When Abby Kline first heard about dialectical behavioral therapy (DBT), she was at a particularly low point in her life. A 36-year-old single mother and Minnesota native with several mental health diagnoses, including autism, post-traumatic stress disorder, schizoaffective and mixed personality disorders, Kline had reached a breaking point. She was suicidal, hospitalized for mental health treatment, and negotiating with Child Protective Services over the care of her then-4-year-old son.
“Child Protection was concerned about my parenting due to my mental health,” Kline said. “They became involved and walked alongside me to safely parent my child.” With the well-being of Kline and her son in mind, CPS staff offered options for her to get a handle on her mental health so her son could continue to be in her care. One option Kline was offered was to enroll in a DBT course, an intensive approach to mental health treatment that involves participation in a class with homework, weekly therapy sessions and optional calls to a 24-hour coaching line.
Though Kline said she rebelled against the idea of spending so much time in therapy, she signed up for DBT anyway. It felt like a middle path, she said. Though she resisted the commitment required, it seemed to be the best of what felt like bad options.
From the start, Kline had a negative attitude.
“At first I thought it was just a bunch of rules to break and conflicting concepts and regulations to argue about,” she said. She knew that building a life worth living was a central goal of DBT, but, she continued, “It didn’t seem that a life worth living was something obtainable.”
Created by Marsha Linehan, an American psychologist and author, DBT teaches people to accept their thoughts, feelings and behaviors — and learn techniques that can change them. This approach is especially effective for people who have difficulty managing or regulating their emotions. Many mental health disorders can be treated with DBT, but it has been found to be particularly effective in the treatment of borderline personality disorder, PTSD, eating disorders and addiction.
Kline’s DBT treatment was offered through Nystrom and Associates, a Minnesota-based regional provider of mental health care services. Sarah Gross, executive director of Nystrom’s DBT program, explained that the therapeutic approach combines “all the really good stuff” from many different treatment modalities. “It is one of the most evidenced-based treatments in the world,” she said.
Gross explained that sometimes, as in Kline’s case, DBT is used as an approach of last resort.
“It is this highly effective approach for people for whom treatment as usual doesn’t seem to work,” she said. Gross said that she has found DBT to be a good fit with her approach to therapy. “It is structured but it also allows for heavy emphasis on the therapeutic relationship and it is emotion-focused: a lot of the things that I am passionate about,” she said.
Because of the level of work and commitment required to do DBT “to fidelity,” Gross said that it is not an appropriate treatment for more common mental illnesses. “It is not the first thing you’d do for mild anxiety,” she said. “There has to be a certain level of severity.”
Sink or swim
Early in her DBT treatment, Kline met with a therapist who explained the program’s goals and approach. Because Kline was still struggling with the idea of committing to the intensive, time-consuming program, and eager to question its tenets and validity, her therapist got down to brass tacks.
“My therapist was patient with me and my reluctance with the process,” Kline recalled. “She told me that I can either sit at the bottom of the pool or I can swim. It was up to me. She said that she was not going to jump in and save me.”
Somehow, this sink-or-swim image worked for Kline. She appreciated the fact that, instead of trying to lead her treatment like other therapists had done in the past, DBT put the reins in her hands. Her recovery was up to her.
“I chose to swim,” Kline said. “I began DBT with no hope or belief that I would improve. I had struggled with my mental health for 22 years. I had constant suicidal ideation. I’ve been in inpatient hospitalization, partial hospitalization, crisis stabilization, day treatment.”
Knowing that her therapist — and the rest of the therapeutic team — were there to offer support in her journey, but would remain nonjudgmental about the way she chose to approach her own healing made Kline decide to go all in, even if she wasn’t optimistic about the odds of her recovery.
“I just made a decision,” she said. “I said to myself, ‘I am going to do this DBT treatment. I am going in with no hope that I am going to change. If it works, it works.’”
