The nuts and bolts of DBT

We provide a breakdown of the components of DBT and what a person could expect when participating in DBT.

Reference:

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

Transcript

SPEAKER_00 0:03

Welcome to the Inner Solutions Podcast. We are your hosts, Donna Hughes and Jessica Heil. We own and operate Inner Solutions, a private practice clinic located in Calgary, Canada. We seek to understand and help our clients by providing empirically supported treatments and evidence-based practices with compassion and expertise. This podcast will provide you with information regarding complex psychological conditions as well as treatments that are available. Today I'm going to be talking about what is dialectical behavior therapy or DBT for short. Inner Solutions is known for its delivery of DBT. That is usually the therapy that people come to Inner Solutions seeking, whether it be because they've been referred by maybe the hospital system or their GP or perhaps even self-referred to us because somebody along the way, or themselves, when they're doing their own research, have determined that dialectical behavior therapy might be the most helpful therapy for them based on the symptoms that they're experiencing. Let's start with talking about what is the history of DBT. DBT was developed by a woman named Marcia Linehan, who in the 1980s began doing research with a variety of people and clientele when she was conducting psychotherapy. And her population oftentimes would be people who were highly suicidal, self-harming, and highly emotional. And what she was noticing is that for people who kind of fit those hallmark signs that I mentioned there, they often found that the types of therapy that were available at the time were simply not effective enough for them, where these people were not able to make the progress that they wanted to. And that left Dr. Linehan feeling quite bummed. She did not love the fact that she was unable to help all the people that she was trying to help. And it just got her wheels turning about the fact that there must be different things that can be done in psychotherapy to help people who are experiencing those really, really intense symptoms. So she started to play around with different interventions and ways of doing therapy and started to do research on the changes that she was making within her own psychotherapy. She was incorporating in a lot of principles of just a variety of other philosophies into her psychotherapy. And this was quite unique where this hadn't really been done before when it came to the types of philosophies that she was incorporating into psychotherapy. She was using a lot of principles of dialectics, which is the idea that two opposing forces can exist at the same time and can create a synthesis from their opposition. Another way of saying that is that there's validity on both sides. And when we can acknowledge validity on both sides, then usually we'll be able to see some new perspective compared to only holding on to the validity of one side. So that's dialectics. And then she also incorporated quite a bit of Zen Buddhism into her psychotherapy work, as well as behavioral therapy. So the three of those therapies and philosophies were integrated to eventually become what is now known as dialectical behavior therapy. DBT is an advanced form of CBT. It is really heavy on the B in the CBT. So lots and lots of behavioral therapy and less work on the C, the cognitive part of the behavioral therapy. And why is that? It's because what was found through research and what Marcia Linehan was noticing with the people that she was working with is that when people are highly emotional, it's really hard to change the way that we're thinking. And if we were to break it down and look at the science as to what happens in the brain when we're experiencing really intense emotions, we know that when emotional intensity rises, we lose access to our prefrontal cortex, which is the part of the brain that really helps us with thinking and planning, logic, executive functioning, weighing, decision making, all of those really important things that are encompassed in our thinking brain. And instead, we are more focusing on uh reactions that come from the midbrain. So that would include things like our fight, flight, and freeze responses. When we're emotional, we can pretty much only fight, flee, and freeze. Whereas when we are feeling regulated, then we have access to that thinking part of the brain. Marsha Lenahan noticed that for people who are highly emotional almost all the time, it meant that they often did not have access to that thinking part of the brain, which would render regular CBT, cognitive behavior therapy, kind of useless if people were not able to access changing their thoughts as CBT prescribes. So instead, she went very, very heavy on the B and formed and created a lot of different behavioral strategies and behavioral skills that help people be able to shift the way that they feel. And then once they shift the way they feel and those emotions come down, then they can access their frontal lobe again and they're able to then change some of the ways that they think. So DBT is still CBT. It still does work with behaviors and cognitions or thoughts, but it does it sort of backwards, behavior first, and then we can change the thoughts. In 1993, Marcia Linehan published her manual on DBT. And this is where DBT was officially recognized, even though it took upwards of a decade to two decades to really get DBT be more in kind of like mainstream psychotherapy. DBT wasn't very popular in Canada, certainly, until, oh gosh, I would say around 2010 was when we really started hearing more about DBT within the mental health community. And even then it was quite obscure. So to put it in perspective, Inner Solutions, as far as I know, was the only DBT clinic in Calgary until around maybe around 2015, 2016. So it's it's been really slow moving of getting DBT into Canada for a long time. And in the States, I think it picked up maybe a little bit quicker than that, but it's still not a very easy therapy to be able to access. And there are not a lot of clinicians that are trained in comprehensive DBT. In a different episode, we're going to talk about the difference between comprehensive DBT and DBT-informed. And you'll see that there is actually quite a big difference, and it matters when it comes to being able to deliver DBT in the way that research has shown us is effective for treating mental health conditions such as borderline personality disorder. I think it's important to note that when Marcia Linahan first started figuring out what DBT was going to be, she never said, I'm creating a treatment for borderline personality disorder. She said that she was creating a treatment for people who are highly suicidal, self-harming, and highly emotional. And then eventually she