The COVID-19 pandemic is unprecedented. The ubiquitous influence of the pandemic has been—and continues to be— felt by individuals globally. Many experiences the fear of being infected or infecting others, disruptions in their daily routines, social isolation, the likelihood of unemployment, financial hardship and the looming economic uncertainty (Ministry of Health Singapore, 2020). As such, there is a detrimental impact on the mental health and wellbeing of individuals, including an increased risk of suicidal behaviour.
Globally, the prevalence rates for depression and anxiety in the COVID-19 pandemic were 28.0% and 26.9% respectively (Nochaiwong et al., 2021). Factors contributing to depression and anxiety include suffering, fear or potential death, grief and financial stressors (World Health Organization, WHO 2022).
Young people have been identified as at increased risk for suicidal and self-harming behaviours (WHO, 2022). Women’s mental health, compared to men’s, has been more adversely impacted by the pandemic (WHO, 2022). In addition, people with existing medical conditions such as asthma, cancer and heart diseases, have been found to be at higher risk for developing mental health disorders (WHO, 2022).
In Singapore, a study conducted by the Institute of Mental Health (IMH) (Ministry of Health Singapore, 2020) found that 8.7% of Singapore residents reported having clinical depression, 9.4% reported having clinical anxiety and 9.3% reported mild to severe stress levels. Older adults were identified as a vulnerable group, particularly, those who lived alone. Similar to the findings from WHO (2022), youths in Singapore were also identified as vulnerable to experiencing poor mental health in response to the pandemic. There is an urgency for countries to boost their mental health and psychosocial support services as part of the pandemic response plan.
According to the COVID-19 mental wellness task force, initiatives in Singapore include providing psychological support via helplines such as the National CARE hotline and a mental health help bot (‘Belle’), incorporating mental health materials in the school curriculum, fostering family resilience and supporting parents with parenting skills.
Here are some recommendations for mental health support during this pandemic:
Parents are encouraged to have conversations with their children about their children’s worries and responses to the pandemic. Parents have been found to underestimate such responses (Pfefferbaum & North, 2020). Such “talk time” can also help in trust and bond-building
Seniors can be equipped with digital skills and also expand their options for help and support i.e. the provision of telehealth counselling and support services (Brydon et al., 2022).
Health care workers can monitor their stress responses and seek assistance in relation to both their work and personal lives from a mental health professional (Pfefferbaum & North, 2020).
People can be encouraged to limit their consumption of news related to COVID-19 to once a day and to focus solely on credible news sources.
Having social interactions with family and friends and offering to help support one another during this difficult period can also be particularly beneficial.
Being outdoors and exercising are good habits for maintaining healthy wellbeing.
As restrictions are slowly easing around the world, it can also be challenging for most people to adjust back to when restrictions were first introduced (during lockdowns). With new changes and uncertainty, being mindful of one’s mental health and well-being is crucial. For example, larger social gatherings (e.g. group of 10) may seem overwhelming at first, therefore it is important for people to recognise their anxiety levels related to social gatherings.
Here are some suggestions that might help regulate your emotions as you enter this new season of Singapore opening up amidst the COVID-19 Pandemic (Black Dog Institute, 2022):
Gradually, increase your time spent in a larger social gathering at your own pace.
You can also start to focus on things that are within your ability and control. For instance, you can engage in different relaxation techniques such as deep breathing and focusing on being in the present in order to better cope with your stress levels (American Psychological Association, 2021).
it can be useful to discuss reasonable adjustments back to work with your managers such as flexible working arrangements and other training opportunities in order to increase work efficacy
Seek professional help if there are concerns regarding stress levels related to the easing of restrictions.
It is particularly evident that the COVID-19 pandemic has taken a toll on the well-being of Singaporeans and the rest of the world. The pandemic has highlighted the importance of mental health and wellbeing and there is an urgent call for countries worldwide to provide people with mental health and psychosocial support to help them maintain psychological wellness.
