Dangers of Non-Adherent DBT

 

While DBT has been used with great benefit, at times it has also been at best inaccurately and at worst, detrimentally applied.  In my own experiences, recollections, and travels as a behaviorist in pursuit of healing for those failed by traditional interventions thus far, I find myself saddened and at times, disappointed when the most promising, effective treatment to revolutionize the mental health world is used as a immediate panacea for anything other than the reparation of wounded and broken lives.  for the rectification of the momentarily intolerable. While it’s commendable that in present day, the utility of skills acquisition isn’t lost anymore on practitioners, there’s also a responsibility to ensure the systematically discriminate, correct, informed, effective, and efficient application of such a ground breaking therapy; because of its very structured and precise nature, DBT is not a venture to dabble in or to be taken lightly.

 

DBT is so target specific, that it’s a bit like radiation therapy in cancer treatment…you don’t target the whole body—you have to hone in on the little 1 or 2 inch patch out of the whole of the body, and target the rays there, specifically, to eradicate the harmful parts.  Using a chemotherapy mentality with DBT involves a whole body dumping of a treatment, which while killing the cancerous cells, injures everything else it comes in contact with as well.  DBT requires the ‘radiation’ method when working on eliminating troubling emotions and behaviors, and the ‘chemotherapy’ method when acquiring tools for building a life worth living. Disastrous outcomes can ensue when the opposite methodology is applied. Often, self-harming behaviors do the very opposite of what they look like they are doing—they are life-saving measures. Putting a damper on these behaviors without there being more effective measures put into place is a recipe for disaster. Chemotherapy is a dampening of all systems in order to wipe out the thing we don’t want.

 

There’s another problem with ineffectively practiced DBT…Let me put it this way: You go to your primary care doctor, and say you’re depressed. He gives you 20 mg. of Prozac. And, sadly, it does nothing. That’s the end of the fallout, right? Actually, wrong. It erodes your faith in the efficacy of medical treatment for your depression! When the 20 mg of Prozac doesn’t work, are you more likely to say, well, “my doctor doesn’t know what he’s doing and I should go see a psychiatrist” or are you more likely to say “what’s the point, it’s not like anything is going to help—even my doctor couldn’t fix it”—because, as it is, you are so depressed it took all you had to even ask him for help!…for the average person, it’s going to be the latter because they aren’t aware that it may take a starting dose of 40 mg or more to even affect change, much less that it might take 60 mg or even more to really alleviate the depression. Or, that you may have to combine medications to really eliminate someone’s pain.

 

The perils of ineffective DBT for a population that is already exhausted, exasperated, and emotionally drained from previously failed efforts at alleviating their suffering, can result in one putting the final ‘nail in the coffin’ so to speak, closing the doors on hope and treatment forever. The average person in the community doesn’t know the difference between adherent DBT and otherwise…much like they don’t know the correct application of azithromycin versus penicillin in an illness.

 

So let’s talk about the dangers of non-adherent DBT, sometimes called’ DBT Lite’ or ’DBT-style’ therapy, or practitioners that “DO” DBT—DBT isn’t something to be ‘done’—it is a way of life, a way of thinking, a way of approaching problems that reduces stress, alleviates hopelessness, and energizes people into willingness to do more, be more, want more; DBT refers not only to philosophy and a group of skills, but also to a set protocol for treatment--requiring 4 major criteria.

 

THE ‘80’S: The Emergence of Effective Treatment—The Rise of DBT

 

For decades now, as the research has continued to build, the use of dialectical behavior therapy has grown to accommodate the treatment of a variety of therapeutic difficulties, illnesses, and disorders. Research began in the very early 1980’s, when DBT  founder/pioneer/guru Marsha Linehan discovered a method for helping people survive the tragedies and failures of their lives and learn tools to build lives worth living. DBT arose out of a need to treat people who were struggling with suicidal ideation, self-harm behaviors, and emotions that weren’t responding to traditional therapies.

 

THE ‘90’S: Practitioners Who Did What Worked—And Were Shunned

 

In the early ‘90’s, DBT therapists were seen as those who “drank the Kool-Aid”…a reference to some inclusive, cult-like community. Misunderstood, because we didn’t subscribe to endless emotionally trapped childhood reiterations of failure, angst, loss, and trauma as voyeurs, and instead focused on change, we found ourselves being painted as ‘those DBT guys/girls’.  In professional circles, we were shied away from; traditional therapists peered upon us in the manner one would investigate a rare white tiger up close and personal—with leery and terrified fascination. And yet, we were hailed as saviors in the therapeutic community for saving those very professionals from the ‘difficult patients’ that everyone was too frustrated to continue treating.

 

THE BEAUTY OF DBT?

 

The combined strategy of using validation for doing what you  knew how to do in the short-term, in that moment of need, along with the acceptance for necessary change—doing things differently in the here-and-now, in order to build a life worth living, in the long-term. This freed people up from having to spend countless hours and energy in defending their methods, protecting their pain, justifying their choices—to acquire tools to develop abilities while conquering incapability—and, move forward, turning elusive priorities into goals that could be achieved.

