How can I tell if DBT is working?

[flourdust]

So, BPD wife has been in a DBT program for about six months. She has group sessions with a facilitator three days each week, for about 3 hours per session. And she has an individual therapist who isn't part of the DBT clinic but is familiar with it -- she meets with that therapist weekly for an hour.

I can't say that I've noticed much improvement. Right after she started the program, there were a couple of weeks where I saw her trying to be in "wise mind" and adjust her thinking and behavior. I praised her for these changes, but they were ephemeral.

More recently, she seems to be using her DBT toolbox as a set of weapons. For example, she brought home a ":)EAR MAN" worksheet to use with me. (She described DEAR MAN as the technique where she gets to make me give her what she wants.) She had a couple of requests; I agreed to one, but the other was that I had to think the same way she did about something. The most I could give her was to listen to how SHE thought about it and try to demonstrate my understanding of HER opinion, even though it did not match her own. That wasn't enough, of course, so that session ended in raging.

She's also tried to use her DBT worksheets to show me how I am wrong about boundaries (I'm not) and to claim that the program is not about her learning to take care of herself but requires that either I be right there working with her or that the program says she should get rid of people who aren't helping her. While there is a grain of truth to those claims, she's magnified and distorted them to back up her desire that I drop my boundaries, put up with verbal abuse, apologize for causing her feelings, etc.

I'm also concerned that perhaps her DBT program just ... .isn't good. All of this is coming through her filter, of course -- she describes a group leader who is pretty much a novice (a Psy.D. student on rotation) who doesn't deviate from the workbook and has difficulty managing the group. She describes her group as constantly in flux, with people dropping out frequently to the point where there have been long stretches where the group membership has been just one or two people. Today, after several days of hot-and-cold hostility, she told me that her group thinks I am planning to leave her, and that they are giving her tips on how to get sole custody of our daughter.

If I take what she is saying at face value, it doesn't SOUND like a very effective group. But I don't know if I can take her description at face value, or even if these are important in determining if DBT is effective.

What should I do here? Try to lobby for her to switch to a different DBT group? Wait it out another six months to see if there is improvement? Accept that DBT isn't going to work for her?

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[SweetCharlotte]

Wouldn't it be better for her to be in more intensive individual DBT first, without group therapy? I thought that group DBT was for long-range management after acute issues were responding. The situation you describe doesn't sound productive. She is in effect being mentored by other pwBPD with little guidance from a professional.  

[flourdust]

Wouldn't it be better for her to be in more intensive individual DBT first, without group therapy? I thought that group DBT was for long-range management after acute issues were responding. The situation you describe doesn't sound productive. She is in effect being mentored by other pwBPD with little guidance from a professional.  

Wow, that's an interesting point. I hadn't heard that there was a recommended sequence from individual to group DBT. The way it was presented to us was that you enroll in a group program, and the group program requires (or provides, for some of them) individual therapy sessions to complement the group ones.

I am worried that the group is heading off the rails, and I'm not sure what's going on with her individual therapist. However, there's a patient privacy firewall between me and them, so I don't know what I can (or should) do.

[an0ught]

Hi flourdust,

More recently, she seems to be using her DBT toolbox as a set of weapons. For example, she brought home a ":)EAR MAN" worksheet to use with me. (She described DEAR MAN as the technique where she gets to make me give her what she wants.) She had a couple of requests; I agreed to one, but the other was that I had to think the same way she did about something. The most I could give her was to listen to how SHE thought about it and try to demonstrate my understanding of HER opinion, even though it did not match her own. That wasn't enough, of course, so that session ended in raging.

Oh dear  . The way I think about DBT and pwBPD getting better in general is someone growing up. They are going through their teen years and they will try to put to use their new body/tools in every conceivable way. Some results are funny even hilarious and some can be scary. Mostly irritating and annoying.

She's also tried to use her DBT worksheets to show me how I am wrong about boundaries (I'm not) and to claim that the program is not about her learning to take care of herself but requires that either I be right there working with her or that the program says she should get rid of people who aren't helping her. While there is a grain of truth to those claims, she's magnified and distorted them to back up her desire that I drop my boundaries, put up with verbal abuse, apologize for causing her feelings, etc.

