Advanced Skills Practice in a Self-help Environment

Historically, DBT has been practiced in a structured individual and group therapy program where both client and therapist receive training and support in DBT skills and principles.

It is an empirically proven treatment developed by Dr. Marsha Linehan and her colleagues at the University of Washington in the early 1990s for chronically suicidal female patients diagnosed with Borderline Personality Disorder. DBT proved to be an invaluable tool for working with emotional pain and preventing self-destructive behavior.

Over time, it has become evident that the DBT skills are useful in a far broader context. On a worldwide level, it is being incorporated into diverse programs that deal with many maladies caused by emotional pain.

What have DBT experts had to say about advanced DBT skills practices?

First, let's look at what Marsha Linehan's Behavioral Technology Transfer Group (BTTG) teaches about the stages of DBT:

(I) Getting behavior under control (no more suicide attempts, self-injury or other behaviors that interfere with therapy); 

(II) Overcoming quiet desperation (e.g., working through post-traumatic stress disorder);

(III) Working through problems of everyday living;

(IV) Achieving a sense of transcendence, overcoming feelings of incompleteness, etc. through peer-led community support.

Most clinical environments are focused on Stage I DBT, upon which, currently, the majority of research is based. Stages I - III are accomplished by individual psychotherapy and skills training in a group therapy situation.

To date, Stage IV DBT has received relatively little attention. It is this stage of DBT that we are addressing.

In an article by Leslie Knowlton in Psychiatric Times that was written not earlier than 1998, Marsha Linehan is quoted as saying:  "In sum, the orientation of DBT is to first get action under control, then to help the patient feel better, to resolve problems in living and residual disorder, and to find joy and, for some, a sense of transcendence. . .All my research is at level one, but you can't stop treatment there (emphasis added). If you don't go to the next levels [patients] will often move back to level one again."

My patients often ask me whether they will ever get better, whether they will ever be happy. It is a difficult question to answer.

And in the same article: Treatment at each level is very different. Level one is behavioral therapy that decreases behaviors that that are life-threatening or interfere with therapy and quality of life, while increasing behavioral skills of mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance and self-management. Level two involves exposure-based procedures. Level three utilizes a range of interventions, and level four involves treatments such as spiritual counseling, existential analysis or any work with a wise person," (emphasis added), Linehan said.

From Linehan's text, Cognitive-Behavioral Treatment of Borderline Personality Disorder (page 461), she states, My patients often ask me whether they will ever get better, whether they will ever be happy. It is a difficult question to answer.  Surely they can get better and happier than they are when they first come to see me. And, yes, I believe that life can be worth living even for a person who has at one time met criteria for BPD.  I am less certain, however, whether anyone can ever completely overcome the effects of the extremely abusive environments many of my patients have experienced. Some amount of grieving may be necessary over their whole lives. The important thing here is not to catastrophize this reality.  Many people over history have had to face and accept extraordinarily painful events;  yet they have gone on and developed lives of reasonable quality or fulfillment. Of course, how to do this is not completely obvious, nor is it easy. Psychotherapy is only a small part of the attempts made by society to confront this dilemma. The limits of psychotherapy may be circumvented by involvement in religion, spiritual practices, study of literature, history or philosophy, community activities, and so on. That is, many of the answers will be found outside of psychotherapy (emphasis added).

And, in another context, she states: the ability of our society to provide community and companionship is limited, even for many of its best members (ML text, p. 461).

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