I’ve been meaning to write a post on this subject for a while and it looks like it will end up a series of posts regarding my experiences of and views on various aspects of DBT. This one is going to revolve around my difficulties with the Interpersonal Effectiveness section of DBT.
First, let me just tip my hat to @maddoggiejo for her alternative acronym for DBT J For those of you not in the know, DBT (Dialectical Behaviour Therapy) is a proven effective therapy for people with a diagnosis of BPD, and there is actually currently ongoing research into extending its use to other diagnoses. DBT has been a ‘miracle cure’ in effect for me. I worked my backside off for 18 months, attending a 2 hour group skills session each week, a 1 hour individual therapy session each week and access to skills ‘phone coaching from my individual therapist 7 days a week (most days ‘til 10pm). In addition, the DBT therapy team had weekly consult with no less than Dr Heidi Heard of Behavioral Tech. I am lucky*** to have had the full programme of DBT. This is the programme on which the evidence of effectiveness of treatment for BPD is based.
I didn’t realise that there was such a hatred, for want of a better word, of DBT. I couldn’t understand given its proven helpfulness for people who are suffering extreme distress, when I came across people on Twitter who loathed the idea and delivery of DBT. It still makes me feel uncomfortable – as if I’m a bit of a fool for buying into it, and when I’m feeling particularly sensitive that hurts me; it took a lot of effort for me to cast aside pre-judgments in order to fully involve myself in a therapy, which at times seemed (and still does in parts) silly.
Before I go on, I want to address something I feel is important in terms of why perhaps some people’s experience of DBT has been negative or unhelpful. I think one of the biggest issues and worries for me regarding DBT access in the UK is not only that it is extremely rare to be able to access the therapy in an outpatient setting but that when it is, it is often not actually DBT. People are being told they’re going to be provided with access to DBT when actually it more often than not turns out to be DBT Lite of some form, for example skills group alone with no other support or therapy in place. It seems as though pushing people into a group which has the tiniest bit of DBT used in it is being called DBT. This isn’t fair for the individual and hardly surprising when people start to think it’s rubbish or doesn’t work. It won’t work if you aren’t actually being provided access to a full DBT programme as used in the RCTs validating it as a useful treatment for those with a diagnosis of personality disorder.
Please don’t get me wrong, access to learning the DBT skills is invaluable and also seems from a layperson’s perspective (ie me) that it is a good way to support other forms of therapy – to give people the knowledge of how to deal with the distress being brought up in other forms of therapy. I can imagine it is also very helpful for those who are willing to then go on to learn more about DBT for themselves and work hard at applying the skills. I see these people on Twitter and admire their determination and success in getting well in this way – I honestly don’t think I would have been able to do that. However, I can see how people who are offered ‘just’ a skills group and oft noted on Twitter that is not delivered by a facilitator with a good knowledge of DBT, people may misunderstand DBT or find it ineffective as a therapy.
Finally, DBT is not and should not be a “one size fits all” therapy. No therapy can ever be said to be effective for everyone with a particular condition or set of problems and people should not be shoe-horned into it if it is not suitable. I don’t like the pressure placed on some people and the damage it can do when they are told that DBT is the therapy that will finally help them and it subsequently turns out to be a therapy that actually isn’t a good fit for them. An individual cannot ‘fail’ at therapy – it may be a therapy that has not been properly delivered or a therapy that is just not right for them. The damage caused by the expectation that a particular therapy is the one to ‘fix’ a person cannot be underestimated – it causes pain and shame in a person who is already suffering extreme distress and self-blame.
So, what finally got me to start this series of blogs on DBT? Well, I got involved in a conversation on Twitter yesterday evening. It started with a professional (@shirnkytri) stating that they had used DEAR MAN and that they ‘practise what they preach’. This made me prickle. DBT without doubt has been lifesaving and life-changing for me but it wasn’t a therapy with which I always agreed and I was fortunate that I had a therapist who was willing and able (and perhaps even relished at times) to discuss and engage with my difficulties with the therapy ideas. This tweet by the professional seemed to provoke anger and virtual eye-rolling from other tweeters, too.