and others figured out that that population largely overlapped with borderline personality disorder. And then eventually DBT became researched enough that it was able to be called an empirically supported treatment for borderline personality disorder. Okay, now I want to talk about what DBT would look like if somebody was to decide that they wanted to venture into DBT, then what would they be able to expect when it comes to how the therapy would be delivered? When people start on DBT, everybody starts in something called pre-treatment. Pre-treatment is the first four or so sessions that a person would have with a primary therapist. So you would be assigned to one therapist and you start to meet with them usually weekly for an hour. During pre-treatment, the focus is on making sure that the clinician has your history, that you and the clinician are beginning to collaborate on what are going to be your treatment goals, that you're completing outcome measures, that's like questionnaires that ask you questions about your mental health state. We use those to be able to look at how progress has gone over time. So we'll do the same set of questionnaires at the beginning of treatment and then throughout treatment. And we do that in intersolutions, but anybody who does comprehensive DBT in an adherent way, meaning again, they're doing it the way that research says it's supposed to be done, will also be using outcome measures. We make sure we've got a really strong crisis plan in place during pretreatment that we will fall back to if we need to throughout treatment. And we're having something called a commitment conversation, which means that after the person has learned enough about DBT, there's lots of psychoed on what is DBT during pretreatment, then at the end of that pre-treatment phase, the clinician and the client are going to have a conversation about how it all sounds and whether the client feels like they're able to commit to the process that is DBT. This is important because DBT is a long-term therapy. If you go through from start to finish, then DBT can often take at least a year and sometimes longer. So it is a big, big, big commitment and it's not something that we want clients to take lightly. It's really important to think through whether this is going to be the right therapy for you. And if it's not, then that's okay. That's why pre-treatment is there, is to be able to make sure that everybody is well informed about what therapy is going to look like before making that decision to move forward. At the end of pretreatments, the clinician will ask for a commitment to staying in therapy for a year. And now this is not a it's not a written commitment. There's no money on the table. It's not like you can't uh walk out of that commitment part way through therapy. Of course, everybody has the right to self-determination, but it is a verbal commitment. And why DBT prescribes this is because what the research shows is that when someone makes a commitment to another person, then that is more likely to be able to manifest in being able to keep that commitment when the going gets tough. So if the therapy is kind of moving forward and um client is, you know, they're making progress and it's kind of like two steps forward, one step back as the months are going by, but they're starting to really lose motivation. Like they're just feeling like this is so tough. It's hard to get to therapy every week. I'm tired, I'm thinking about that I want to quit and feeling hopeless. Then this is where the clinician will say to their client, look, remember, we talked about this, that this was going to be really hard. And we made a commitment to each other to work with each other for a year so that we can get you closer to the life that you want to live. And usually when a client hears that, and especially as long as there's been some progress, then usually that's where their own wisdom is going to kick in. They're gonna be like, you know what, you're right. This is really important for me to keep on going. So that commitment conversation is an important thing in DBT because it really does help somebody keep going, even though it's hard, even when the novelty wears off. So that's pre-treatment. And then we go into stage one DBT. Stage one is all about behavioral regulation. This is the place in DBT where we are going to be working on any behaviors that make a person's life untenable. This could be things such as certainly if there's self-harm or suicide behaviors, then we're targeting that in stage one. This could be addiction behaviors, it could be eating disorder behaviors, it could be avoidance behaviors, it could be panic attacks, it could be anger outbursts, having a lot of relational instability, really anything that is a behavior that is making life worse, that there's less quality of life, then that's where we're going to be focusing our efforts and energy. We do this by having our clients come in for weekly individual therapy, and they also attend a DBT skills class. The DBT skills classes are where they learn the DBT skills. Remember, I said that DBT is quite behaviorally focused. There's lots and lots of different behavioral skills in DBT that will help a person start to gain that behavioral regulation. The DBT skills fall into four categories. These include mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Those four categories of skills are usually taught in a DBT skills class, which in adherent DBT, so back to the DBT that is done the way that the research shows us is most effective. Those skills classes are 24 weeks. So again, big, big, big commitment and important to have enough time to be able to learn all of those different skills. There are 80 plus skills in DBT when you break everything down. It's a lot of skills. It takes a lot of time to not only learn that, but figure out how to start to be able to integrate that into your life. And so that amount of time is important to have in order for things to really start to gel. Our skills classes at Inner Solutions are two and a half hours per week. That is what is standard for an adherent program. And I've seen other programs that have done modifications of this where maybe they're meeting for a little bit less time as well. These groups are psycho-educational groups. They really are classes more than groups. They are a place for people to come and meet together to be able to learn the skills. There's very little sharing in a DBT skills class. When there is sharing, it's all about how the client was able to try out the skill. And if it worked for them, then we can celebrate that. And if it didn't work, then we're able to help troubleshoot. So very different than standard group therapy. You're really not there to share details of your life. You're there to be able to learn the skills and start to apply them. So back to the stages. So stage one, we're working on behavioral