There is More to DBT Than Just the Skills: DBT Stylistic & Commitment Strategies
Effective Dialectical Behavioural Therapy (DBT) is not just about therapists learning the skills and imparting them on clients, but HOW those skills are introduced, taught and practiced is essential to clinical outcomes. This is where the Stylistic and Commitment Strategies of DBT come in. DBT therapists will use specific strategies to engage and motivate clients to fully embrace the full treatment programme to ensure skills are fully obtained and practiced, reviewed and embodied once successful.
But commitment and motivation can be very hard for the client population DBT is designed for. People living with a personality disorder are highly likely to be fearful of hoping for change after years of emotional pain, behavioural dysregulation and relationship problems. It is 'easier' to give up hope than to hope and be dissapointed, and this makes a lot of sense. And yet, without a degree of openness to the therapy no change can occur. Here are some of the main strategies DBT therapists use to engage and motivate clients:
1) Reciprocal Communication
Reciprocal communication is a fairly typical communication style in psychotherapy, consisting of warmth and genuineness. The relationship between therapist and client is considered one of the central components of DBT therapy and reciprocal communication is foundational in building a relationship that will carry the therapy. If the client does not experience a sense of warmth and genuineness from the therapist they are likely to experience wounding by misattunement and invalidation and their protective defences are likely to activate making skill learning incredibly difficult.
2) Irreverent Communication:
DBT therapists use irreverent communication when a client is stuck or spiraling into emotional overwhelm, the aim is to increase engagement by 'shaking up' established ways of thinking, feeling and acting. Irreverent strategies, just like reciprocal strategies, must come from a position of compassion for the client. At its most basic, irreverence involves using a matter-of-fact or confrontational tone to discuss subjects that often are not discussed or skirted around. Irreverent communication can also include unexpected humor or the therapist behaving in a way that surprises the client as it is not 'expected' behaviour. The use of mild 'surprise' can bring a clients attention back to the present and focus on solving the problem at hand.
3) Self Disclosure
Therapist self-disclosure can be considered part of the reciprocal communication strategies. A DBT therapist will make considered self-disclosure(s) to normalise the human experience of emotions, distress, uncertainty and successful skill use. Humility on the part of the therapist assists genuine connection from which trust in the therapist and therefore in the therapy can grow.
4) Commitment Strategies:
from the outset DBT therapists will work to motivate clients to engage willingly in treatment and will use commitment strategies to do so. It is not uncommon for people with BPD/ EUPD to move swiftly from high levels of motivation to low levels of motivation and back again several times even within the course of one session. Commitment to treatment and the behavioral practice this requires is paramount to successful outcomes, hence commitment strategies will always be used at any time that a therapist observes a lessening in commitment. Examples of commitment strategies include:
a) Devils Advocate: this is where the therapist may advocate for the reasons not to commit to treatment. This can enhance a sense of autonomy and choice.
b) Assessing pros and cons: this is where the therapist will offer a balanced view of the pros and cons of entering or continuing DBT including reviewing other models of therapy that may or may not be preferred by the client. Again increasing autonomy.
c) Foot in the Door: The age old sales technique of asking for a very small commitment in the hope that will lead to greater commitment later. This might look like asking the client to complete a skill practice just once, in the hope the likely positive outcome will enhance the willingness to repeat skill rehearsal.
d) Door in the Face: This involves asking for something much larger than the client will likely be willing to offer, but then settling for something less. So for example, a socially anxious client may be asked to speak to 5 new people at an upcoming networking event, this is likely to be met with "I'm not doing that!" (door in the face), the therapist will follow with, "well what about just one person, could you do that?"
e) Freedom to Choose with Lack of Alternatives: Reminding the client that making a change or engaging in treatment is their free choice, but with a questions of is not this change / treatment then what alternative will you choose? This can remind the client that the reason they are likely in DBT therapy is because they have already tried so many methods to solve their problems which haven't worked. So maybe the therapeutic skills are worth a try.
As with all Psychotherapies the conscious use of presence, positioning, pace and attunement on the part of the therapist are possibly not even noticed by the client and yet they are significant in the success of the therapy. I believe that therapeutic delivery is much like an artform that the therapist works and reworks time and time again over the course of the therapy. Marsha Linehan, founder of DBT touches on the nuances of moment to moment strategy changes in her 1993 works:
"The tension between patients' alternating, excessively high and low aspirations and expectations relative to their own capabilities offers a formidable challenge to therapists; it requires moment-to-moment changes in the use of supportive acceptance versus confrontation and change strategies..... Stylistically, DBT blends a matter-of-fact, somewhat irreverent, and at times outrageous attitude .... with warmth, flexibility responsiveness to the patient, and strategic self-disclosure." (pg 19)
Over my years of practice I have fallen in love with the DBT approach to working with chronic distress and emotional dysregulation. It is particularly this stylistic balancing act that I observe to be so effective in enabling highly fearful and avoidant clients to lean into help and try out new ways of being.
If you would like to know more about DBT, or are interested in starting DBT therapy for Borderline Personality Disorder (BPD) / Emotionally Unstable Personality Disorder (EUPD) or ADHD, please get in touch. Myself or a member of my team are always happy to answer questions and share our love and passion for this amazing therapy.
Linehan. M (1993) Cognitive Behavioural Treatment of Borderline Personality Disorder. Guilford Press