Some Local Helplines and support:
National CARE hotline (8am-8pm daily): 1800-202-6868
Brydon, A., Bhar, S., Doyle, C., Batchelor, F., Lovelock, H., Almond, H., Mitchell, L., Nedeljkovic, M., Savvas, S., & Wuthrich, V. (2022). National Survey on the Impact of COVID-19 on the Mental Health of Australian Residential Aged Care Residents and Staff. Clinical Gerontologist, 45(1), 58-70.https://doi.org/10.1080/07317115.2021.1985671
Nochaiwong, S., Ruengorn, C., Thavorn, K., Hutton, B., Awiphan, R., Phosuya, C., Ruanta, Y., Wongpakaran, N., & Wongpakaran, T. (2021). Global prevalence of mental health issues among the general population during the coronavirus disease-2019 pandemic: a systematic review and meta-analysis. Scientific Reports, 11(1), 10173. https://doi.org/10.1038/s41598-021-89700-8
For many people, when they hear the word ‘Psychiatrist’, it would instantly conjure up an image of a doctor prescribing medicine for someone with a mental health condition. This is true to the extent that a psychiatrist is a medical doctor who has undergone training to become a mental health specialist. While prescribing medications are indeed part of the treatment process, what really goes on in between – from the first session to the very end?
On your very first session, your psychiatrist will most likely spend 1-1.5 hours with you to gain a better understanding of what you’re coming in for. Mental health conditions can be a touchy subject for many, and it is understandable that you’d feel hesitant to open up to a complete stranger right away. However, trust that your psychiatrist has your best interests in mind, and will do his/her best to provide optimal treatment. Don’t be afraid of being judged for your symptoms, rest assured that the psychiatrist’s office is a safe and non-judgemental space. The psychiatrist will want to know as much as you’re willing to share, and being honest with your psychiatrist will be extremely helpful for an accurate diagnosis and the development of an effective treatment plan. Just as what you’d expect when you seek a General Practitioner for physical conditions, your psychiatrist would start off by asking broader questions such as, “What brings you here today,” or “How can I help you?” For some individuals, especially if it’s their first time at a psychiatrist’s, open-ended questions like these may be nerve-wracking. You may feel a little overwhelmed, not knowing how to start or where to begin. However, there are no hard and fast rules as to how the session should flow. Simply communicating your symptoms and your concerns would be a great start, and your psychiatrist will guide you through the interview.
Your psychiatrist will also run through a history-taking process, paying special attention to your medical history, family history, your current lifestyle habits and general patterns of sleep. It is important to let your psychiatrist know if you’re on certain medications, as some may have side effects that may fuel certain mental health conditions. Avoid downplaying or dismissing any information related to your physical or mental wellbeing, the clue to an accurate diagnosis may very well lie in the details. As such, going for your first session prepared with a complete list of medications, dosages, and your compliance with them can be very beneficial. Many studies have also shown that genetics play a role in mental health disorders. If you have a family member who suffers from a psychiatric issue, be sure to let your psychiatrist know for him to have a clearer idea of the situation. If need be, your psychiatrist may also ask permission to speak with other family members.
Depending on the patient’s circumstance, the psychiatrist may conduct a physical check-up if necessary, or possibly laboratory tests to exclude other possible causes for your condition. These are done to confirm that what you’re experiencing are not due to other medical conditions which may give rise to similar symptoms. Hence, if your psychiatrist asks for these procedures to be carried out, don’t feel too worried! Questionnaires to further assess your symptoms may also be given, so do make sure to answer them as truthfully as possible.
Depending on the complexities of your condition, medication options or other forms of treatment may be prescribed. If you are given medications, the psychiatrist would counsel you on how you can tell if the medications are working. Over the course of your recovery journey, take note of how subtle changes to the medications made by your psychiatrist affects you. Do they stabilise or improve your condition, or do they seem to send you on a downward spiral? How have you been feeling since you started taking them? Whatever the outcome, keep your psychiatrist in the know of how you’re coping. In the same vein, it is very important that you do not adjust your medications on your own without seeking professional advice! Patients may get impatient if they’re not seeing the desired change after a while, but constant and unregulated changes can cause undesirable fluctuations, potentially worsening the situation. We need to understand that there could be catastrophic, life-threatening consequences if we do not take them seriously.