Doing DBT right requires a big time commitment, Kline said. “There is homework. There is in- class work. It is constant.” In the beginning, because she was disassociating and her mental health felt particularly shaky, Kline was enrolled in Nystrom’s adaptive DBP class. “Later, my mental health got better and I was able to progress and move into the mainstream class,” Kline said, “which was instrumental for my well-being.”
The DBT class met once a week, Kline said. She also had an individual therapy session every week. The two can be scheduled on the same day or different days, she explained, but “mine happened to be on different days.” Because of this, Kline moved to a part-time schedule at work, saying: “I took Wednesdays and Mondays off so I could really focus and do my DBT.”
Kline’s classes and therapy happened during the day, while her son was at school. “I’d drop him off and pick him up every day,” she said. “I was busy, to say the least, but it worked. I quickly realized I needed this change in my life so bad.” Because her desire to find a more livable life was so strong, Kline said she put all of her energy into keeping her head above water.
“I knew I wanted something different from the life that I had,” she said. “I was willing to take everything off the table for this. I needed something different from what I had. Was I perfect? No. But I can say I improved.”
Another central feature of DBT is a set of coping skills designed to support participants’ mental health during times of emotional distress or crisis. Sometimes, Kline said she struggled to apply those skills, and she would call the coaching line. “I would really struggle,” she said, “but I would have someone on the other line, saying, ‘You got this. You can do this. I believe in you. You are going to make it.’ Nobody treated me as fragile, which I really appreciated.”
The program takes a team approach to treatment, with therapists meeting together to discuss the progress of individual patients and the toll the work was taking on the practitioners. “We call that ‘therapy for the therapists,’” Gross said. “It reduces burnout. DBT is a community of therapists treating a community of clients.”
This approach requires commitment, Gross said, but is worth it.
“DBT is by far the most effective therapy in the shortest period of time. We have a really heavy emphasis on clarity and precision. When people are doing more of a talk therapy approach, they are pulling in the topic of the moment. In DBT we start with people’s ‘life worth living’ goals.”
It wasn’t long before Kline felt she had the power to make a more livable life for herself.
“I wanted something more than I had,” Kline said. “I had to think about that even when I was feeling bad. I had my therapist on my shoulder saying, ‘You can sink or you can swim.’ That became my motto. I became really good at choosing to swim.”
‘Deep change and great joy’
Kline admits that there are times when choosing to swim can feel harder than letting herself sink to the bottom, but the positive changes she’s seen in her mental health since she began the program feel worth it.
Kline participated in Nystrom’s intensive DBT program for a year. Now she’s in the after-care program, a weekly two-hour group that focuses on participants incorporating DBT skills into their everyday lives. She is still working part-time and on disability. Kline sees the program as a lifeline that she’s not yet willing to give up. “I am trying to take care of myself as much as I can,” she said. “I told my therapist I wasn’t ready to graduate. This program is really filling a void.”
Gross said she and her colleagues are in awe of clients like Kline and their serious commitment to DBT. “Most of our clients really want to be here and they want to get better,” she said. “The lives they are living feel miserable and they are committed to doing hard work to get better.”
The same goes for the members of the therapy team. “Our DBT providers are really remarkable people and have a passion and commitment for this work and their clients, who are high-risk,” Gross said. “It is a very courageous and really unique approach. We are all passionate about what we do because it works.” Her own commitment to the work is inspired by her clients: “They are incredible people who want to be well. They are interesting and passionate, often very intuitive. They are brave and inspirational.”
Kline doesn’t know where she’d be today without DBT.
“It was a life-changer for me,” she said. “It really set me on a path that was a deep change and great joy. It was an impactful year for me.” Though she believes that anyone could benefit from the therapy, she said, “I specifically recommend it for people who are struggling to identify that they want change in their lives, for people who don’t even know that they can change, because that was where I was at, and here I am so much healthier today.”
Andy Steiner
Andy Steiner is a Twin Cities-based writer and editor. Before becoming a full-time freelancer, she worked as senior editor at Utne Reader and editor of the Minnesota Women’s Press. Email her at asteiner@minnpost.com.