Games. There are two keystone tools on this Staying Board. Validation and Boundaries. Validation is something we can work on with our partner - the book "The high conflict couple" e.g. has partner exercises. Communication is a game of win-win. Now when it comes to boundaries things are not so clear. Boundaries are about conflicts, are about drawing lines and consequences. Conflicts about the conflict management - should we call this meta-conflict   - won't help. To get better at boundaries we all need to work diligently on ourselves. And pay the consequences if we are messing bits up. Learn from the mistakes and move on.

I'm also concerned that perhaps her DBT program just ... .isn't good. All of this is coming through her filter, of course -- she describes a group leader who is pretty much a novice (a Psy.D. student on rotation) who doesn't deviate from the workbook and has difficulty managing the group. She describes her group as constantly in flux, with people dropping out frequently to the point where there have been long stretches where the group membership has been just one or two people.

That is of course a concern and consistent with her throwing around tools carelessly. But it is her job to reject it and find something better. Maybe at a point individual therapy. Right now this is what you have - she is in some framework and getting some education. As all long time members here can assure you - you don't have to believe in the tools for them to work. You just need to use them consistently. And there is nothing to stop you to use them on your side all the time.

Today, after several days of hot-and-cold hostility, she told me that her group thinks I am planning to leave her, and that they are giving her tips on how to get sole custody of our daughter.

Have I mentioned games? Triangulation? The group is reflecting what she is feeling. Tell her she is afraid of you leaving. Validate her fear.  Don't deny the relationship is distressed - you were not here if it was not. Consider using SET.

If I take what she is saying at face value, it doesn't SOUND like a very effective group. But I don't know if I can take her description at face value, or even if these are important in determining if DBT is effective.

What should I do here? Try to lobby for her to switch to a different DBT group? Wait it out another six months to see if there is improvement? Accept that DBT isn't going to work for her?

Focus on your own behavior. Don't underestimate how much your behavior shapes her behavior.

With respect to the DBT group validate any concerns she has about the DBT group but don't take ownership. It is her time, her effort. As long as she feels she gets something out of it - fine. If she finds something better - great. It is important that she keeps going to some form of T.

[flourdust]

Thanks, an0ught.

I've mentioned elsewhere that I'm having only mixed success (to be generous) with validation. It seems to work better if I'm validating her feelings about anything that isn't our relationship. Issues with her job, her father, that sort of thing. When I've tried validation when her feelings are about me, it just comes across as deflection.

Your suggestion that I try to validate her feeling that I'm going to leave her is interesting -- I usually just deny it and then avoid being drawn into a circular argument about it. I might try your approach to see if it's helpful.

There's no question that my behavior is influencing hers. In the last few months, as I've learned about DBT and codependency, I've been making changes that I think are generally positive for me ... .but very destabilizing for her. I set boundaries -- she's never seen me do that before. I've started trying validation, avoiding JADE, avoiding excess apologies, avoiding taking ownership of her blamestorms -- these are all new. And by approaching all of these things more clinically, the side effect is that I've become cooler and more detached, which can certainly feed into her perception of abandonment.

Your view on the DBT program and how much influence I can realistically expect to have on it ... .hmm. Well, you may be right. I'm still ruminating on that one. I recognize that I have to let her own what is hers, but realistically, there are a few things where the consequences of me NOT playing rescuer are worse.

For an unrelated example, she's abandoned a lot of self-care activities. Her car hasn't been serviced in over a year. I've reminded her, helped her plan what to do, suggested when she could make the appointments, and so on ... .and it just hasn't happened. So I finally went ahead and scheduled service for her car, and I'll spend a day working out of a coffee shop while I get her car fixed at the garage next door. It's far from ideal. I'd rather she could be enough of an adult to take care of her own car. But if it breaks down, then the consequences will be a ton of expense and inconvenience for the whole family. So I'm coming to the rescue, again.

I bring this up, because I'm having similar thoughts about the DBT program. It's her program, her treatment, and she has to own it -- and it might fail, regardless of how good the program is. But if it's a bad program, and I can take steps to get her into a better one, then the long-term consequences might be worth it.

