In this brief overview of Dialectical Behavioral Therapy (DBT), we are illustrating the efficacy of DBT for the treatment of patients with suicidal behavior, bipolar disorder, and borderline personality disorder. DBT has been shown to reduce severe dysfunctional behaviors in clients. DBT uses validation has a tool to the client accept unpleasant thoughts and feelings rather than react to them in a dysfunctional way. Simply put, dialectical means that two ideas can be true at the same time. Validation is the action of telling someone that what they see, feel, think or experience is real, logical and understandable. It’s important to remember that validation is non-judgmental and doesn’t mean you agree or even approve of the behavior you are validating.
Over the last year, Visions has effectively trained the staff to be DBT informed. We hold regular DBT skills groups at our residential and outpatient facilities. We have adopted and incorporated DBT skills into our day-to-day interactions with clients and are finding it to be incredibly beneficial.
I took some time to speak to Jesse Engdahl, MA, RRW, about his observations and experience with running the DBT skills group. He said, “We are happily surprised that it’s (DBT) become a community within a community. It’s set itself apart through the kids’ commitment to not only use the skills but in their support of each other. There is a high level of trust. We have kids coming into IOP who’ve felt marginalized and who hadn’t felt a broader amount of support, but find their place in DBT.”
The emphasis on validation in DBT is profound. Someone suffering from borderline personality disorder often has a movie playing in their heads and when the validity of that “movie” is denied, it can create a waterfall of dysregulation which can include anxiety, depression, anger, and fear. Taking a counter-intuitive stance and validating one’s reality is has been shown to be particularly efficacious. It deescalates the anxiety, and it teaches the client to self-regulate.
Joseph Rogers, MDiv-Candidate and DBT skills group facilitator and mindfulness teacher succinctly illustrates the value of our DBT groups, “Our DBT skills group gives our clients the confidence that they have the ability to meet their difficulties with skills that can be found within themselves and their capabilities. By utilizing daily skills diary cards and reporting on their results, clients are able to see where they are being effective and can acknowledge the positive outcomes they are responsible for through their actions. DBT has the ability to move clients out of their diagnosis toward a confidence in their personhood.”
I’m concerned for the survivors of sexual trauma and abuse, and the potentiality of getting triggered
simply by watching the news, or scrolling through Facebook or Twitter feeds. I’m wary of the media and the backlash from the recent Steubenville rape trial. It’s easy for that trauma to rise, presenting itself as fury and heightened emotions. It’s easy to slip back into the story of your own trauma, reliving moment-by-moment that which haunts you.
Signs of being triggered can include:
Angry outbursts
Flashbacks
Feeling emotionally numb or closed off
Avoiding certain areas, or subjects
Anxiety: tightness in the chest or throat, feelings of panic, et cetera.
Sometimes, we can feel tempted to continue to watch the news or read the feeds despite feeling triggered, believing we “should” be able to watch these things and be ok. It’s in the past, after all. Right? Wrong. The trouble with trauma is this: our bodies can’t always tell the difference between time and space. When we get triggered, we are often thrust back into that moment of trauma, sometimes too fast to stop ourselves. Over time, and with deep work, we can learn to recognize our bodies’ signals and responses to a trigger and take steps to stop it in its tracks or at least hold a safe space for it to just “be.” EMDR, DBT, CBT and TF-CBT are all useful therapeutic modalities for treating trauma. Additionally, yoga, meditation, and mindfulness practices are helpful in getting the “issues out of our tissues” as Tommy Rosen likes to say.
If you find that you are getting triggered from newsfeeds and current events, please:
Unplug
Step away from technology
Talk to someone and ask for help.
Surround yourself with safe people.
Take a lot of deep breaths.
If you practice yoga, this is a good time to get on your mat. A gentle practice of breath and movement can guide you back to the present moment.
Be of service. Helping others gets us out of ourselves and into action.
Yes, it can be tremendously debilitating when a trigger occurs, but you are not alone. There are people around you who will help you without judgment. You are safe now.
Aleksandra Petrovic, LMSW, is a trauma specialist, coming to Visions via New York where she worked with underprivileged children and their families. Aleksandra’s work led her to a hospital outpatient program for dual-diagnosed adolescents, which used DBT (Dialectical Behavioral Therapy) as their primary modality of treatment. Continuing to help underprivileged youth, Aleksandra went on to work at a state-run adolescent recovery center with children ages 5-16 who had been shuffled through the foster care system until they could no longer be placed due to their behavior. Aleksandra earned her B.A at Columbia University, double majoring in psychology and French literature, with a minor in neuroscience. She went on to earn her masters degree in social work at Hunter’s School of Social Work in NYC.
Aleksandra has completed her training in EMDR at the EMDR Institute under its founder Francine Shapiro. She uses EMDR (Eye Movement Desensitation and Reprocessing) and TF-CBT (Trauma Focused Cognitive Behavioral Therapy) regularly when working with clients and their trauma(s).
