Dialectical Behaviour Therapy

How do we live with impossible dilemmas?

How can someone stop self harming when it's the only way they know of coping?

What is DBT and how did it help Louise?

Dr Michaela Swales and Louise Brinton-Clark talk to Dr Lucy Maddox.

This episode includes reference to self-harm.

Podcast episode produced by Dr Lucy Maddox for BABCP

Show Notes and Transcript

If you're interested in finding out more about the British Association for Behavioural and Cognitive Psychotherapies, or about Dialectical Behaviour Therapy here are some resources...

Websites

babcp.com is the British Association for Behavioural and Cognitive Psychotherapies website and it links to the CBT register of accredited CBT therapists in the UK (or go straight to cbtregisteruk.com). BABCP also has a DBT special interest groups which members can join.

https://www.sfdbt.org/ is the Society for DBT website which has a list of accredited DBT therapists in the UK

https://www.behavioraltech.org/ has research articles and a good video on "What is DBT?"

Books

Heard, H. L., & Swales, M. A. (2016). Dialectical behaviour therapy: distinctive features. Routledge.

Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. Guilford Press.

Linehan, M. (2014). DBT Skills Training Manual. Guilford Publications.

Linehan, M. M. (2014). DBT Skills Training Handouts and Worksheets. Guilford Publications.

Swales, M. A. (Ed.). (2017). The Oxford Handbook of Dialectical Behaviour Therapy. Oxford University Press.

Transcript

Louise: It is a life-saving treatment for some people.

I don't believe I would have graduated or got married or even, it sounds really daft, even have passed my driving test.

Lucy: This is Let's Talk About CBT and I'm Dr Lucy Maddox. This episode is all about a type of talking therapy called dialectical behaviour therapy or DBT. This is one of the family of cognitive behavioural therapies or CBT which was talked about in episode one. We talk a bit about self-harm today, so please take care of yourself, if you know that's a tricky subject for you.

To get away from the acronyms and try to understand what DBT is actually like I went to Bangor, in Wales, to meet with Dr Michaela Swales and Louise Brinton-Clark.

Louise: My name's Louise Brinton-Clark, I have been a member of a DBT group, dialectical behaviour therapy group, both as a service user and as a graduate facilitator.

Michaela: My name's Michaela Swales, I'm a clinical psychologist, I'm also the director of the British Isles DBT training team. So, as well as having delivered DBT for probably the best part of 20 years in my clinical practice, I've also spent the last 15 years or so training others to deliver DBT.

Lucy: Dialectical behaviour therapy is a bit of a mouthful, I asked Michaela to explain what it means.

Michaela: So, within the treatment, we do a lot to help people change things and we do a lot to help people accept things. And in a way, those two things acceptance and change, at least on the face of it, look like they're totally in contradiction. They're what's termed in a particular branch of philosophy – not that you need to know philosophy to do this treatment – a dialectic. They're two things that are in almost polar opposites to each other, but there's value in both of them.

And so constantly in the treatment we're always looking for both change-based ways to solve problems and acceptance-based ways to live your life. And being dialectical means looking at both of those things, and sometimes you have to do a mix of those things to really get things to work.

It is a behavioural treatment, so it focuses a lot on changing behaviours, both those things that other people can see that we do, but also those things that we experience internally. And as we know from lots of areas of life, changing our behaviour is hard, it takes a lot of hard work. And I think many of the people who come for this treatment have a lot of things in their life that they are really struggling with, multiple things. And so it is a tough treatment.

Lucy: I also asked Louise to explain DBT.

Louise: My understanding of what dialectical behaviour therapy is it's working with opposites but bringing them together. It's that thinking in extremes, isn't it? It's called black and white thinking.

Lucy: Which I guess we all get into sometimes.

Louise: We do get into. And that grey area, my god, the grey area is the size of the universe, really. It's immeasurable.

And I know what I typically used to do, and I guess I still do sometimes, is thinking in those extremes, that stereotypical, "I hate you, don't leave me." It's two total opposites of the same thing.