regulation, and we're doing that by having individual therapy as well as the skills class that are happening concurrently. And there's also something in DBT called phone coaching. Phone coaching in adherent DBT provides our clients with access to 24-7 coaching. There will always be a DBT clinician who is available in order to be able to help our clients coach. What coaching looks like, it is not therapy and it's not crisis counseling. It is coaching on skills, perhaps because the client has tried skills and the skills haven't been working and they're just not sure what else to try. And sometimes it would be that they can't think of what skill to try. So they need some help to be able to figure out where to start. It's a nice addition to the therapy because it means that clients aren't having to wait a full week in between sessions, that if something big happens, they're able to reach out and get access to help right away. And then the last thing that is important to mention that also happens during stage one and throughout all the stages is that in adherent DBT, the clinicians are meeting once a week for a weekly consultation meeting. Now, obviously, this doesn't necessarily directly impact our clients, but it is important to know because it means that when you are participating in DBT, you have a team of therapists who will meet together every week. And if your primary therapist is struggling to figure out how to help you or to be able to gain traction on a certain behavior or whatever it might be, then they're able to go to their team and they can get help on figuring out what to do to make sure that therapy moves forward. So it's it's kind of it's again, it's a cool feature. It's unique in DBT that there are there are other therapies that do consultations for sure, but DBT has its own way of doing so, where it also makes sure that it's holding the therapist accountable to providing DBT uh adherently. So back to that adherent word. I know I've I've used it quite a few times so far in this episode. Let me just define it. Adherence is when you make sure that the therapy that you're doing is actually the therapy that has been shown to be effective in research. Okay, so that's that's what adherence really means. And it is really, really important to be adherent when you are doing a complicated therapy such as DBT and working with complex mental health conditions such as those that bring people to DBT. Okay, so it's it's something not to take lightly. It's something that's really important to consider. So stage one DBT, all those components are happening. We've got our clients who are attending individual therapy skills class and they're participating in phone coaching, and we've got our therapists who are also attending the DBT consultation team meetings weekly. Around the six-month mark, we start to notice that our clients are doing behaviorally better, that they are having progress with the things that they initially came in with. And sometime around that point is usually when we will transition into DBT stage two, although everybody's different. So I've seen some people be able to fly through DBT stage one and they start stage two sometime when they haven't even completed uh skills class yet, but they are able just to start doing stage two despite skills class still going. And I have lots of clients who take longer than six months to complete stage one. So everybody's different. It just depends on your own progress and the complexity of your own mental health. But around the six-month mark is on average when we would see people going into stage two DBT. And stage two DBT is all about being able to process, reprocess past adverse experiences. This is a place to be able to do trauma work if somebody has trauma that has happened in their life. And for many people, even if they don't really resonate with the word trauma, they still might have things that have happened in the past that have colored the way that they see themselves, the world, and others. We would reprocess those experiences using evidence-based trauma treatments. And trauma treatments can be used for a range of things. So again, it doesn't have to be traumatic per se in order to benefit from using a trauma treatment. But we would use things such as prolonged exposure, EMDR, or cognitive processing therapy in the stage to be able to release some of those emotions that are residual from the past. Oftentimes at the end of stage one, people are doing better, but they're not necessarily feeling better. And that's because they do have these things lingering from the past that need to be reprocessed. Once those past things are reprocessed, then usually people are feeling a lot better. And then they would transition into stage three DBT, which is the final stage that we do at Inner Solutions. DBT stage three is building a life that's worth living. It is creating a sense of self-respect, a sense of meaning and purpose in your life. It is looking at creating really positive relationships. We're strengthening and maintaining relationships. We are looking at things like completing our schooling or our careers, just overall, just making sure that life feels like it has a lot of value to us. At that point in the therapy, we are now reducing those sessions from weekly to bi-weekly and once every three weeks, once every four weeks until finally we're done. I mentioned before that DBT is usually about a year and sometimes a little bit longer. Generally speaking, if if DBT is flowing exactly the way that I would expect it to, then usually people are going to be going through about 40 to 50 sessions before they're complete. And that can be kind of um spread out. Like if you think about 40 to 50 sessions, if we're starting to go to bi-weekly or once every three weeks, et cetera, then even though it may be a year in the sense that it's less than 52 sessions, right? 52 weeks a year, it still might take longer than a year because we've spread those sessions out. So that's where I'd say that a good ballpark of how long will you actually be in a DBT program is usually somewhere between one to two years. Next episode, we're going to talk about what are the differences between comprehensive DBT and DBT-informed treatment. And that's going to carry forward this conversation that I've had about why adherence is so important. And sometimes when we're able to let go of adherence as well. So it's not to say that DBT always has to be 100% adherent. There's reasons why we might drop some of that adherence. So stay tuned for next episode. I'm excited to be able to talk to you about that topic. Take care for now. Thanks so much for listening. If you found today's episode helpful, please go ahead and leave us a review. And you can also follow the show so that you don't miss out on any future episodes. For more information about us, you can check out our website, www.innersolutions.ca.