DBT~ DON'T CRY OUT LOUD!

I recently started DBT classes. For those of you who are unfamiliar with DBT, it is “therapy” originally created to treat those “difficult” to handle patients who suffer from *GASP* Borderline Personality Disorder (BPD). DBT stands for Dialectical Behavioral Therapy, which promotes LIFE SKILLS for EMOTIONAL health. Dialectical behavior therapy (DBT) is a psychosocial treatment developed by Marsha M. Linehan specifically to treat Borderline Personality Disorder. While DBT was designed for Borderline Personality Disorder, it is used for patients with other diagnosis’s as well (such as Complex PTSD & Trauma).

DBT combines cognitive and behavioral therapy, and incorporates mythologies from various spiritual practices including Eastern mindfulness techniques. DBT is done in a group setting, which meets once a week for 2-2.5 hours and clients are taught 4 specific skills:
Core Mindfulness skills
Emotion regulation skills
Interpersonal effectiveness skills
Distress tolerance skills

Let me provide some color around the above skills to give you a flavor of the goals of DBT, and what the “therapy” is supposed to accomplish (or, I should say, eliminate). In addition to the group DBT classes, the client should also be in a “therapeutic” relationship to discuss “issues” that come up during the week. Self-injurious and suicidal behavior should be first on the radar screen closely followed by therapy interfering behaviors.

Mindfulness is the first skill taught in the class. Mindfulness comes from the Zen tradition and the core skills are:
WHAT skills:
Observe
Describe
Participate
HOW skills:
Non-judgmentally
One-mindfully
Effectively
There is a super fun DVD on this! But please ensure you've consumed maximum caffeine dose, because Linehan on DVD - YAWN!

Mindfulness is the first module taught, rightfully so – if one finds oneself on the bathroom floor at midnight, with a razor in one hand and a glass of wine in the other, feeling no pain while watching blood drip down one’s wrist – all while watching the scene take place while outside one body, mindfulness obviously is not a skill being practiced. Each class begins with a mindfulness practice. While mindfulness comes from a meditative perspective from Buddism and western contemplative spirituality, DBT carefully avoids any religious connotation.

Interpersonal Effectiveness is similar to assertiveness and problem-solving classes, such as those taught in business school or human resource management classes/seminars. These skills include saying no and coping with interpersonal conflict. (enough said)

Distress Tolerance skills teach one the ability to “accept” oneself and the current situation, in a non-judgmental fashion (there is a “reason” why a person does something/anything – and we “accept” that person as they are – except of course, if the patient is “expressing” self injurious behavior, and one is a mental health professional – “acceptance” does not come into play in the aforementioned circumstance). *Note that “acceptance does not mean approval. While most approaches in mental health treatment focus on “changing” distressing events, these approaches place little emphasis on learning to bear pain “skillfully”. Clients are taught 4 crisis survival skills: “self-soothing”, “improving the moment”, “distracting” and “pros and cons”. Some examples include, if one is in the throes of an “intrusive memory”, or depressed – try taking a warm bath, or having a cup of tea. This should help - if not, clients are encouraged to have a *distress tolerence list* handy - and this would be a good time to whip that out!

Emotion Regulation is the forth skill taught in DBT. Learning to regulate your emotions is crucial to these volatile clientele for they frequently exhibit suicidal and self injurious behavior and are often emotionally disregulated – angry, frustrated, depressed and anxious (perhaps no different than most of society in today’s troubling, uncertain economic times).
Emotion regulation skills taught include:
Identifying and labeling emotions
Identifying obstacles to changing emotions
Reducing vulnerability to “emotion mind”
Increasing positive emotional events
Increasing mindfulness to current emotions
Taking opposite action
Applying distress tolerance techniques

Opposite emotion is perhaps my favorite. If one finds oneself crying uncontrollably, or overwhelmed with feelings of self hate or hopelessness, just put on 'The Wedding Singer' (don't become emotionally disregulated if you don't own 'The Wedding Singer' - any comedy will do - 'The Wedding Singer' (or any movie with Adam Sandler and Drew Barrymore - are at the top of my distress tolerance list!) or, if you prefer books to movies, pick up the latest romance novel – this should provide immediate relief! But, be careful NOT to read anything potentially triggering, such as researching BPD, or Trauma, I wouldn't suggest picking up 'The Courage to Heal' during these "distressing moments".

