Everyday Inspiration; Day 14: Recreate a Single Day

Good Morning, World!!! Today’s Finding Everyday Inspiration’s assignment is to recreate a single day. I can think of many day’s I could recreate however, I choose not for various reasons. If I recreate a single day even one of the best days of my life that means I would have to relive some of the worst days of my life.

Don’t get me wrong, I remember and recreate some of the great moments in my life when things get tough especially when PTSD symptoms occur. I just don’t want to recreate a single because everyday has made me who I am today and I wouldn’t trade it for the world. Yes, I would have loved to not experienced the trauma I endured throughout my life however those trauma’s helped shaped who I am today. I most definitely wouldn’t want to recreate the trauma’s I endured. I don’t think anyone would want to recreate the trauma’s they endured.

Yes, I would love to have certain positive moments recreated at the moment especially since I have been struggling as of lately however I know I will get through this despite the doubts I currently have. I guess what I am saying is all the experiences I have had in my life is what made me who I am today. As much as I want to recreate a single day; it means it would recreate who I am at this moment in time.

I should really get going. It’s four in the morning and I haven’t been to sleep yet. I have to be up in three hours. I have to be up in three hours so I can get ready for the day and attend my therapy appointment. A much needed appointment. As I end this post I want to thank you for reading. I hope everyone has a great Hump Day (Wednesday). Peace Out, World!!!

I’m Dreaming of Sleep

Good Morning, World!!! It’s nearly two thirty in the morning in my neck of the world. Right now, I’m dreaming of sleep. I haven’t been sleeping very well since I was assaulted nearly a month ago.

Having a good nights sleep is crucial to ones overall health especially for those of us who have a mental health diagnosis. Something I have learned over the years is to have a sleep schedule or what people in the mental health field call sleep hygiene.

For me sleep hygiene means going to bed at the same time as well as getting up at the same time. For me, I tend to go to bed at 11:30pm on week nights (Sunday – Thursday) and get up at 7:30ish in the morning on week days (Monday – Friday). Unfortunately, I toss and turn and unable to sleep so I get up. I tend to get up and stay up at the same time week days and wish my sleep hygiene schedule would work right now.

Now that I have rambled on and on about my sleep hygiene and the lack of sleep I am getting, I might as well as end this blog post and try to sleep. I hope you have an awesome day. Peace Out!!!

An Update From My Last Post

Hello, World!!! It has been about a week since I last posted. Sadly, my last post was about me getting traumatized again. I apologize for not updating you sooner. I’m just attempting to get my baring’s back after what happened and its not an easy process to do so.

Updating you is one way I am attempting to get my baring’s back. As you may realize it hasn’t been the easiest of weeks after dealing with an assault. Not just any type of an assault but a sexual assault. An assault that I don’t remember much of due to the fact that I was knocked out by a rock or brick or something similar.

At this point in time I don’t know if its a good thing or a bad thing but I do know that detective is looking into it as that a stranger reported seeing the first part of the assault. The part of me getting knocked out was reported to the police. The fortunate part was someone not only called the police but took pictures as well. Unfortunately, by the time the police showed up, I had left the park unwillingly with the person who assaulted me. I don’t remember this  and wish the detective didn’t tell me. I am however grateful that someone did call the police and took pictures. Anyway, the detective and I set up a time for me to “be interviewed” to share what I remember (or the lack there of) and put me in touch with the victim’s advocate.

The victim advocate contacted me shortly after the phone conversation with the detective ended. She told me what to expect next in the process of reporting. She will be in attendance when I talk with the detective in person. The victim advocate will me walking along side of me the entire way. The victim advocate also encouraged me to do “good self-care.”

Doing good self-care for me includes me going to my follow up appointment with my doctor. My doctor looked me over and she took my stitches out. The stitches that were located below the belt. She also helped me fill out some paper work that could help me pay for any future appointments regarding the assault. Knowing that I can have more help paying for any therapy or doctors appointments has given me some hope. My doctor has encouraged me to continue getting the support of my mental health treatment team as well as my friends and partner, Junior.

My friends as well as Junior  have always been in my corner and they are continuing to do so. In fact my friends have been checking up on me on the regular basis. Junior continues to be the rock I need as well give me the love and support that is much needed at the moment. Junior and my friends are such a blessing to me in my life and am beyond grateful to have them in my life especially right now.

