Dialectical behaviour therapy is characterised and distinguished from other approaches by its emphasis on the balance between acceptance and change. The tension between these approaches is highly complex and difficult to manage.
Therapies with a primary focus on client change can be experienced as invalidating by highly emotionally dysregulated clients. On the other hand, exhortation to accept one’s current situation by itself offers little solace to an individual who experiences life as painfully unendurable (Miller et al., 2007; p61).
Change-based strategies are essentially about problem-solving – defining, understanding and accepting a selected problem, then generating and implementing alternative solutions (p61).
The skills sets of Distress Tolerance, Mindfulness, Emotion Regulation and Interpersonal Skills are the core change-based strategies appropriate for working with adolescents. The first three of these skills sets are relatively unique to DBT.
Two additional change-based strategies are: Irreverent communication style and Chain analysis.
Other change strategies employed by DBT are contingency management, exposure and cognitive modification. These elements are derived from earlier therapeutic approaches such as Cognitive Behaviour Therapy and they are not included here.
Both validation (the most obvious acceptance strategy) and problem solving strategies are used in almost every interaction with the client, but the relative frequency of each depends on the individual client and their current level of vulnerability (Miller et al., 2007; p59).
While acceptance and change are used in balance most of the time, it is essential to start with acceptance-based strategies before introducing change-based strategies. A strong and secure therapeutic relationship based on absolute acceptance is necessary before change can be effectively introduced. Validation of the trauma and hardships experienced by the client is essential before personal change can be contemplated.
On the other hand, take care not to stay with acceptance strategies alone for too long. For young people with multiple disadvantages and few resources, it is easy to become overwhelmed by the complexity and hardship of the client’s situation. However, shying away from change for too long does not help the client. No matter how powerful the adversity in the environment, finding ways to change and respond differently will almost always lead to some kind of improvement.
Working on change-based strategies with clients who experience overwhelming emotions introduces a range of ‘treatment interfering behaviours’ on the part of practitioners. These mostly involve expressions of feelings such as impatience, irritation, frustration and disappointment that commonly arise when practitioners expect changes from clients that do not take place at the pace desired by the practitioner. Expression of these feelings is not helpful and will harm the therapeutic work. It is essential that practitioners are aware of their own treatment interfering behaviours and actively work on these issues when they arise. Supervision is essential.