beingwell magazine Summer 2007

Carol suffered from depression most of her life and tried many different treatments to deal with the condition.

Some of those treatments worked for a while, says the Newmarket resident, but she found none offered her a way to cope with her condition in the long-term.

Her self-esteem was boosted by psychotherapy sessions but the feelings of self-worth would slip away before long. It was like “being on an emotional roller coaster,” she said. One treatment she tried involved role play. Another, the Silva Method, focused on positive thinking.

“They were good at the time but, in a few months, I’d slide back down and be super depressed again,” said Carol, who asked her last name not be used.

“None of them were sustaining for me. It was easy to fall back into my old traps of thinking negatively and expecting the worst.”

Her psychiatrist eventually recommended her to a program offered through Southlake Regional Health Centre. The program uses a treatment called Dialectical Behaviour Therapy, known as DBT, and was different from any of her earlier  treatments: Rather than delving into her past to discover the roots of her depression, DBT focuses on teaching new behaviours and ways of dealing with her depression and anxieties.

Also unlike other treatments, DBT feels more like attending school. “It’s not like group therapy or anything,” Carol said. Though treatment is, indeed, offered in a group environment, it does not employ the sharing of personal stories or  bonding to effect change.

Dialectical behaviour therapy was  developed by Dr. Marsha Linehan at the University of Washington, Seattle, specifically to treat patients with borderline personality disorder (BPD). 

The treatment arose from Dr. Linehan’s work with chronically-suicidal female patients who were frequently arriving in hospital emergency rooms. According to Mara Zanchettin, MSW, RSW, team leader of the brief therapy clinic at Southlake, Dr. Linehan found traditional types of treatment helped only slightly.

Given her expertise in behaviour therapy and its limitations with this population, she went on to create a new form of treatment: using cognitive behaviour therapy (which involves examining a person’s thoughts and behaviours) together with the Eastern tradition of mindfulness.

“She brought those two fields together and developed a  series of skills meant to address the four major areas of of difficulty for clients with BPD: emotion regulation, distress tolerance, interpersonal effectiveness and core sense of self,” said Ms Zanchettin, who runs the DBT therapy at Southlake along with colleague Sheri Van Dijk, MSW, RSW.

“It’s really the treatment of choice for patients who have the most complex problems or who have not had significant improvement in their symptoms despite treatment.”
Though designed for patients with borderline personality disorder, those with other conditions, such as unrelenting interpersonal conflicts, frequent recurrence of emotional instability and being in a constant state of crisis, along with self-esteem and identity problems also benefit from DBT treatment, Ms Zanchettin said.

People who struggled with long-term depression, such as Carol, benefit from the treatment as well. Clients enrolled in DBT at Southlake often have long-term mood problems and their condition isn’t improving with other forms of treatment, Ms Zanchettin said.

A dialectical behaviour therapy session operates more like a classroom, with clients seated around a table. Each session starts with a mindfulness practice during which those taking the course focus their concentration on one thing. The mindfulness exercises are fashioned after the work done bv Jon Kabat-Zinn, pioneer in the field of mindfulness meditation for emotional and physical healing.

“Mindfulness helps clients take control of their attention,” Ms Zanchettin said. “It gives people the chance to focus on the present, rather than ruminate on the past.” The mind gets to take a break. In keeping with the school-like feel of the course, each session includes new learning material to start with at once, as well as work to be done at home and reviewed at the next session.

The homework usually includes a behavioural skill students are asked to practise during the week. For example, they may be asked to practise being non-judgmental in their dealings with people during the week. They will be asked to notice the amount of judging they do and replace that behaviour with more productive ways of dealing with people. Or homework might include practising a self-soothing behaviour, such as taking a walk or reading self-help material.

Those attending the sessions are asked to talk about how they used those skills and must describe what they experienced. The sessions try to encourage clients to learn and practise new behaviours that help them cope with their condition, rather than focusing on the emotional roots of those conditions.