As I finish up this post I want to thank you for reading and being a support in your own way. I hope to post again soon however I do ask for your patience if I don’t blog for a while due to recent events. I plan on blogging in the next few days but the way things are at moment I don’t want to give in false hopes. Again, thank you for reading. I hope you have a good night and don’t let the bed bugs bite. Peace Out!!!

Ted, Through Thick & Thin

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Good Morning, World!!! I think it’s time that I introduce the world to my best friend; Ted. Ted is pictured above and YES, he is stuffed Teddy Bear. Ted is a 38 year old stuffed animal that I’ve had since the day I was born.

This means he has been with me in both the good and the bad times. He has seen me through the trauma’s I’ve experienced as well as witnessed the triumphs in my life. For me Ted has been there when no human has. So, I guess you can say Ted has been with me through thick and thin.

I bring up Ted because he is the one thing I do to self soothe. As I mentioned in a previous post (https://gertiesjourney.com/2017/09/05/poor-air-quality-therapy-challenging-day/) my therapist and I talked about self soothing and how I feel like I don’t deserve to self soothe. During the discussion about self soothing, I brought up Ted and how he is the one thing I self soothe with. According to my therapist, as I talked about Ted, my body language changed to “being relaxed and comfortable.” She also brought up the fact that it was the first time she had seen me smile when discussing a part of my childhood. I can’t deny the fact that when discussing Ted, I’m relaxed as well it is most likely the first time she had seen me smile while talking about my childhood since she has been my therapist for only five months.

I, of course avoid talking about me like the plague. In fact, I rather have the plague than discuss my childhood. My therapist picked up on this quite quickly am grateful for it. She just like Diana, doesn’t push to talk about things I’m not ready to discuss. She might ask me questions but she respects how much or how little I tell her, just like Diana did.

I miss Diana and hope that she is getting better however I am happy with my new therapist. In fact I think my new therapist is realizing how beneficial stuffed animals are for me regarding therapy just like did. The reason I think this is because she saw how “relaxed and comfortable” I was when I talked about Ted. I’m hoping that when I have my next session with my therapist that she will be okay with me bringing a stuffed animal to therapy as it helps me discuss painful memories of my childhood.

As, I finish up this blog post, I realize that I’m holding Ted as write. If I think back to the start of my blog, I’ve held Ted during most of my blog post. So, yes, Ted has been a part of most aspects of my life including blogging. I hope that everyone has a great day and Peace Out all.

Phuk PTSD!!!

I just wish my nightmares would fucking stop. It is fucking angering that I keep having severe nightmares. Nightmares that appear to be increasing in severity. A severity I haven’t experienced in years and is quite concerning.

Thankfully, Junior is helping me through the after effects of the nightmare. He has been cuddling with me as it seems to be helping me the most at the moment. Feeling safe and secure in his arms is quite helpful. Another thing that is helpful for me right now is watching some television (T.V). Junior and I are watching M*A*S*H. Comedy and humor always seem to help me.

It never seizes to amaze me the love Junior has for me. He stays awake with me after my nightmare knowing that he will be sleep deprived when he does a 48hour shift. Junior’s love and kindness gives me hope that things will get better. It’s nice to know that no matter how bad things get for me, Junior won’t leave. I’ve put him through a lot of shit the last few months and he hasn’t left me. Junior has stated that he won’t ever leave me due to my mental health conditions.

I should get going as I want to spend some time with Junior and hopefully get back to sleep. I hope everyone has a good rest of the night. Happy Friday and Peace Out!!!

Consistency is a Necessity for Recovery

Over the years I have learned that consistency with who my treatment team is key to my recovery. Unfortunately, as of lately that hasn’t been happening for me.

I learned on St. Patrick’s Day that my new therapist, was leaving the agency I seek services at for my mental health treatment. This loss hits me hard as this therapist was the direct supervisor of Diana and was updating me on her health at Diana’s request. Not only that, I was just starting to feel comfortable with her style of therapy as it was slightly different from Diana’s therapy style.

As difficult as it is to loose another therapist so close to Diana’s sudden departure due to cancer, I appreciate her effort in making sure she found the right fit. A fit I am unsure of at the moment and realize the uncertainty of a new therapist is causing some anxiety.

To lessen my anxiety of having a new therapist, my therapist thought it would be a good idea for me to meet the new therapist during our last session together at the location I will be now going to. No, I’m not changing mental health agencies, its that my new therapist is at different location than the one leaving and Diana were at. I am really appreciative of my therapist doing this for me as I know she didn’t have to do so.

