Every therapeutic approach has a way of conceptualizing where a client is at in treatment. While of course not all approaches fit every person or problem, I find that having a general roadmap of where therapy can take us is extremely helpful for a couple reasons. One is that it allows you to track and celebrate your progress, and two is that it allows you to see where you might be getting stuck. I want to review one of those roadmaps today, which may give you a better idea of where you are at and what you might want to work on in therapy.
Dialectical Behavioral Therapy (DBT) is a type of Cognitive-Behavioral treatment that was developed by Marsha Linehan and intended specifically for difficult-to-treat mental disorders. While DBT was primarily developed through Marsha’s work with chronically-suicidal individuals, DBT’s structure acknowledges the human journey that is relevant to us all. One major theoretical underpinning of DBT is the constant balance of accepting where one is at in life, while simultaneously identifying goals and cultivating the desire to change. Sound relatable?
DBT is conceptualized in stages, and the focus of sessions will depend upon what stage you are in. Even if you are not participating in DBT, I find that the stages are a helpful framework from which to identify priorities for healing and growth.
Stage 1: Stabilization and achieving behavioral control
The first stage in DBT focuses us on behaviors that interfere with our life (such as suicidal thoughts, urges, and actions), as well as behaviors that interfere with our quality of life. This includes behaviors that arise out of good-intentioned strategies to manage strong emotions, such as addictions, damaging relationships, shirking responsibilities, collapsing in despair, verbally berating ourselves, etc.
Even if you aren’t having suicidal thoughts, you may feel hopeless if you have no idea how to make yourself feel better or get out of a stuck place. You might feel that your current methods of dealing with strong negative emotions aren’t working, whatever they are, and it motivates you to look for another way. This is sometimes the state in which people come to therapy.
The goal of stage one is to achieve control over our behaviors. This means that we don’t feel derailed from taking the necessary steps to perform basic responsibilities and there isn’t a constant sense of crisis and giving up. We are also better able to soothe ourselves when we have intrusive thoughts or sudden pangs of shame or fear. Again, working on “stage one” does not mean that we don’t also talk about future goals, past trauma, or spirituality. However, in order to really feel like we can move forward, we must develop a sense of stability and confidence in our ability to access supportive resources such as safe human connection.
The analogy here would be learning how to feel secure coming back to a boat prior to doing deeper and deeper dives into the water. While diving will allow us to explore unseen (or unconscious) parts of ourselves, we need to feel confident in our ability to know how to get back to the boat. Especially if the unknown scares us or is potentially overwhelming to us, it is very important that we develop the capacity to regulate our internal state prior to full immersion (i.e. making prolonged and intentional contact with difficult cues, memories, body sensations, or emotions).
Stage 2: Processing past trauma and moving into full emotional experiencing
Once individuals achieve behavioral control, a feeling of stability, and/or develop accessible supports outside of therapy, it’s possible to then work on addressing past trauma. While talking about traumatic experiences can happen even from day 1 in therapy, it’s incredibly important to work on increasing our ability to tolerate and regulate our emotions simultaneously (if not prior) to entering into potentially overwhelming emotional territory. This means it is not a great idea to work on fully engaging with past traumatic memories before:
Gaining a sense of stability
Developing skills to ground and self-soothe when experiencing mood swings, shame spirals, flashbacks, or intrusive thoughts
Increasing access to an external support network (outside of therapy) including friends, family, sponsors, and activities
The goal of stage 2 is to be able to experience emotions fully, all emotions, even the ones that we try our best to avoid because they are painful. This might include being able to face fears about who we are, who others are, and fears about the future.
Processing trauma can happen in a number of ways. There is not one “best” trauma treatment out there, although there is probably one that is best for you. Some trauma treatments involve re-telling the traumatic memory (or memories) repeatedly until the emotional tone attached to the memory reduces, through a process called habituation. Other treatments focus more on engaging with the felt-sense of the body. This might involve shifting the physical, somatic experience of the trauma from being stuck or trapped in our body, to a feeling of resolution.
Moving through trauma treatment can help us reduce reactivity in the presence of reminders of the traumatic event, allow us to differentiate between “then” and “now,” and take back the power to define how we want to be in the world rather than feel that we are doomed to simply react to our circumstances.
