Generations of children and adults with chronic emotional dysregulation leading to suicidality and self-harming behaviors have lacked effective treatment options. Early therapists and psychiatrists recognized the plight of these individuals, but due to the complexity of the illness and lack of scientific knowledge, they were unable to treat them successfully. Many were told they simply could not be helped.
Even now, sufferers of acute psychiatric disorders are often seen as a burden to the mental health system. Some are told they are being manipulative or that they must not want to get better.
As COVID-19 exacerbated a mental health crisis that was already brewing around the world, increasing rates of depression, anxiety, and suicide, it became even more important for us to understand the chronic symptoms and behaviors of “untreatable” mental health sufferers.
Dialectical Behavior Therapy (DBT) is a decades-old treatment that has been proven effective in treating people suffering from serious and chronic mental illness. In the late 1970s, American psychologist, Dr. Marsha Linehan, noticed that traditional therapies weren’t effective in treating people with chronic suicidality. She tried several different types of therapy—therapies focused on understanding and changing behaviors made her clients feel invalidated, but therapies focused on acceptance weren’t helpful in moving the patient toward healing.
By combining the change strategies of cognitive behavior therapies and the acceptance focus of mindfulness and eastern philosophies, Dr. Linehan created a unique therapy, now known as DBT.
While DBT has been around for decades, bringing it to those who need it is still a work in progress. I have been intensively trained in DBT and was the team leader of a DBT program for adolescents in a Utah residential care facility. Now, I am part of a DBT team, with my colleagues at Dakota Family Services and Dakota Boys and Girls Ranch, that has created a comprehensive DBT program for adolescents and their families. We are working together to provide this important treatment option for North Dakota kids.
So, why DBT?
Why might you consider DBT a worthwhile option for adolescents (your patients or your children) who are not making progress with traditional therapy? Because it works!
DBT is unique in its creation of human connection and relationship. When someone is chronically suicidal, they have trouble finding reasons to live. DBT allows me and my colleagues to build real connections with the people in our offices where we get to be ourselves and they get to be themselves.
For some of our adolescent patients, this is the first safe connection they have felt in a long time (sometimes ever) where they can be themselves. In DBT individual sessions and family skills groups, they can heal and make mistakes without the fear of abandonment.
DBT isn’t about decreasing suffering, although that is often a welcome result of the treatment. Instead, it is about creating a life that would suck to leave. The desire to die by suicide and the desire to hurt yourself decreases when you are fulfilled by the day-to-day activities of your own life. I’ve seen patients move from choosing to stay alive only because they don’t want to abandon their dog, to being excited to wake up and live. As a DBT therapist, I get to be part of people’s journey of falling in love with themselves and their life. Why wouldn’t I love that for everyone I meet?
I love the assumptions of DBT and how they balance acceptance and change.
Assumption #1: Therapists are jerks (meaning they make mistakes).
I love having the understanding with my patients that we will both make mistakes. And then we will come together to take responsibility for our actions and repair and rebuild the relationship so it can become a safe place for change, growth, and building a life worth living.
Assumption #2: Everyone is doing the best they can.
The best someone can do is based on the environment and the context. For instance, if I studied and studied for a very important math test and then took it in a quiet room, at the perfect temperature, with perfect lighting, after a healthy breakfast and a good night’s sleep, with my calculator, I might get an 85%. Is that the best I could do in the situation? Absolutely. Could I do better? For sure, there is always room to improve, but at that moment, I did my best.
Now let’s say I studied the exact same amount for the exact same math test, but I slept poorly the night before, the room was hot and bright, I forgot my calculator, and someone was standing over me screaming while I took the test. Would I get an 85% or better? Not likely. In this second scenario, would anyone say I should have tried harder? I hope not. I did the best I could, given my circumstances, on both tests.
Assumption #3: Everyone needs to try harder, do better, and be more motivated to change.
Just because I am doing my best does not mean I can’t do better. DBT provides the all-important balance of ACCEPTANCE AND CHANGE. When I was a child, there was a musical advertised on the radio called, “I love you, you’re perfect, now change.” This is how I understand the DBT philosophy. People grow when they feel safe and accepted. People grow when they feel loved and acknowledged for doing the best they can.
Assumption #4: Everyone wants to improve and be happy.
Too many children feel hopeless and lost, saying they do not want to be happy because being sad, afraid, or angry is just who they are. Unfortunately, in many cases, they have been told this by other mental health providers.
People sit in my office and say, “I guess I like being angry. I must or why would I still be this way?”
The answer is that change is hard, and they need the right conditions to grow. If it were easy, they would have already done it.
So, what exactly is DBT?
While some therapists use pieces of DBT in their practices, it is intended to be a comprehensive treatment that involves weekly individual therapy, a weekly skills group, phone coaching (adolescents and/or parents can text and call their therapist during the week, within certain rules), and a weekly consultation meeting for the therapists on the team.
The DBT Program we provide at Dakota Family Services is faithful to Dr. Linehan’s model, and is the only comprehensive, intensive DBT program in North Dakota. Our DBT Program is an all-encompassing treatment where participants learn new skills, learn about themselves, and build a life worth living—all with a therapist walking alongside them through individual therapy and phone coaching designed to build their motivation, hope, and ability.
Because people and problems don’t exist in a vacuum, improving treatment outcomes requires the participation of parents or caregivers. The multi-family skills group teaches adolescents and their families the skills they need to improve their ability to tolerate strong emotions, be present in the current moment (on purpose), regulate their emotions, and build strong relationships.
Finally, our DBT team of therapists holds weekly consultation meetings. So, if you are having difficulty learning a skill or dealing with a specific situation, the entire team will be able to help come up with solutions. In addition, the team meets to ensure your therapist is giving you the best treatment possible. It’s like having a team of therapists walking alongside you to support you and your family in this healing journey.
The mindfulness difference
Mindfulness has almost become a dirty word. When something is touted as a miracle for healing all wounds, people become skeptical and frustrated. I’ve seen people visibly flinch when I suggest we discuss mindfulness! But it has numerous benefits and is a key component of DBT, so it’s important to understand how DBT therapists define mindfulness.
Mindfulness is “paying attention to the present moment, on purpose, non-judgmentally.”
Leo Tolstoy said, “Remember that there is only one important time, and it is now. The present moment is the only time over which we have dominion.”
The skills people learn in DBT (or any other therapy for that matter) are not useful if they don’t know how to remain in the present moment because the present moment is the only time they can do anything. The present moment is not always fun or pleasant and in fact, it can be exceedingly uncomfortable and painful. But it does not become less painful by pretending it doesn’t exist. Nor does it become less painful by adding other past or future pains to it.
So, we practice mindfulness to give ourselves options for a better way forward. We practice mindfulness so we can choose a life worth living over death and over pain.
So, again, why DBT?
DBT provides a light in the darkness, where we acknowledge pain but do not suffer because of it. We let ourselves be in unfortunate or uncomfortable situations because they give us room to use and practice our skills. We rise from adversity and provide a way forward for ourselves and for the people around us.
Why DBT? Because everyone deserves to live a life worth living. Because learning these skills gives us freedom. And because staying alive is a goal worth fighting for.