A Curious Professional Journey

I did not set out to become a therapist who utilized Dialectical Behavior Therapy (DBT). When I was in graduate school, I had hoped to become a therapist who worked mainly with married couples and families, which is where I put much of the focus of my training. I had taken a class that referenced DBT and had also heard what a nightmare clients with borderline personality disorder (BPD) were to work with. But since that was never going to be me (ha!), what did I have to worry about?
Turns out, quite a bit.

For my predoctoral internship I was matched with a clinic that specialized in working with families going through oversea adoptions. Often families who had successful adoptions would later discover that the children had attachment disorder. While at this clinic, I worked with various licensed therapists and families in a variety of modalities, including: individual work, EMDR, support groups, skills groups for the children and developmental assessments.

Attachment disorder is difficult to treat and the burnout rate among therapists who do this important work is high. The clinicians I worked with, and under, were passionate and gifted. I still bear a scar on my left arm from where a child who had become dysregulated bit me. In a conversation with my supervisor, he explained to me that many of these children with attachment disorder will grow up to be clients with BPD. This is not a population for the faint of heart, and while the success rate is not exactly through the roof, it was an important part of my development.

Fast forwarding to the end of my internship, I was out pounding the pavement, trying to find a job in the field without much success. A former classmate and friend of mine had recently interviewed for a job at a community mental health center. They were looking for an already-licensed therapist to train in DBT who was willing to work with BDP clients. My friend told me, “this job doesn’t pay for shit, so I’m taking a pass. Thought that you might be interested instead.” Funny right?

Despite the glowing recommendation from my friend, I applied. During the interview, the interviewer (correctly) noted my lack of experience with BPD. I remembered what my supervisor told me and responded that I had experience, I just worked with them earlier in the process when it was still seen as Attachment Disorder.

I never received feedback to know for certain if that’s what sealed the deal, but I had gotten the job. My friend had been right when he said it didn’t pay very much, but what it did offer me was training in DBT and that changed my life forever.

My Challenging Work with Sarah

For those not familiar with DBT, it is a skills-based modality with regularly assigned homework that incorporates concepts and practices drawn from mindfulness, Buddhism, Hegel, and basic methods of therapeutic validation. Many of these concepts are abstract, and often difficult for clients to fully grasp and embrace. It can be especially tough for those with developmental challenges typically associated with attachment and personality disorders.

For me to be able to explain them to these clients in ways that they could understand and implement in their daily lives, as well as during times of crisis, I really had to learn these concepts backwards and forwards, breaking each down to its essence.

One of my earliest clients, whom I shall call “Sarah,” was very hesitant to embrace these concepts. Partly, because they were difficult to understand, but Sarah had also been through a LOT of therapy before arriving at DBT. (DBT is rarely the first stop on a client’s therapy journey and as we say, “nobody gets to DBT by accident.”)

Therapy had yet to help her in any way she could appreciate. Her arms were covered in scars from many attempts at suicide and self-injury. Estranged from most of her family, she lived with her grandparents because no group home or assisted living facility wanted the liability risk. At the time, she proved unable to hold down a job of any kind. As such, Sarah’s world was small, and her human contact was limited to intermittent conversations with her grandparents, therapists, medical personnel, and DBT Group members during her frequent hospital stays.

During one session, we were talking about suicide and self-harm when Sarah stated that she was likely to die from suicide at some point, because what was the point of living if this was all there was to life? What would happen to her after her grandparents passed away? I replied that those were excellent questions. Her life as it was currently constructed was about survival and little more. Why would any therapist expect her to embrace such a life? For Sarah, being told that “things could always be worse,” was of little consolation. What was the point of staying alive when things could get worse?

One of DBT’s core concepts is referred to as “A Life Worth Living.” In essence, it asks the client what would have to change about their life so ideations like self-harm or trying to commit suicide would organically come off the table? Of course, we must survive before we can thrive, but what did thriving look like to Sarah?