In general, psychiatrists usually work closely with psychologists and therapists, as some mental health conditions are best treated with both neuropharmacological support and psychotherapy. Thus, your psychiatrist may also refer you for psychotherapy if deemed fit. Depending on the level of care required to address the patient’s symptoms, psychiatrists may recommend treatment programmes if more intensive care is needed.
So you are going to see a psychologist for the first time – now what should we expect? The thought of having to step into a psychologist’s room for the first time can be nerve-racking, and understandably so. Oftentimes, individuals may be apprehensive and would wonder if talking to a complete stranger is really going to help, or if opening up your innermost thoughts to a stranger was too much of a risk to take. However, rest be assured that these mental health professionals are well-versed in psychotherapy methods to help you manage your issues as best as possible, and will work closely with you at a comfortable pace. Just like in the treatment of physical illnesses by physicians, patient privacy and confidentiality are also primary obligations for psychologists. In this article, we hope to give you a clearer idea of what you can expect from your visit to a psychologist, especially if it is your first session.
First things first, it is important to understand that psychotherapy isn’t merely a one-off session. While the duration of treatment may vary from one person to another, the American Psychological Association (APA) reports that “recent research indicates that on average 15 to 20 sessions are required for 50 percent of patients to recover as indicated by self-reported symptom measures.” The type and duration of treatment also heavily depend on the nature and severity of each client’s conditions, and it would simply be unfair to make an overgeneralised statement. Regardless, it would be beneficial to go in with an open mind, and to have an honest conversation with your psychologist. It really helps to trust that the process works, while acknowledging that it takes time.
Meeting the psychologist
At the beginning, the first few sessions would aim to help one identify the most pertinent issue that needs to be dealt with. The psychologist will talk through with you gathering some information on your life history, your family’s mental health history, the problems you are dealing with, and analyse those details – no matter how insignificant they may seem at first – that could have possibly led to emotional distress or coping difficulties. For the psychologist, being able to get a good grasp of the situation and seeing the big picture is vital for formulating the treatment plan and treatment process, as it will help to determine the type of psychotherapy that is best suited for you. The psychologist is trained to listen and analyse your conditions in order to help you with your recovery. As such, it is equally important that you don’t hold yourself back from being fully honest with your psychologist. To a large extent, the patient’s participation in the therapy is an important determinant of the success of the outcome.
While we fully understand that it can be unnerving, these mental health professionals are trained to help you work through the challenges you face, and the therapy room is very much a safe, non-judgemental space. Goal-setting is one of the key aspects of psychotherapy, and it is exceptionally important to set goals from the start that you can use to track your progress. You may start by identifying personally meaningful broad motives, hopes and dreams – having a clear direction in mind will better steer future sessions towards alleviating symptoms of distress and tackling the root cause of one’s concerns. Don’t worry if you feel the need to change your goals or take a different approach halfway through the treatment process. Psychotherapy is a dynamic process after all, and increased self-discovery along the way can certainly give you a better sense of what needs to be changed.
Different approaches to psychotherapy
There are several approaches to psychotherapy that can be implemented in the following sessions. Not strictly limited to one or the other, psychologists may make use of psychoanalysis and psychodynamic therapies, cognitive-behavioural, interpersonal, and other types of talk therapy. They can help you focus on changing problematic behaviours, feelings, and thoughts to build on healthy habits, or teach you emotion-coping strategies to cope with your symptoms. Forms of treatment like cognitive-behavioural therapy also aim to help individuals recognise negative thought and behaviour patterns, thereby working towards a positive change. Each session is essentially a problem-solving session. By allowing yourself to talk to your psychologist about your most difficult moments, your feelings and the change you want to observe, the psychologist is then able to make use of his/her expertise to assist you. Many mental health professionals don’t limit their treatment to any one approach. Instead, they blend elements from different approaches and tailor their treatment according to each patient’s needs.
