by my work with certain people. I noticed that they could seem relatively well adjusted in certain situations and yet, in others, they had great difficulty functioning and even made situations worse through angry actions, self-mutilation or suicidal behavior. The typical strategies that I used in my cognitive behavioral therapy worked for a short period but then seemed to backfire, leaving both my client and me confused and desperate for answers. At the time, I was the chief psychologist at a local community mental health center, supervising doctoral interns and just launching my career as a clinical psychologist. I felt great pressure to figure out what to do with this subset of people who seemed to suffer so greatly and yet not respond to the traditional therapeutic interventions that I knew so well. I was beginning to doubt my abilities, as a large number of people with these kinds of problems began to apply for services in our clinic.
Around the time I was noticing this trend, I saw a flier promoting a lecture by a psychologist from the University of Washington whom I had never heard of before. Her name was Marsha Linehan, and she was working with people who were self-injurers and were often suicidal. The flier highlighted the fact that often these clients don’t respond well to traditional cognitive behavioral therapy. I knew I had to attend the lecture and drove straight into the city to listen to her speak. That day began a nearly 30-year involvement with a therapy now known as dialectical behavior therapy (DBT).
Eastern Spiritual Practices and Concepts
Dr. Linehan spoke at length about the significant research she was doing to help people with these problems. She had added an acceptance-based component to traditional behavior therapy and incorporated Eastern spiritual practices and concepts into this therapy. She taught her clients mindfulness meditation and concepts such as impermanence of experience and the wisdom of their symptoms. Impermanence means that the only constant in life is change. The nature of the world is constant movement and change in both the physical world and the world of emotions, mental images and thoughts. Thus much of getting stuck in them is related to actively holding on to them rather than letting them run their natural course. Her concept of understanding the wisdom of the symptoms has to do with recognizing that we are all products of our environments and biology. We learn how to soothe ourselves in both healthy and unhealthy ways. We could not have learned anything different up to this point. But now, with therapy, we can. Incorporating these concepts into a treatment model to use with clients was remarkable and extremely innovative at the time.
Dr. Linehan described the overall philosophical basis of DBT as incorporating dialectics. She saw the importance of helping clients to recognize that opposites can coexist and be synthesized. One example of this is the central concept of Wise Mind, which is the synthesis of Logical Mind and Emotional Mind. Wise Mind incorporates aspects of both logic and emotion to view a given situation with both our reason and our hearts. Good decisions often come from a synthesis of these two.
She described the dialectic of balancing acceptance with change. This means that the therapist accepts the clients where they are and at the same time pushes them for change. The clients are then helped to accept their emotions when there are no reasonable alternatives and to change their behavior in response to their thoughts and feelings.
Dr. Linehan put forth a biosocial model. This model highlights the idea that problems develop from the interface between biological factors such as emotional vulnerability and environmental factors such a trauma and invalidating environments. This combination of biology and environment predisposes an individual to emotion dysregulation, which can be highly associated with self-injury and chronic suicidality. Clients are taught this biosocial theory to help them understand what may have led to their high levels of emotional responding and concomitant problematic responses.
The Treatment: Dialectical Behavior Therapy
DBT treatment is quite comprehensive and involves FOUR components:
- Individual therapy
- Group skills training classes
- Between-session telephone coaching
- Consultation team for therapists
Individual therapy involves working one on one with the client to address the most serious target behaviors that threaten the individual’s life and relationships. A hierarchy of priorities is followed, in that the focus of the session must be on the priority that is most threatening. For these clients, the highest priority for treatment is suicidal behavior. This issue must be targeted before items that are lower on the hierarchy can be addressed. The hierarchy is as follows:
1) Self-injurious or suicidal behaviors
2) Therapy-interfering behaviors (exhibited by both client and therapist)
3) Quality of life issues
4) Skills acquisition
Individual therapy sessions are aided by the use of a weekly diary card to help the clients track their target behaviors and to assess the events and thoughts and feelings that lead to their occurrence. This is known as performing a behavioral chain analysis. Allowing the client and therapist to see the antecedents and consequences of life-threatening and self-injurious behavior allows them to work on understanding it with compassion and leads to the development of alternative ways of coping. The use of the diary card is an important part of the treatment and is the first order of business in all individual sessions.
