About DBT Therapy
Dialectical Behaviour Therapy (DBT) is a treatment that was developed in the 1980s, and was formalized in 1993 by Dr Marsha Linehan, a psychologist in the United States. Details of her professional work and univeristy activities can be found on her univeristy website http://faculty.washington.edu/linehan/
DBT has a text book and manual for therapists written by Dr Linehan, and has been implemented throughout the world. Dr Linehan has a comprehensive web site for professionals and the public full of information on DBT www.behavioraltech.org.
DBT is the most thoroughly researched therapy for people with self harm and suicidal behaviours. It has consistent significant findings in reducing the frequency of self harm behaviours, as well as reducing inpatient admission rates and improving global functioning and adjustment.
The treatment was originally designed and tested specifically for people diagnosed with Borderline Personality Disorder. Since then, DBT has been extended to several other clinical populations with significant positive results. It appears to be very helpful to a range of people dealing with personal difficulties. This is partly because it is a structured program, and also because it is a skills based program that focusses on strategies that clients have found actually work for them. DBT also provides clinicians with a very effective range of strategies to help their clients.
DBT is very helpful for people who struggle with their emotions, or those who have also experienced an environment that is critical of them or invalidating. It is also helpful for people who experience impulsivity, signifant distress, or who have difficulty in maintaining relationships or life situations, such as employment.
Some of the specific psychological problems that can be helped with DBT include clinical depression and anxiety, self harm and suicidal behaviours, binge eating, post-traumatic stress disorder, and substance use problems.
Some individuals have several of these problems at the same time. As a result of this complex range of difficulties, the person concerned can find it hard to maintain steady relationships, employment, or a sense of self. Partners, families, friends, and even mental health professionals, are often quite uncertain about how to help the person they care about. Sometimes friends and family can become very frustrated and eventually engage in some difficult behaviours themselves, in their attempts to cope with the situation.
DBT is a treatment specifically for this kind of person, who has this kind of set of problems. It is highly structured, which helps all concerned.
There are 4 stages of DBT. The first stage of treatment is Stage 0. This stage is called Pre-Commitment, and involves the participant getting ready for the treatment, and making a commitment to the goals of DBT, one of which is to build a life worth living.
The second stage of DBT is Stage 1, and is what most people are referring to when they talk about DBT. Stage 1 DBT is described in the text book and manual written by Dr Linehan, involves 4 modules of Skills Training, that is usually taught over 12 months. Each module targets specific areas of personal growth.
The modules are:
Core Mindfulness, which is an adaption of Bhuddist mindfulness techniques that are helpful for these kinds of problems
Interpersonal Effectiveness, which teaches skills for building and maintaining relationships and self care in relationships
Emotion Regulation, which covers strategies for balancing emotions, changing them, and enhancing resiliance and coping
Distress Tolerance, which teaches strategies for tolerating and surviving distressing situations and self care
Participants attend 2.5 hour weekly group sessions, and 1 hour of individual therapy every week, totalling 3.5 hours of treatment per week that continues for the period of the program.
DBT Skills Groups teach a set of skills that work in coping with a range of situations, which is why they are called Skills Groups. Group session are psycho-educational, and are run like a class, with handouts, lectures, people taking notes, and discussion. They are not like a traditional therapy group. Disclosure of people’s personal histories is not expected and time is not spent on reviewing people’s week or current concerns, though they are still supportive in tone. There is also no discussion of self harm in these groups, and they are structured, lead by two facilitators, and are a safe environment. A sample of the type of content in these groups can be found at www.dbtselfhelp.com which provides an example of some lessons and content typically used in DBT programs.
Clients bring what they have learnt in the group to the individual DBT therapy session. These sessions discuss how to apply the information learnt in the group to their personal situation and problems. Individual sessions are also structured. DBT participants also have access to phone coaching, to help them practice the things they are learning in the group sessions at home between sessions.
DBT therapists also attend a two hourly clinician group every week, to support the individual therapist and the team in what they are doing with their clients.
DBT participants have homework exercises and worksheets. DBT is a very active form of therapy for both the therapist and client!
DBT is skills-based and assumes that clients can learn new ways of dealing with a whole set of situations, when they are given the right information and right type of support. This belief in the client’s ability to grow is respectful and empowering, but also can be confronting. Clients usually stabilise a lot of their behaviours during the 12 months of the program, but may continue to feel intense responses at times.