To make the most of the treatment process, “homework” may sometimes be assigned as between-session tasks to clients as part of your treatment. A variety of homework assignments exist – sometimes in the form of practising new skills, habits, and other coping mechanisms, or someone who is dealing with complicated emotions could be asked to record your negative thoughts in nightly journal entries. When you return for your next session, the psychologist would then check in on your progress, and address any issues that may have arisen while you were completing your tasks. For some clients the benefits of therapy can be achieved in a few sessions, while for other clients they might need more to improve. Empirical evidence supports the benefits of homework in promoting positive symptom change and increasing patient functioning, that is, the quality of a client’s participation in therapy through active application of what they learn will lead to improvements in their conditions.
Was the psychologist right for you?
Often during the conversation with the psychotherapist, or after the session, you may feel a sense of relief, elation, or anxiety and exhaustion. However you feel, it is important to take note of those feelings. Did the psychologist put you at ease? Did he/she listen to you carefully and demonstrate compassion? Did he/she develop a plan to guide you with your goals and show expertise and confidence in working with issues that you have? For the treatment to be effective, you need to be able to ‘click’ with the psychologist, that is you are able to build trust and a strong connection with your psychologist.
To end off, the first session with a psychologist is understandably a bit intimidating and overwhelming, but the first step in the journey to recovery is a critical step to regain your mental wellbeing.
Many of us are absorbed in an endless, self-defeating rat race. The nature of modern society has instilled in us a “winner/loser” mindset, and its systems highly prioritise external rewards and punishments as measures of our personal success and social worth. This oftentimes forces us to shift our perception of self-worth from the satisfying efforts of personal endeavour, to the critical imperative of achieving yardsticks of success defined by the rest of society. When we are constantly striving to win a race while focusing on external factors largely beyond our design or control, we’re surely putting ourselves at a disadvantageous position.
The overwhelming pressure to conform to societal expectations, or to outrun others in the race of life, can make one particularly susceptible to depression if negative emotions are not managed well. As we aim for perfection – as most people would – we need to understand that total perfection is unattainable. The more we believe that we have failed to reach a certain state of “perfection”, the greater the extent to which we experience low self-esteem, self-hatred, and depression. Depression can be extremely debilitating to one’s mental health. Apart from the diminishing enthusiasm for life and self-esteem, depressed individuals may self-isolate and pull away from their social circles, making it all the more difficult for them to get the help they need.
Perhaps one of the healthiest things we can do for ourselves is to accept who we are. Self-acceptance might just be the antidote to excessive self-resentment and discontentment. It is important that we fight against influences that force us to conform to certain standards rather than to accept ourselves. Presented below are a couple of talk therapy methods that we use to guide you towards achieving that.
What is ACT?
Acceptance and Commitment Therapy (ACT) is a form of talk therapy suitable for the treatment of individuals displaying symptoms of depression. As its name suggests, it’s core aims are to help individuals accept whatever is beyond their control, and to commit to actions or habits that will serve to enrich their quality of life. ACT helps us to clarify what is genuinely important to us (i.e our values), and thus assists us to set more meaningful and life-enriching goals. Along the way, it also guides us to practise useful emotion-coping strategies such as mindfulness in order to equip us with skills to handle negative emotions effectively and healthily. While the number of ACT sessions may differ for each individual, the benefits acquired by clients are largely similar:
Learning to be fully present in the “here-and-now”, and to stop obsessive worrying over the past or future
Become aware of what they are avoiding (be it consciously or subconsciously), and to increase self-awareness
Learning to enjoy greater balance and emotional stability, and to be less upset by unpleasant experiences
Learning to observe thoughts such that one does not feel held captive by them, and to develop openness
To develop self-acceptance and self-compassion
Clarifying one’s personal values and taking the appropriate action towards his goals.
You may be wondering, does it really work? The good news is that ACT is considered to be an empirically validated treatment by the American Psychological Association (APA). Through program evaluation data, research has also shown that Veterans who completed ACT treatment phases displayed a significant decrease in depression in addition to improved self-awareness and a better quality of life.
What is DBT?
Apart from ACT, another alternative for the treatment of depression is Dialectical Behaviour Therapy (DBT). While originally used for the treatment of Borderline Personality Disorder, DBT has since been adapted to treat other mental health conditions including depression, anxiety, and post-traumatic stress disorder. A type of cognitive behavioural therapy, DBT aims to help individuals who struggle with emotional-regulation and are exhibiting maladaptive or self-destructing behaviours. It is not an uncommon sight for persons with depression to engage in substance-abuse or self-harm. As such, DBT helps to build on distress tolerance, such that people who struggle with these are able to handle negative life-circumstances better and to avoid falling back on such devastating coping methods.
