This feature by Blaise Aguirre, MD is Part 1 of 2 in a series about how the book DBT for Dummies came about and the road to becoming the number one bestseller on Amazon. In this first part, Blaise begins by sharing how he first found DBT.
In April 2021, Gillian Galen, PsyD and I published DBT for Dummies. It was a ground breaking moment not only for us as authors, but also to bring DBT into mainstream conversation. Before discussing why we wrote DBT for Dummies, I want to start by telling you the journey of how I got to DBT. With that, the journey to the book will make more sense.
I went to medical school to become a psychiatrist. I wanted to be a psychiatrist to do psychotherapy. I especially wanted to work with people who had borderline personality disorder (BPD). In my early experience, people with BPD suffered in ways that led them to very destructive behavior and yet, at the same time, the behavior was in the service of wanting to end their suffering. People with BPD had some wonderful qualities: empathy, compassion, artistry, creativity, and often a great sense of humor. Also, they experienced rageful anger and severe mood swings, they were ineffective in their relationships (including the relationships with their therapists), and – within the mental health profession – they were the most stigmatized of patients.
I trained at a program that focused on psychodynamic therapy, the type of therapy that many people call Freudian therapy. My training was based on the idea that emotions and behaviors are manifestations of early childhood experiences which can lead to a series of repetitive thoughts and behaviors that emanate from the unconscious mind. The unconscious mind, I was taught, was the one that was outside of a person’s awareness. I was taught that the therapist’s task was to dig into the patient’s past and bring these old memories and experiences into the person’s awareness. By doing so, the person would then be able to take greater control of his or her life.
In my early career, the first part of this approach seemed to work well. I was able to explore my patients’ early childhood. They seemed to enjoy the process, and so did I. They had many “aha” moments and felt heard, but this is where I started to get stuck with some patients, particularly those with BPD.
I remember getting stuck when a patient would say something like: “So now I understand a lot about my childhood and why it makes sense that I am angry and sad at times. But what do I do with it?”
Wasn’t that insight enough? I stumbled. I didn’t know how to answer the question.
My patient asked for a consultation with a DBT therapist and came back with a big smile to our next session. “Have you heard of ‘opposite action’, ‘direct communication’, ‘interpersonal effectiveness’? I had just one session with that social worker, and she gave me so many useful ideas! Why can’t we do that?” they asked.
My colleagues who were using DBT therapy were getting remarkable results. What is more, they were taking patients that no one else wanted to work with! The patients with borderline personality disorder. These were not easy cases. Many had struggled with suicidal and self-injurious behaviors for so many years, and the talk therapies they had been in had not helped. Nor had the medications and inpatient hospitalizations helped to reduce their suffering.
What was this strange type of therapy? I started asking my senior colleagues about DBT. They did not practice DBT themselves, and they had all sorts of opinions, both positive and negative. Some of the positive perspectives included that it was very helpful because it provided skills, because it allowed people to reconnect with their spiritual side, and because it was practical and easy to understand. Further, that the group component allowed for patients to see that others could do it. Some of the negative commentary included that it was: “A condescending treatment. Patients have to go to ‘class,” they have ‘homework,’ they have ‘rules’ that must be obeyed.” Also that “Linehan basically put together a program that worked for her by taking skills from other therapies and from different traditions and then called it her own therapy. It’s like a cult.”
Some of the criticisms of DBT concerned me, but they all came from people who did not practice DBT. So, I asked my 3East colleague and DBT trainer, Dr. Michael Hollander, PhD, who told me some things I had never heard before and which immediately changed the way I saw patients:
- The problems exhibited by patients are caused by skills deficits rather than intentionally trying to be “abusive” or “manipulative” or “gamey.” What then could be more compassionate than to teach people the skills or show them how to use the skills when needed?
- That at any given point in time, given their circumstances, that each of our patients and each of us is doing the best we can, and yet that this does not mean that we cannot do better.
With this newfound insight, Blaise begins his journey with DBT and to writing DBT for Dummies. Read here for part 2!
Blaise Aguirre, MD, is an expert in child, adolescent, and adult psychotherapy, including dialectical behavior therapy (DBT) and psychopharmacology. He is the founding medical director of McLean 3East, a unique, residential DBT program for young women exhibiting self-endangering behaviors and traits of borderline personality disorder (BPD) Dr. Aguirre has been a staff psychiatrist at McLean since 2000 and is nationally and internationally recognized for his extensive work in the treatment of mood and personality disorders in adolescents. Read his full bio here.
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