Dialectical Behavior Therapy Workshop with Sara Dhuse, PhD.

I have been privileged over the last 4 years to work with and be mentored by Mrs. Sharon Dhuse.  She has been serving Baptist Theological College (BTC) for the last 10 years with her husband as a second career missionary.  After serving many years as a social worker in the foster care system in Chicago, she is now investing her life in training Christian workers here in Cebu.  Since this will be her last semester here in Cebu, we thought it appropriate to invite her daughter to Cebu to share her training and skills.  And thankfully Dr. Sara R. Dhuse accepted our invitation to share her gifts with us.  

BTC hosted an all-day seminar Dialectical Behavior Therapy Workshop on August 17, 2013.  We had about 40 attendees including pastors, Compassion case workers, social workers, guidance counselors and counselors working with trafficked children here in Cebu.  The following is a short summary of the material presented:

Dialectical Behavior Therapy (DBT) is a very structured model of counseling that teaches the clients to be self-aware and keep track of target behaviors and emotions, as well as urges to do self-harm.  It also teaches skills to evaluate their situation and do chain analysis in order to cope well with stress, regulate their emotions and improve their relationships with others.  This method combines standard cognitive-behavioral techniques and a person-centered model of intervention and mindfulness activities. 

The methodology is based on the assumptions that these clients lack the skills they need to:

• understand and regulate their emotions (Emotion Regulation Skills)
• cope with distress (Distress Tolerance Skills)
• communicate effectively with others (Interpersonal Effectiveness Skill)
• pay attention in their lives and make good decisions (Core Mindfulness Skills)

Dialectical Behavior Therapy (DBT) was originally created by Marsha Linehan to treat people diagnosed with Borderline Personality Disorder, but it has also been found helpful for any person with emotional dysregulation problems.  Recent research has found DBT to also be helpful for individuals with substance abuse, bulimia, binge-eating, depression and anxiety.  It has also been adapted for use with children and adolescents. 

People with Borderline Personality Disorder usually have problems with:

• Emotional dysregulation (intense emotions)
• Chaotic relationships and fear of abandonment
• Impulsivity with suicide attempts, self-harm and other damaging behaviors
• Lack of sense of self and feelings of emptiness
• Dissociation

Most people who suffer from emotional dysregulation have been exposed to invalidating environments where: Normal expression of emotion is ignored; Extreme displays of emotion are intermittently enforced; And complicated problems are presented as easy to solve.  In treatment, the crucial point where healing can occur is when a therapist creates a validating environment.

In the creation of this validating environment a therapist must pay attention to the dialectical transaction.  (Dialectical means incorporating two different views that appear opposite and find ways to integrate both, which is called synthesis).  There are three dialectical patterns that we usually engage in:

• Emotional vulnerability vs. self-invalidation
• Active passivity vs. apparent competence
• Unrelenting crisis vs. inhibiting grieving

What would a dialectical transaction of emotional vulnerability vs. self-invalidation look like?  The client might start with self-invalidation, saying something like, “I should not be afraid.”  The counselor would validate that statement, but also open the possibility that it’s ok to be afraid by saying something like, “I see that you’re not afraid, but I also notice that you hesitate when say that so I wonder if you might have a little fear.  Many times people that are in that situation has a tendency to be afraid.”  This will help the client toward self-validation which leads to the emotional vulnerability piece, beginning to open the client to the vulnerability of their emotion of fear.  Then the client can begin to be honest enough to accept his need instead of staying in self-invalidation (when the person denies, ignores or cannot accept what they truly feel or think about themselves).  Emotional vulnerability is a must to healing and allowing clients to accept their real situation without judging themselves is a key factor in achieving this.  How does this look in counseling?  Accepting a person with unacceptable behavior can result in this person knowing he or she is loved and accepted and not forced to change.  This will help them begin to overcome their resistance to change. 

The personal acceptance of the therapist is also very important here.  She needs to acknowledge and embrace her personal limitations and feeling of inadequacy.  Without this internal work she will be blaming and projecting her own discomfort and intolerance to the very person she is trying to help, and this person will feel judged and unaccepted by her.  The personal acceptance of the therapist translates into safety and emotional validity to her client.  When the client feels safe and accepted by the therapist they will also learn to accept themselves.  Then they can begin the work of understanding who they are, developing self-control by regulating emotional reactions and choosing to live their lives congruent with their values and with purpose.  Their experience with their therapist transfers to their current relationships.  As they trust their therapist, they learn to trust themselves with their progress, and eventually they can create a new validating environment for themselves and for others around them. 

People that choose Dialectical Behavior Therapy as a model of intervention require their clients to be in a one year DBT program.  DBT has four modes of intervention: Weekly Individual therapy;  Weekly Skills Group; Skills Coaching and Consultation Group.  Since this is a skill based approached the clients learn to pay attention to what is going on inside and outside of them.  This is done by developing mindfulness skills.  They also learn to focus on target behaviors for change with Diary Cards that are checked weekly by the therapist.

In the structure of individual session, the therapist leads you to these 3 main processes

1.  Review Diary Card

2.  Set Agenda  -  The agenda is based on the hierarchy:

• Life Interfering Behavior
• Therapy Interfering Behavior
• Quality of Life Interfering Behavior
• Topics Client would like to discuss

3.  Chain Analysis – a thorough step-by-step description of the chain of events leading up to and following an unhelpful behavior.  Basically asking the questions: “What made you do that? And what made you do the things that led up to that?  What was the result?  And what was the result of that result?”  These questions help the client identify the cycles of unhealthy behavior in which they are engaging.

Dr. Dhuse presented a very helpful paradigm for us mental health practitioners here in Cebu.  Thanks so much!!