DBT can be considered a holistic approach to depression treatment. Apart from tackling maladaptive behaviours, it encourages a shift in the clients’ perspective on life, for it equips them with the necessary skills to cope with intense emotions. In short, it empowers you to cope with them with a positive outlook. DBT also recognises that interpersonal effectiveness is key, and hence it strives to help these troubled individuals to reconnect and enhance their relationships with others.
ACT Versus DBT
ACT and DBT are both highly effective methods of treatment for depression. Both forms of psychotherapy allow for individuals to tackle the notion of suffering head-on, and to avoid suppressing undesirable or uncomfortable feelings. Both promote psychological flexibility, and encourage people to behave in a conscious or effective way towards their life-choosing directions. The practice of mindfulness is also a commonality between both therapy methods, and it plays a crucial role in ensuring that persons are well aware of their values, goals and emotions.
However, overlaps between the two are considerably limited too. The main differences between ACT and DBT would be that DBT leans towards a more educative approach while ACT emphasises an experiential one. Perspective wise, DBT adopts a biosocial perspective on behaviour while that of ACT is contextual. Moreover, the underlying philosophy behind each form of therapy also differs. DBT philosophy is dialectical (i.e using logical reasoning and analysis), while the philosophy behind ACT is functional contextualism. With that said, the analysis of clients’ experiences, the use of languages as well as experiential exercises will be different for each type of therapy.
Caregivers with a family member affected by addiction problems are often exhausted, drained dry of their empathy and compassionate capacities.
They recount countless cycles of suspended hope followed by just as many broken promises as they watch the affected person return time and again to their compulsive addiction despite a seemingly obvious trail of destruction behind them.
Caregivers learn to cope with the endless demands on their energies by blending the words uttered by the affected persons as a cocktail of lies, manipulation and attention-seeking antics to get what they want.In time, the cries for help from the affected person turn into cries for help by the boy who cried wolf and eventually fading into indistinguishable white noise.
Professor Lisa Firestone of the Glendon Association observes that there is a natural tendency for caregivers to minimise any suicide expressions in general.Responses such as, “Well, his past attempts weren’t serious.” or “He is just manipulating to get something.” are commonly observed.There is also a general tendency to not want the expressions to be true.In the case of addicts, words such as “I want to die” or “I am going to end my life” no longer convey the same meaning or gravity of their sense of desperation.
Why should we want to pay attention to an addict’s cry for help?
In Singapore, we lose 1.1 lives every day to suicide.It is still the leading cause of death for youths aged 10 to 29.While direct correlation evidence is still being researched on, studies in America have shown that more than 90% of people who kill themselves suffer from depression have a substance abuse disorder or both. Suicidality and addiction share a high concordance relationship.
When we overlay the statistics with a physiological lens, we note that both groups of persons have been observed in studies to have a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis which essentially controls our body’s response to stress.
In a person with a normal functioning HPA axis, on the reception of a stressor, the hypothalamus in our brain instructs the secretion of the corticotropin-releasing factor (CRF) and vasopressin to stimulate our pituitary glands to produce the adrenocorticotropic hormone (ACTH).The ACTH, in turn, stimulates glucocorticoid synthesis and release (commonly referred to as cortisol) from the adrenal glands.This chain reaction provides a person the increased energy to handle the stress event and to do so without suffering from the pain and fatigue.When the stress event is gone, the body produces a negative feedback loop which then brings the body system back to homeostasis.
In a person exposed to a persistent or extreme level of stress, or in a person who frequently activates the HPA axis through substance use, the body starts to blunt the sensitivity of the HPA axis and blunt cell receptivity to cortisol in its efforts to return to and maintain homeostasis.This alteration to the sensitivity of the HPA axis affects our ability to tolerate physical and mental stresses and creates a need for a much bigger stimulus to activate the HPA axis (which may mean higher dosage of substance use); and when the HPA axis does react, produces a much bigger and exaggerated response (which may translate to more aggressive behaviours).
