Annie described her life as a “living hell” as she was referred from one specialist to another. She was also prescribed various psychotropic medications. 

She reported that the medications had severe side effects that only increased her depression levels. 

So, Annie found a way to self-medicate by taking her mother’s pain medications and over time ended up with an addiction to pain medications.

Overview Journey of DBT

Marsha M. Linehan is the creator of dialectical behavior therapy (DBT), a type of psychotherapy that combines behavioral science with Zen concepts like acceptance and mindfulness.

There are different stages of treatment which determine which behaviors are to take priority and to be targeted in treatment.  DBT begins with a pretreatment stage which measures the commitment to treatment and is then divided into four stages of treatment. 

The client may shift back and forth between “pretreatment” and Stage One.  The shifting between pretreatment and Stage One may occur due to the client’s struggle of moving from a life of dyscontrol and overwhelming emotions to a life of control and the gained freedom from the reality of nonacceptance. 

There is also no set timeframe allotted for each stage, but the focus of treatment is based on the client’s goals.

The “D” in DBT stands for dialectical, which originates from a dialectical philosophy that views reality as a holistic and ever-changing process that is not stagnant, but instead consists of opposing views continually synthesizing and changing (Linehan, 1993).

The core strategy is to assist the client to balance acceptance and change which can occur with behavioral problem solving and ongoing validation by the therapist. 

Case Study

Annie is a twenty (20) year old, single, female Caucasian who is considered a clinically complex client. Her diagnoses are Major Depression and Substance Abuse Disorder. 

Annie has participated in mental health treatment over the course of three years in outpatient and intensive outpatient programs.   Her family has been supportive throughout this time but feels helpless because Annie continues to struggle with her addiction. Her high depression level has begun to cause her to shut down and withdraw from her family.

However, Annie’s relationship with her parents has been marked by periods of conflict and fighting. Annie’s parents had become very reactive and anxious addressing her defiant behavior.  Annie had reached the point of not being able to get out of bed and constantly yelling at her parents due to her feelings of despair.  Annie’s parents continued to research inpatient programs that work with dual diagnosis and offered treatments which are evidence-based.

Annie’s parents planned for Annie to receive a comprehensive psychological evaluation while waiting for a confirmation of availability for admission to an inpatient facility.  Annie was accepted and admitted to an inpatient program for young women ages 18 to 28. 

The treatment program will be using Dialectical Behavior Therapy (DBT). Using DBT begins with the identification of problematic behavioral patterns which are at the core of Annie’s difficulties preventing her from functioning in all life domains. 

These patterns are systematically targeted according to a hierarchy prioritizing behavior which threatens Annie’s functionality, treatment, and quality of life. 

DBT is utilized as the framework for conceptualizing Annie’s presenting problems.  The DBT structure and treatment strategies work to inform the development of a DBT and producing an individualized treatment plan in concert with the recommendations from the comprehensive psychological evaluation.  

The therapist will focus on restructuring Annie’s beliefs about herself and how she sees herself in relationships with others, especially her immediate family, and developing her interpersonal skills and self-management skills.  

Overall, the focus of treatment is individualized and includes specific cognitive, behavioral, and systemic interventions designed to address Annie’s dysfunctional themes. 

Annie struggled in the beginning due to her high level of depression and adjustment to the structured days in the milieu.  She spent additional time with the therapist to recommit to DBT treatment and her goals, which were agreed upon from the beginning of treatment. 

DBT intervention helps by encouraging the client to focus on their gifts and their capabilities to assure the client is doing the best they can. 

Stage One

In Stage One the client is often miserable, and they present with out of control behaviors including, attempted suicide, self-harming, using drugs and alcohol in excess and engaging in other types of self-destructive. 

The goal of Stage One is to move the client from the out-of-control to achieving behavioral control. The feeling of being out of control only increases the fear of not being able gaining control. 

Annie will work with her therapist to begin to gain behavioral control and see treatment as a way to benefit her overall health, i.e., mind, body, and spirit. 