After the first 12 months, which is a very steep learning curve, Stage 2 DBT commences. This involves DBT Graduates in maintaining everything they have learnt, integrating it into their daily life, and extending or generalizing their skills to new situations. It also involves resolving any underlying issues, such as trauma that has occurred in the past. Traditionally Stage 2 DBT can be conducted in groups, or in ongoing individual therapy. Generally, it can take anywhere from 6 months to 2 years for people to move through this stage. At The Melbourne DBT Centre we have a structured DBT Graduates program that has been designed by graduates themselves, to meet what they have identified as their needs.
Stage 3 DBT involves the person moving forward in their life, having developed a whole range of personal skills that work for them, into the life they want to live.
The overarching goal of DBT is to Build a Life Worth Living. This is often the primary motivation for engaging in 12 months of therapy, when sometimes its a struggle at times to just hold on day to day. Stage 3 DBT involves people finding their direction, and moving forward to achieve their personal goals. Usually by Stage 3, clients are well underway to having a life they want to live.
As a therapist, it is an absolute joy to travel alongside someone who started at Stage 1, and has gotten themselves to a position of personal balance and begun achieving things that matter to them in Stage 3. It really is possible for people to recover their lives, and mastering the skills offered in DBT and participating in the program provides the help needed.
People in DBT programs say they actually enjoy participating in the program, and DBT Graduates uniformly say that DBT has made a tremendous difference in their lives. The treatment really does work!
The DBT Modules
Core Mindfulness is the first module in DBT. It is called Core Mindfulness because the set of skills in this module are the foundation skills for the rest of the treatment. This module borrows a few strategies from Buddhist meditation techniques that have been shown to be effective for treatment of psychiatric and psychological difficulties.
DBT uses a particular form of mindfulness, that is based on the work of Dr Jon Kabbot-Zinn, who has thoroughly researched the effect of these techniques on a range of medical conditions since the 1970s www.umassmed.edu/behavmed/faculty/kabat-zinn.cfm For a sample of these techniques, Dr Jon Kabbot-Zinn has a full mindfulness exercise to participate in on YouTube www.youtube.com/watch?v=3nwwKbM_vJc. DBT Mindfulness includes several other techniques in addition to this introduction by Dr Kabbot-Zinn, that have been specifically developed and researched.
Benefits of this module include: strategies to deal with dissociation, anxiety management, understanding of origins of psychological distress, and the beginnings of learning to hold the mind or attention on one point of focus, rather than where ever emotions or memories direct the attention. Eventually, participants in DBT can learn to use their mindfulness skills to manage very intense experiences, such as self harm urges and intrusive memories, and have moments of feeling calm and connected emotionally.
The second module is Interpersonal Effectiveness. This module covers skills to cope with and improve relationships, and how to look after yourself within various types of relationships.
This module is very active and challenging, but is absolutely essential for people who are either too passive, or too aggressive in their exchanges with others. It also helps people learn how to go about getting what they want in their interactions with others, without giving up their self respect or autonomy. This module is also very helpful for people with depression and anxiety, and is often the module people return to later when they have completed the program, to get a revision, because the skills are so helpful and essential.
The third module is Emotion Regulation. This module covers a host of strategies to manage and change emotions, to become more robust in the face of emotional triggers, and to enhance positive emotions and have more positive feelings.
The content of this module rings very true for many participants, and is in some ways what many participants crave the most: to find ways to understand, settle and soothe their feelings, and change them if they wish. It also provides strategies to become more robust or resilient emotionally, to “grow some protective emotional skin” as a past participant has said, regarding their own natural sensitivity.
The final DBT module is Distress Tolerance. This module has a huge range of practical techniques, all of which are about tolerating the distress of the moment, without doing anything to make the situation worse. It also includes some guides for making peace with events or people who have caused suffering.
The strategies in this module are quite pleasant to practice, after the challenging nature of the previous modules! It includes a section on radical acceptance, which is an advanced Buddhist concept, that helps in mustering a response to experiences or circumstances that we find intolerable but cant change, or that cause us deep suffering. For this reason, this module is like an advanced Mindfulness class.
