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Doughnuts and the Beach: The Importance of DBT

May 03, 2011

Opposite ideas or feelings may initially appear to be contradictory.  For instance, how can I want to look great in my swimsuit for a trip to the beach but also really want to eat that glazed doughnut?  Or how will the anger I have toward my dog who chewed one of my new shoes fit into my desire to snuggle with her tonight?  Such seemingly conflicting points of view might lead one to see the world through a polarizing perspective.  Unresolved, these contradictory feelings may also lead to poor decisions and dysfunction in life.

Patients with rapid-cycling mood changes or personality disorders often develop polarized senses of their worlds in the same ways I just mentioned.  Not knowing if one will feel elated or depressed at any given point in time - or if intimate relationships will suddenly end because of one's symptoms - can easily polarize affected people to expect bad and scary things always to occur.  Many such individuals start to experience hopelessness, agony, and despair which often leads to making self-injurious and impulsive decisions, like attempting suicide.

Historically, mental health providers had few interventions for the patients who saw their worlds in these rapidly cycling ways.  Medications seemed to help only minimally.  Hospitalization actually appeared to worsen symptoms.  No psychotherapeutic techniques proved to be effective.  Treatment options for people with these illnesses were limited, and many psychiatrists and psychologists felt unable to help them recover.  At Skyland Trail, we began to see that more and more individuals with such needs were requesting admission into our programs and looking to us for help.  We wanted to offer that assistance and developed a program with that goal in mind.

Out of desperation to help her patients who saw the world as contradictory opposites, a clinical researcher named Dr. Marsha Linehan developed a new type of therapy that has been shown to help people with rapid-cycling mood disorders, personality disorders, and even co-morbid mood and substance use disorders reconcile their polarized views of the world, and ultimately feel and function better.  The therapy is called Dialectical Behavior Therapy (DBT) and has provided hope to many patients who previously thought they might not recover.

One of the basic tenets of DBT is that two things that appear opposite can be true at the same time.  One might feel so horrible that death seems like an acceptable option while simultaneously deciding to keep living; one might be so angry at one's spouse that escaping the relationship sounds appealing while simultaneously wanting to invest in maintaining the relationship.  These co-occurring ideas and feelings that seem opposite can indeed simultaneously be true.  Such dialectics can open a new way of seeing the world and provide relief to mentally ill patients who historically saw only one option in difficult situations.

Skyland Trail is committed to remaining informed and engaged in providing the best, evidence-based care for the clients we serve.  As the research literature showed that DBT is an emerging, effective treatment for many of our patients, we decided it was essential for our clinical services to integrate DBT into the tools we use to help our patients recover from illness.  To that end, we sent a multi-disciplinary team to two weeks of intensive DBT training and developed a DBT Recovery Community with high fidelity to Dr. Linehan's model of the therapy.  We are one of only several residential treatment facilities for adults across the country with a DBT team and the capabilities of providing this type of therapy for patients.

Preliminary clinical and functional outcome data suggest that our DBT recovery community provides significant help for patients with certain needs.  Learning and practicing new tools like mindfulness (meditation), distress tolerance, and alternative coping strategies during times of despair are integral to DBT, and our DBT team supports our patients and one another in cultivating these tools.

Helping patients expand their world views and expectations is not merely a component of DBT, it is also a theme within Skyland Trail.  People with any type of mental illness tend to become focused on their illness and themselves.  We believe that this can become consuming and toxic.  Through DBT, art and horticultural therapies, team exercises, volunteerism, and many other programs offered at Skyland Trail, our intent is to expand patients' views of the world and their place in it.  Integrating DBT into our services fits very nicely with the philosophy that drives everything we do.

In the spirit of expanding options and seeing things differently, I ate my doughnut.  It tasted great and I felt satiated for that moment.  Then I committed to going to the gym every day before the beach trip.  That felt good, too.  Expansion of my world view led to new options that helped me in several unanticipated ways.  Skyland Trail's intensive DBT team helps our patients resolve more-serious conflicts, and hopefully new, happy points of view.

Learn More:

Dialectical Behavior Therapy Program >
Outpatient DBT Program >

Ray Kotwicki, MD, MPH

Chief Medical Officer

Dr. Ray Kotwicki is the chief medical officer of Skyland Trail. Located in Atlanta, Skyland Trail is a nationally recognized nonprofit mental health treatment organization serving adults ages 18 and older. For 26 years, Skyland Trail has been inspiring people with mental illnesses to thrive through a holistic program of evidence-based psychiatric treatment, integrated medical care, research and education. Before joining Skyland Trail as full time chief medical officer, Dr. Kotwicki served as an associate professor the Department of Psychiatry and Behavioral Sciences at Emory University’s School of Medicine, and as an associate professor at Emory University’s Rollins School of Public Health. He remains on adjunctive faculty at the Emory University School of Medicine, as well as at the University of Miami Miller School of Medicine. Dr. Kotwicki is a Diplomate of the American Board of Psychiatry and Neurology, and has been elected an officer of the Georgia Psychiatric Physicians’ Association. Dr. Kotwicki received his undergraduate and medical degrees from the University of Wisconsin Medical School, and completed post-graduate training at Harvard Medical School, the Boston University School of Medicine, and Emory University, where he also earned a Master’s degree in public health.