The 'snap out of it!' approach
to mental illness may have gone out with treatments like
lobotomies, laudanum, and straightjackets, but it may
again be time to throw off the kid gloves. Tough love
is making a comeback.
A tough talking revolution called
dialectical behaviour therapy (DBT) was unleashed on
psychotherapists' couches in the early 1990s by Dr Marsha
Linehan, a professor of psychiatry and psychology at
the University of Washington. It takes a gloves-off
approach to treating borderline personality disorder,
a condition typically marked by intense anger, emotional
neediness, dissociative behaviour, self-mutilation and
persistent attempts at suicide. Proponents swear by
the therapy's 'irreverent communication' methods, saying
it 'jolts' these notoriously difficult-to-treat patients
to (as Dr Phil would say) "jack it up and do something
about it."
DIALECTICAL
MATERIAL
DBT is based on the idea that understanding is reached
through resolution of two opposing arguments. On one
side, it balances 'radical acceptance' (which teaches
patients to accept who they are and admit that they
are not who they want to be) with problem-solving techniques
aimed at helping patients learn skills for regulating
emotions and coping with stress. On the other side,
DBT insists that patients make a commitment to stop
self-destructive acts and presents them with four options
for responding to a problem: solve it, feel better about
it by regulating your response, tolerate the problem
or just stay miserable. For instance, a patient might
say "I want to die." Her DBT doctor will reply, "What's
stopping you?" "You're basically saying to your patient
'yes, this awful thing happened and this is how you
feel about it, but now it's time to do something about
it,'" says Dr Marlene Hunter, a GP-psychotherapist and
director of the Labyrinth Victoria Centre for Dissociation,
in Victoria, BC.
The therapy's a hit with both doctors
and patients. "DBT is very good in that it gives patients
a different perspective and teaches them to just be
aware of their feelings without working too hard to
change them," says Dr Hunter. "Just being aware, watching
and observing helps them temper their reactions." Studies
have shown that patients who underwent DBT made fewer
suicide attempts, spent less time in hospital and were
more likely to stick with their treatment program than
those who received other, more standard types of therapy.
Today, DBT's applications have been expanded and it's
not just used for borderline personality disorder but
also for anxiety, depression and post-traumatic stress
disorder.
TOUGH
COMPASSION
But the same confrontational approach that appeals to
practitioners and patients has earned DBT the label
of being a tough love therapy. "I'm not sure I agree
with that," says Dr Shelley McMain, head of the Dialectical
Behaviour Therapy Clinic at the Centre for Addiction
and Mental Health in Toronto. "One of the key findings
from DBT research is that many clients find it a very
compassionate approach that makes them feel understood."
Dr Hunter agrees. "It's an effective
approach for people who have trouble taking ownership
of their problems, but it's not for everybody," she
says. "I certainly would not recommend it for people
who are very, very emotionally fragile."
Dr McMain and other counsellors
in her clinic were Canadian DBT pioneers, having adopted
the approach about eight years ago, but the treatment
continues to gain acceptance apace. Correctional Services
have been using DBT since 1997 to treat female inmates
with emotional and behavioural problems.
But Dr Hunter cautions that DBT
should not be seen as a one-size-fits-all solution to
borderline personality disorder. "Nothing works for
everybody," she says. "For some, DBT is very confrontational,
so I would not use it until the patient feels a degree
of security within themselves and with us."
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