Lucy: So, like push-pull kind of… Two opposites, how do we reconcile them?

Louise: Or hurting yourself to stop the pain.

Lucy: DBT is a treatment that's often used to treat severe self-harm and huge ups and downs in mood. It's a pretty comprehensive treatment package as both Michaela and Louise told me about.

What does it look like when people are referred for dialectical behaviour therapy or for people who are thinking about having it?

Michaela: Typically, people have multiple problems when they come, and one of the things that the treatment tries to do is rather than parcel off these different pieces is to try to understand how all of these different behaviours relate to what the treatment considers the core problem, really, which is a difficulty in managing and regulating emotions. So, in order to do that, the treatment has a number of components.

Lucy: Full DBT has four main components, a skills group or class, individual sessions, skills coaching course, and something called a therapist consult. Louise was at university while she was having DBT and she found her skills group hugely important.

Louise: So, I don't think I would have graduated from university without group. Year three for me in university was a really, really tough year. When I was doing group then, was quite depressed, I was still abusing over the counter medications and stuff like that.

It was a really nice, honest environment, so perhaps talking about why we engage in some behaviours that actually might be, I don't like the term, attention seeking. Let's call it support seeking, for the purpose of this conversation. But we might be doing some behaviours for support seeking, and I felt like in the group, in that environment it was a really safe space to say, "This is why I've done this." And actually, it opened up the floor for other people to say, "Actually, I've done that as well."

It's like a massive relief, it's a freedom, it's a weight lifted.

Lucy: And skills group is just one part of the treatment.

Michaela: Anyone who's tried to learn anything new will know that just going to a skills class doesn't necessarily change your behaviour. Most people have tried at some point in their life to learn a language. And you can go to skills classes to learn language as much as you like, but that doesn't mean you'll get to be fluent. And in a way, we're trying to teach people to be fluent in a new language around managing their emotions and their relationships and so on.

So, in addition to skills class, people in DBT meet with an individual therapist once a week on their own. And each week, the therapist and the person coming for help will work together to try and figure out how to get these new skills to apply to the particular problems that their person is bringing to therapy.

DBT also has a mechanism where people in the treatment can contact their individual therapist for coaching in how to apply the skills actually in the moment when it's really difficult.

So, DBT from the person receiving it, that's what it looks like, they have those three different what we call modalities, skills training, individual therapy and skills coaching calls. But in addition, therapists who are working in this way meet together in what's called the DBT consultation team every week. And people coming for the treatment know about this consultation team. And the aim of that team is to make sure that the therapist is delivering the most effective treatment possible.

Lucy: And that's really full on, actually, isn't it? But also, what an incredible package to get.

Michaela: Yes.

Lucy: Sometimes services offer a kind of DBT lite.

Michaela: They do, yes.

Lucy: Is that still DBT? Or is it something a bit different?

Michaela: I think the evidence base that's emerging is that the best evidence for people who have multiple complex problems and are highly suicidal is for full programme DBT.

There is an emerging evidence now, looking at skills classes where therapists are trained in the full programme, but they're offering skills classes and they're still going to consultation team, and offering some kind of skills coaching that for people who have slightly less severe problems that might do well.

I think if we could get the benefits of this treatment with it being less intense, that's a win-win all round, because it would mean that more people could access the treatment. And at the same time, the best evidence we have is for the full programme.

Lucy: I asked both Michaela and Louise to talk me through the different skills modules.

Michaela: In standard skills classes there are four modules taught. One is mindfulness, another is distress tolerance, those are the two on the acceptance side. And then, there is a module called emotion regulation and another on interpersonal effectiveness, and they're on the change side.

Mindfulness really focuses on… our minds tend to gallop off into the future or gallop to the past. And often, if we think about it, we're rarely in any one moment.

Now, if in one's past and one's future there are things that are not particularly troubling or might even be quite pleasant, that's not really so much of an issue. But for many of the people, if not all of the people, who come to this treatment, there's a lot of pain and difficulty in their past. And also, they have a lot of worry and anxiety about the future and often not a lot of hope, given what's happened to them in their past.

