A DEEPER UNDERSTANDING
Frequently Asked Questions
How do I choose a therapist?
Developing a good relationship with your therapist and feeling comfortable talking to them about your most personal concerns is an essential part of your healing. For this reason, it can be challenging to choose a therapist that is right for you. To help you, here are a few things to look for when choosing a therapist:
- They are warm and easy to talk to.
- They have experience working in the area you are interested in.
- They are compassionate and strong.
- You trust in their abilities.
- They have the credentials to practice in the area they are working in (i.e., specifically trained in family therapy, PTSD, DBT, etc.).
- They demonstrate honesty and integrity.
- They are empathetic and open-minded.
- They install you with the confidence that they can guide you out of your comfort zone and see you to a different and healthier place.
- They are focused on goal-setting and results.
Remember that it is vital to know whether or not your therapist is a good fit for you and that a phone chat with them beforehand may be wise. Be clear on what you’d like to work on, and remember why you’re looking for a therapist.
What kind of therapy do clients receive in DBT?
Clients in comprehensive DBT* receive three main modes of treatment – individual therapy, skills group, and phone coaching. In individual therapy, clients receive once-weekly individual sessions that are typically 60 minutes in length. Clients also attend a 2.5 hour weekly skills group for 24 weeks. Unlike regular group psychotherapy, these skills groups are psychoeducational classes during which clients learn four sets of important skills:
Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.
Clients are also asked to call their therapists for skills coaching if they would like in-the-moment guidance on how to use DBT skills to avoid engaging in ineffective behavior. The therapist then walks them through skillful alternatives to ineffective behaviors.
*Comprehensive refers to outpatient DBT as it is researched and developed at Dr. Linehan’s research lab.
What are the targets and goals of treatment in DBT?
The most important of the overall goals in DBT is helping clients create “lives worth living.” What makes a life worth living varies from client to client. For some clients, a life worth living is getting married and having kids. For others, it’s finishing school and finding a solid group of friends. Others might find it’s volunteering for a meaningful cause in a different country or creating art. While these goals will differ, all clients have in common the task of bringing problem behaviors, especially behaviors that could result in death, under control.
For this reason, DBT organizes treatment into four stages with targets. Targets refer to the problems being addressed at any given time in therapy. Here are the four stages with targeted behaviours in DBT:
Stage I: Moving from Being Out of Control of One’s Behavior to Being in Control
Target 1: Reduce and then eliminate life-threatening behaviors (e.g., suicide attempts, suicidal thinking, intentional self-harm).
Target 2: Reduce and then eliminate behaviors that interfere with treatment (e.g., behavior that “burns out” people who try to help, sporadic completion of homework assignments, non-attendance of sessions, etc.). This target includes reducing and then eliminating the use of hospitalization as a way to handle crises.
Target 3: Decreasing behaviors that destroy the quality of life (e.g., depression, phobias, eating disorders, non-attendance at work or school, neglect of medical problems, lack of money, substandard housing, lack of friends, etc.).
Target 4: Learn skills that help people do the following:
- Control their attention, so they stop worrying about the future or obsessing about the past. Also, increase awareness of the “present moment” so they learn more about what makes them feel good or feel bad.
- Start new relationships, improve current relationships, or end bad relationships.
- Understand what emotions are, how they function, and how to experience them in a not overwhelming way.
- Tolerate emotional pain without resorting to self-harm or self-destructive behaviors.
Stage II: Moving from Being Emotionally Shut Down to Experiencing Emotions Fully
The main target of this stage is to help clients experience feelings without having to shut down by dissociating, avoiding life, or having symptoms of post-traumatic stress disorder (PTSD). In DBT, we say that clients entering this stage are now in control of their behavior but are in “quiet desperation.” Teaching someone to suffer in silence is not the goal of treatment.
In this stage, the therapist works with the client to treat PTSD and/or teaches them to experience all of their emotions without shutting them down and letting them take the driver’s seat.
Stage III: Building an Ordinary Life, Solving Ordinary Life Problems
In Stage III, clients work on ordinary problems like marital or partner conflict, job dissatisfaction, career goals, etc. This stage aims to help people work towards having a sense of meaning and purpose in their lives and a strong sense of self-worth.
Stage IV: Moving from Incompleteness to Completeness/Connection
Most people may struggle with “existential” problems despite completing therapy at the end of Stage III. Even if they have the lives they wanted, they may feel somewhat empty or incomplete. Some people refer to this as “spiritual dryness” or “an empty feeling inside.” Although research on this stage is lacking, Marsha Linehan added it after realizing that many clients go on to seek meaning through spiritual paths, churches, synagogues, or temples. Clients would also change their career paths or relationships.
The Interconnectedness of all the DBT Stages
Although these stages of treatment and target priorities are presented in order of importance, we believe they are all interconnected. If someone kills themself, they won’t get the help they need to change the quality of their life. Therefore, DBT focuses on life-threatening behavior first.
However, suppose the client is staying alive but is neither coming to therapy nor doing the things required in therapy. In that case, they won’t get the help needed to solve non-life-threatening problems like depression or substance abuse.
