Updated thoughts on DBT

It appears my post about getting DBT notes has gotten some attention recently. This made me realize I’m long overdue for updating here about my current thoughts on DBT.

Here’s a link to an earlier post about my thoughts on DBT: Do I need to rethink my feelings about DBT?

There is a part of me that feels I was robbed of a “true” DBT experience. I know now that strict adherence to DBT protocols would not have allowed for me to do individual therapy for DBT while waiting for an opening in the skills group.  I never got to join the group before being kicked out.  From what I’ve learned in coursework about DBT I think I would have really benefited from the interpersonal effectiveness modules at that time in my life.

I think that the therapist I was working with could have done a lot more to work with me regarding my anxiety around phone calls. I do still feel that it seems backwards to kick me out for self-injuring and being too anxious to make coaching calls.  I don’t believe that low severity NSSI should be classified as “therapy interfering behavior”. I still find this rule to be very backwards. However, I do think that it could have been possible to sell me on this part of the treatment if it had been explained the right way. The way I experienced it, I was just ambushed one day with an ultimatum to do the calls or quit. I think if the role the calls play in the model of treatment had been explained to me clearly  I might have been able to buy into them more.

My non-DBT therapist at that time was doing a lot to unintentionally reinforce my self harm. When I didn’t self harm  after feeling upset she would ask in excruciating detail why I had not self harmed. This led me to self harm more since I never had a good answer for why I hadn’t done it. If I self harmed when upset I didn’t have to generate a reason why I didn’t do it. I didn’t have the language at that time to articulate this. But I think a lot of problems around the coaching calls besides the phone anxiety related me to at some level understanding that in many cases talking about my self harm in therapy was making it occur more often.

The “DBT” I encountered in hospital and partial hospital settings was DBT in it’s worst form. It was done in a way that didn’t strictly adhere to the protocol (It was just handouts) and was run by people with minimal training in the therapy. This didn’t help my opinion of DBT. I think my DBT experiences drive home how much damage can be done when people deviate from a manualized brand name treatment but still label it with the brand name. It was a long time before I realized that I didn’t ever get DBT in the way Linehan intended. If I had realized this maybe I might have made different choices about trying DBT again.

I still object to the way DBT can be pushed aggressively and I think the rules around NSSI and coaching calls are too strict. But I have warmed up to the benefits a lot of the skills can offer.

I’ve warmed up to Linehan as a person. I love watching her call out people on bullshit at conferences. She is a wonderful public speaker. I love her presentations about the iatrogenic impacts of hospitalization. Despite her data against hospitalization being being correlational, I think she makes a really good point in this area about the lack of evidence in favor of hospitalization.  That said, I’ve not warmed up to her so much that I’d ever want to work closely with her in a professional context.

I don’t think I’ve warmed up to DBT enough to do DBT as a clinician. I certainly use some DBT handouts with clients, but that’s different from doing DBT and I don’t represent what I do as DBT. I don’t think I could buy into all the parts of the treatment sincerely enough to do it. I also think that with DBT if I were to strictly follow the protocol it would be wrong for me to continue my own self harm while treating it as a “therapy interfering behavior” for my clients. I believe I could stop self harming if I were in this situation. But I’m not sure I want to. For me, the benefits of self-harm still feel greater than the negative consequences.

My feelings towards DBT are more positive than they were in the past, but I maintain some criticisms of the treatment design.