There is another key piece in DBT that I have not yet mentioned and this is “phone coaching”. Frequent, short “coaching” calls with the DBT instructor are encouraged with one caveat – if the client has already utilized a “maladaptive behavior”, such as drinking, cutting, overdose of ativan, the rule is that the “Coach” is to tell the client “Please don’t call me – you’ve dealt with the pain for now” – and must not talk to the client for 24 hours. (Now, should that client be seriously suicidal (especially after not being “accepted” by their *trusted DBT coach* - of course she should call 911 or go to the nearest emergency room (or, just kill herself – since the person she reached out to has refused to help).

DBT is NOT for everyone – it was developed for clients who have been diagnosed with BPD, or other “severely disordered” or “self-injuring” clients. It is not for “normal” people. An example of a “perfect DBT client” is someone who has repeatedly been in trouble with the law, inappropriate anger, mood swings with intense depression, irritability and anxiety. Recurring suicidal threats or self injurious behavior, unstable personal relationships, black/white view of people and situations (alternating between: all good/all bad) and frantic efforts to avoid abandonment.

DBT promotes “acceptance” rather than denial and shame and therefore uses language that is descriptive and non-judgmental and pejorative overtones are avoided. For example, rather than say “Gawd, she must be PMSing – she sure is *bitchy*”, you would instead say, “She seems to be emotionally disregulated today”.

And good news for “clinicians”! Working with this *highly volatile client group* is draining, so there are consultation groups for clinicians to talk about “cases” they’re working on and review their responses.

NOW THAT I HAVE EXPLAINED WHAT DBT IS, LET ME TELL YOU MY THOUGHTS ON DBT

As I mentioned earlier, I have been attending DBT classes so the opinion that I offer is not from a “clinical” perspective, but from a “client” perspective. First, I would like to say that DBT is not “therapy” – it is in no way designed to focus on the symptoms that lead to the “abnormal”, “bad”, “unacceptable” behavior of these “highly volatile clients”. Read any article on DBT and you’ll see that DBT was designed for the “HOPELESS”. Second, I would offer that these clients are *ordered* to attend DBT classes because they are exhibiting “bad”, “unacceptable” behavior – and DBT is their *last hope*. Furthermore, these PEOPLE (and they are REAL PEOPLE, with REAL EMOTIONS – NOT a “diagnosis”) already believe that they are “bad”, and “abnormal”, and have lived their lives “hiding” behind a mask that is acceptable to society, never revealing how they really feel because they KNOW that they will be deemed “insane” or “incurable”, and now, being sent to DBT – is VALIDATING what they learned as children!

“JUST SHUT UP AND BEHAVE!”

“STOP CRYING OR I’LL GIVE YOU SOMETHING TO CRY ABOUT!”

“IF YOU TELL, I WILL KILL YOU! – NO ONE WOULD BELIEVE YOU ANYWAY!”

DBT teaches PEOPLE, adults who were abused as children, women who have lived their lives in silence for fear of ridicule and blame – that their “abusers” were right; they should not cry, they should not tell, they should behave themselves and hide behind a socially acceptable mask – and DBT will teach them to do this in an “acceptable” way. Not by dissociating or self-injuring – but by “noticing”, “distracting”, and being “mindful” of the fact that no one really wants to hear or know that abuse happens and the affects of the abuse never go away.

DBT has taught me to “suffer in silence” – because if it gets to be too much, if the pain bleeds out, if I exhibit behavior that is “unacceptable” to my therapist and others – then I may be labeled as a “volatile client” who is “difficult” to handle and told that DBT is my last hope!
My friendly advice to all the CSA survivors, victims of repeated abuse, or rape – don’t think about the past, put it all behind you – because if you’re unable to “deal” with the pain without “acting out” than you too will be attending classes to teach you how to “forget the pain and stay in the present” and to “half-smile” when you’re sad. And chances are, you already learned these “skills” as a child and it didn’t cost you $2-$4 grand to learn them! In my personal opinion, DBT does nothing a good “mood stabilizer” and an “anti-psychotic” can’t do…..for a fraction of the cost!
DON’T CRY OUT LOUD!

*DISCLAIMER: While factual information on DBT has been researched and presented in this article – the opinions expressed are those of the author through personal experience. While Marsha Linehan was contacted, she refused to comment. For additional information about DBT please consult with a *qualified* DBT clinician in your area.