My last session with my therapist has come and gone and tears shed on both ends which was quite unexpected for the both of us since our therapeutic relationship had only been for four months. Of course having therapist who was the direct supervisor of your previous therapist (Diana) was helpful to building trust with her. Even though I only met with my new therapist of all of seven minutes for an introduction and to set up a first appointment, I found it quite helpful.

As helpful as I found meeting my new therapist, no matter how briefly, I still have anxiety regarding my first appointment with her. As with any first appointment, I have with anyone, my anxiety usually increases however this time the anxiety is higher than it usually is. Not sure why but it is and if I continue to ask why I notice my anxiety start to rise.  I’ve also realized as my first appointment with my new therapist quickly approaches, there is an increase in the anxiety.

The increase of anxiety is where the use of my Dialectical Behavior Therapy (DBT) skills come in handy to help even if I don’t want to use them. See, DBT skills have helped me through some tough moments as an adult. Even though seeing a new therapist isn’t the toughest thing I have experienced in my life, it’s anxiety provoking enough needing to use my skills.

As I use my skills, I realize that there is a number of reason why to my anxiety is so high regarding my first appointment with this new therapist. Actually, there a roughly a handful of reasons. All those reasons lead to both the grief I have for Diana’s sudden departure due to cancer and having a new therapist leave in less than five months which leads to the consistency I need for my own recovery. Consistency that I fear I won’t have with my new therapist as she appears to be close to retirement age but then again that might not be an issue either but its an issue I have to wait till deal with in my first session with her. For me consistency is key for me to start to trusting people and hope that my new therapist sticks around for a good eighteen months. I don’t that doesn’t sound long but I don’t want to ask for too much as I am seeing her at a community mental health agency and know realistically that people don’t stick around for as long as Diana did. I trusted Diana and still do and hope she is doing well. Most importantly, I hope I can trust my new therapist.

Before, I end this particular post I want share something positive. I am slowly starting to trust my case manager. I see she is trying really hard and to me that shows that she cares. She cares enough to try to build a good rapport and to me that is a sign I can trust her. When I first wrote about her I didn’t give her such a positive light and its not any of her fault. I was angry at needing a case manager and that anger showed through in that particular post. My care manager does care and does want to help me. For me trusting her is a big thing.

It looks like this post is coming to an end and before it ends, I want to tell you all thanks for reading. I am grateful for each one of you. Have a wonderful Sunday evening all and Peace Out!!!

Dialectical Behavior Therapy (DBT)

Happy Friday!!! It being Friday, that means it is time for me to do my educational feature. I have decided to do the topic of Dialectical Behavior Therapy (DBT). The reason being is because I did the topic of Borderline Personality Disorder (BPD). I got the following information off of the  Linehan Institute; Behavior Tech at:   http://behavioraltech.org/resources/whatisdbt.cfm

What is DBT?

Overview

Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment that was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD) and it is now recognized as the gold standard psychological treatment for this population. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.

What are the components of DBT?

In its standard form, there are four components of DBT: skills training group, individual treatment, DBT phone coaching, and consultation team.

  1. DBT skills training group is focused on enhancing clients’ capabilities by teaching them behavioral skills. The group is run like a class where the group leader teaches the skills and assigns homework for clients to practice using the skills in their everyday lives. Groups meet on a weekly basis for approximately 2.5 hours and it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a 1-year program. Briefer schedules that teach only a subset of the skills have also been developed for particular populations and settings.
  2. DBT individual therapy is focused on enhancing client motivation and helping clients to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for as long as the client is in therapy and runs concurrently with skills groups.
  3. DBT phone coaching is focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most.
  4. DBT therapist consultation team is intended to be therapy for the therapists and to support DBT providers in their work with people who often have severe, complex, difficult-to-treat disorders. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. Teams typically meet weekly and are composed of individual therapists and group leaders who share responsibility for each client’s care.

What skills are taught in DBT?

DBT includes four sets of behavioral skills.

  • Mindfulness: the practice of being fully aware and present in this one moment
  • Distress Tolerance: how to tolerate pain in difficult situations, not change it
  • Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others
  • Emotion Regulation: how to change emotions that you want to change

There is increasing evidence that DBT skills training alone is a promising intervention for a wide variety of both clinical and nonclinical populations and across settings.

What does “dialectical” mean?

The term “dialectical” means a synthesis or integration of opposites. The primary dialectic within DBT is between the seemingly opposite strategies of acceptance and change. For example, DBT therapists accept clients as they are while also acknowledging that they need to change in order to reach their goals. In addition, all of the skills and strategies taught in DBT are balanced in terms of acceptance and change. For example, the four skills modules include two sets of acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness).

