How Delivering DBT to a High-risk Population Made me a Better Person
By Randy Flanery, PhD
Dialectical Behavior Therapy (DBT) is an evidence-based treatment for people with powerful urges to harm themselves and in doing so, DBT confronts the fundamental human question of why keep living. Albert Camus, twentieth century existentialist philosopher, in the The Myth of Sisyphus, declares:
“There is but one truly serious philosophical question, and that is suicide. Judging whether life is or is not worth living amounts to answering fundamental questions of philosophy. All of the rest- whether or not the world has three dimensions, whether the mind has nine or twelve categories- comes afterwards. These are games; one must first answer.”
To answer affirmatively, that existence in and of itself, is superior to non-existence, means confronting how life is to be lived. The DBT answer is to live “a life worth living,” in accordance with one’s fundamental values. But what makes a life worth living? What are humans to strive for and how are tribulations to be survived?
As an undergraduate, I confronted these issues personally as I read Camus, among other writers, while contemplating who was I fundamentally, what I intended to do in life, and how I would do it. I also encountered existential questions, including the question of whether one should live or die during my graduate training in clinical psychology. If one of my patients was suicidal, my professional obligation was to determine if that person could keep themselves safe, or if they could not, to admit them to a hospital. Existence rather than nonexistence, a commitment to living, was my foundation personally and professionally.
At this point, I was committed to living, personally and for those I was obliged to; others could answer differently. It was a start, but I had not truly reflected upon my values or selected my life goals, nor had I considered how I intended to conduct myself in striving for those goals. My convictions were incomplete, implicitly selfish and shallow, and disconnected from core principles. I was developing a moral compass, a project still in development. But over the years I discovered my purpose and what gave my life meaning, so much so that I became complacent and self-satisfied. When I began doing DBT with very suicidal people, my convictions about how to live life according to my values were challenged.
DBT: A Road Map to Escape Hell
The creator of DBT, Marsha Linehan, describes the origins and development of the treatment in her memoir, Building a Life Worth Living (2020). Her professional mission became to help people who are so miserable that non-existence seems like a solution. As a senior in high school, Dr. Linehan herself was in that state and was hospitalized for disabling depression, propensities to harm herself and recurring temptations to take her life. She was living in Hell and did not wish to remain there. She promised God that she would find a way out and return to escort others to a fuller life, and at age 50, she fulfilled her promise. In 1993, the roadmap to get out of psychological Hell was published, Cognitive Behavioral Treatment for Borderline Personality Disorder.
Stages of Fully Becoming a DBT Therapist
I progressed thru a series of stages of adopting the DBT treatment philosophy and fully employing its principles and the process was much like developing a lasting authentic, life-long attachment to someone. The first stage was introductory, when I heard of a new treatment for people who were difficult to work with and known to have a poor prognosis. I should know, I had worked with them with the best of intentions, ineffectually, for a decade. DBT was the first treatment demonstrated to be effective. I purchased the manual for the skills group, complete with handouts and worksheets. The handouts for the skills were useful, easy to use, and time saving for me. It was a purely transactional relationship and I was a fickle provider of DBT. The full treatment model was intellectually demanding to learn and I thought I could just use the handouts but eventually I realized I was not doing justice to the treatment without understanding the concepts and philosophy underlying it. It was like doing psychodynamic psychotherapy without a grasp of transference. Thus began the courtship phase, where I learned about the treatment, found it attractive, and sought to know more. Then I encountered difficulties. My complaints were numerous: it was too complicated, there were too many skills, some of which were unnecessary, and in total, DBT was overwhelming. I would pout, throw it aside for a while, only to return to it later because I missed its effectiveness and elegance.
Then came the seduction stage. I decided to fully adhere to the protocol when treating conditions for which it had been empirically demonstrated to be effective: BPD, major depressive disorder, the persistently suicidal, binge eating disorder, and those who were frequently emotionally and behaviorally dysregulated. I made a formal decision to fully follow the protocol with specific individuals, and with my other patients I did as I always had. Full adherence meant adopting the treatment philosophy: a dual focus on behavior change and acceptance of the person, being dialectical when approaching clinical issues, and relying on mindfulness at every turn. It also meant joining a consultation team and providing coaching, which was a major personal, time and intellectual commitment. I initially adopted DBT for practical reasons, not the least of which was my desire to feel competent, but I ended up seduced into broadening my world view and gaining a more comprehensive understanding of humans, their behavior, and myself.
I valued offering such an effective treatment and to do so I had to do things I would have preferred not to. What clinician in their right mind would agree to be so available outside normal work hours? Given the demands of clinical care, how in good conscience could I allocate two hours a week to a consultation team meeting? And those assumptions and agreements, did I really agree? I did to be fully adherent to DBT practice, little knowing what the unintended consequences would be.
A curious process ensued. I found elements of DBT subtly intruding into my non-DBT sessions. I started sharing DBT skills and concepts with clients who were not vulnerable to dysregulation. I was asking people to check the facts more, with an expanded explanation of what it was and how to do it. I caught myself offering dialectical descriptions of challenging clinical situations, without identifying it as such. My inner dialogue during therapy sessions began to include statements like “I need to teach this person some TIPP (DISTRESS TOLERANCE) skills,” or “… needs to stop invalidating themselves”, and “Well that sucks, and it is what it is.” I knew I was co-opted when I began practicing DBT on myself. I had always been biased towards pushing change with clients, to the neglect of conveying acceptance and enhancing the therapeutic relationship. Now I was explicitly monitoring myself to keep my interventions balanced between the two. I started to do a minute of mindfulness prior to sessions with difficult clients (and staff meetings).
The seduction phase ended when I radically accepted who I had become. I was fully-wedded to the DBT way, striving to better live a life worth living. This was confirmed when I needed to give unwelcome feedback to a colleague and request that they do some things differently, which I really, really, did not want to do but I did (Opposite Action). I wrote out a DEAR MAN script and I made sure to validate the many things I could about the clinician’s actions before giving the corrective feedback. The person did not like what I was saying and said some unfair things to me, in my opinion. But I managed to recover from the invalidation, as did my colleague. Whenever my colleague was doing what I had requested, I made sure to acknowledge the behavior and thank them for having made the change.
The full endorsement of DBT practice, professionally and personally, did not contradict my preexisting world view, principles, and values but my basic values were clarified and enhanced. DBT has broadened my view of the world, others, and myself. I can act more effectively in the world and I am more resilient in the face of adversity. DBT has helped me to remove impediments to living my values fully. Becoming a DBT therapist allowed me to reflect upon my actions nonjudgmentally and accurately and realize I had not been living up to my values. Fortunately, DBT has given me a toolkit for resisting temptations to act contrarily to my values. Now, I am less prone to unnecessarily harsh self-criticism and more committed to self-care in order to be of service to others. I am better able to engage in heart-felt conversations with people with whom I really disagree, without irreparably damaging the relationship. It would be incorrect to equate this with a religious awakening as it was not a transcendent experience. It was a use of human intellect and the application of psychological principles to better embody my values.
In future blogs, I intend to elucidate some DBT tools that, when employed, may make a therapist not only a better therapist but also a better human being:
- The consequences of adopting a dialectical perspective on life.
- Learning to validate and to overcome invalidation.
- The paradox of radical acceptance as an antidote to suffering
- How DBT induces a character strength, or the virtue, of humility.