I also think that within this stage can be the work of resolving painful beliefs about ourselves and the world. Many times, even in the absence of having experienced a major catastrophic event, we come to see ourselves as unworthy, unlovable, a burden, a failure, etc. Following the path of these beliefs can lead us to memories of bad parenting, being bullied at school, or painfully embarrassing moments. Being stuck in these modes of thinking can cause immense pain and overwhelming fear. Resolving them helps us to adopt new, more flexible views of the world which can make us feel at ease with ourselves and new situations.
Stage 3: Define individual goals and achieve self-respect
As we process our trauma, we create a coherent narrative of what happened and how it has shaped us into who we are today. We feel more comfortable with ambiguity and change, we are more in touch with our own personal values, and we can learn self-respect. When we are more certain of ourselves and feel more love for ourselves, it is so much easier to move forward without the fear of being paralyzed by overwhelming emotion or confusion.
When we are not so worried about being triggered, we can clearly define our future goals and how to take steps toward them. We have ups and downs of course, these never go away in our human experience, but we feel more confident that we can handle them as they come.
Resolving trauma also leads us to be able to rely on our support system in a healthy way. Most of the time, trauma makes us feel helpless and separate from others. It’s very natural to reach out to others when we are feeling upset or need comfort, however trauma responses often leave us feeling exaggerated amounts of emotion that can make it difficult for us to clearly ask for what we need or be hesitant to rely on others to give it to us. Resolving trauma won’t necessarily turn an introvert into an extrovert, but it will help us to feel more clear and deserving of the types of connection that we individually need.
Stage 4: Achieve a sense of completeness
What is inevitable, I think, is that once we resolve feeling we are in a state of crisis (stage 1) and desperately wanting the world to be different than it is (stage 2), it becomes easier to imagine how you want to be in the world (stage 3). Rather than merely reacting to the world around us, we feel capable and able to take steps towards our goals. As we start achieving goals and feeling capable in our abilities to handle life, questions might come up for us about how to feel at peace, complete, and fulfilled.
Being human is pretty strange. Our lifespan is temporary, lives are unpredictable, and most of the objects we spend time chasing (i.e. money, job, house, Instagram accounts full of cool pictures), we don’t take with us when we die. I don’t pretend to know with authority what happens to us after we die, and while I do have my own beliefs, I would never force them on anyone else. What I do think is important is for us to ask the difficult questions that lead us to developing our own values about how we want to live. Asking difficult questions that don’t have easy or clear answers can feel confusing, but it can also lead us to surrendering in the face of so many unknowns in life. We really are just trying to do our best with the information we have. We are all in the same boat in this regard.
I see this stage as something we may always have our eye on, even while we work on stabilizing, processing past trauma, and identifying achievable life goals. We are stretched to ask, “How do I make the most out of my experience here? What is important for me to focus on? How do I have faith and trust in my own and other’s goodness?”
While therapy is a place where you can explore these questions, oftentimes people turn to other sources for answers or to learn methods of inquiry that can help them come up with their own answers. Usually when we seek a transcendent state of being, we turn to spiritual groups, self-help gurus, or books on philosophy.
As previously mentioned, just because there are “stages” of therapy does not mean that we walk through these stages in a perfectly linear fashion. Stabilizing happens not all at once, but in increments, and we might have momentary episodes of falling apart despite making tons of progress. If that does happen, it doesn’t mean that we are back at square one, it is just a testament to the insidious way traumatic memories maintain themselves in our body.
Just because I reviewed stages as according to DBT, does not mean that they are not applicable to where you are at in therapy even if you are not seeing a DBT therapist. The first step in therapy, across many different modalities, is most always to achieve stability. When in crisis, it is very difficult, if not impossible, to learn new information or work on changing old patterns and beliefs. Both of those tasks (learning new information and changing old patterns) take energy, and if all our energy is tied up in managing the crisis, we just don’t have the bandwidth for anything else.
Having stages as a loose structure for knowing where we are at and where we are going provides a general framework for identifying how therapy is actually meant to help you, and if it actually is. It can also empower you to define goals for yourself no matter where you are at in life.
Linehan, Marsha. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. The Guildford Press.
Linehan, Marsha; Wilks, Chelsey. (2015). The Course and Evolution of Dialectical Behavioral Therapy. American Journal of Psychotherapy.(Vol. 69, No. 2). Pg. 97 – 110. DOI: 10.1176/appi.psychotherapy.2015.69.2.97.
- Nina Tomkiewicz, LCSW
- To learn more about how online therapy can help you work through these stages of change, contact us here.