Annie over time had lost her self-respect and self-worth perspective.  In Stage One treatment will focus on increasing Annie’s self-respect and problem-solving to support her functionality in daily living activities and developing healthy relationships.

One of the skills gained in DBT treatment is “Interpersonal Effectiveness” with a focus on interpersonal effectiveness to help the client learn how to interact positively and productively with others. “Distress Tolerance” is a DBT skill that helps the client find a healthier alternative to handling distress, i.e., meditating rather than turning to drugs. The therapist introduced Annie to a brief demonstration of “Mindfulness.”

The therapist explained to Annie that in a state of mindfulness she would find a place of “radical acceptance” which will begin to help her to accept herself and others and tolerate distress in a “state of observation” also nonjudgmental to learn how to make more appropriate decisions. 

Stage Two

In Stage Two, clients may feel they are living a life of quiet desperation.  Although they have their life-threatening behavior under control from a behavioral approach, they report still suffering from a feeling of failure in life.  The goal of Stage Two is to help move the client from quiet desperation to one of a full emotional experience. 

Annie desires to be able to feel again since her emotions have been “numbed out” due to her substance abuse. “Emotional Regulation” is another skill found in DBT techniques which helps the client learn to control their feelings rather than being controlled by them. 

Annie had to begin to find her inner strength which she had forgotten, since introducing pain medications into her life.  She would learn how to identify emotions, understand them, and manage them appropriately.

Stage Three

In Stage Three, the challenge is to learn to live, to build interpersonal skills, define life goals, learn self-respect, find self-worth and find peace and happiness.  Stage Three builds on Stage Two and continues to validate the courage it takes to move forward in treatment.

Annie has been suffering from depression and substance abuse.  The substances were utilized to help Annie cope with her severe depression.  Pain medication decreases serotonin, a chemical in the brain which then increases low mood. 

Therefore, Annie will learn to live a life without drugs and other destructive behaviors to cope. However, this is also the point of surrender and considering deeper meaning. Annie was beginning to discover the strengths she possessed with love for writing poetry. 

As her therapist began to validate her gift of writing there was an increase in the connection between her and the therapist.  The therapist also demonstrated the ability to hold an empathic attitude and began to teach Annie to trust and validate herself.

“Mindfulness and Meditation” are derived from Buddhist practices and helps clients to learn to focus nonjudgmentally on the world around them.  Annie worked with the therapist to practice mindfulness which helped to balance her rational and emotional mind. 

Dr. Daniel Siegel stated,

“Mindfulness is a very important, empowering, and personal internal experience, a necessity blend of personal ways of knowing along with external visions from the nature of the mind.”

Annie was beginning to see that as she practiced mindfulness, she was able to form a strong and steady interpersonal attunement and resonance.  Introducing the client to mindfulness is life-enhancing and allow self-actualization and transcendence to occur, unencumbered by their mental health diagnosis, i.e., depression.

Stage Four

Stage Four for some people becomes the stage for seeking a deeper meaning through a spiritual existence.  Dr. Marsha Linehan developed Stage Four for clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. 

The goal of this stage is to help the client move from a sense of being incomplete and finding a life that involves an ongoing capacity for experiencing unconditional love, joy, and freedom.  Annie held on to her belief in guardian angels because of a couple of her life experiences where she knew in her heart that she could have been killed in a car accident while driving under the influence. 

Also, a time when she could not remember how many pills she took.  She stated that her “guardian angels” were clearly with her and kept her safe during a time in her life when she felt out of control.

Annie completed the inpatient program and now continues to see an outpatient therapist once per week.  Monthly family sessions also continue as she adjusts to being back home again.  She has abstained from using pain medication and is going back to school.  S

he decided to work on a degree in English and reports she is most excited about her creative writing class which will keep her mindful of her gift of writing poetry. 

Learn about New Roads Core Values and Journey with DBT. Watch the video below.

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