DBT: Change in Our Own Backyard

Can acceptance and change coexist in the same therapy? I am frequently asked this question by patients who worry that accepting themselves or their current situation will prevent them from forging change—away from their histories of substance abuse, strong emotions, interpersonal difficulties, treatment dropout, and sometimes even suicidal or other self-harming behavior.

The answer is yes. And one treatment is Dialectical Behavior Therapy (DBT).

Developed by Dr. Marsha Linehan at the University of Washington in the late 1970s, DBT was originally intended to help people who were suicidal or struggling with urges to harm themselves. After years of research, including randomized, controlled trials, DBT is now considered to be an empirically supported treatment for individuals with Borderline Personality Disorder (BPD). More recently, a modified version of DBT has been developed to treat people who struggle with a range of mental health issues that do not meet the criteria for BPD, including substance abuse and eating disorders.

The theory behind the approach is that some people view the world in shades of black and white and are prone to react in a more intense manner toward emotional situations. When triggered, their emotional arousal can increase far more quickly than the average person, and they may feel that emotion more intensely and take a longer time to return to normal. People with these symptoms frequently do not have methods for coping with sudden surges of emotion and find ways to act out negatively instead.

In practice, DBT integrates teachings in mindfulness and acceptance with cognitive behavior therapy focused on change. DBT treatment usually involves participation in a weekly 90-minute skills training group as well as weekly individual DBT therapy. Skills training teaches specific lessons in mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness, all designed to help learn to (1) be non-judgmental in the moment, (2) identify and manage emotions, (3) cope with triggering urges/crises without making them worse, and (4) meet objectives in relationships, using tools such as asking for what one needs and saying no. Individual sessions emphasize problem-solving around the past week’s issues and the behaviors the person used in response. In short, the group sessions teach positive coping skills, which are then reinforced through supported individual application.

Despite a boatload of research supporting the validity of dialectical work, clients still tend to prioritize the goal of change over acceptance, often working from a place of self-doubt and fear. I often remind them of the classic DBT conjunction junction, that and always serves us better than or. For goodness sake, even Dorothy from The Wizard of Oz spoke to acceptance in the middle of a tornado of change, commenting, "…If I ever go looking for my heart's desire again, I won't look any further than my own backyard; because if it isn't there, I never really lost it to begin with."

The question for me becomes: what change can we find in our own backyard, when we take time to slow down, connect to self, and try to develop a better understanding of those around us? In all likelihood, our heart’s desire is already there, lodged somewhere deep within the dirt of our own psyche. With a little digging up and dusting off – and the introduction of new coping skills – that old backyard might become a place of change, a place that actually feels like home.