Using Dialectical Behavior Therapy Techniques with Imago and Family Therapy

August 24th, 2011
By John Migueis, LCSW Family Problems Topic Expert Contributor

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I am not formally trained in DBT. My knowledge of it coming from texts, watching trained practitioners do it and gradually incorporating it into my practice. I’m comfortable with its use due to my background and training in similar modalities and have found the skills to be valuable for those who have a difficult time with more traditional approaches.

One area where DBT has been most helpful to me is in couples and family work as a compliment to Imago and traditional Family and Couples therapy.

Imago’s dialogue draws from communication skills such as “I messages”, Mirroring, Validation and Empathy. Most family and couples therapy around communication, regardless of modality, has included this skill set for decades.  In fact, it’s rare to read a book or manual on family therapy without any of these skills coming up. Many times couples and families who come to therapy become dysregulated in their communication and do not have the discipline to put them into practice. The “dialogue” does a good job in helping folks get communication on an empathic level but, in my opinion, falls short of helping them understand how to modulate intensity and the practical dimension of effective interpersonal skills. Lastly, clients often state that the skills seem packaged for “vacuum interactions” and most triggers occur unexpectedly; that although great in theory they do not feel the dialogue is a realistic alternative to their normal way of communicating. This is half true, in my opinion. The skills are useful in that, they give clients the tools to communicate but they do not increase or improve real world capacity to regulate this communication.

The Interpersonal Effectiveness handouts in the Skills Training Manual for Treating Borderline Personality Disorder  by Marsha Linehan has been useful in helping couples and families in my practice achieve the following:

• Understand the building blocks of relationships and interpersonal skill development- Many times couples and families in therapy aren’t able to recognize the areas they need to be attentive to in order to improve their ability to effectively manage relationships.  Clients can have a hard time putting words to where the relationship is breaking down.  “The situation for interpersonal skills” handout allows couples and families to organize these components in a way that allows for a more straightforward self-assessment of their relationship.  This skill set provides a “what to look for” when it comes to interpersonal skills so that folks are able to at least get a baseline.
• Understanding the purpose of interpersonal skills- Many clients get stuck on meeting the concrete or representative/historical need at hand. The “Goals of Interpersonal Skills” handout allows couples and families to broaden their understanding to include relationship maintenance and self-respect as equal parts to the communication equation. This handout can allow folks to get away from just going after the widget and to consider other, equally important factors in delivering the message.
• Understanding Legitimate Rights and Factors reducing Interpersonal Effectiveness-This allows couples and family members to receive “permission” to communicate a need and works to eliminate the barriers to interpersonal effectiveness (also included as a worksheet in Linehan’s manual).
• Modulating Intensity-The “Options for Intensity of Asking or Saying No, and Factors to Consider Deciding” has been the most valuable tool in helping couples and families in my practice. It asks clients to consider the intensity they are applying to their communication around a need. It presents ten items they should account for in a very concrete, guided and understandable way. Many couples and families actually assign a number to each of the ten items to come up with a ball park average on how firm they are going to be in the face of a demand or in making one.
• “DEAR MAN, GIVE, FAST”-I use the Imago dialogue within this framework across all three of Linehan’s communication worksheets. This helps couples understand why the dialogue makes sense while providing them a way to apply theory to how they communicate in very concrete ways.

Of course, going through the skills involves more than just providing the hand outs. Much of the information presented may not make sense to your client. The therapist should really have a strong command of the material before using it and should prepare to spend a full session discussing each hand out.

Adding the DBT communication module as a compliment to couples or family work can help folks feel comfortable in asserting a need effectively. I have found that applying the module lessens the learning curve around communication significantly. This has allowed me to move on to other issues beneath the surface more quickly. This occurs because the module provides clients with a much greater capacity to tolerate or communicate charged material that may be at the core of what brought them into my office.

©Copyright 2011 by John Migueis, LCSW, therapist in Scotch Plains, NJ. All Rights Reserved.

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