Another important part of the therapy involves the labeling and analysis of the behaviors that interfere with the successful use of therapy. These behaviors could include not showing up for appointments and arriving late on the part of the client. Since the philosophy of DBT involves the development of genuineness on the part of both client and therapist, it is important for the therapist to acknowledge when they, too, are engaging in therapy-threatening behaviors such as not paying close attention during sessions or not returning telephone calls. This is where the consultation team is so important to provide support and to help the therapist stay adherent to the principles of DBT.
As a DBT program within a training clinic, the issue of therapy-interfering behaviors is so important. The students doing the therapy are well-trained, intelligent and connected to their clients. They also need to be aware of how difficult it can be to help people who are in great emotional pain and who engage in self-injurious behaviors as a result. The emotional toll on them as new therapists can be great and the support they receive from the consultation team and supervisor is crucial. All therapists may act in ways that are problematic for the therapeutic relationship. When this happens, it is pointed out by either the consultation team or supervisor. Our students are encouraged to see themselves as human and vulnerable and prone to the same fears and concerns that their clients may have. This also helps everyone involved develop compassion for the human condition. We strive to help our students accept their vulnerability as young professionals in training. The courage of our clients is matched by the courage of our students who are fully in the moment with the clients, helping them create lives worth living.
The third priority of treatment has to do with improving the quality of life in general for the clients. This includes maximizing use of their abilities so that they can maintain gainful employment or do well in school (depending on the age of the client). Learning how to engage in meaningful recreational and social activities is also stressed.
The fourth priority involves using the skills taught in the skills group classes. This means helping the clients to find the correct skills to use in a given situation. The development of skill use involves the gradual shaping of behavior to be most effective in a given situation.
Finally, individual goals are addressed after the client has learned enough self-regulation to no longer self-harm or engage in quality of life interfering behaviors. This is often the focus of what is considered stage two of the treatment. While the target behaviors in this stage are important and serious, the client’s ability to self-regulate and not engage in suicidal behavior is relatively well-established.
Group Skills Training Classes
Group skills training classes for adult clients usually consist of five to eight members. For adolescents, multi-family group classes are run so that parents can learn these skills along with the adolescent client. This increases the likelihood that the skills will generalize to the home environment since the parent is taught to use the skills for themselves and to apply them to their own lives. There are five or six families in each multi-family skills group.
There are five modules to the skills classes:
Mindfulness skills: Learning to focus on experiencing reality as it is in the present moment without judging it or holding on to it.
Emotion regulation skills: Learning to understand the presence and function of emotions, to decrease unique and shared emotional vulnerabilities and, where possible, to reduce painful emotions.
Distress tolerance skills: Learning how to get through crises without making them worse and to accept painful emotions and events where necessary without judging, pushing away, or holding on to the experience.
Interpersonal effectiveness skills: Learning how to be effective and respectful with other people while maintaining self-respect. People learn to ask for what they need, say no when appropriate and cope with interpersonal conflict.
Middle path skills: Learning about dialectical dilemmas in life and applying the dialectic that two things that seem like opposites can both be true. Learning to look at the world in a less absolute way and accepting that the only constant in the world is change.
The five modules of skills help clients learn, relearn and overlearn behaviors that help decrease mood-dependent self-destructive behavior and intense emotional arousal while helping to increase interpersonal and occupational/ educational competence.
Between-Session Telephone Coaching
Between-session telephone coaching is an important way to help clients generalize the skills that they learn in therapy to real-world settings. Clients are encouraged to call when they need to use a skill in a given situation. The therapist helps the client select an appropriate skill or skills to use and then encourages the implementation of it. These calls last 10-15 minutes and are focused on the situation at hand and the skill to be used.