EMDR is a
“one-on-one form of psychotherapy that is designed to reduce trauma-related stress, anxiety, and depression symptoms associated with posttraumatic stress disorder (PTSD) and to improve overall mental health functioning. (via SAMSHA)
TF-CBT is a
“psychosocial treatment model designed to treat posttraumatic stress and related emotional and behavioral problems in children and adolescents. Initially developed to address the psychological trauma associated with child sexual abuse, the model has been adapted for use with children who have a wide array of traumatic experiences, including domestic violence, traumatic loss, and the often multiple psychological traumas experienced by children prior to foster care placement.” (via SAMHSA)
Aleksandra will use TF-CBT by having a client paint or write their story several times until there is a full range of emotions expressed. The repetition of reading and writing eventually desensitizes the severity of the impact of one’s memories. Aleksandra also uses Internal Family Systems (IFS) to help her clients safely access their trauma, helping them “go back” into the traumatic scene and “save” their younger selves. Processes such as these require a commitment to doing difficult work, but they are worth the efforts. Deep trauma work employed in the modalities Aleksandra uses is extremely beneficial for treating trauma in adolescents and helping them process their trauma in a safe, therapeutic way.
Aleksandra uses the treatment modality most beneficial to her client’s needs whether it’s EMDR, TF-CBT, IFS, writing, movement, or art. Her approach and style are right in line with the Visions’ holistic, client-based approach to adolescent treatment. Her work with the kids at Visions is very individualized–Aleksandra first focuses on building a rapport with the kids, and creating a trusting, safe environment for them to express themselves. When she treats trauma, she assesses where the client is emotionally, whether their trauma was chronic or an isolated event, their awareness surrounding their trauma, if it is repressed or glaringly present, and whether or not there are any psychological issues like mood disorders, depression, or mania present resulting in a dual diagnosis.
Aleksandra has taken her own trauma recovery and transformed it into a path of being of service to adolescents struggling with their own deep traumas. She believes that treating trauma is a crucial step in working on one’s recovery from addiction, eating disorders and other mental health issues. Aleksandra recognizes the influence of major and minor traumas as often being the underlying cause of substance abuse and self-harming behaviors. We are so fortunate to have such a compassionate, caring trauma specialist as part of our clinical team at Visions Our clients now have access to trauma treatment in both our residential and outpatient programs, as we recognize the deep impact unresolved trauma has on one’s recovery.
We are pleased to welcome Dr. Georgina Smith, Ph.D to the Visions clinical team. She has been working with adults, families, and children since 2001, making her vast knowledge of neurofeedback and Dialectical Behavorial Therapy (DBT) accessible to a wide range of clientele. Dr. Smith specializes in treating survivors of trauma, abuse, and those suffering from eating disorders, and addiction. She also treats individuals suffering from chronic depression, self-injury, mood, personality, and anxiety disorders. Her knowledge and use of neurofeedback and DBT allows her to help her clients in a way that empowers them be engaged in their own recovery. Dr. Smith’s approach is holistic, and caring, and she ardently believes in ensuring that her clients feel seen. Her work with adolescents has built an authentic treatment style where she is able to form a genuine connection with her clients, so they feel seen, heard, validated and challenged. Dr. Smith encourages them to be ok in the skin they’re in. That particular tenant of treatment spreads healing throughout one’s mind, body, and spirit.
With the addition of Dr. Georgina Smith, clients have access to DBT in all phases of their treatment. DBT, in particular, is one of the most efficacious treatments for mood disorders, namely Borderline Personality Disorder. DBT uses mindfulness, self-awareness, and skill building in the areas of trauma, emotional regulation, interpersonal effectiveness and crisis management. One of the most remarkable pieces of DBT is its effectiveness in teaching clients to regulate their emotions and recognize when they are becoming deregulated. Self-awareness in someone trying to manage extreme emotions is undeniably helpful.
Currently, Dr. Smith is seeing Visions’ clients for DBT as well as running a DBT group on a weekly basis. We are looking forward to working with Dr. Smith and are excited to have her as part of our clinical staff. She is down to earth, and brings a sense of realness to her groups and throughout her clinical practice. She says it best, “So many of the kids I’ve worked with are struggling to make sense of things they’ve been through, struggling with their sense of self and others, and a confusing, chaotic world. The space I create with them is about being ok wherever they are, whoever they are, so we can open the doors to choice and change. It is about ownership, realness & empowerment.” Welcome to the VTeam, Georgina!
Symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder. The history of symptoms can be traced back to adolescence or at least early childhood.
The symptoms have caused and continue to cause significant distress or negative consequences in different aspects of the person’s life.