The Interpersonal Effectiveness module of DBT still sticks in my throat a little. I found DEAR MAN, GIVE, FAST all rather patronising. I entered DBT being able to ask for what I needed, say ‘no’, keep my self-respect, etc. I was a lawyer for goodness sake, I’d have been pretty shit at my job if I wasn’t able to negotiate and effectively interact with people! The interpersonal difficulties I had often arose in the context of mental health services – not being listened to. For me, it was always my extreme emotions that would get in the way. Lots of people in group did find they needed help with this and I don’t want to come across as arrogant and different people find different things difficult but to me it was like teaching grandma to suck eggs – I know that’s the right saying but don’t for the life of me know why. I can understand therefore why some people would be turned off to an extent if all they had access to was a group teaching them mnemonics.
I went through the IP skills group module 3 times! The first time I didn’t participate because I felt so insulted and couldn’t see how it could possibly help me. However, the second time I tried to be ‘willing’ in DBT parlance and yes don’t even get me started on the willing vs. wilfulness aspect of DBT, that will have to be another blog. I took from it the idea of priorities, which seems fairly basic again for a lot of people but I’m an extremely honest person with an incredibly good memory for what people say and this would often cause problems. I needed to learn to step back and ask myself “What, in this particular situation is most important – my objective, the relationship with the individual, or my self-respect?” My absolute honesty and memory of interactions would sometimes get in the way of me getting what I needed or keeping a relationship – basically, I learnt that sometimes, I need to regulate my emotions and bite my tongue where appropriate. And, for the sake of completeness, the third time I went through the module, I taught/led several of the skills groups.
I also spent time in my individual sessions being able to work through ‘interpersonal’ stuff with my therapist. This is where the full programme comes into its own. If I had just been attending a skills group and first came across the IP module I would have probably have said “sack this shit” and quit. Having individual therapy meant that with the help of my therapist I could extract from the IP module what was useful for me and work on that. We could also use other approaches that complemented DBT to address my particular difficulties; this generally meant I have had to learn to accept certain disordered aspects of my family relationships (disorder that I haven’t created, I hasten to add) and how to deal with those in a way that isn’t going to be harmful to me or lead me to burn out trying to ‘fix’ them all – how to enjoy them without getting too sucked in.
As alluded to earlier, there was more than a few bumps in the road on my DBT journey and I struggled with a number of aspects of the ideas/theories/terminology of the therapy and one of these I am going to blog about in the future – the idea of willingness vs. wilfulness. However, DBT has been invaluable to me and I do want to also blog in the future regarding the aspects that were really helpful for me, which include mindfulness, emotion regulation, (self) validation and, self-compassion.
So, although there are parts of DBT that made me angry and still make me prickle, it’s a therapy for which I will be eternally grateful. Yes that will annoy some of you reading this in the ‘haters’ camp but the difference it has helped me make in my life is just astonishing.
***I say ‘lucky’ but I was externally funded by my trust to do DBT in a neighbouring trust. There was no PD service in my trust at the time and for a number of years I had been referred to specialist psychotherapy services in the Greater Manchester area but always refused due to being “too high risk”. As a result of this lack of access to the therapeutic support I needed, I became more and more unwell – greater frequency & lengthier hospitalisations, damage to my organs etc and at the time of acceptance into DBT, I was 5 & ½ months into a s3 and had just lost a tribunal. I agreed to DBT because I would have done anything to get off section and it was the first time there was actually an option of therapy for me. Luckily, the trust governance (who were at that time managing my risk due to the severity of it), my own cmht and the DBT team in the neighbouring trust were willing to take a therapeutic risk. My only alternatives were a residential TC to which I didn’t want to go or a locked unit for some unknown amount of time. I won’t go in to the ins and outs of everything but felt it important for people to have some background. Yes, I was ‘lucky’ to access a full DBT programme but if I’d had some form of treatment years earlier, it may never have been necessary.