Consultation Team for Therapists
Another unique aspect of Linehan’s work was that she saw the need for therapists to have lots of support and created what is now called a DBT consultation team. The purpose of this team is to give support and encouragement to the therapists because of the intensity of this work. As Linehan saw it, the treatment team is essential to support the therapists who are working with clients whose primary targets for treatment begin with reducing and eliminating suicide attempts and completions and stopping self-injury. Understandably, therapists often experience burnout when working with high-risk clients who are suicidal and/or engage in self-injurious behavior.
For many years I practiced “DBT informed therapy” without the support of a DBT consultation team. Although it was difficult work, the theory and the clients’ responses to this treatment motivated me to continue. As I began teaching DBT to some of the doctoral students and witnessed the same aha moments I had experienced myself, I sought out opportunities to get more specialized professional training in this area. Last year, Hofstra sponsored a number of the faculty and professional staff, Phyllis Ohr, PhD; Merry McVey- Noble, PhD; Teresa Grella-Hillebrand, LMFT; and me, along with doctoral students from the PhD Program in Clinical Psychology, to attend an intensive training in DBT at Columbia University. After the two-week training was completed, our group returned with increased knowledge of the model and a renewed commitment to providing the most comprehensive DBT treatment we could offer to the community. Together we created a model-coherent DBT consultation team that now services over 20 adult and adolescent clients.
The current DBT team functions as an aspect of training in two of the clinics within the Saltzman Community Services Center: the Counseling and Mental Health Professions Clinic and the Psychological Evaluation Research and Counseling Clinic. The doctoral and master’s level students in each of these clinics are afforded the unique opportunity to be trained in DBT, work with clients and their families, and be part of a DBT consultation team. We are one of very few doctoral and master’s training clinics in the country that offers a fully functioning DBT program and consultation team. The students involved in this clinic get supervision in the consultation team and then small group supervision to learn and get feedback on their ongoing cases. This is a very time-intensive endeavor and can be emotionally and intellectually challenging for all involved. That is why the experience of working as a team is so important for support, encouragement and understanding. The care we give to each other is then passed on to clients through their therapist. In the end, it is about creating a safe environment for both the client and the therapist and for both to go “where angels fear to tread.”
A unique aspect of our treatment package is that we have added a family therapy component to traditional DBT treatment in our clinic. Our treatment team currently has two clinical interns in the Marriage and Family Therapy program who are trained in DBT. A licensed marriage and family therapist, Teresa Grella-Hillebrand, who is also a member of the DBT team, supervises these clinical interns. The interns conduct all of the family sessions for the DBT clients who require them.
Although we are now aware that there are some researchers exploring the value of incorporating family therapy in DBT treatment, our decision to require it for some of our DBT client cases occurred in response to a number of referrals of young adolescents to the clinic. These adolescents range in age from 11 to 13, with histories that include prior suicide attempts and self-injurious behavior. A crucial piece of the biosocial model of DBT is the client’s environment. For the emerging adolescent, the family is often the most important environmental component.
The family component of teaching DBT skills is addressed in the multi-family skills class. However, it became apparent that the families of younger adolescents required more support than could be provided in a two-hour group setting with multiple families. Many of these families appeared to be caught in negative interactional patterns that had been reinforced over time, resulting in relational wounds between family members. While the multi-family class teaches family members new skills to help individuals cope with difficult emotions and interpersonal interactions, family therapy addresses the underlying processes in a family that can block the use of new skills. The family therapists on the DBT team incorporate an understanding of the DBT model and skills with their foundational knowledge of systems to help families address relational issues that threaten to undermine treatment. At this time, family therapy is available to all adolescent and adult clients who are in DBT treatment on an “as needed” or “as requested” basis.
Creating a Life Worth Living
The ultimate goal of dialectical behavior therapy is to help our clients and their families create a life worth living. This means accepting the pain that comes with life and all its struggles while engaging in value-based living. These values and their meanings are determined by each client and are always placed at the forefront of the therapy. We do our best to meet our clients where they are and continue to push for change – being ever mindful that this balance of acceptance and change is a never-ending dance.