[an0ught]

For an unrelated example, she's abandoned a lot of self-care activities. Her car hasn't been serviced in over a year. I've reminded her, helped her plan what to do, suggested when she could make the appointments, and so on ... .and it just hasn't happened. So I finally went ahead and scheduled service for her car, and I'll spend a day working out of a coffee shop while I get her car fixed at the garage next door. It's far from ideal. I'd rather she could be enough of an adult to take care of her own car. But if it breaks down, then the consequences will be a ton of expense and inconvenience for the whole family. So I'm coming to the rescue, again.

I bring this up, because I'm having similar thoughts about the DBT program. It's her program, her treatment, and she has to own it -- and it might fail, regardless of how good the program is. But if it's a bad program, and I can take steps to get her into a better one, then the long-term consequences might be worth it.

Yeah, it is a balancing act. It would be nice if drawing boundary lines just needed a few rules - my stuff vs. her stuff. Life is not so simple and there is quite a bit of our stuff with various degrees of ownership. Often it boils down to going back to our values and making difficult judgment calls.

Still a a principle keeping her issues separate from yours is a good policy. As is letting her fail where it is her problem, she refused to take action and she lives and learns from it. Thankfully behavior can be learned from small things often equally well as from big things like cars.

[teapay]

Flourdust,  my wife has been in dbt for about as long as yours.  It is group once a week and once a week individual counseling with a dbt T.  Group is small and consists entirely of substance abusers.  Before that she was doing dbt workbooks with her regular T and AA meetings 4 or 5 nights a week.  I'm looking at a horizon of like  2 or more years to see much effect in daily life. Can't say I've been astounded by her progress so far. DBT has been shown effective in many clinical studies, but in many ways I think it is oversold and overhyped.  When you read the scientific  literature it is significantly more effective than ordinary therapy mainly for suicide attempts, hospitalizations, treatment drop out. I guess I've seen this for my wife. For many other BPD behaviors however it is hit or miss.  Improvements may be statistically significant but   when you look at the absolute numbers of people improving, for what and how much in these studies it is less impressive to the average Joe.  Those studies also are fairly clean compared to real life.  The Ts performing the dbt are well trained, specialists in BPD and often the test subjects have been diagnosed and culled for comorbidities and other things to homogenized the study population.  Some long term follow up studies seem to indicate higher remission rates after 4 to 10 years of treatment.  This all makes me alittle hopeful but certainly tempers my expectations.  I have heard some good individual stories though, so I'll take whatever I can get from it.

[teapay]

Just some follow up comments on therapy and dbt. Hope it gives others some insight if they are going through or hope to go through similar with their partner. It is just one persons experience, though.  The relationship between my wife and her CBT therapist for two years finally ruptured and they discontinued see one another.  My wife had attached to her T and began expressing BPD on her T and the T finally had enough of it.  I saw that attachment developing before things started heading south and tried to warn the T but the T didn't believe me and then ended up over her head.  My wife got very suicidal due to attached/abandonment and verbally abusive to the T due to splitting.  8 months of ER or almost ER visits hasn't been fun at home. Ultimately the T got frustrated and scared and bowed out.

My wife is continuing Dbt with another T and dbt group, but it is primarily a sub abuse group.  The dbt T gave my wife the Briggs Meyer personality test.  My wife tested as introverted type with feelings.  She wanted me to read the type, rub my face in it. I did.  It does not sound much like my wife, but how my wife wants to be seen.  It's a type that is interested in helping others but is highly responsible, controlled and rational.  It is quite at odds with my wifes current life and expressed BPD, although there is probably a small nugget of truth to it when my wife was doing much better.  The use of Briggs Meyer and the result, though, makes me somewhat doubt the competence of the T and that she is being snowed by my wife like others have been.  This, and the problems she has had with other Ts  emphasize some of the difficulties involved with actually treating the disease.  My wife knows she has BPD and has accepted it to some degree but that is always tenuous.  Having been doing this for awhile, I tend not to get to too involved in my wife therapy or agitiate it because it tends to produce the same suicidal, splitting, accompanied by lots of physcial self harm.

Just some thoughts.