And so, the fact that our minds do this bouncing around becomes really problematic, because it generates a lot of distress. And so, one of the things we work on is how to remain more in the present.

And so, the other thing we teach in mindfulness is to notice when judgements show up and to work on being more factual and describing things in a more factual way. Or at least just noticing judgements and trying to let them go, because they so often really crank up our emotions in unhelpful directions.

Louise: Mindfulness we do every week. And I think there's a bit of a misconception about mindfulness. We think it's just about looking at trees (laughs) and things like that, and I think that really puts people off. I actually really disliked the idea of mindfulness when I first started. But actually, as time went on, I learned it was more you could incorporate it into your everyday life.

Michaela: In distress tolerance, what we focus on there is the fact that lots of things happen in life that are really difficult, really painful things. And often we can't solve them, or we can't solve them now. And we all have to learn skills in life to be able to get through a crisis without making it worse.

Lucy: Easier said than done.

Michaela: Much easier said than done.

Louise: So, recently, I hit a bit of a depressive spot because I'm losing my job. My immediate response in my head is to, "Right, that's it, I'm going to bed, there's no point, blah de blah." If I'd done that, there would have been a whole heap of consequences. I would have lost my job a lot sooner (laughs) before the closure of the unit that I'm working in.

Whereas previously, if I had gone with my initial even just staying in bed, even if I'm not talking about self-damaging behaviours, just staying in bed, that just makes things worse. And we have to recognise that we have a choice. I don't have a choice in losing my job, but I have a choice in how I respond to that. It's recognising that choice and recognising consequences.

Michaela: On the change side, we have emotion regulation. We spend a lot of time talking about emotions in DBT. They're often the thing that cause the most pain and distress to the people that we work with. And we want to first of all start off by helping people understand the different emotions that they might experience, and how that connects to what's happening.

Many of the people we work with were raised in environments that didn't really help them understand the different sorts of emotions that they might have, and often they were criticised or even punished for having emotions at all. So, that's not going to help you learn.

So, we start off by really trying to help everyone get a better emotional vocabulary about the different emotions that you might have, like fear and anger and shame and sadness. And understand what might set those off and what thoughts go with that, what that feels like in your body, what it leads you to want to do.

And then, we have a whole set of skills that help us work on how to change our emotional responses, depending on what emotions we're having. And also, we think a lot about often emotions are giving us a clue to something that's happening, it's like a little warning sign that there's something to pay attention to.

So we also work a lot on trying to figure out how do you know when an emotion is telling you something that you should act on, versus when is actually your emotion somehow inaccurate to the context? Or it may be accurate to the context, so maybe somebody has said something that was difficult, they've given you some difficult feedback. Maybe they said they didn't like your new hairstyle for example.

But the level of your distress in response is more as if they told you you were a dreadful person. So, that although having a degree of anger would be perfectly natural in those circumstances, the intensity is just more than what you want to have to deal with. So, we try and help people figure out what would be a reasonable emotion to have in that circumstance, and also how much of that emotion would they like to be feeling, given the context? And to try and to be able to regulate emotions down to the level that they are useful.

Louise: Well, I guess I can regulate my emotions, my emotions still feel unregulated but I'm not responding to them in the same way, does that make sense?

Lucy: Yeah.

Louise: So, that would be things like acting opposite and stuff like that.

Michaela: And then, in interpersonal effectiveness we focus on how to interact with people to increase the chances that people will give you what would be helpful to you. So asking for what you want and also saying no to things that you don't want.

Louise: The other module is interpersonal effectiveness, which is probably my favourite because it's meant I've been able to maintain relationships. I've stopped arguing with people, I've stopped arguing with myself in my head.

Lucy: Wow, that's major.

Louise: I typically would ruminate a lot and argue with people in my head and it was exhausting. My favourite skill of that is the DEARMAN skill.