What Does This Mean In Practical Terms?
Many suicidal persons described having a voice in their head which is constantly there; telling them how much they need to seek fulfilment and comfort by reaching for the desired stimulus, whether it be a substance or a behaviour, of which one is killing themselves.Their mind starts to command them to constantly plan, to seek out and to take actions to soothe the unbearable lack that they are feeling.Eventually, the voice in the head goes from coaxing and persuading to being more intensive and aggressive towards the self to take immediate drastic actions.
The relief of death, a final refuge, becomes alluring and pleasurable and the fear of dying eventually transforms into the fear of not dying and becoming the loser, disappointment, and burden that they already believe themselves to be to their caregivers.This dual push towards drastic action and the need for an ever-increasing amount of substance in addicts leads to an increase in the risk level of suicidality.
What Can We Look Out For?
How then does the caregiver separate the wheat from the chaff amid the chaos that addiction has already wrought onto the family system to detect the risks of suicidality?
Below are some, though not exclusive, common markers to look out for. It is particularly useful to note changes in the content of the affected person’s expressions and any escalation or sudden extinction of intensity.
Intense Emotional Outbursts
Extreme Isolation or Withdrawal
The feeling of Being a Misfit in Every Way
Researching or Procuring Means of Suicide.
Self-Harm, Including Risky Substance Use or Behaviours.
Planning of Affairs.
Presence of Trigger Events
Loss of Primary Relationship.
Physical or Mental Health Conditions That Debilitate.
Abuse or Trauma Events.
What Can Caregivers Do On Observing The Signs?
Ask the Suicide Questions:
In the past few weeks, have you ever wished that you were dead?
In the past few weeks, have you felt that you or your family would be better off if you were dead?
In the past week, have you made plans about killing yourself?
Have you tried to kill yourself?
If the answers are yes to any or to all the questions, caregivers are encouraged to take the following first steps:
Be empathetic towards the suicidal wish.
The objective is not to agree with the act of suicide but to understand what has happened to lead the affected person to the conclusion that suicide is the only solution.
Find a genuine connection with the affected person.
However difficult that person might have been in your life, express what this person means to you personally and how the loss of this person would affect you.
Make a safety plan.
Ask the affected person to agree to not take or delay any action to harm themselves until they get to or you get them to professional help.
Professor Lisa Firestone observes that suicidal persons are generally ambivalent: a part of them wants to die but a part of them wants to live as well.There is often a process of the dividing up of the self within the person, between an aspect which is life affirming and engaging with the outer world; and the anti-self, which is self-critical, self-hating and ultimately suicidal.The key to recovery is to connect with and help strengthen that part of them that wants to keep on living.
6 Dazzi, T., Gribble, R., Wessely, S., & Fear, N. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299
Originating from the Greek word ‘wound’, trauma is used to describe the unwelcome recollection of disturbing experiences – those which can cause one to relive horrifying, spine-chilling moments of a disaster or a tragic event which leaves a deep mark on a person’s life.
Flashbacks can be particularly frightening for people with Post-traumatic Stress Disorder (PTSD), which is a delayed stress reaction, where an individual involuntarily re-experiences the mental and physical responses (i.e emotional, cognitive and behavioural aspects) that accompanied the past trauma. Symptoms can be particularly intrusive, presenting themselves in the form of nightmares and emotional distress upon remembering upsetting memories, and even certain physical reactivity after the exposure to traumatic reminders. Additionally, depending on the severity of one’s condition, the negative alterations in mood and behaviours may vary. Alterations may comprise of (non-exhaustive):
Exaggerated self-blame or others for causing the trauma, and a sense of invalidation
Decreased interest in activities
Increased irritability or aggression
Hyper-vigilance, excessive paranoia or heightened startle reaction
Difficulty sleeping or concentrating
Risky or destructive behaviour (can include the development of maladaptive coping strategies such as substance abuse)
A sense of isolation
Avoiding trauma-related stimuli / reminders of the traumatic event (including places, activities, people, thoughts or feelings that may bring back unwanted memories).