Focusing on how they feel is a common part of the problem for many clients, since they already tend to spend too much time brooding over emotions. DBT encourages clients to use the logical/reasoning part of their brains, thereby approaching their lives with a more balanced perspective.

“(DBT) is a very instructive experience,” Ms Zanchettin said. “It’s not so much about sharing what happened when you were 10 years old child. The present is what is viewed as most relevant.  Once clients have a greater sense of control over their lives through DBT, they can move onto other types of psychotherapy if they feel they would like to address family of origin issues.”

The treatment runs for eight months and clients attend a one-and-a-half-hour session once a week.

One of the most dramatic changes those taking the course see is they develop better coping skills and gain more control over their lives, Ms Zanchettin says. Self-esteem and mood improve — and they don’t need to rely on other treatment programs at the hospital as much as they once did.

Clients also give the weekly sessions good reviews. Only about four per cent of those who participate drop out of the group before it is completed. “We just get a lot of praise for their  experience,” she said, noting that Southlake is the only hospital in York Region that provides the treatment. “It’s usually something they had never tried before.”

Those who complete the group can continue by attending a once-a-month follow up group. They come back to continue reviewing the material covered during the program as well  as talking about what they have practised in real life.

“Clients are really appreciative of that,”  she says. “This way it really fits with the concept of learning.” Ms Zanchettin and Ms Van Dijk are also involved in the York Region Interagency DBT group which takes place at York Support Services and is specifically intended for clients with BPD. The follow-up course has been running for  six months and no data yet exists on whether clients maintain improvements after the course is completed.

“We suspect it does help, though,” Ms Zanchettin said. Borderline personality disorder is known among many health care professionals as an especially difficult condition to treat. About 75 to 85 per cent of patients with the disorder are women, and those with it account for about two per cent of the general population, says Dr. Stephen Stokl, a staff psychiatrist at Southlake who also runs a private practice in Newmarket.

One of the symptoms of people with borderline personality disorder is the inability to regulate emotions, he says. Someone with the condition can feel great in the morning but be depressed, even suicidal, at lunch.

“People aren’t able to regulate their emotions, so the smallest mishap can put them over the top,” Dr. Stokl says, noting the same person can feel fine again by dinnertime.

Still, patients often say they feel empty or void inside, or that they simply “can’t do life,” he says. The condition makes relationships tough, since someone with the disorder can love a person one minute but consider the same person the worst in the world later that day.

Those with borderline personality disorder often engage in reckless or self-destructive behaviour, such as drug and alcohol abuse, punching or cutting themselves or promiscuous sexual behavior. Between 10 and 15 per cent of those with the disorder commit suicide. Since patients with borderline personality  disorder can be very judgmental — of  themselves and others — and DBT therapy focuses on helping them catch those negative thoughts, Dr. Stokl says.

Therapists ring a bell if someone in the group says something judgmental during a session to remind them such thoughts aren’t allowed.

“You need to catch yourself, think about what you’re saying, and reframe it in a positive, healthy manner for both yourself and others,”  he says.

Meanwhile, Carol has found what she’s learned in the DBT course helpful in maintaining her home-based business. Focusing on the task at hand is especially important with no co-workers nearby to remind her she should be working, she says.
When she feels herself getting overwhelmed by the tasks she needs to complete, she can use what she has learned in the course to refocus.

Rather than becoming overwhelmed, she sits quietly and focuses on an object, such as a pen on her desk, or concentrate on her breathing, while her thoughts return to the task at hand.

Since starting DBT, she has expanded her social circle and is no longer judgmental of the people in her life. Other times, she can still catch herself viewing the world in black and white and demanding things be a certain way, rather than compromising.
Through the sessions she has learned to stop, re-evaluate, and decide what is realistic rather than simply how she wants things to be.

“One of the things with depression is getting tied into old beliefs,” she says. DBT teaches clients new thinking patterns to create a fresh outlook.

Referrals to the Dialectical Behaviour Therapy program must be made through a physician.

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