Lucy: What does that mean?

Louise: So, an example is, I've been invited to a party, and I don't want to go. D, describe, that's a description, I've been invited to this party, I don't want to go. So, the E is express, so I would express I don't want to go. (Laughs) A is assert, be assertive, not confrontational, not defensive, assertive, I don't want to go. And try not to apologise.

Lucy: So, just clearly stating what you want.

Louise: Yeah, try not to apologise, don't apologise for your wishes, because no apology is needed.

Reinforce, so just say you were saying to me, "Oh but I really want you to come, I really want you to come." "I really don't want to. I'd rather stay at home that night." Stay mindful, so keep the goal in mind, just be aware of your emotions, be aware of what's going on in your body.

You're doing the DEARMAN skill, but the person opposite you isn't. (Laughs) And the person opposite you also has a goal in mind, appear confident. You want to appear confident without appearing confrontational. So, perhaps it's sometimes better to do it in person.

So, if you're doing it in person, body language, head up, shoulders back, even if you don't feel it, that other person does not know that you do not feel confident. And negotiate. I don't want to come to the party, but how about we meet up for a coffee in a couple of days? Compromise.

Lucy: That's sounds really useful.

Louise: I love this skill and it's actually really, really helped in a lot of situations, it's quite funny when you use it, because people who know me and who've known me for a long time, such as my brother, and he knows how confrontational or argumentative I can be. And then, I suddenly use this skill and he's like, "Um, okey dokey." (Laughter) People typically respond quite well to it.

Lucy: DBT is particularly recommended for severe self-harm. And this often comes along with a controversial diagnosis, which I asked Michaela and Louise about.

You mentioned that this approach, although it can be helpful for anyone, is perhaps particularly helpful for individuals who have quite complex difficulties going on and maybe are engaging in self-harm.

Michaela: Yeah.

Lucy: And sometimes that comes along with quite a controversial diagnosis of borderline personality disorder.

Michaela: Yes.

Lucy: Which people may or may not have heard about who are listening to this. I just wondered if you had a view or if DBT approaches had a view on the diagnosis itself?

Michaela: Yeah. DBT was designed specifically for people who have been given a diagnosis of borderline personality disorder. The main reason for that was that in order to get funding to study a treatment, the funders – it's changing slightly now, but certainly for the last 20 years – have only really funded things that were based on people with particular diagnoses.

But in fact, the treatment developer originally developed the treatment for suicidal behaviours. And then, started to think particularly about the problems that people who get given that diagnosis of borderline personality disorder have and how that linked to suicidal behaviour.

But DBT is a behavioural treatment and so, what that means is that it really sees the problems that end up being labelled as borderline personality disorder as really a set of behavioural patterns that people have learned. Like we all learn as we're growing up in our environment.

We learn ways of behaving and responding and experiencing the world so that really the patterns that end up with this label are ways the people have learned to cope. So, that what we're trying to work out in DBT is what of those behaviours are problematic for the person? What do they want to change? And it's like what is it that they want out of treatment? And how are these behavioural patterns getting in the way of that?

So, whilst it's the case that often people who come into this treatment have got that diagnosis or could get that diagnosis, what we're really interested in as DBT therapists are what are those behaviours that are causing somebody trouble and suffering? And how can we help change them?

Louise: I have this massive conflict about the diagnosis, they were talking about the BPD diagnosis with me when I was 15, which is far too young, I was 15. I was diagnosed when I was 18. I had a life of loads of trauma, I responded accordingly (laughs). I reacted normally to abnormal circumstances. Those reactions were a problem. But it was my reaction.

I will be forever on my medical record be down as somebody who has borderline personality disorder. You could say I meet one of the criteria or two, but I no longer meet the criteria, but I still have that diagnosis.

Lucy: So, both Michaela and Louise were really clear there about the limits and potential pitfalls of the diagnosis of borderline personality disorder. I should add just for balance, that there are some people who can find it a real relief to have a diagnosis that they recognise.