 

TODAY...AND BEYOND

 

As time passed, DBT proved its efficacy for a population previously deemed “untreatable, unmanageable, difficult, manipulating”—the most elusive disorder to treat and therefore the most difficult in the realm of behavioral/mental medicine—Borderline Personality Disorder.  With notoriety gaining for conquering the treatment deficits in this population, research began on investigating the efficacious application of DBT for other illnesses and disorders. The numbers began to come in—DBT was heralded as successful, for treating PTSD, trauma, eating disorders, depression, and personality disorders in general. 

 

With that framework,  DBT is being applied to basically all disorders that weren’t responding to familiar interventions—whether or not supported by research based evidence.

 

UNFORTUNATELY, A GREATER DANGER LURKED…

 

There are inherent dangers of applying a precisely formulated therapy incompletely, incorrectly, or indiscriminately. It requires us to have a behavioral background to appreciate the nuances of managing and fine-tuning the ingredients needed to shape wanted behaviors in, and unwanted ones out.

 

DBT was developed to treat conditions where behavioral control was lacking. People who responded effectively to DBT were people who had

1. instability in relationships,

2. difficulty in self-regulating emotions with impulsive behaviors,

3. a sense of self that was tied to circumstances and people

4. difficulty with their reactions:

   --having quick reactivity to things

   --were reactive to more things than the average person

   --were slower to achieve baseline emotional functioning

5. environments that were invalidating, criticizing, misunderstanding of their needs,

6. had recurrent suicidiality in thoughts or gestures, or self-harming or self-mutilating behaviors

7. chronic feelings of emptiness, and

8. possible experiences with transient/fleeting times of paranoid thinking or dissociation.

 

3 BIG ISSUES

 

Misuse

 

DBT began being applied to people who had overwhelming amounts of control as well…meaning, people who had used behavior sanctioned by society, approved manner of acting with superior control, and used that style, those behaviors, to manage distress. The danger?  DBT was developed for the opposite issue—behaviors that were out of control. People with overpowering amounts of control developed disorders/illnesses such as Major Depression, Severe Anxiety, Anorexia (not Bulimia), Obsessive Compulsive Disorder, Avoidant PD, Narcissistic PD, Paranoid PD, Autism Spectrum Disorders. These people didn’t need their behaviors ‘reigned in’—they needed skills to teach them how to open up, take educated emotional risks, activate their physiology to experience safety, and engage in relationships in vulnerable and meaningful ways. This population necessitated skills to move from a “why bother” mentality along with a “it can only be one way” thought  process towards looking at what works, and being flexible with trying new things, and developing hope. Fortunately for them, Radically Open DBT was developed.

 

Abuse

Secondly, there was the grave danger in using DBT without the skills to manage contingencies. Regarding the application DBT without complete understanding of behavioral principles, what does this mean? Quite simple: if a therapist isn’t fully trained and skillfull in DBT application, one of two things or both can happen: a person can’t learn to anticipate and generalize skills to all the various places and things that the need may arise in, and worse yet, a therapist can easily unintentionally reinforce the very behaviors that you are working so hard to eliminate. For example: say you are trying to stop self-harm, and you call your therapist for help after doing so (instead of before, for coaching in skills)—if your therapist tends to you, as nice as this may feel, in the long run, your brain ‘pairs’ the activity of “I self-harm, and I get ‘warm fuzzies’ and caring from my therapist”…unwittingly, the therapist has actually reinforced the behavior that was keeping you from developing new skills, and reaching new goals. And sadly, the thing that you came to see the therapist about in the first place, was the level of havoc the self-harm behavior was creating in your life, and all the ways it was getting in the way of you having what you wanted.   

 

 

“Adequate” Use

And perhaps saddest of all, was watching people turn into “stable mental patients”…people who no longer “act out” or are problematic to others, but internally, find no real resolution to their own quandaries and ailments. This is what happens when just ‘skills are taught’…DBT is not about teaching skills—it’s not about giving a man a fish to eat, it’s about teaching him to fish so he can feed himself the rest of his life. DBT requires the capacity to behaviorally manage people whose suffering of a moment is greater than a whole lifetime of pain for others.  It’s not enough to watch people who come to us for help end the cycle of self-defeating behaviors. It’s not enough for me, it shouldn’t be enough for the therapeutic community, and it shouldn’t be enough for you.

 

DBT is meant to produce life building changes relatively quickly. It’s not enough to eliminate ‘quality of life threatening behaviors’ (a target of stage I DBT)…there has to be an implementation of quality of life enhancing behaviors. (For this, there is the newly acquired DBT-ACES program.)

 

 

It’s time to move from just surviving to living. It’s time to begin thriving.       

 

 

—Minal Parekh Shah, MS, NCC, LPC