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The DBT (Dialectic Behavior Therapy) Project
at Psych Associates of Maryland

PSYCH ASSOCIATES OF MARYLAND

Dialectic Behavior Therapy

Psych Associates of Maryland presents comprehensive DBT. We have both Traditional DBT and RO(Radically Open)-DBT. Read more below.

See whether DBT can benefit you!

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Traditional DBT

What is traditional-DBT?

DBT levels of care are chosen with your intake therapist and decided at admission. The following levels of care are available based on the child's symptoms and levels of need.

LEVEL I Care

The team has several levels of care.  At the most intense level of treatment the team sees an adolescent 5 times a week.

  • One individual therapy session – schedule varies but all appointments are available after school hours six days a week
  • One family therapy session – schedule also varies similar to the individual therapy
  • Two adolescent DBT skills group – one mid-week group and one group Saturday
  • One DBT skill group for the parents – all parent groups are at the same time as the adolescent skill group

This level of treatment includes parent coaching and adolescent crisis calls in between sessions when either or both are experiencing difficulties.  These calls are typically short in duration and if more extensive intervention is necessary the on-call therapist may either meet the client at the office or send the family to the Emergency Room for evaluation.  Additionally, this level of care includes case coordination with psychiatrists, nutritionist and designated adult at school.  The team is experienced in advocating for 504 plans or IEPs.  When needed the team attends school meetings by phone or in person.  The team also meets weekly to review each case and to insure that the staff is all working together on the same page with the adolescents family

LEVEL II Care

Level II care typically includes only one therapy session a week.  The group schedule remains the same.  At this level, there is less need for in between session intervention and significantly less safety issues.  Normally at this level less coordination is necessary because the client has made some progress and the outside parties are in maintenance mode.

LEVEL III Care

Level III care includes only individual DBT informed individual sessions or only group sessions.

road on sunny day

Radically Open - DBT

What is RO-DBT?

Is a trans-diagnostic model of treatment to address issues of Over-Control. So in loose translation, it doesn’t matter what the diagnosis is if you identify with any of the following:

  • Lack Receptivity and Openness, e.g. avoiding feedback and novel situations
  • Lack Flexible Responding, e.g. compulsive need for structure, rigid responding
  • Lack Emotional Expression and Awareness, e.g. inhibited or disingenuous expressions
  • Lack Social Connectedness and Intimacy, e.g. aloof and distant relationships
    Static and dynamic content editing

This is 20 years of research that says one of the ways we can improve people’s functioning is to focus not on the diagnosis but on the social signaling that impairs their ability to address isolation and emotional loneliness.

RO—Developing a passion for going opposite to where you are

  • Radical openness is more than awareness—it is actively seeking the things one wants to avoid or may find uncomfortable in order to learn.
  • It involves purposeful self-enquiry and cultivating a willingness to be “wrong” –with an intention to change if needed.

Treatment targets not the diagnosis but:

  • Emphasizes the communicative functions of emotional expression -- Social Signaling Matters!
  • Promotes the formation of close social bonds research shows we are psychologically healthier if we have at least one close friend
  • Teaches patients skills to activate the neural substrates linked to social safety thereby allowing them to be more open to their environment
  • It integrates older evolutionary theory with current brain-behavioral science

Frequently Asked Questions

What is Dialectical Behavior Therapy?

Dialectic Behavior Therapy (DBT) is a treatment that focuses on symptoms not diagnosis and solutions not problems. The work is different substantially than more traditional therapies.  DBT focuses on four core modules - Distress Tolerance, Interpersonal Effectiveness, Emotional Regulation and Mindfulness. By focusing on learning these core skills, research has shown a decrease in self-harm, suicidality, substance use and other harmful behaviors.  While originally DBT was focused on treating people with a Borderline Personality Disorder diagnosis, it has since grown to be one of the most effective treatments for a variety of symptoms and diagnosis.

Why do people engage in self-destructive behavior?

A key 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.Additionally, sometimes clients have mood disorders – 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. A person who is emotionally vulnerable tends to have quick, intense, and difficult-to-control emotional reactions that make his or her 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? The “environment,” in this case, is usually other people. “Invalidating” refers to a failure to treat a person in a manner that conveys attention, respect, and understanding. 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 extraverts who tease her about her shyness); to extremes of physical or emotional abuse. In DBT, we think that borderline personality disorder arises from the transaction between emotional vulnerability and the invalidating environment.