How does DBT prioritize treatment targets?

Clients who receive DBT typically have multiple problems that require treatment. DBT uses a hierarchy of treatment targets to help the therapist determine the order in which problems should be addressed. The treatment targets in order of priority are:

  1. Life-threatening behaviors: First and foremost, behaviors that could lead to the client’s death are targeted, including all forms of suicidal and non-suicidal self-injury, suicidal ideation, suicide communications, and other behaviors engaged in for the purpose of causing bodily harm.
  2. Therapy-interfering behaviors: This includes any behavior that interferes with the client receiving effective treatment. These behaviors can be on the part of the client and/or the therapist, such as coming late to sessions, cancelling appointments, and being non-collaborative in working towards treatment goals.
  3. Quality of life behaviors: This category includes any other type of behavior that interferes with clients having a reasonable quality of life, such as mental disorders, relationship problems, and financial or housing crises.
  4. Skills acquisition: This refers to the need for clients to learn new skillful behaviors to replace ineffective behaviors and help them achieve their goals.

Within a session, presenting problems are addressed in the above order. For example, if the client is expressing a wish to commit suicide and reports recurrent binge eating, the therapist will target the suicidal behaviors first. The underlying assumption is that DBT will be ineffective if the client is dead or refuses to attend treatment sessions.

What are the stages of treatment in DBT?

DBT is divided into four stages of treatment. Stages are defined by the severity of the client’s behaviors, and therapists work with their clients to reach the goals of each stage in their progress toward having a life that they experience as worth living.

  1. In Stage 1, the client is miserable and their behavior is out of control: they may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When clients first start DBT treatment, they often describe their experience of their mental illness as “being in hell.” The goal of Stage 1 is for the client to move from being out of control to achieving behavioral control.
  2. In Stage 2, they’re living a life of quiet desperation: their behavior is under control but they continue to suffer, often due to past trauma and invalidation. Their emotional experience is inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.
  3. In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that the client leads a life of ordinary happiness and unhappiness.
  4. For some people, a fourth stage is needed: finding a deeper meaning through a spiritual existence. Linehan has posited a Stage 4 specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.

How effective is DBT?

Research has shown DBT to be effective in reducing suicidal behavior, non-suicidal self-injury, psychiatric hospitalization, treatment dropout, substance use, anger, and depression and improving social and global functioning. For a review of the research on DBT, click here. In this video, DBT Developer and Behavioral Tech founder Dr. Marsha Linehan describes the amazing changes she’s seen in people who have received DBT and gotten out of hell.

Dive Deeper

Philosophy and Principles of DBT

DBT is based on three philosophical positions. Behavioral science underpins the DBT bio-social model of the development of BPD, as well as the DBT behavioral change strategies and protocols. Zen and contemplative practices underpin DBT mindfulness skills and acceptance practices for both therapists and clients. DBT was the first psychotherapy to incorporate mindfulness as a core component, and the Mindfulness skills in DBT are a behavioral translation of Zen practice. The dialectical synthesis of a “technology” of acceptance with a “technology” of change was what distinguished DBT from the behavioral interventions of the 1970s and 1980s. Dialectics furthermore keeps the entire treatment focused on a synthesis of opposites, primarily on acceptance and change, but also on the whole as well as the parts, and maintains an emphasis on flexibility, movement, speed, and flow in the treatment.

True to dialectics, DBT strategies are designed in pairs representing acceptance (validation, reciprocal communication, environmental intervention on behalf of the client) and change (problem solving, irreverence, consultation-to-the-patients about how they can change their own environment). Strategies are further divided into procedures; a set of principles guides the selection of strategies and procedures depending on the needs of the individual client. Clients are also taught a series of behavioral skills designed to promote both acceptance and change. A focus on replacing dysfunctional behaviors with skillful behaviors is woven throughout DBT.

DBT is a principle-based treatment that includes protocols. As a principle-based treatment, DBT is quite flexible due to its modular construction. Not only are strategies and procedures individualized, but various aspects of the treatment, such as disorder-specific protocols, can be included or withdrawn from the treatment as needed. To guide therapists in individualizing priorities for targeting disorders and behavioral problems, DBT incorporates a concept of levels of disorder (based on severity, risk, disability, pervasiveness, and complexity) that in turn guides stages of treatment and provides a hierarchy of what to treat when for a particular patient. In contrast, skills training is protocol based. Once a skills curriculum is determined, what is taught in a session is guided by the curriculum, not by the needs of a single client during that session.