Sarah said she wanted to be able to live on her own (or with occasional assistance that would come when needed), to have a job and her own money, and MAYBE (some pie in the sky stuff here) even have some friends! To her, that would be “A Life Worth Living.” I told her it was possible to have those things, but it is going to take work. DBT, like life, is like playing a sport. It requires clients to consider making choices that someone who could live on their own, hold down a job, and had friends would make. I challenged Sarah by asking, “are you making any of those choices right now?”

She reluctantly conceded that she was not. She could not fault her grandparents for not having faith she could live on her own; the paramedics were at their house at least once a month, if not weekly due to Sarah’s self-harm and suicide attempts. Her time in and out of the hospital and subsequent therapy appointments throughout the week, made it hard for her to hold a job.

I asked Sarah what she saw as the biggest obstacle to getting to her “Life Worth Living?”

“The cutting,” she said.

I agreed. If we could find other more skillful and adaptive ways to tolerate distress, the idea of her living on her own and being able to stay out of the hospital (and therefore able to work), seemed more plausible. That session was when Sarah committed to taking self-harm off the table.

This was no small commitment. Sarah used self-harm weekly for over ten years. Neither she nor I had any illusions that it would be easy for her. In a paradoxical way, self-injury had kept her alive as a coping skill on more than one occasion. She had a concept of how to resolve physical pain, while emotional pain seemed too overwhelming. In order for her to make this work, it was a matter of buying into DBT and its skills. Would the skills be as effective as a coping mechanism for her while keeping her safe? It was a leap of faith I was asking her to make – to put her trust in DBT and our therapeutic relationship. We were off.

Sarah’s Rocky Progress Forward

Gradually the ambulances stopped coming to Sarah’s grandparents’ house and while she never went to the hospital again, it was not a smooth, upward trajectory. There were setbacks, but one day without self-harm became a week which became a month, and then we were at her quarterly review. With her grandparents present, they attended many of Sarah’s appointments and reviews, Sarah proudly told them she had gone three months without hurting herself. She had been practicing her DBT skills (Distract, Self Soothe, Opposite to Emotion, Pros and Cons) and she had plans to share!

Sarah told them about wanting to live on her own and have a job. Her grandparents were pleased, surprised, and anxious all at the same time. These were big steps to take. While they praised Sarah for her efforts and progress it didn’t stop them from worrying. Sarah wasn’t derailed and instead offered to negotiate with them: if she could keep up this progress for nine more months and graduate from Stage 1 of DBT, would they support her? First in getting a job and second in finding a place to live?

As her therapist, I jumped in explaining that this seemed like a good Wise Mind (middle path between reason and emotions) compromise. Assuming she succeeded it would be a new experience with new kinds of stress and new opportunities for her to use her skills. If she could navigate holding down a job while using what she had been practicing, it would stand to reason she could do the same living on her own.

Her grandparents agreed to the plan – the smile it brought to Sarah’s face was one I hadn’t seen before. I wasn’t sure who was more excited at that moment, me or her! Being able to observe her having faith in herself and her future remains one of the most powerful experiences I have shared with a client. I did not know then what the future held, but I knew that DBT worked, and I could not turn my back on something that worked. From that moment on, I was a DBT therapist.

***

It’s been almost 25 years, throughout which I have worked with thousands of clients on achieving their “lives worth living.” I have seen clients who went from thinking about suicide almost every day to taking it completely off the table. Many were clients who now have healthy relationships and rewarding careers, just like Sarah. The work is challenging, and I am thankful for the support of a great team. The pride I take in seeing how hard these clients work on themselves is impossible to describe. They continue to make me a better therapist and I would not have it any other way.

Questions for Thought and Discussion

• What serendipitous experiences have you had over the years that have opened interesting clinical doors for you?
• In what ways are the core premises of Dialectical Behavior Therapy consistent with your orientation to therapy?
• What are some of the limitations you have experienced or anticipate in the application of DBT principles and techniques?

File under: The Art of Psychotherapy, Musings and Reflections