Dialectical Behaviour Therapy: In a Nutshell

• Marsha Linehan pioneered the research and treatment methodology originally for symptoms of suicidality and it expanded to address the areas that people with BPD struggle with. It’s now used for anyone with “emotional dysregulation” issues.
• Effective for depression, anxiety, emotional dysregulation, eating disorders, substance abuse, and PTSD symptoms
• The only data-supported treatment for BPD, thus the treatment having been designated “Best Practice” for BPD in many parts of the USA and Canada.
• Understands suicidal and other dysfunctional behaviours as part of the persons “learned problem-solving repertoire.”
• 4 Components to DBT

• • • 1:1 skills learning.
    • Phone Coaching.
    • Grad Group to ensure integration and long term take away of therapy.
    • Whole team consult meeting to ensure we are our doing our best work and “practicing what we teach.”

DBT 101:

• • A long-term therapy delivered in stages to address complex layers of symptoms and problems.
  • Establishes a clear diagnosis (on all axes).
  • Target behaviours are clearly defined and prioritized.
  • Co-occurring disorders are identified, prioritized, and treated.
  • Focuses therapy on active problem solving balanced by a corresponding emphasis on validating the persons’ current emotional, cognitive, and behavioural responses just as they are.
  • Expects a verbal commitment to treatment. Preferably, a one-year minimum commitment is considered the norm, with the expectation that a person learns strategies for self-management and integrates them into life to ensure improved capacity is achieved.
  • Treatment is renewable after one year, only if there has been improvement in target behaviours and/or goals.

Treatment involves:

• A designated primary therapist who coordinates all treatment with the client.
• Weekly one hour psychotherapy and behavioural therapy with the primary therapist.
• Group skills training sessions during Stage 1 work for 12 weeks once a week.
• Collaboration with multidiscipline therapists.
• Use of other appropriate resources (ancillary treatments) for specifically targeted problems, as long as there is only one primary therapist.
• Working with the client on ‘how to deal with other systems/persons’ versus telling the system/person how to work with the client.

Core DBT strategies:

• Validation and problem solving.

Core DBT Skills:

• Distress tolerance skills.
• Emotion regulation skills.
• Mindfulness skills.
• Interpersonal skills.
• Life management skills.

DBT Comparisons with Conventional Psychotherapies:

• Behaviourally focused (even when the client moves to higher levels of functioning).
• Directive.
• Seeks to motivate the patient.
• Fast paced.
• Present focused.
• Encompasses numerous problem-solving strategies.
• Uses a “consultation-to-the-patient” philosophy.
• Coaches the client to become their own “case manager.”
• Explicit in a commitment to treatment and time frame.

The DBT Program has been designed to provide therapy to anyone regardless of formal diagnosis:

• Experiencing mild to severe problems with mood swings, depression, anxiety, and generally unstable emotions.
• Having difficulty managing stress.
• Having relationship problems and/or fear of abandonment and rejection.
• Behaving impulsively.
• Experiencing confusion about identity; and self-esteem issues.
• Experiencing suicidal thoughts, self- harm urges, and other behaviours that risk well-being and quality of life.
• Wanting to improve the quality of their life and learn DBT skills to change behaviour and thinking patterns while restructuring their lives.

The DBT ‘program’ begins with a pretreatment phase which determines if this program is appropriate for the client and goals as well as the direction of therapy determined.

The program includes individual therapy, phone coaching, and classes teaching the core skills of DBT, as well as graduate group sessions.  Sessions may also involve a family member as necessary.

Treatment occurs in ‘stages’ and as a person progresses they work with their therapist to individualize the program for them.

Individual appointments are available Monday through Friday including evenings and (limited) Saturdays. Groups and classes are held in the day and evenings.

Appointments are booked directly with your individual therapist.

Program Information Pamphlet (click here)

Fill out the Self Referral Form (click here)

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Characteristics of DBT Therapists and persons who work best with Borderline Clients:

• Comfortable with the ambiguity and paradox inherent in the DBT strategies.
• Holds a stance of acceptance (validation) and expectation for change.
• Finds the “inherent wisdom” and “goodness” in the moment and the person.
• Unwavering centredness.
• Compassionate flexibility.
• Observes limits, while flexibly changing, adapting, and “giving in,” as the situation requires.
• Nurtures with “benevolent demandingness.”
• Stays certain on select principles while “stepping into the storm.”
• Able to be appropriately transparent, yet not becoming a “friend or sole provider.”
• Aware of their vulnerable times and uses support.
• “Joins” with another yet remains centered in themselves.
• Tolerates dependency yet expects "the client will do what they want to do."
• Acts as the clients “backbone” while making them use their own.
• Has a “Teflon skin.”
• Holds unbelievable faith in the clients ‘worth’ and capacity to change, despite high odds.
• Believes that the future will be better and there is “HOPE IN HELL.”

There are many different kinds of counselling but some have stood the test of time better than others. One form of counselling that has scientific evidence of effectiveness is Cognitive Behaviourial Therapy (CBT).