The Development of DBT

In the late 1970s, Marsha M. Linehan attempted to apply standard Cognitive Behavior Therapy (CBT) to the problems of adult women with histories of chronic suicide attempts, suicidal ideation, and non-suicidal injury. Trained as a behaviorist, she was interested in treating these and other discrete behaviors. Through consultation with colleagues, however, she concluded that she was treating women who met criteria for Borderline Personality Disorder (BPD). In the late 1970s, CBT had gained prominence as an effective psychotherapy for a range of serious problems. Dr. Linehan was keenly interested in investigating whether or not it would prove helpful for individuals whose suicidality was in response to extremely painful problems. As she and her research team applied standard CBT, they encountered numerous problems with its use. Three were particularly troublesome:

  1. Clients receiving CBT found the unrelenting focus on change inherent to CBT to be invalidating. Clients responded by withdrawing from treatment, by becoming angry, or by vacillating between the two. This resulted in a high drop-out rate. If clients do not attend treatment, they cannot benefit from treatment.
  2. Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. For example, the research team noticed through its review of taped sessions that therapists would “back off” pushing for change of behavior when the client’s response was one of anger, emotional withdrawal, shame, or threats of self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they did not want to discuss to one they did want to discuss.
  3. The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients (suicide attempts, self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, and more) and have session time devoted to helping the client learn and apply more adaptive skills.

In response to these key problems with standard CBT, Linehan and her research team made significant modifications to standard CBT.

They added acceptance-based or validation strategies to the change-based strategies of CBT. Adding these communicated to the clients that they were both acceptable as they were and that their behaviors, including those that were self-harming, made real sense in some way. Further, therapists learned to highlight for clients when their thoughts, feelings, and behaviors were “perfectly normal,” helping clients discover that they had sound judgment and that they were capable of learning how and when to trust themselves. The new emphasis on acceptance did not occur to the exclusion of the emphasis on change: clients must change if they want to build a life worth living.

In the course of weaving in acceptance with change, Linehan noticed that another set of strategies – dialectics – came into play. Dialectical strategies give the therapist a means to balance acceptance and change in each session. They also serve to prevent both therapist and client from becoming stuck in the rigid thoughts, feelings, and behaviors that can occur when emotions run high, as they often do in the treatment of clients diagnosed with BPD. Dialectical strategies and a dialectical world view, with its emphasis on holism and synthesis, enable the therapist to blend acceptance and change in a manner that results in movement, speed, and flow in individual sessions and across the entire treatment. This counters the tendency, found in treatment with clients diagnosed with BPD, to become entrenched in arguments and polarizing or extreme positions.

Significant changes were also made to the structure of treatment in order to solve the problems encountered in the application of standard CBT.

In her original treatment manual, Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993), Linehan hypothesizes that any comprehensive psychotherapy must meet five critical functions. The therapy must:

  1. Enhance and maintain the client’s motivation to change
  2. Enhance the client’s capabilities
  3. Ensure that the client’s new capabilities are generalized to all relevant environments
  4. Enhance the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities
  5. Structure the environment so that treatment can take place

As already described, the structure of DBT includes four components: skills group, individual treatment, DBT phone coaching, and consultation team. These components meet the five critical functions of a comprehensive psychotherapy in the following ways:

  1. It is typically the individual therapist who maintains the client’s motivation for treatment, since the individual therapist is the most prominent individual working with the client.
  2. Skills are acquired and strengthened, and generalized through the combination of skills groups and homework assignments.
  3. Clients capabilities are generalized through phone coaching (clients are instructed to call therapists for coaching prior to engaging in self harm), in vivo coaching, and homework assignments.
  4. Therapists’ capabilities are enhanced and burnout is prevented through weekly consultation team meetings. The consultation team helps the therapist stay balanced in his or her approach to the client, while supporting and cheerleading the therapist in applying effective interventions.
  5. The environment can be structured in a variety of ways. For example, the home environment could be structured by the client and therapist meeting with family members to ensure that the client is not being reinforced for maladaptive behaviors or punished for effective behaviors in the home

True to dialectics, DBT strategies are designed in pairs representing acceptance (validation, reciprocal communication, environmental intervention on behalf of the client) and change (problem solving, irreverence, consultation-to-the-patients about how they can change their own environment). Strategies are further divided into procedures; a set of principles guides the selection of strategies and procedures depending on the needs of the individual client. Clients are also taught a series of behavioral skills designed to promote both acceptance and change. A focus on replacing dysfunctional behaviors with skillful behaviors is woven throughout DBT.

