This feature by Donna Pattie, MSW, LICSW is Part 1 of 2 in a series about treatment strategies to help clients build the lives they want. In this first part, Donna addresses the dialectical lens she uses with clients starting in session one, as well as a framework to help therapists and clients see the spectrum from misery and suffering to envisioning the life they want.
“Long-term happiness means experiencing life as worth living,” Marsha Linehan writes in the DBT Skills Training Manual, Second Edition. She says, “Of course, all lives are worth living in reality. No life is not worth living. But what is important is that you experience your life as worth living – one that is satisfying and one that brings happiness.”
DBT is not just a suicide treatment, it is a build a life program. The challenge and opportunity for us as therapists is to start orienting our clients towards such a vision from day one and to use strategies throughout their journey to help them commit to building a life that they experience as more fulfilling.
When starting DBT with clients, what I hear frequently are statements such as, “I just can’t live this way anymore” and “I’ve tried everything, and it doesn’t work. Dying is my only way out.” Research shows that suicidal and self-harm behaviors are ways to problem-solve unwanted emotions. Unfortunately, while these behaviors may work to provide short-term relief, they often don’t lead to a life that is fulfilling. It can feel impossible to face another day when experiencing chronic suffering, to say nothing of conceiving of future goals. For therapists it can be daunting to see beyond our client’s suffering and hold hope for the future, and it is crucial.
While having hope is important; the dilemma is that hope also makes us vulnerable to greater loss if what we hope for is not achieved. It is crucial as therapists to skillfully offer a dialectical lens starting in session one, accepting that they are doing the best they can and that a different life is possible with change. Talking people out of hopelessness doesn’t work. It is important to validate that hopelessness and a desire to escape emotional pain makes sense, given nothing else has worked. At the same time, we must ask them to let go of hopelessness by trying new behaviors in new environments, mindfully and repeatedly taking in feedback, as they move toward their goals.
Frequently, I see DBT clinicians struggling to help clients discern goals beyond not acting on suicide or self-harm or reducing dysregulation, increasing skill use, etc. While those are important behaviors to target, we need to broaden our scope to a larger vision. Helping our clients imagine a better future is key.
A new client came to her first session saying, “I just don’t want to feel this way anymore. I don’t want to be suicidal. Nothing has worked.” After offering data on what DBT effectively treats, I shared testimonies from others who entered treatment with similar struggles. In response, my client looked at me skeptically and said, “I am not sure if I buy it yet, but I want what you’re selling.”
One of my DBT mentors, Randy Wolbert, gave permission to share a framework he uses to help therapists and clients see the spectrum from misery and suffering to envisioning the life they want. I have found this especially helpful to start in session one and to continue throughout treatment to help clients stay the course. On one side, we have misery and suffering and, on the other, the life you want. You are in the middle and get to choose the path and course correct as needed.
Misery and Suffering————-You————-Life You Want
The path toward building a life is paved with skills, exposure, being mindful of current emotions, and managing extreme emotions. The path of misery is not using skills, acting on unwanted emotions, avoidance and employing numbing behaviors.
With my new client I listened as she described what behaviors were causing her problems, and I listened for a possible overarching goal or vision for the future (i.e. being competent, reliable, resilient).
Questions I find particularly helpful in this process are:
- What do you want that others have, that you don’t have?
- If we solved some of these problems, what would you want your life to look like?
In session one, she identified the overarching goal as to have peace in her life. By session four, we defined more specific goals and were able to link behaviors to goals.
Misery and Suffering column: Chronic suicidal thoughts and behaviors, frequent hospitalizations, conflict with family and friends, unemployment, financial instability
Life You Want column: Peace in my family, bounce back from strong emotions, have stable friends, be a reliable worker, financial stability
Stay tuned for part two, in which we will explore linking DBT treatment strategies to client goals.
Donna Pattie, MSW, LICSW is the DBT Trainer and Consultant for 15 DBT outpatient teams at Nystrom & Associates, Ltd across the state of MN. Donna is a Linehan Board Certified DBT therapist and DBT Team Lead in New Brighton, MN for a Linehan Board Program Certified Team. Read her full bio here.