Unlike what most would perceive, PTSD does not solely affect individuals who have been through a tragic event personally. Apart from the direct exposure to a trauma, people can also develop PTSD through the witnessing of the event, or upon learning that a close one was exposed to the trauma. The indirect exposure to aversive details of the trauma in the course of professional duties (such as first responders or paramedics) can also make one prone to developing PTSD. With the effects lasting a lifetime for some individuals, PTSD can be debilitating to one’s mental health, robbing one of joy and freedom.
This is where Dialectical Behavioural Therapy (DBT) comes in. DBT is a comprehensive cognitive-behavioural treatment that can provide strong empirical support for individuals struggling with PTSD, Borderline Personality Disorder (BPD), Non-Suicidal Self-Injury (NSSI), and others. Intended to help persons with complex issues that place them at high risks of suicide or other self-destructive behaviours, DBT focuses on imparting the knowledge and skills to cope with PTSD and trauma reminders. Moreover, it also aims to assure the generalisation and application of skills learnt to the environment beyond the treatment setting, as well as to ensure that dysfunctional behaviours are not inadvertently reinforced. DBT consists of four stages, with the first two being the standard, essential stages for all clients.
Stage 1: Aiming to Achieve Better Stability and Behavioural Control
It is safe to say that most of the work is done at stage 1, where clients work hand-in-hand with their therapists to target behavioural dyscontrol and to address the chaos within them. When clients first take on DBT, they are often said to be at their lowest point in their lives. As such, stage 1 focuses on achieving control over life-threatening behaviours, therapy-interfering behaviours, as well as other factors that are causing a decline in their quality of life. At the same time, it will serve to increase one’s behavioural skills which can include mindfulness, interpersonal effectiveness , emotion regulation, distress tolerance and self-management. In short, this helps the individual to stabilise, and to reduce the frequency of impulsive and emotional outbursts.
However, stage 1 alone is insufficient. Although there are reductions in unwanted behaviours arising from the traumatic experience, these people may not have perfect control over their condition yet, and thus may still feel depressed, and anxious along with other PTSD symptoms.
In this stage, trauma-focused treatment is engaged, and past traumatic experiences are safely explored. Therapists will help clients to emotionally process them by approaching (gradually) the avoided trauma-related memories, as well as to help them continue applying the skills learnt in stage 1. With that said, the main objective of stage 2 is to discourage the client from silencing and burying the emotional pain.
Subsequently, this makes it easier for therapists to assess the severity of the problems, the relationships between the issues faced and to determine the hierarchy of needs based on the client’s goals.
Stage 3: Achieving Ordinary Happiness and Tackling Unhappiness
Upon ensuring that the individual is no longer suffocating under the same weight of fear that they once were, stage 3 aims to maintain progress and reasonable goal-setting. This establishes greater stability and addresses any other remaining problems in living. As the clients’ previous undesirable behaviours may have disrupted other aspects of their lives, stage 3 will also focus on improving relationships, and increasing valued daily activities.
Stage 4: Regaining the Capacity for Sustained Joy
Lastly, some people will choose to engage in stage 4 to find comfort in and to work towards spiritual fulfilment. This mainly helps to tackle any feelings of incompleteness as well as to ensure one’s capability to maintain an ongoing capacity for happiness.
DBT is an efficacious prototypic phase-based treatment of PTSD as it is a support-oriented approach to treatment, helping individuals to identify their own strengths and then building upon them to improve the person’s outlook on their life. By improving one’s ability to cultivate emotional regulation, increasing one’s ability to handle challenging emotions, and coping with conflict properly through interpersonal effectiveness, DBT can help traumatised individuals develop invaluable life skills that will allow them to achieve an overall improved quality of life.
Zimbardo, P. G., Johnson, R. L., & McCann, V. (2017). Psychology: Core Concepts (8th ed.). Pearson. (Accessed 22/11/2020)
Wagner, A. (2015). Applications of dialectical behaviour therapy to the treatment of trauma-related problems. Portland DBT Institute. https://adaa.org/sites/default/files/Wagner_MC.pdf (Accessed 22/11/2020)