DBT + Narrative Therapy

Dialectical behaviour therapy (DBT) and narrative therapy are both systemic therapies, which means that they view your life as a “system of systems:” Everything is a web of interacting factors. Every family or community is a system of relationships. Every land is a system of peoples, resources, values, rules and history. DBT would say that each link within each system has the potential -- in fact the necessity-- to change. Narrative therapy would say that each unique outcome within each system offers stories that can inspire change.

In DBT, dialectics means to hold two seemingly opposite things together as true at the same time. The main dialectic about me as your therapist is that I will wholly and absolutely accept you, just as you are; and I will push for you to change and grow. DBT is emotion-focused: Every emotion is what Linehan calls a “full-system response,” made up of bodily sensations, thoughts, values, motor functions and actions. So DBT explores how the full system of each emotion shapes and is shaped by all of life's other systems, and this insight helps us to build emotional mastery for being in life.

Narrative therapy says that the stories we tell about our lives create our identities. Compounding traumas (e.g., microagressions, multiple oppressions, repeated abuse) and even survival (e.g., the evolution of our fight-or-flight response) have conditioned us to tell stories of fear, shame and loss. These dominant stories hold truth and are important: They tell us to hide ourselves from danger, often because the danger is real; they tell us to despair, often because real horrors and injustices have occurred that we need to mourn. But dominant stories can also distort truth in ways that tell us our identities are the problem, are shameful, are hopeless or powerless. Narrative therapy is preference-focused: We all have certain values, accomplishments, hopes and commitments that we hold as more precious than others. So narrative therapy explores the stories that “thicken” these preferred parts of our identities, and this storying helps us to build up our preferred selves.

I love DBT because it can bring us right into our bodies and emotions when it's safe enough to go there, and because it can help us just as much to notice at times when going there is not safe enough. The more we fine-tune these forms of emotional mastery, the more insight we gain into how we can both love and shape our reality.

I love narrative therapy because it takes us into our imaginations, memories and hopes. These adventures can help us to connect with what we hold most precious. In these connections, we start to weave our preferred stories into our actual identities in the here-and-now.

You'll notice that I'm speaking about DBT and narrative therapy together, rather than giving each their own separte section. That's because I use these two models in tandem. I believe that they balance each other out: embodiment versus imagination, and reality versus ideals. DBT would call this pairing a dialectic: a greater synthesis of two polarities. Narrative therapy would call this pairing multi-storied: a thick description of experience. In my experience (and I admit that not everyone agrees with me), DBT and narrative therapy make a lot of room for one another and bring out each other's best.

You may also wish to check out my blog post DBT 101: It's So Much More Than Just the Skills!

My Specific Approach to DBT

It's important for you to know that the DBT that I use is classified as modified because I do not adhere strictly to the pure model, in the following ways:

  • While DBT is my primary model, I also rely heavily on narrative therapy as a secondary model and on various other frameworks as additional models.
  • I do not belong to a weekly DBT consultation team, which is a standard requirement of the pure model, and membership of which again requires adherence to the pure DBT model; instead I prefer my clinical and peer consultation meetings to include practicionners who work in diverse ways from one another. That way, my colleagues and I can help each other to stay balanced by differing ways of working and thinking.
  • I am not affiliated with any DBT skills training groups, which are a core part of DBT. To supplement the lack of skills training groups in my practice: (a) I refer clients as often as I can to DBT skills groups or mindfulness groups; (b) I incorporate a DBT skills training component into the beginning of each session, which covers the four DBT skills categories (i.e., core mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness), and which requires homework of my clients.

Even with these modifications, I believe that my approach and skills in DBT are in-depth. In addition to ongoing reading, study and training in DBT, I also keep the following DBT-informed practices throughout my professional and personal life:

  • I rehearse, over and over, my commitment to dialectics in all the paradoxes in my work and personal life: acceptance-versus-change, anger-versus-love, justice-versus-graciousness, caution-versus-openheartedness, and on and on;
  • I value the wisdom of non-rational reasoning, which can bubble up when we trust our gut or intuition rather than logic or emotion on their own;
  • I practice personal meditation daily, usually for 45 minutes;
  • I practice all groups of DBT skills in my personal life, including the more advanced mindfulness skills that I draw from mindfulness-based cognitive therapy (MBCT); and
  • I spend a total of about 14 days per year in silent retreat.

All that said, if you are looking for pure DBT rather than my modified approach, I have some excellent colleagues to whom I can happily refer you.

What Happens in a Block of Sessions

Getting Started (The Orientation/Co-Assessment Phase)

Our first four sessions will jump around between exploring the following things: (1) your values, commitments, joys and strengths that could help us shrink whatever problems brought you to therapy; (2) your short-term and longer-term hopes and dreams; and (3) the problems that you’ve come to therapy for help with. (4) Based on #’s 1-3 and our usual session stuff (see “In each session,” below), we’ll agree on the following: (a) whether our relationship feels like a good enough fit to keep going; (b) some things we'll focus on during the rest of our block of sessions; (c) how often our sessions will happen in this block (which can be either weekly or every other week); (d) the number of sessions that this block of sessions will be — somewhere between 8-20 sessions, depending on what your needs and hopes are. You’re not financially locked into this commitment; but I hope you’ll consider my belief that seeing therapy through for the agreed-upon schedule and timeline tends to be much more beneficial toward your goals.