If you're interested, have a look at the show notes for a few more references and debates on this topic.

So, what if you're thinking of having DBT yourself?

Michaela: Just as in the skills that we're teaching, people who come for treatment there's acceptance and change. There is also that in the style of the therapy. Part of being a DBT therapist is to be validating and genuine and understanding of your client's difficulties and that's very, very important.

And there is also a component which is trying to challenge and motivate people to change. And sometimes in therapy it's called being irreverent.

Sometimes you might say things that therapists might not normally say, you might be a bit challenging. The reason for that is that there's lots of research to show that if we are really totally immersed in feeling overwhelmed, it's hard for us to pay attention to sometimes what people are saying or asking us. Whereas if somebody's a bit irreverent and says the unexpected thing, it is like a novel stimulus and we turn toward it, and then there's a little opening of being to think differently.

The treatment takes a very strong stance that getting a reduction and stopping suicidal and self-harming behaviour is top priority. And for most people in the treatment, from the research within about 16 weeks on average, that behaviour has come right down, is much more infrequent.

And then, what we then work on are other things that the person says are issues. And so, once that's out of the way, you could say we can then really get on with the business of helping with these other things, because we don't have be worrying that the person is going to die.

Louise: I think I would focus on the fact that it is a behaviour therapy, it's not going to resolve any trauma initially. So, imagine most people who enter DBT have experienced some type of trauma, because you speak to people with that BPD diagnosis, have actually had quite traumatic backgrounds. That's not to invalidate the trauma, but actually it's to get you stable enough to address that trauma.

That's what it was for me. You couldn't see the depression and the anxiety that I was experiencing because I was in this constant cycle of crisis and putting myself into hospital. The depression and the anxiety and the trauma couldn't be addressed.

The time will come when you will do that trauma work, it has to be safe for you and for the people working with you as well.

Lucy: And what are the things that you particularly like about the DBT approach? What got you into it?

Michaela: It tries to see people's problems as being ways that they've learned to cope. To me it normalises how people have learned to do things. There is a real sense that we are in this endeavour together to try and find solutions to very, very difficult problems, and it's not like just because I'm a therapist that I would necessarily have all the answers.

Lucy: So, getting alongside someone?

Michaela: Really, yeah.

Louise: It's helped my relationships as well, so I'm married now.

Lucy: Congratulations.

Louise: Yeah, I'm married. I got married on Christmas Eve of 2016. I said for years that I would never even be in a relationship because I couldn't cope with people and I wouldn't inflict myself upon anybody else.

I've been over two years since I last self-harmed.

Lucy: That's amazing. Well done.

Louise: I was actually discharged from the community mental health team in January. That's the first time in my life that I've gone… so it was a collaborative discharge. We worked together towards it. Previously, when I've been discharged, it's because I've not been engaging with the service or I've discharged myself in a fit of, "I don't need you." This was actually collaborative.

I don't believe I would have graduated or got married or even it sounds really daft, even have passed my driving test, because I wasn't safe to drive because of things I was doing. Living a life worth living, even things like contributing to society, I don't know that I would have been able to do these things without these skills.

Like I said before, even just in this past week, I've chosen to use my skills in order to get through some difficulties I've been experiencing, and it has got me through the past week. It has.

Lucy: Huge thanks to Louise and Michaela for speaking to me. I hope that's helped give a flavour of DBT. If you want any more information check out the show notes for some more links.

That's it from me, next episode, we'll be thinking about another member of the wider CBT family, so I hope you tune back in.

This podcast is brought to you by the British Association of Behavioural and Cognitive Psychotherapies or BABCP, for more information about BABCP and cognitive behavioural therapies in general, check out www.babcp.com.

Thanks to Gabe Stebbing for the title music, Jason Shaw and Entertainment for the Braindead for the incidental music. Michaela Swales and Louise Brinton-Clark for being interviewed and Eliza Lomas for editing consultation.

Any feedback or ideas please do let us know, and please rate us on iTunes, if you've enjoyed the show.

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