The modules do not have to be completed in this order, however, Core Mindfulness must always be completed first as it teaches the foundation skills of DBT. More information can be found about the modules and structure of DBT on Linehan’s DBT website www.behaviouraltech.org and on www.dbtselfhelp.com
Pre-commitment in DBT
Before Stage 1 DBT commences, involving weekly Skills Groups and Individual Sessions, a participant must complete Stage 0, or Pre-commitment. This stage can take anywhere from one session to 12 months of individual sessions, though this long is very unusual.
Stage 0 DBT involves the person getting ready for the DBT program and making a commitment to participate. Stage O also involves the clinician and client reviewing the person’s relevant history, discussing diagnosis, defining and understanding the list of problems the person wants to deal with, addressing any issues that would otherwise make effective engagement in the treatment impossible, such as daily binge drinking, and last but not least, making a commitment to working through the DBT Treatment Hierarchy.
The DBT Treatment Hierarchy is a set of sequential goals. It guides the focus of the clinician in every group, individual and phone session and every interaction with the client throughout the treatment. It is the structure DBT therapists use to direct what they should focus on, step by step with each patient.
For the DBT Treatment Heirarchy to work, the DBT participant needs to also be willing to work on goals of the Heirarchy with their DBT therapist, and commit to working through the issues they are bringing to the therapy in this order. The implication of this hierarchy in DBT is that an agreement is made to deal first of all with self harm and suicidal behaviours, and then to address anything getting in the way of the therapy, and then to move into improving the overall quality of life for the person concerned.
DBT for Adolescents
In 2007, Dr Marsha Linehan, along with Dr Alec Miller and Dr Jill Rathus, wrote Dialectical Behaviour Therapy with Suicidal Adolescents. This book outlines a tested and established adaption of standard DBT for adolescents with self harm, emotional and relationship problems. An example of one of these programs in which Dr Miller has been involved can be found at http://psych.ucsf.edu/lpphc.aspx?id=2370
The main changes to the standard, original form of DBT involve the DBT Skills Groups being delivered as a Multi Family Skills Training Group, where the teen brings along one family member or other relevant person, and they both participate in the group together.In addition to the 4 standard DBT modules, an extra module has been developed especially for adolescents and their families called ‘Walking the Middle Path’. This module outlines a series of delimmas that the adolescent and their family often deal with, and teaches skills to deal with these situations.
At The Melbourne DBT Centre, our DBT for Teens Program closely follows this published and researched treatment model. For more information about our DBT for Teens Program, please go to the tab on our web site or contact us to book in an appointment..
DBT for Binge Eating & Bulimia
In 2009, Safer, Telch and Chen, with Linehan’s support, published a new DBT treatment manual for helping people with bulimia and binge eating problems. This treatment model has been trailed, and researched. It has good treatment outcomes for participants, which means it works!
The main change to standard or comprehensive DBT is that in the DBT Skills Groups, there is direct discussion and focus on how all the DBT skills are applied to dealing with eating difficulties. There is also some new strategies for therapist and clients that are specific to dealing with eating problems.
At The Melbourne DBT Centre, our DBT for Bulimia & Eating Problems Program closely follows this published and researched treatment model. Participants attend weekly 1 hour Individual DBT therapy and a weekly 2 hour DBT Skills Groups with other participants in the program.
The program is helpful for anyone with bulimia, binge eating, over-eating, or most other types of eating problems. It is not suitable for anorexia nervosa.
The program is not a weight loss or eating technique program. The focus of the therapy is on learning skills to manage difficult emotions, as these difficult emotions are usually the underlying reason or trigger for why people binge eat or purge.
For more information about our DBT for Bulimia & Eating Problems Program, please go to the tab on our web site or contact us to book in an appointment.
DBT Graduates Program
Graduates of our DBT program have the option of joining our DBT Graduates Program. This program is also open to Graduates of any DBT Program that want to maintain and practice their skills.
This program has been designed by previous DBT graduates who have worked with Dr Johnson to create a Graduates Program that works for them. Its focus is to maintain and extend what they have learnt in the DBT program.
DBT Graduate Groups involve a combination of DBT skills review, problem solving, mindfulness practice and support. Sessions focus on support in applying DBT skills and addressing other personal difficulties. In the DBT treatment heirarchy, participants in the DBT Graduates Program are engaged in Stage 2 and Stage 3 DBT.
Groups are 1.5 hours in length, and Medicare rebates apply subject to an appropriate referral.