Orientation Group: Back to Basics

The following is a synopsis of a weekly Dialectical Behavior Therapy (DBT) group lesson, based on the work of Marsha Linehan out of the University of Washington. This week’s lesson is actually outside of the normal DBT content, it is solely based on the codependency literature, specifically the work of a wonderful fellowship called CODA.

New Disclaimer: I LOVE doing this, I think it is desperately needed, and I WANT to do it. However, I have zero time to do it so, while I am committed to giving it my all, I may fall behind or skip a week or two. I apologize in advance for that, and for the fact that I will not be spell checking, fixing formatting, or doing a read through before I post. No offense, but I gotta draw the line somewhere!

Orientation Group: Back to Basics

Last week was a wrap up group to help instill all of the things we’ve learned over the past several months. It really helps to hear the skills again and again, and to keep practicing them. I find myself using these skills in everyday life more and more, but it’s only because of practice and hearing, seeing, and teaching the skills again and again.

This weeks group focuses mainly on what DBT is, how it evolved, and the benefits of being in a DBT group. We then went on to discuss what BPD is and how that diagnosis evolved, how it is made, and why it is so under-diagnosed.

The purpose of this group is to allow each group member to reflect on why they first came to group, and to re-establish their goals. It helps people to feel empowered, as we review symptoms and explore the walls that Dr. Linehan has knocked down over the years. At times, people feel shame and hopelessness in reviewing the BPD symptoms and stigmas, however I encourage everyone in group to move past the struggles of BPD, and to focus on one of the guiding dialectics of group: You are here because you want to change, but you have to try harder and be more motivated to build a life worth living (Linehan, 1993).

Marsha Linehan, the creator of DBT, is responsible for providing my field with the tools needed to take a diagnosis that was seen as hopeless and unhelpable and making it a diagnosis that not only has hope, but can be a diagnosis that we as clinicians want to work with! That’s an amazing accomplishment and, although it can be difficult to forgive my field for perpetuating the stereotypes we see today around this disorder, professionals such as Linehan have worked hard to continue breaking down these walls to provide people with the skills they need to WANT to live. One of the most inspirational things about Linehan is her personal story, where she has admitted publicly to suffering with extreme BPD symptoms, yet she persevered in order to help herself, and others build a life worth living. (see article here http://www.nytimes.com/2011/06/23/health/23lives.html?_r=0

So that being said, the discussion of DBT and how it evolved starts with, none other than, Sigmund Freud. Love him or hate him, Freud was responsible for many of the theories and interventions that are still helpful to us today. His psychoanalytic technique focuses on uncovering unconsciouss processes that plague us, and coming to terms with the drives that make us human. Along then came the behaviorists, who focused more on what we do then what we bury unconsciously, and changing our behavior with reinforcements and punishments. Around this time, the cognitive theorists began to emerge, who’s focus was more on thoughts that we have, and how our distorted thinking leads to problems such as depression, anxiety, etc. In the 80’s and early 90’s, we began to recognize, through experimental research, that a combination of cognitive and behavioral strategies is bound to help most of the ailments that our clients are battling.

So Marsha Linehan, in her infinite wisdom, publishes her book titled Cognitive-Behavioral Therapy for Borderline Personality Disorder. In 1993, Linehan recognized that a woman publishing a book about Dialectical Behavior Therapy, an unknown entity, would surely be overlooked, even laughed at in light of the diagnostic focus: Borderline Personality Disorder. At the time, this was a disorder that had a horrible prognosis, and the therapeutic community was tight to avoid treating, due to the lack of progress clients were thought to make. In addition, the nature of the symptoms made it hard for clinicians to avoid burn-out, being drained of our resources, and even risking law suits. Because the therapeutic relationship is such a deeply intimate relationship, the Borderline individual’s fear of abandonment is going to emerge, and this will be a very difficult relationship then to maintain. Linehan came around with a groundbreaking idea, however. She suggested that the failures of these clients is more a result of OUR failures as a field, as we were applying the wrong therapy to this disorder. While CBT is known to work for almost everything, Linehan proved, through good solid research, that the addition of  dialectical principals, validation, and other such principals to a CBT framework will result in a decrease in these most difficult symptoms.

So all of this is miraculous! And it is why I do DBT, because I have seen it work time and time again, for people who feel hopeless, helpless, and unloved. I believe 100% in DBT and its ability to help people overcome horrible symptoms, and we have the research to prove that it works! I have dedicated my life’s work to doing this with a younger population, because I know that providing these skills to youth, who are more flexible in their thinking and behaviors, can change their lives forever. Just like I have seen 12 step programs work for the sick and suffering addict (Alcoholics Anonymous, 1929), I have seen the same type of results with youth and adults with BPD symptoms and DBT.

So what exactly is BPD? It is 5 or more of these symptoms:

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

(3) identity disturbance: markedly and persistently unstable self image or sense of self

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sexsubstance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms (pasted in from psychologytoday.com)

In my opinion, one of the worst decisions we have made as a field is to reserve this diagnosis for ages 18+. Because of our efforts to save kids from this “horrible” diagnosis, they often get diagnosed with 5-10 other diagnoses, which not only points them in the wrong direction therapeutically, but also leaves them feeling more helpless and overwhelmed then if they just had one, identifiable, albeit difficult diagnosis to have. while the concept makes sense, a young person’s personality is still forming as a teenager, we are missing the boat in a HUGE way, and doing these kids a HUGE disservice. Instead of instilling in the public that BPD is a treatable, manageable illness like any other, we seem to be desperately trying to avoid assigning it, which just perpetuates the shame and misinformation that has surrounded BPD for a hundred years.

So, if you have been told that you have Bipolar Disorder, be skeptical. This is an extremely rare disorder in my opinion, and it is much more likely that you have BPD. the same goes for lots of other disorders that seem to get thrown around too much, and while I certainly am cautious in diagnosing BPD just like anyone else, I would rather see someone get the living skills of DBT that we ALL need to have a better quality of life, than to suggest someone go on a heavy drug such as Lithium, which is necessary to manage a biologically-based mental illness such as Bipolar disorder. And while it is very true that someone may have multiple diagnoses, we need to be focusing on the treatments that work, rather than on the labels that may be more subjective than we think.

So the bottom line for all of you laypeople is, don’t be afraid of any diagnoses you may have. You can build a life worth living no matter WHAT your experiences, symptoms, or struggles are, and DBT WORKS! For any and for all of us!

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