For that reason, treatment-interfering behaviors are the second priority in Stage I. But coming to treatment is certainly not enough. A client stays alive and comes to therapy to solve the other problems that are making her miserable. To truly have a life worth living, the client must learn new skills, experience emotions, and accomplish common life goals. Therapy is not finished until all of this is accomplished.
Why do people engage in self-destructive behavior?
A fundamental assumption in DBT is that self-destructive behaviors are learned coping techniques for unbearably intense and negative emotions. Negative emotions like shame, guilt, sadness, fear, and anger are a normal part of life. However, it seems that some people are particularly inclined to have very intense and frequent negative emotions. Sometimes, the human brain is simply “hard-wired” to experience stronger emotions, just like an expensive stereo is “hard-wired” to produce very complex sounds. Or it could be that severe emotional or physical trauma causes changes in the brain to make it more vulnerable to intense feeling states.
In addition, sometimes clients have mood disorders (e.g., major depression or generalized anxiety) that are not controlled by standard medications and thus lead to emotional suffering. Any one of these factors, or any combination of them, can lead to a problem called emotional vulnerability. An emotionally vulnerable person tends to have quick, intense, and difficult-to-control emotional reactions that make their life seem like a rollercoaster. Extreme emotional vulnerability is rarely the sole cause of psychological problems. An invalidating environment is also a major contributing factor.
What is an invalidating environment?
“Invalidating” refers to a failure to treat a person in a manner that conveys attention, respect, and understanding. The “environment,” in this case, is usually other people. Examples of an invalidating environment can range from mismatched personalities of children and parents (e.g., a shy child growing up in a family of extroverts who tease them about their shyness) to extreme environments of physical or emotional abuse. In DBT, we believe that borderline personality disorder arises from the transaction between emotional vulnerability and the invalidating environment.
Back to the example of a shy child: If an introverted child is teased by siblings or forced to go into social situations they want to avoid, they may learn to have tantrums to let others realize that they’re scared. If their shyness is only taken seriously when they have an outburst, they learn (without being conscious of it) that tantrums work. They have not been “validated.” In this case, forms of validation could have included:
- Telling the child that being shy is normal for some people
- Teaching them that shy people have to work harder to overcome social anxiety
- Helping them learn skills for managing shyness, so it does not interfere with their life
This is a relatively benign example. Some individuals, however, grow up in situations where they are abused or neglected. They may learn more extreme ways of getting other people to take them seriously. Further, because they are in painful circumstances, they may learn to cope with emotional pain by thinking about suicide, cutting themselves, restricting their food intake, or using drugs and alcohol. A vicious cycle can get started.
For example, the person is really sad and scared. They have no one who listens to them, and they are afraid to ask for help or know no support is available. Perhaps they try to kill themselves. Then, when their pain is treated seriously at the hospital, they learn (without being conscious of it) that when they’re suicidal, other people understand how badly they feel. Repeated self-injury can result if it is seen as the only means for getting better or achieving understanding from other people.
What does ‘Dialectical’ mean?
Dialectics is the idea that opposites can both have validity, and that when we acknowledge the validity in each polarity, we can conceptualize something new. One of the most important dialectics in DBT is the idea that to move towards wellness, both acceptance and change need to be considered. To focus on just acceptance might mean that a client feels understood and cared for, but they would be unlikely to make a lot of progress on their goals. To focus on just change might mean that a client would learn strategies to move toward their goals, but they may feel overwhelmed by the pace of the therapist or feel misunderstood by the therapist since the therapist isn’t acknowledging how they feel or the effort that they have already put into their wellness. Being dialectical means recognizing that both acceptance of the client just as they are is necessary while simultaneously encouraging the client to try out change-focused strategies. In combining both acceptance and change, progress is more likely to happen.
Can DBT treat conditions other than Borderline Personality Disorder?
DBT was originally designed to treat five areas of dysregulation: cognitive, emotional, behavioral, self, and interpersonal. If the mental health concerns that a person experiences falls into one of these categories, DBT can help. DBT is a structured therapy that teaches skills to help clients learn how to behave more effectively, regulate emotion, shift thinking patterns, maintain and build relationships, and have a stable self-image and self-worth.
Do you treat children?
While Inner Solutions™ has team members who specialize in the treatment of adolescents, we do not offer any clinical services to children under the age of 15. We do offer psychoeducational services to children.
Does Inner Solutions™ do direct billing with insurance companies?
Inner Solutions does not offer direct billing. However, you will receive an electronic receipt immediately after your session, which you can then submit to your benefits for reimbursement.
Is DBT offered to Albertans through AHS?
Alberta Health Services has a DBT program that is available with a referral from a family doctor. There is typically a waitlist of several months and up to a year to get into the program. Acceptance into this program is based on severity of symptoms, with those struggling with severe symptoms getting first priority.
I am a Medical Professional. Can I refer a client to you?
If you are a medical professional inquiring about whether Inner Solutions™ is a good fit for your patient, you are welcome to contact us to query about your client before encouraging them to complete a referral. Once you’re sure that you would like your patient to start at Inner Solutions™, please direct them to our self-referral form on our website and contact them directly. Our self-referral form includes a question about how a person came to hear about Inner Solutions™, and they can indicate there that you referred them to us.