In Each Session

  1. we'll review your daily DBT Diary Card from the past week, which is a mindfulness tool that helps you to grow awareness about factors that may shape the events in your life;
  2. we’ll spend about 10 minutes on emotion-based skills training (i.e., DBT skills in core mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance; or advanced mindfulness training in MBCT), which will include taking up your homework and learning new things;
  3. we’ll make a to-do list of things to explore for the rest of the session, ranked in this order of importance: (i) anything that puts your life in danger, (ii) anything that gets in the way of therapy working well for us (this might be things I’m doing or not doing, or things you’re doing or not doing), and (iii) things that relate to what we've decided to focus on in our work;
  4. we’ll go through our to-do list by exploring (a) things that help you to feel joyful, comfortable, safe or strong (these might be emotions like joy or gratitude; skills or actions that you’re proud of; virtues that you enact like kindness or bravery; or values that you tap into, like sticking up for yourself or someone else); (b) things that contribute to you feeling miserable, overwhelmed, unsafe or helpless (these might be painful emotions like shame or self-hatred, actions that you feel uncomfortable or unhappy about, beliefs that keep you stuck, or memories that trigger you); (c) things that DBT calls the links between the different things I just mentioned in “a” and “b,” and what you might want to pay close attention to, cherish and/or change about those links;
  5. we’ll check in about whether we both feel on track with our goals, what we’re each taking away from our session (narrative therapy calls this witnessing) and what each of us will do for homework before next time.

Wrapping Up a Block of Sessions

In the last couple of sessions in a block, we’ll:

  1. talk about whether and how therapy has been helpful for you;
  2. celebrate your progress;
  3. take notice of any areas where you might want to work further;
  4. decide whether we’ve reached the end of our work together, or whether it would likely be beneficial to keep working together for a new block of sessions with new or updated goals;
  5. decide on and share in a goodbye ritual, or decide on how often and for how many sessions we'll meet in the next block.

What Happens Outside of Sessions

Homework

I'm a therapist who believes in homework (insert groan or cheer as appropriate). Some people love it, some people don't. Why do I recommend it? Because I think some of therapy is about developing emotional mastery, similarly to how you might master a second language. If you practice only when you’re talking to your language teacher, you are unlikely to grow mastery of the language, and your growth will certainly be much slower. Also, you’ll be giving your language teacher a lot of money for parts of your training that you could be doing at home for free! So to put it bluntly, I recommend therapy homework because:

  • I believe that it helps the benefits of your therapy to be stronger and more generalizable to your life;
  • I believe that these benefits will take this effect much faster than without homework; and finally
  • It's cheaper! It's a lot of money you might not have to pay me for hours of skill-development that you could instead be doing at home for free.

The two types of homework I'll assign to you are:

(1) your daily DBT Diary Card and (2) handouts, worksheets and/or app-based lessons about DBT skills and/or mindfulness skills.

Out-of-Session DBT Phone Coaching

To my weekly clients, I offer multiple phone coaching calls between sessions, at no extra cost.

DBT phone coaching calls are very short, about five to ten minutes long each. Like Marsha Linehan, I believe that therapy doesn’t only happen within the session. Your life is different than the therapy room. So you can phone me between sessions to get coaching on using your skills (i.e., DBT skills in core mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness; or MBCT advanced mindfulness skills) out in real life. These calls are insecure, so we keep our phone conversations to skills-based content rather than “deep stuff.”

How Can This Kind of Therapy Help?

In therapy, we can't be sure about how things will turn out. The potential benefits of psychotherapy have a pretty wide range and depth and can be described in all kinds of ways. I like Marsha Linehan’s metaphor of a house that is made up of four levels of emotional mastery:

  • Level 1 in the “basement” is about gaining a sense of control in how you engage with your thoughts, emotions, body sensations, motor functions and actions;
  • level 2 on the “main level” is about gaining the ability to experience your emotions without being regularly overwhelmed by them;
  • level 3 on the "2nd floor" is about gaining the ability to experience “ordinary happiness and unhappiness;” and
  • level 4 in the “attic” is about connecting (and over and over reconnecting) with a deep sense of freedom;
  • all levels of the house are about growing insight into your life and emotional mastery in how you use that insight.

If you develop more mastery at any level of the house in a given season of your life, your life will likely feel substantially more fulfilling, sustainable and worthwhile than it did before. These “levels” of course are not always in order: you might operate sometimes at one level, and sometimes at another, and sometimes at multiple levels at a time. Wherever you might be in the house, mindfulness of where you tend to land right now and where you’d like to get to in the near future can give us a helpful blueprint for our work together.

Contact Me

To set up a free phone consultation, please contact me at alejandra@lindan.ca. Alternately, you can text or phone me at 647 968 7628. I’ll respond within 24 hours if you contact me Tuesday-Saturday, and within 60 hours if you contact me Sunday-Monday.


Alejandra Lindan, MMT, RP (she/her)
Registered Psychotherapist #001976