Back to the example of a shy child: If a shy child is teased by his siblings or forced to go into social situation she wants to avoid, he may learn to have tantrums to let others realize that he’s scared. If his shyness is only taken seriously when he has an outburst, he learns (without being conscious of it) that tantrums work. He has not been “validated.” In this case, forms of validation could have included telling the person that being shy is normal for some people, teaching him that shy people have to work harder to overcome social anxiety, or helping him learn skills for managing shyness so it does not interfere with his 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: The person is really sad and scared, she has no one who listens to her, she is afraid to ask for help or knows no help is available, and so she tries to kill herself. Then, when her pain is treated seriously at the hospital, she learns (without being conscious of it) that when she’s suicidal, other people understand how badly she feels. Repeated self-injury can result if it is seen as the only means for getting better or achieving understanding from other people.

What kind of therapy do clients receive in DBT?

Clients in standard 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 an hour to an hour-and-a half in length. Clients also must attend a two-hour weekly skills group for at least one year. Unlike with regular group psychotherapy, these skills groups emerge as 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 individual therapists for skills coaching prior to hurting themselves. The therapist then walks them through alternatives to self-harm or suicidal behaviors.

It should be noted that in standard DBT, it is the individual therapist who is “in charge” of the treatment. This means it is the individual therapist’s job to coordinate the treatment with the other people – skills group leaders, psychiatrists, and vocational counselors. In collaboration with the client, the therapist keeps track of how the treatment is going, how things are going with everyone involved in the treatment, and whether or not the treatment is helping the client reach his or her goals.

In some situations, DBT clients may also be on medications for problems like major depression bipolar disorder, are transient (short-term) psychotic episodes.

What are the top 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 life partner. Others might find it’s joining a religious or spiritual group and buying a house near a place of worship. While all 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 behaviors 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, non-collaboration with therapists, 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, sub standard housing, lack of friends, etc.) and increasing behaviors that make a life worth living (e.g., going to school or having a satisfying job, having friends, having enough money to live on, living in a decent apartment, not feeling depressed and anxious all the time, etc.).

Target 4: Learn skills that help people do the following:

a) 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 and more about what makes them feel good or feel bad.

b) Start new relationships, improve current relationships, or end bad relationships.

c) Understand what emotions are, how they function, and how to experience them in a way that is not overwhelming.

d) 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 the client to experience all of his or her emotions without shutting the emotions down and letting the emotions 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. Some clients choose to continue with the same therapist to accomplish these goals. Some take a long break from therapy and work on these goals without a therapist. Some decide to take a break and then work with a different therapist in a different type of therapy.

Stage IV. Moving from Incompleteness to Completeness/Connection

Most people may struggle with “existential” problems despite having completed 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.

Although these stages of treatment and target priorities are presented in order of importance, we believe they are all interconnected. If someone kills herself, she won’t get the help that she needs to change the quality of her life. Therefore, DBT focuses on life threatening behavior first. However, if the client is staying alive but is neither coming to therapy nor doing the things required in therapy, she 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 in order to solve the other problems which are making her miserable. To truly have a life worth living, the client must learn new skills, learn to experience emotions, and accomplish ordinary life goals. Therapy is not finished until all of this is accomplished.

How is DBT different from regular Cognitive Behavioral Therapy?

DBT is a modification of standard cognitive behavioral treatment. As briefly stated above, Marsha Linehan and her team of therapists used standard CBT techniques, such as skills training, homework assignments, symptom rating scales, and behavioral analysis in addressing clients’ problems. While these worked for some people, others were put off by the constant focus on change. Clients felt the degree of their suffering was being underestimated, and that their therapists were overestimating how helpful they were being to their clients. As a result, clients dropped out of treatment, became very frustrated, shut down or all three. Linehan’s research team, which videotaped all their sessions with clients, began to notice new strategies that helped clients tolerate their pain and worked to make a “life worth living.” As acceptance strategies were added to the change strategies, clients felt their therapists understood them much better. They stayed in treatment instead of dropping out, felt better about their relationships with their therapists, and improved faster.

The balance between acceptance and change strategies in therapy formed the fundamental “dialectic” that resulted in the treatment’s name. “Dialectic” means ‘weighing and integrating contradictory facts or ideas with a view to resolving apparent contradictions.’ In DBT, therapists and clients work hard to balance change with acceptance, two seemingly contradictory forces or strategies. Likewise, in life outside therapy, people struggle to have balanced actions, feelings, and thoughts. We work to integrate both passionate feelings and logical thoughts. We put effort into meeting our own needs and wants while meeting the needs and wants of others who are important to us. We struggle to have the right mix of work and play.

In DBT, there are treatment strategies that are specifically dialectical; these strategies help both the therapist and the client get “unstuck” from extreme positions or from emphasizing too much change or too much acceptance. These strategies keep the therapy in balance, moving back and forth between acceptance and change in a way that helps the client reach his or her ultimate goals as quickly as possible.

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