You know if you have had this kind of therapy in the past because this form of counselling has you do homework. The therapist will offer suggestions and recommend experiments. Sessions tend to be structured – there is an agenda to the meetings.

Other kinds of therapy can be excellent at keeping the ‘walking wounded walking,’ but cognitive therapy can get you better and keep you better. It can be used for depression, anxiety, obsessive compulsive disorder, bipolar disorders, and even schizophrenia and personality disorders. It can and often is combined with medication. While not the only kind of counselling to show long term benefit, cognitive therapy gives you a big "bang for a buck.” Differences happen fairly early in therapy – six sessions is usually enough to see a significant difference.

Some therapists think of cognitive therapy as simply one type of tool in a chest full of tools, applying the various tools as needed. Some argue that really depressed patients don’t have the mental function to “do” cognitive therapy. There is some validity to this, but some concrete achievable steps early on often lead to big improvements. Cognitive therapists would argue that ‘a little of this type of cognitive therapy, a little of that’ means that none of the techniques are likely to be used to the point of effectiveness. We would recommend cognitive therapy for a particular patient because we would feel the time and the patient are right for it. For someone in a crisis, we might recommend strategies to tolerate the situation and cope better before embarking on formal cognitive therapy.

How it begins:

Cognitive Therapy has the patient start noting events that cause stress, even minor stress. It might be being 5 minutes late for an appointment and being caught in traffic, it could be the boss being mildly critical of some aspect of your work, it could be an argument with a loved one. It might be nothing more than your car breaking down or your computer not working for you.

The premise of Cognitive Therapy is that events generate thoughts and it is those thoughts that make us feel an array of feelings. Of course, clinical depression itself causes negative thoughts so it’s a bit of the chicken and the egg situation. Regardless, it is easy to imagine that there are all sorts of factors influencing the level of serotonin in the brain. Things like friends, exercise, and the feeling of a job well done all raise serotonin, as does medication. Factors like being overly sensitive, putting oneself down, and worrying all lower serotonin. It doesn’t matter that low levels of serotonin tend to make you worry – the act of continuing to worry lowers serotonin by itself. Every time you catch yourself having a distorted thought or a thought incongruent with the situation and the evidence, you can come up with a more appropriate thought. Instead of running with that negative thought, that’s one less factor pushing down the serotonin, thus giving medication, time, and other positive influences a chance to raise the serotonin and thus prevent further worrying.

The counsellor acts as a coach, helping you identify and record successful events. They teach you to note the thoughts that the event generated and identify the feeling that followed. They show you how to come up with realistic alternative thoughts that you might have had in response to the event and what kind of “thought distortion” you used in the first place to end up feeling badly.

A simple example is as follows.

You are a secretary and your boss steps out of his office, comments on your lousy spelling, and disappears inside, slamming his door on the way. This was the event. Your thoughts in response to this event might be any one or more of the following.

1. He doesn’t like the work I do.
2. I’m not a good secretary.
3. This is a hint he’s going to fire me.
4. I’m not a likeable person, after all, if I was, he wouldn’t criticize me.
5. My, he’s having a bad day.
6. So, I can’t spell, neither can he – so there!
7. I’m not a great speller, but I have many other endearing/valuable characteristics.
8. He knew I couldn’t spell when he hired me and told me it wasn’t a problem, that wasn’t what he was hiring me for.
9. I know, I’m not a good speller and I’m going to start working on that immediately – I’m going to …

The first 4 responses are likely to involve thought distortions. Two commonly used thought distortions are generalization and looking at things as black or white. You took a mild criticism on one occasion about one part of your work and generalized it to your whole job all of the time. Or you exaggerated – he made a mildly critical remark but you react as if he had spent 30 minutes criticizing everything about you; or you perhaps used the black and white thought distortion. You figure either you are a terrific secretary, or you are a terrible secretary. You KNOW you’re not a terrific secretary because he just criticized you, so you must be a terrible secretary – so now it’s realistic that you fear for your job? Reality is of course that none of us is perfect, we muddle along doing the best job we can with the resources we have. All of us could do a better job, but it might involve increased stress, more fatigue, or compromising other parts of our lives. And if we can’t accept our imperfections and compromises, we are doomed to be miserable.

Recognizing that we have generalized, we can rethink the event and come up with amore realistic thought about the event. “My spelling is not great but the boss has been over reacting to everyone all week.” “He has praised other aspects of my work often enough that I have no valid reason to feel threatened over this one area.” "Heck, I might go into his office, apologize about the spelling errors and comment on mood this week and ask if there is anything I can do to help.”

With practice, the time between the event and the corrected thought becomes shorter and shorter until it becomes automatic to think the right way – even though initially it feels very awkward and artificial and is hard to do.

