DBT For Dummies. Gillian Galen

      

In the same way that individual therapy helps the patient stay motivated for treatment, the consultation team works to ensure that the therapist remains motivated in order to provide the best treatment possible. Teams typically meet weekly for an hour to an hour and a half, and are composed of individual therapists, family therapists, group leaders, and anyone else providing DBT therapy. It’s such an essential component that a therapist can’t say that they are providing DBT therapy if they aren’t on a consultation team. Chapter 17 covers therapist consultation teams in more detail.

Incorporating Dialectics

      

The fundamental principle underlying the practice of DBT is the recognition of and emphasis on the dialectical process. The dialectical philosophy at the core of DBT is that seemingly opposing experiences such as thoughts, emotions, or behaviors can coexist, and both make sense. In other words, two ideas that are seemingly in complete opposition to each other can both be true at the same time. This requires that a therapist and a patient be able to look at a situation from multiple perspectives and find a way to synthesize the seemingly opposite ideas.

Within this framework, reality consists of opposing forces that are in tension, not dissimilar from a game of tug-of-war. As it pertains to therapy, in many cases the push to apply change-oriented treatment strategies often creates a resistance to the recommendations. The therapist pulls in one direction and the patient in another. This is because the prospect of facing the emotional turmoil and suffering that many people with conditions like BPD experience during therapy feels more painful than they are willing to bear. Dialectical philosophy also recognizes that opposing forces are incomplete on their own; you can’t have a tug-of-war with only one team.

      Practitioners noted that it was by moving into a collaborative and accepting stance, rather than one solely focused on trying to get their patients to change, that the possibility of change occurred. And so, when the therapist balances and synthesizes both acceptance and change-focused strategies in a compassionate therapy, the patient experiences the freedom they need to heal. In many cases, prior to DBT, patients experienced the opposite. They either noted locking horns with their therapists, who insisted that the patients had to change, or they experienced passive, though caring, therapists who simply listened and didn’t offer ideas that could help. In some cases, individual therapists would swing between the two extremes, another style that was unhelpful to patients who themselves would tend to swing between extremes.

      Another way that this manifested in traditional therapies is that frequently the therapist would feel that their formulation of the patient or their interpretations of the patient’s behavior was “right.” In DBT, the therapist lets go of the need to be right and is open to the idea that there are other possibilities in the moment. Finally, in DBT, there is an emphasis on moving away from a rigid style of therapy, and so there is often a lot of movement, speed, and flow within a therapy session. This is achieved by the therapist using various strategies to increase or decrease the intensity, seriousness, lightness, or energy of the therapeutic interaction, and then in so doing assessing what works best for any one particular patient, rather than assuming that a single style works equally well for all patients.

      The following sections delve more deeply into the dialectical process. Flip to Chapter 15 for even more information.

      Searching for multiple truths in any situation

The core dialectic in DBT is that acceptance and change coexist. This is best illustrated by an example. Imagine that you’re stuck in very heavy traffic. You can’t get out of the car, there are no nearby exits, and your mobile app tells you that you’re at least an hour away from a meeting that you should have been at 30 minutes ago. What can you do? For some people, there could be rage, for others resignation, and for others an attempt to solve the problem a different way, like calling in to the meeting. The reality of that moment requires the acceptance that the moment is as it is.

      So, if there is acceptance of the moment, where does change come into the picture? Because a traffic jam can be so aggravating, it can lead to persistent suffering. Another way to consider it is to say, “I cannot make the traffic be anything other than what it is, but I can change my reaction to the heavy traffic. I can learn to relax when I am in intolerable situations.” Imagine that your identical twin was traveling in the car next to you and you were both in the same traffic. Imagine that you were not accepting reality and fighting it all the way, feeling that it was unfair that the traffic was so bad. What would your state of mind be? On the other hand, if your twin were practicing to see that change coexists in the moment and that the one thing that they can control is their state of mind and their reaction to the stressful situation, they would be in a far more relaxed state of mind. What research shows is that the more emotionally regulated a person is, the more capable they are of solving problems, and that the more dysregulated a person is, the fewer options come to mind.

      

From a philosophical perspective, we have the thesis on one side and an antithesis on the other side. Then comes what Dr. Linehan termed the dialectical synthesis, which is the integration of the two perspectives: “I can be in a situation that I don’t like and yet accept it, and by doing so, I can make the changes necessary to be more effective. As a result, difficult moments are opportunities for me to learn to be more capable and skillful.” For example, a thesis might be “I can’t bear being stuck in traffic.” The antithesis to this is “I can bear being stuck in traffic.” The synthesis is finding a way to bear the unbearable by finding a different route, changing the reaction to the problem of being stuck in traffic, or learning to accept being stuck in traffic.

      Moving from contradiction to synthesis

      For people who enter DBT, life is much more complicated than being stuck in traffic jams. Often intense emotions lead people who are struggling to behave in self-destructive ways, and self-injury like cutting is a very common behavior in people who have intense emotions. Many people, when seeing self-injurious behavior, would say, “Cutting yourself is a serious problem!” However, people who cut don’t always see this as a problem. Instead, they see self-injury as a solution to the problem of intense emotions. So, the behavior is both a problem and a solution? This appears to be a contradiction. From a dialectical perspective, however, both positions are true.

The synthesis is that people who have intense emotions that lead to significant psychological suffering want the suffering to end, and that self-injury is a quick way to solve the problem of emotional suffering. People who self-injure have been found to have higher activity in the amygdala, the part of the brain that experiences emotions, in response to emotional images. Higher activity in the amygdala is associated with a feeling of distress. Although for many people, self-injury would increase amygdalar activity, paradoxically, in people who for whom self-injury is regulating, there is a reduction in amygdalar activity, and this in turn leads to a reduction in negative mood and an increase in positive mood.

      And yet self-injury is only a short-term solution that doesn’t solve the problem of long-term emotional distress. When we move the focus from the self-injury to the problem being intense emotions, we develop a new perspective on the various points of view as having validity. The contradiction has become a new way of seeing things through the synthesis of seeing the perspective of each.

      Another seeming contradiction is that DBT therapists hold the assumption that in the absence of other information, a person is doing the best they can. The contradictory position that the therapists also hold in mind is that a person in DBT can do better. So, how can a person be doing the best they can, and also be able to do better? Here the contradiction is explained by the consideration that if a person is incapable