The skills of DBT are of little value unless they are put to use in the moment that they are needed. When times are calm and emotions are better regulated, it’s easy to see how the skills can be useful, and many patients can explain how the skills would work in their day-to-day life. However, in times of emotional turmoil, the more familiar, often maladaptive, behaviors are the ones that tend to show up first. When the urges to self-harm or use substances show up, the more intense the emotions, the more likely the unskilled person is to use these old forms of dealing with the urges.
Dr. Linehan recognized that life’s most challenging problems tended not to happen when patients were in therapy. They could happen at any time, day or night. She emphasized the importance of intersession coaching to help patients generalize the skills they had learned in the skills training group to their everyday life. The duration of a skills-coaching call is intended to be a brief call of typically no more than 15 minutes to offer patients support and ideas to deal with an in-the-moment situation.
A therapist consultation team
One of the more difficult aspects of working with suicidal patients is that it’s common for therapists to become discouraged and burned out. Dealing with suicidal people every day can make therapists feel much of the despair that their patients feel. Behavioral change can take time, and many therapists worry about their patients’ safety during episodes of emotional distress. The therapist consultation team is intended to be therapy for the therapists, supporting them in their work with patients who have severe, complex, and often difficult-to-treat disorders.
Incorporating Dialectics
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.
