Why DBT Works
Written by Jennifer Leydecker, LMFT, Licensed Marriage and Family Therapist
In May of 2017, CHC opened its doors to RISE, an Intensive Outpatient Program (IOP) for teens ages 13-18 who have suicidal thoughts/behaviors, recently attempted suicide, and/or repetitively engage in self-harm behaviors. In 2018, CHC joined forces with Stanford Children’s Health to increase capacity and complement expertise.
With the program’s third anniversary approaching, it offers some space for reflection. The primary goal of RISE has always been to address symptoms of severe anxiety and depression in order to reduce suffering, suicidality and self-harm. Currently, dialectical behavior therapy (DBT) is the only well-established, evidence-based treatment for decreasing suicidal thoughts or self-harming behaviors in youth. As a member of the founding team, we knew from the start we wanted nothing less.
Acceptance and Change
DBT combines behavioral science with mindfulness concepts to help people who have difficulty regulating emotions. Dialectical means that multiple opposing perspectives can be true at the same time. The main dialectic in DBT holds that both acceptance and change are needed to move forward. DBT encourages clients to set the direction for their treatment and feel more invested in the process, allowing for a sense of agency and increasing their commitment level. The stakes are high: as a clinician within the IOP setting, I have 12 weeks to support DBT skills development as a means of stabilizing life-threatening behaviors.
There are four modules in DBT: Mindfulness, Distress Tolerance, Emotion Regulation and Interpersonal Effectiveness. At the start of each module, we discuss some of the core components and assumptions of DBT to help set the tone for treatment going forward. The core assumptions I find most adolescents connect with are:
- Everyone is doing the best they can.
- They want to improve.
- They need to try harder, do better, be more motivated to change.
- We may not have caused our problems and we need to find a way to solve them.
DBT skills allow clients to problem-solve, while balancing the dialectic of change and acceptance.
The four options that DBT presents for dealing with a problem offer a useful roadmap. These options are frequently called upon as we address life-threatening behaviors and those that interfere with daily functioning and contribute to thoughts of dying or hurting oneself. They include:
1. Solve the problem.
While this may sound simple, in fact there are a lot of factors that may have contributed to the problem to begin with and thus can lead to significant unpacking and problem analysis. I spend a lot of time identifying the problem as sometimes it is deceiving, wrapped up in layers that we need to decipher before we can work to identify all the possible solutions. We bring in the concept of dialectics when we are trying to solve the problem, looking at what information we may be missing, for an alternate perspective or kernel of truth for the other side and most importantly, removing our judgments, interpretations and blame.
Once we have gotten down to the facts of the situation, we are then able to use some of our problem-solving skills to look at as many possible solutions as we can, identify pitfalls and make a plan. This includes rehearsal and emotional preparation for having those difficult conversations, to ensure we are effective and prepared for whatever might come our way. We also practice more effective behaviors and establish successes along the way to help develop and reinforce the skills we are learning.
2. Feel better about the problem.
This begins with just knowing what we are feeling. Our days are fast paced with expectations and interactions where we are constantly moving from one moment to the next. I have found that in order to be more efficient, we sometimes push our emotions down as we have learned not to trust them or believe they get in the way of doing what is expected. While that may work in the short term, longer term those emotions build up or come out sideways and we have not developed the skills to manage them in the moment. Thus the first step of feeling better is recognizing and validating your own emotions in the moment.
Practicing mindful awareness of our emotions can be incredibly helpful in recognizing our internal signals when we are experiencing specific emotions. We learn to recognize what behavior the emotion is triggering, such as, yelling, running away, staying in bed or engaging in self-harm. There are times when our emotions are bigger than we can move through, so learning how to tolerate them in order to get to a point where our brains can help us problem-solve is critical. Other times we use skills to recognize the facts of a situation and choose an effective behavior that will be beneficial in both the short- and long-term.
3. Tolerate the problem.
Sometimes the reality of our situation is one that causes us great pain and suffering, or our emotions are so high that we cannot seem to see outside of the swirl of thoughts or anguish we are experiencing in the moment. DBT offers skills to help in those crisis moments when we can’t seem to make it through another moment of pain and helps us accept the reality of our current situation, our past and/or our future. Radical acceptance, recognizes that there are situations where we cannot change the facts of that situation. Working to radically accept the facts, (e.g., a past experience that continues to cause suffering) can help us move through the misery we experience from fighting the reality and decrease those overwhelming emotions so we can create the space to envision a life worth living.
We recognize that there is pain in living, we each experience loss, failure and other forms of physical and emotional pain, and by accepting this, we can see that life can be worth living even in those moments of pain.
4. Do nothing; stay miserable.
Most adolescents come to the RISE IOP at a really dark time in their lives. Misery is a familiar feeling and can in some cases feel like a warm blanket; the pain they know is easier than the pain they don’t know. While each adolescent that joins the RISE makes a commitment to do the work to move away from engaging in self-harming and suicidal behaviors, there are times where “doing nothing” seems easier than the work that needs to be done to move through the misery and make changes. But most people do want to feel better, and the “do nothing” option can serve as a motivator.
Once we choose one of these options as our desired outcome, we can then learn and practice the appropriate DBT skill(s) to get us there.
Building a Life Worth Living
Along my journey as a DBT clinician, I have found these problem-solving options helpful in supporting adolescents and families as they work through factors that interfere with communication, emotion regulation and navigating daily life. Feeling validated and supported where they are while also offering opportunities for change and acceptance seems to move most dedicated adolescents to a place where they are willing to do the hard work and see shifts toward more effective behaviors, realizing their own life worth living. And at the end of the day, what matters more than that?
About the Author
Jennifer Leydecker, LMFT, has training in supporting LGBTQ youth, managing difficult behaviors of tweens and teens, depression, anxiety, self-harm, crisis intervention, substance abuse and trauma focused therapy.
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