DBT is a principle-based treatment that includes protocols. As a principle-based treatment, DBT is quite flexible due to its modular construction. Not only are strategies and procedures individualized, but various aspects of the treatment, such as disorder-specific protocols, can be included or withdrawn from the treatment as needed. To guide therapists in individualizing priorities for targeting disorders and behavioral problems, DBT incorporates a concept of levels of disorder (based on severity, risk, disability, pervasiveness, and complexity) that in turn guides stages of treatment and provides a hierarchy of what to treat when for a particular patient. In contrast, skills training is protocol based. Once a skills curriculum is determined, what is taught in a session is guided by the curriculum, not by the needs of a single client during that session.

  1. Clients receiving CBT found the unrelenting focus on change inherent to CBT to be invalidating. Clients responded by withdrawing from treatment, by becoming angry, or by vacillating between the two. This resulted in a high drop-out rate. If clients do not attend treatment, they cannot benefit from treatment.
  2. Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. For example, the research team noticed through its review of taped sessions that therapists would “back off” pushing for change of behavior when the client’s response was one of anger, emotional withdrawal, shame, or threats of self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they did not want to discuss to one they did want to discuss.
  3. The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients (suicide attempts, self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, and more) and have session time devoted to helping the client learn and apply more adaptive skills.
  4. In response to these key problems with standard CBT, Linehan and her research team made significant modifications to standard CBT.

They added acceptance-based or validation strategies to the change-based strategies of CBT. Adding these communicated to the clients that they were both acceptable as they were and that their behaviors, including those that were self-harming, made real sense in some way. Further, therapists learned to highlight for clients when their thoughts, feelings, and behaviors were “perfectly normal,” helping clients discover that they had sound judgment and that they were capable of learning how and when to trust themselves. The new emphasis on acceptance did not occur to the exclusion of the emphasis on change: clients must change if they want to build a life worth living.

In the course of weaving in acceptance with change, Linehan noticed that another set of strategies – dialectics – came into play. Dialectical strategies give the therapist a means to balance acceptance and change in each session. They also serve to prevent both therapist and client from becoming stuck in the rigid thoughts, feelings, and behaviors that can occur when emotions run high, as they often do in the treatment of clients diagnosed with BPD. Dialectical strategies and a dialectical world view, with its emphasis on holism and synthesis, enable the therapist to blend acceptance and change in a manner that results in movement, speed, and flow in individual sessions and across the entire treatment. This counters the tendency, found in treatment with clients diagnosed with BPD, to become entrenched in arguments and polarizing or extreme positions.

Significant changes were also made to the structure of treatment in order to solve the problems encountered in the application of standard CBT.

In her original treatment manual, Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993), Linehan hypothesizes that any comprehensive psychotherapy must meet five critical functions. The therapy must:

  1. Enhance and maintain the client’s motivation to change
  2. Enhance the client’s capabilities
  3. Ensure that the client’s new capabilities are generalized to all relevant environments
  4. Enhance the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities
  5. Structure the environment so that treatment can take place

As already described, the structure of DBT includes four components: skills group, individual treatment, DBT phone coaching, and consultation team. These components meet the five critical functions of a comprehensive psychotherapy in the following ways:

  1. It is typically the individual therapist who maintains the client’s motivation for treatment, since the individual therapist is the most prominent individual working with the client.
  2. Skills are acquired and strengthened, and generalized through the combination of skills groups and homework assignments.
  3. Clients capabilities are generalized through phone coaching (clients are instructed to call therapists for coaching prior to engaging in self harm), in vivo coaching, and homework assignments.
  4. Therapists’ capabilities are enhanced and burnout is prevented through weekly consultation team meetings. The consultation team helps the therapist stay balanced in his or her approach to the client, while supporting and cheerleading the therapist in applying effective interventions.
  5. The environment can be structured in a variety of ways. For example, the home environment could be structured by the client and therapist meeting with family members to ensure that the client is not being reinforced for maladaptive behaviors or punished for effective behaviors in the home.

DBT has personally saved my life and am grateful to have had the opportunity to take an intensive outpatient DBT program. DBT is awesome and it is one of the best decisions I have made in my life. Have an awesome Friday and Peace Out!!