Two things can be true: Dialectical behavior therapy (DBT) is an effective treatment and clients can find it challenging to access the modality. DBT’s evidence-based approach to treatment is a game-changer for some clients. At the same time, as many practitioners have discovered, others struggle to learn and integrate DBT skills.
Research shows that clients may drop out of DBT skills training due to difficulties in tolerating and regulating emotions, staying engaged in content, and comprehending the material. If you utilize DBT in your clinical or educational work, you may have encountered these barriers.
Fortunately, preliminary research suggests that incorporating specific strategies when teaching DBT skills can significantly improve client retention and skill acquisition. Facilitators are encouraged to create a supportive environment, personalize skills to individual needs, and integrate creative interventions such as storytelling.
For the purposes of this post, I will use story as an umbrella term that encompasses various story-based interventions, including metaphor, poetry, and personal narratives.
In therapeutic and educational settings, it is widely known that using metaphorical stories can help clients better understand concepts, gain insight, and ultimately change behaviors. Additionally, incorporating stories into treatment can lead to a more connected, enjoyable, and interactive group process. When teaching DBT skills, facilitators can use story to help clients:
Erickson and Rossi (1979) were among the first clinicians to investigate the ways in which story could be utilized in therapy. They believed that using metaphors was an effective way for therapists to communicate with clients at both the conscious and unconscious levels. These researchers proposed that metaphorical meaning activated unconscious processes and brought them to conscious awareness, leading to insights that may not have been accessible otherwise.
Additionally, incorporating metaphors in therapy has been found to create neurological changes in the brain, which may increase the likelihood of behavioral changes. Mills and Crowley (2014) demonstrated that the brain processes metaphor differently than concrete language. Metaphoric language may increase the likelihood of behavioral changes as “the input of the metaphor activates unconscious association patterns that interrupt the old behavioral response by generating new meanings, which in turn produce new behavioral response” (Mills and Crowley, 2014). In other words, metaphors can help clients break old patterns and change behaviors.
In Action-Based DBT, clients learn skills through stories. In my work conducting Action-Based DBT groups, I have found that story is a tool to support clients in overcoming a common challenge: implementing strategies they have learned in sessions outside of the therapeutic space.
Does this scenario sound familiar?: You provide psychoeducation on a specific DBT skill to a client over the course of numerous individual sessions. The client seems to understand the skill and reports that they will use it before the next session. When they arrive at therapy the following week, the client’s shoulders are slouched and they make brief eye contact with you before they look away. You can feel the client’s shame fill the room. A few minutes into session, they report that they were engaged in the problem behavior instead of using DBT skills.
How can you help a client practice this skill outside of therapy? The answer may lie in creative arts therapies. Clinicians can bolster skill learning with metaphor, rather than relying on skill acquisition through psychoeducation and verbal processing alone.
Incorporating story while teaching skills creates an opportunity for the client to bring awareness to some of the thought processes occurring at an unconscious level—and these insights can lead to behavioral change.
In addition to activating processes that support the development of insight, story can also create a sense of safety for a client by providing both distance and containment (Emunah, 2019; Landy, 1993). Through metaphor, clients can explore complex, multifaceted concepts that may be too emotionally taxing to address within a traditional skills-training session. Story provides distance from the content the individual brings into session, which may be necessary when working with skills that become easily dysregulated.
Imagine that you plan to conduct a behavioral chain analysis, a DBT assessment tool through which a client describes the sequence of events surrounding a target behavior (Linehan, 1993). Chain analysis can be quite effective, but it can be uncomfortable and dysregulating for clients to share the details of their inner world that lead to a target behavior, especially in a group setting (Rizvi & Ritschel, 2014). The desire to avoid shame often results in a client leaving out details surrounding the target event or refusing to participate in the analysis entirely.
By encouraging the participant to describe the events leading up to the incident as a story, the facilitator creates distance between the client and their personal narrative. To generate a safer space for the client to process an event that is tied to feelings of shame, the therapist may employ a number of distancing strategies. For example, the clinician may prompt the client to:
Story creates an opening for clients to engage in material that they may otherwise repress or refrain from disclosing. These story-based interventions generate a “psychological distance from one’s own overwhelming feelings” and provide an “indirect, non-confrontational approach to exploration and problem-solving” (Dwivedi, 2010). Additionally, utilizing story warms the client up to participate in effective, evidenced-based DBT interventions, such as a chain analysis or dairy card.
Overall, stories create containers and generate opportunities for clients to project their own lived experiences outward, which can be helpful for clients who are inclined to become emotionally dysregulated or withdrawn (Emunah, 2019).
A primary barrier to participation in DBT skills training is that participants can feel bored when learning the material, and so they may have a difficult time staying engaged. Interventions that utilize story can keep clients interested in the group process and invested in the material. Story increases engagement by:
When clients are more engaged in the DBT skills training process, it is a more effective (and pleasant) experience for everyone involved.
To find a therapist, visit the Psychology Today Therapy Directory.
References
If you would like support in incorporating drama therapy into your clinical work, check out my Action-Based DBT program manual, which provides a comprehensive curriculum detailing how to use creative arts strategies to teach DBT skills.
Dwivedi, K. N. (2010). The therapeutic use of stories. In C. Nicholson, M. Irwin, & K. Dwivedi (Eds.), Children and adolescents in trauma: Creative therapeutic approaches (pp. 115-128). Jessica Kingsley Publishers.
Emunah, R. (2019). Acting for real: Drama therapy process, technique, and performance (2nd ed.). Routledge.
Erickson, M. H., & Rossi, E. L. (1976). Two level communication and the microdynamics of trance and suggestion. American Journal of Clinical Hypnosis, 18(3), 153-171.
Landy, R. (1993). Persona and performance: The meaning of role in drama therapy and everyday life. Guildford.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
Mills, J. C., & Crowley, R. J. (2014). Therapeutic metaphors for children and the child within. Routledge.
Rizvi, S. L., & Ritschel, L. A. (2014). Mastering the art of chain analysis in dialectical behavior therapy. Cognitive and Behavioral Practice, 21(3), 335-349.
Siegel, D.J. 2020. The Developing Mind: How Relationships and the Brain Interact to Shape who we are. Third Edition. New York: The Guilford Press.
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