Using Dialectical Behavior Therapy Techniques with Imago and Family Therapy

I am not formally trained in dialectical behavior therapy (DBT). My knowledge of it comes 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 therapy approaches.

One area in which 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 these skills 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.

The Interpersonal Effectiveness handouts in the Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan have 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. They can have a hard time explaining why 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.
• Understanding the purpose of interpersonal skills. Many people in therapy get stuck on meeting the concrete or representative/historical needs 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 people 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 them to consider the intensity they are applying to their communication around a need. It presents 10 items they should account for in a very concrete, guided, and understandable way. Many couples and families assign a number to each of the 10 items to come up with a ball park average on how firm they are going to be in the face of a demand.
• “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 with a way to apply theory to how they communicate in concrete ways.

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

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

Reference:

1. Linehan, M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.

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