Often, how we feel is driven by a series of incorrect assumptions we make about other people, how they feel, what they think, and how they will react to a given situation. A man driving home wants to tell his wife he’s going away for a golfing weekend with his buddies. He’s rehearsing in his mind how the conversation will go. He assumes that she will tell him “we can’t afford it,” “you need to spend more time with the kids,” ” I had plans for this weekend…” He gets more and more upset over how he assumes she is going to react. As a result, he’s looking for a fight as he comes in the door, and with an attitude like that, it’s not surprising he often gets one. I find that patients who make assumptions about how others will act / overreact, are wrong more often than they are right, and that they spend an inordinate amount of time stewing about these assumptions. Cognitive therapy teaches you to challenge these assumptions, to test them, and to recognize when you are making assumptions so you can stop reacting to thoughts that they never had, or might not have.

Cognitive therapy provides you with tools to come up with better ways to look at events. These tools include things like charting, worst case scenario, experiments, making lists, etc. A patient might feel that they cannot lean on a friend, for fear of losing them, even though they themselves have “been there" for the friend on many occasions. The counsellor shows that this fear may be unrealistic and has the patient challenge that belief with an experiment, opening up a little to the end and observing their reaction – did it meet the pessimistic expectations and fears of the patient? In a different situation, the patient might express incredible fear of a bad outcome – If I ask for a raise, or ask for help, or say no to more overtime, I risk losing my job.” This logic is used to justify continuing to work 12 – 14 hour days to the frustration of both patient and employer. The counsellor might tackle this fear of losing the job with a question “What would actually happen if you lost your job?” Often when presented with questions like that, the patient describes an outcome that is nothing like as bleak as they feared – they realize that they could find other work, they do have talents, they’d actually enjoy some time off, they wouldn’t mind selling an expensive house and living within their means for a while, they’d actually cope. The counselor might have them evaluate the actual likelihood of losing the job. What evidence is there that if you said no, you’d be fired?

The same might be said of losing a loved one, that they actually end up pushing that person away. A counsellor might help the patient evaluate what the important things in their life are. Is this relationship they fear losing equal to 100 percent of what they do in life, their kids, their job, and their friends? So, despite saying that this person is everything to them, it isn’t really true and shouldn’t be thought of in those kind of terms – it ain’t healthy or realistic.

Recognizing thought distortions alone often helps patients feel better, but that is just the beginning. The therapist goes on to help you correct some of the core beliefs about yourself and your world. This involves some understanding of the past but does not dwell on it. For example, the daughter of a dominating father and a timid mother becomes very timid herself and lets people run all over her, especially her husband. The counsellor doesn’t need to go into great detail of how and when every hurt happened, just enough to recognize that there is a pattern in how you deal with the world, that there is a reason for it, and now that you recognize it’s a pattern, there are some things you can do about it. The counsellor shows you how to recognize these patterns and helps you take the first steps to changing some of these patterns. It may be that you were genetically predisposed to be timid, but lacking examples of how to assert yourself effectively, you are doomed to never change, unless you acquire the right tools.

Patterns of behaviour include things like pushing people away, letting others control you, being domineering yourself for fear of losing control, relying on alcohol to help you cope, or avoiding conflict to a degree that it only lets things fester. Anxiety makes us avoid doing things that are hard for us – if I do this I might get hurt – so I won’t, but often anxiety can build to the point you can’t leave home and can’t go shopping or can’t make a decision (in case it's the wrong one).

It’s at least possible to do cognitive therapy on your own – the books are certainly our there – David Burns, “Feeling Good, The New Mood Therapy” is a classic and there are many others, but cognitive therapy is a bit like learning to play an instrument – it really helps to have a teacher show you the right way. While they can’t do the playing for you, they can point out the right strategies. Depression in particular can make it very difficult to do something like this on your own because of the poor concentration, lack of motivation and interest, and the general pessimism with which depression is usually associated. The counsellor plays both coach and cheerleader.

It’s easy to be skeptical – how is it possible to change the way you feel just by keeping some lists. There is new scientific evidence that when you think in a different way long enough, the brain actually makes new connections and severs old ones -you literally change the wiring in your brain. You don’t have to tell yourself to feel better – you just have to do the homework and you will automatically start to feel better. The brain works by associations. How many of us can’t help but think of the Lone Ranger on hearing the William Tell Overture – cognitive therapists take advantage of the way the brain works to create new associations and new pathways to change you, possibly forever.

Depression is felt to be a combination of stresses, genetics, personality, and belief systems. Each individual with depression has differing ratios of these to add up to depression. So it is that the roles of counselling and medication vary in importance from person to person. Someone who has been fine all their life until losing their job may only need a six month prescription of an antidepressant and never looks back. Someone else with long-standing depression may well get more from counselling than from medication, while others won’t get better with either on its own--they need both.

Cognitive therapy works, it doesn’t take a lifetime of sessions, results can be seen within weeks, and it may just change your life. While most of us don’t have full medical coverage, and it is expensive, a financial investment in your future mental health may pay many times over.

Please call and discuss your own situation to determine if this therapy and the therapist you speak to can be of help to you!