By Dr. Kathryn Korslund
Although most therapists are aware of dialectical behavior therapy (DBT) in some way, shape, or form, few non-practitioners understand what, exactly, is implied by the approach’s “dialectics.” Generally speaking, the notion of a “dialectical” process suggests compromising, blending together, or creating something entirely new; transforming black and white into grey, so to speak. In the context of DBT, however, dialectics involves a push for coexistence, an effort to hold two ostensibly opposing forces next to each other without compromising either’s integrity while searching for synthesis; weaving a black-and-white plaid, so to speak.
In fact, the practice of DBT itself emerged from Dr. Marsha Linehan’s attempts to reconcile acceptance- and change-based therapies without losing the effective elements of either.
Change vs. Acceptance
Change based treatments have typically approached the problem of severe depression or anxiety, with a focus on what the patient needed to change — about themselves, about their circumstances, about their mindset — in order to improve their mental and/or emotional wellbeing. While change is clearly needed in the context of maladaptive behaviors that are a threat to themselves or others — and thus must be changed — these behaviors are often only exacerbated when a patient is made to feel like they are the problem, like they are somehow defective.
As such, psychologists like Carl Rogers — one of the founders of humanistic, or “client-centered,” psychology — chose to approach treatment from the opposite direction, focusing not on change, but on acceptance. Using variations of this framework, therapists explained to patients that there is a healthy, functioning, well-adjusted person within them, and that their ultimate goal should be working toward self-actualizing that person. Unfortunately, many patients (mis)took this emphasis on acceptance as a resignation, as their therapist hopelessly throwing their hands up in the air. “I’m severely depressed, I’m really struggling here, but you’re not going to help me change,” the thinking would go.
Finding a Third Way: DBT
While Dr. Linehan didn’t set out to develop an entirely novel therapeutic method, she did recognize that neither the “change” nor “acceptance” approaches were working as effectively as patients or practitioners would like. At the same time, both approaches were grounded in accepted theory and had a range of demonstrable benefits. Ultimately, Dr. Linehan realized that in order to secure better outcomes for her patients — who, at the time, were mostly suicidal people who the psychiatric establishment had deemed untreatable — she was going to have to find a way to help them change in the long run while learning to accept themselves as they were in the moment. And thus, DBT was born.
One of the cornerstone questions we tackle with DBT asks, “What would give you a life that you would experience as worth living?” For patients struggling with severe depression or anxiety, answering this question frequently requires a lot of work, work that is seldom painless. As therapists, our responsibility to is to help guide these patients as they search for the answer, a responsibility which involves getting the patients to a place where they are stable enough and have enough fortitude to probe incredibly sensitive areas of their past, present and future.
First and foremost, we strive to eliminate impulsive “escape behaviors.” Patients who are dissatisfied with their overall wellbeing tend to turn their backs on anything in their lives that is difficult or stress-inducing. When things — a job, a marriage, etc. — get hard, the easiest thing for people struggling with depression or anxiety to do is quit. In DBT, we help patients move past this knee-jerk reaction and tolerate the pain of “sitting with” and working to solve life problems rather than escaping them. Such problem solving isn’t always easy, but accepting both the necessity and strenuousness of this endeavor is a critical step in the recovery process.
To do this, DBT also involves developing patients’ capacity for tolerating the distress of change and cultivating skills for emotional self-regulation. For those who struggle with depression and anxiety— and, to a lesser extent, even for those who don’t — many painful episodes stem from instances where one’s emotions exceed one’s control. With DBT, we teach patients various methods for handling difficult emotions and even finding a small grain of good in their most trying times.
In the end, all of us at THIRA Health recognize both the power and the attendant responsibility of DBT-based treatment programs. There’s a shared burden in the dialectical treatment experience that the therapist and the patient must take on equally, one that requires radical acceptance, honesty, compassion and courage. When both parties truly buy into this process, patients are on the road to achieving comprehensive, durable recoveries that enable them to find value in — and even relish — their everyday lives, something that they would’ve previously thought to be impossible.