The symptoms are seen in at least two of the following areas
Thoughts (ways of looking at the world, thinking about self or others, and interacting)
Emotions (appropriateness, intensity, and range of emotional functioning)
Interpersonal Functioning (relationships and interpersonal skills)
In layman’s terms, someone suffering from a personality disorder often views the world in their own way. Because the perceptions of those around them are often skewed to meet a reality only they see, the subsequent social issues stemming from the inability to interact with others appropriately is troubling–both for the one afflicted and those on the receiving end of the negative behaviors and perceptions. For the Borderline Personality Disorder (BDP), the major symptoms revolve around interpersonal interactions, negative sense of self, significant mood swings, and impulsivity. Where Narcissistic Personality disorder presents itself as grandiose and uncaring yet hungry for recognition, Borderline Personality Disorders can often be summed up like this: “I hate you…don’t leave me.”
Unfortunately, personality disorders are sometimes used as a quick label for a difficult client. However, the criteria are pretty significant and the diagnosis itself should be made after significant assessment by a qualified professional. Those ensconced in the emotional turmoil of a legitimate personality disorder need be able to find some solace in their psychiatric care and trust in the individuals providing care, especially since treatment for personality disorders are long term. The type of therapeutic treatment used depends upon the type of personality disorder being treated. The various types of therapy used to treat personality disorders may include:
Personality disorders are tricky and can be hard to address. Applying DBT, for example, has shown positive results in the treatment of BPD–recent studies have shown lower suicide rates, less self-harming incidents, and less self-removal from treatment. We must remember that psychiatry is a relatively young science, so the growth and change is happening quickly as practitioners eagerly seek resolution to some of the most challenging psychological quandaries. A therapist once said to me, “If someone were to observe a given client in a single session, they could come up with a variety of diagnoses, when the fact is, that client could have just been having a bad day.” So, whether a client is simply having that bad day or truly struggling with a bona fide disorder, it’s befitting to remember the words of Hippocrates as we unravel the mysteries of mental illness: “Cure sometimes, treat often, comfort always.”
Sometimes someone comes into contact with treatment because their drug use got out of control only to discover their problem isn’t actually addiction, but rather, an untreated mental health issue. Often times the misuse of drugs and alcohol is an ardent attempt to quell the feelings of anxiety or lift the fog of depression. Sometimes it’s a way to disengage from the flashbacks of trauma. Sometimes it’s a way to close the door on a panic attack. However, many times, these modes of self-treatment go too far, and the claws of addiction sink in, creating another layer to uncover and treat. Still, once the addiction piece of the puzzle is treated, therein lies the deeper, more complicated issue of mental illness. What then?
At Visions, we have embraced the mental health component of treatment and are adding a mental health track to our existing treatment plan. We are utilizing a wider range of treatment methodologies and branching into the area of Dialectical Behavioral Training (DBT). DBT is a “comprehensive cognitive behavioral treatment developed by Marsha M. Linehan over the last 25 years,”[i] and has primarily been used to treat patients struggling with suicidal ideation, suicide attempts, a desire to self-harm, and self-mutilation. After discovering numerous problems with the traditional use of cognitive behavioral therapy (CBT) in treating this particular clientele, Linehan began to integrate validation strategies (also known as acceptance-based interventions) into her treatment methodology. By integrating these validation strategies, Linehan inevitably began empowering her clientele and creating an environment of acceptance, while also encouraging them to begin to recognize the need to consciously change negative behaviors. DBT has also become one of the more successful treatments for patients suffering from borderline personality disorder (BPD), a group typically resistant to the traditional use of CBT.
To illustrate some of the problems Marsha Linehan and her team encountered, here are the three issues they found to be the most troublesome with traditional CBT:
Clients receiving CBT found the unrelenting focus on change inherent to CBT invalidating. Clients responded by withdrawing from treatment, by becoming angry, or by vacillating between the two. This resulted in a high drop out rate. And, obviously, if clients do not attend treatment, they cannot benefit from treatment.
Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. In other words, therapists were unwittingly under the control of consequences outside their awareness, just as all humans are. For example, the research team noticed through its review of audio taped sessions that therapists would “back off” pushing for change of behavior when the client’s response was one of anger, or emotional withdrawal, or shame, or threatened self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they didn’t want to discuss to one they did want to discuss.
The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients – suicide attempts, urges to self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, etc, AND have session time devoted to helping the client learn and apply more adaptive skills.[ii]
In addition to utilizing validation strategies, DBT also employs the use of mindfulness as one of the core concepts behind this therapy. Mindfulness is beneficial in the treatment of addiction and mental illness: it introduces the concept of non-judgmental observation, where we can observe our own actions and behaviors without criticism; Being mindful requires that we are engaged in present-time awareness: the here and now. This is where mindfulness is truly invaluable. If we are aware of our actions in the here and now, we are less likely to get caught in the destructive patterns of “what if? and “remember when?” In the practice of meditation, the act of “coming back to the breath” helps one stay in the present. Learning how to label emotions and feelings that may present themselves can help sufferers from getting lost in negative thought patterns. For example, if we are feeling scared or triggered, paranoid or angry, naming that emotion with non-judgmental observation will help us retain our present-time awareness.
In time, hopefully, the implementation of treatments such as DBT and mindfulness will help provide sufferers with some valuable tools for regulating emotion, distress tolerance and managing interpersonal relationships.
