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Introducing Dialectical Behavioral Therapy into the Wilderness

By Meghan Vivo

It’s your first time rock-climbing. The harness is strapped tightly around you; you tug on the ropes, you know you’re safe. You reach your right hand up to a crevice between two large boulders. You lift your left foot to rest on a neighboring arch in the rocks below. Slowly, your arms and legs heave your body weight up onto the rocks, far above solid ground. Your heart pumps faster, you begin to sweat. Though you know you’re safe, there’s a lingering nervousness deep within your stomach. You’ve never felt so alive.

Rock-climbing and other outdoor adventure activities are exhilarating. Why? Every second, you’re using your five senses to take in the experience – the smell of fresh air, the look and feel of the rocks below, the sound of your heart pounding beneath your skin – and your attention is focused on the task at hand, and nowhere else. This “mindfulness” is just one skill that is emphasized in dialectical behavioral therapy (DBT). These interactive, “in the moment” experiences also are a hallmark of wilderness therapy, which is why some wilderness programs are utilizing DBT in their work with troubled teens.

One such program, SageWalk the Wilderness School, located in central Oregon, helps teens aged 13-17 address issues like depression, substance abuse, attention deficit, and anger management in the wilderness setting. The first of its kind to incorporate dialectical behavioral therapy into a wilderness program, SageWalk therapists train students to cope with difficult emotions not by turning to substance abuse, eating disorders, or other destructive behaviors, but by utilizing the four DBT skill sets – mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. Four DBT-trained therapists from SageWalk sat down with us to discuss DBT and its role in the wilderness setting.

What is DBT?

Dialectical behavioral therapy is a comprehensive treatment approach that combines cognitive and behavioral therapies to teach people to express their emotions in a positive way. Originally developed by Marsha M. Linehan to treat borderline personality disorders, DBT traditionally has been used in hospital settings, detention centers, and substance abuse treatment facilities.

The main premise of dialectic theory is that problems happen when people see the world in polar opposites – right or wrong, happy or sad, drunk or sober. DBT seeks to bring all extremes to a balanced center and help people find a healthy middle ground using the following skills.

“Mindfulness is about being in the here and now,” explains Laurie Wilmot, a therapist at SageWalk. “In any given moment, teens are taught to observe, describe, and participate in what’s going on around them in a non-judgmental way.” For example, a teen might observe himself putting up a tent and describe the situation in factual terms (“My hands are sweating” or “The tent has four poles”) rather than emotional or judgmental terms (“I’ll never get this right”). By paying attention to detailed facts rather than “zoning out” or jumping to conclusions, he is actively participating in the experience.

When people become agitated or angry, it becomes more difficult to live in the moment and observe without judgment or emotional reaction. It’s easier to argue and fight back than to listen attentively. “If we notice we are feeling angry and then judge the anger as a bad emotion to feel, we are more likely to react negatively to it by acting out with destructive behavior. If we do not judge the anger, we are more likely to experience the emotion until it dissipates. Through conscious breathing, listening to music, practicing yoga or meditation, doing one thing at a time, and letting go of distractions and worries, people deepen their awareness of being alive and are able to relax and gain emotional clarity,” states Wilmot.

Research has shown that mindfulness practice significantly improves emotional functioning. Through mindfulness exercises, teens realize that a new behavioral choice can dramatically affect the way they feel and relate to other people. According to Wilmot, “DBT teaches that every person has a ‘reasonable mind’ that is logical and fact-driven; an ‘emotion mind’ that is highly charged and irrational; and a ‘wise mind’ that integrates the two and incorporates an intuitive sense of truth and ‘knowing’ the right thing to do. Everyone can achieve wise mind if they learn to manage their emotions and stop judging themselves.”

“Adolescents in stressful situations often become consumed by emotional extremes, going from excited to depressed, angry to withdrawn,” observes Trudy Godat, a therapist at SageWalk. “DBT encourages teens to regulate their emotional experience by getting off the emotional see-saw and taking time to think before they react.”

In general, an emotional experience begins with something that “triggers” an emotional response. One emotion can launch a series of secondary emotions, such as when fear triggers anger and then anger triggers shame or sadness. Once a triggering event occurs, our brains interpret what that trigger means. For example, seeing two of your friends talking to each other won’t elicit an emotional response, but interpreting the event to mean your friends are talking about you will likely elicit anger.

Emotional responses are exacerbated by stressors or vulnerability factors like inadequate sleep, financial problems, overworking, lack of exercise, consuming too much caffeine or junk food, and so on. In many cases, we follow up on an emotional response with facial and postural expressions, actions, and words, which usually intensify the emotional experience. However, it is possible to consciously reduce negative triggers and vulnerabilities by developing a healthy lifestyle, cultivating positive relationships, problem-solving, planning enjoyable events, working toward personal goals, and taking a positive outlook on life.

“Emotions motivate us to act, in both healthy and unhealthy ways,” states Godat. “The more we face difficult emotions rather than running away or turning to a destructive behavior, we can become confident in our ability to regulate our emotions. For teens who have never tried to experience negative emotions without running away, these skills can take time and support to learn.” For this reason, it is extremely valuable to learn DBT skills from experts in a therapeutic environment like a boarding school, residential treatment center, or wilderness camp.

Distress tolerance is about getting through a difficult situation without making it worse. Pain and distress are an inevitable part of life. The sooner a person accepts this reality, the less they will fight against it. Of course, this doesn’t mean it is wise to stop trying to make situations better and resolve conflicts. It simply means choosing your battles carefully and preserving your strength for the battles you can actually win.

“Most of teens’ destructive behaviors are an attempt to escape from painful feelings and memories,” notes Meghan Flaherty, a therapist at SageWalk. “While students are doing the hard long-term work of addressing their substance abuse, depression, defiance, and other harmful behaviors, DBT encourages healthy distractions like listening to uplifting music, finding hobbies, counting to ten, or taking a short vacation from your worries by reading or resting for 20 minutes. At SageWalk, we show kids that community service, an act of kindness, and even watching the news to remember the struggles of people less fortunate are actually tools they can use to tolerate difficult situations in healthy ways.”

Therapists that use DBT also teach patients to evaluate the pros and cons of a given situation and to find meaning in their suffering. What provides the most benefit in the long run – using drugs and alcohol or finding a healthy distraction? Even though a drug may offer immediate relief, the benefit is temporary and you inevitably feel more depressed and hopeless afterward. Instead of seeking instant gratification, patients learn to predict negative consequences and feelings, and to anticipate feeling proud and hopeful when they successfully try a more productive approach.

“In a world where teens are always looking to be instantly gratified by the next best thing or the newest gadget, being in the wilderness slows down their world so they can learn to appreciate the small things like a good cup of oatmeal or shelter from the rain. They master basic skills, get their endorphins pumping from physical activity, and actually begin to feel better both physically and emotionally,” says Flaherty.

Dialectical behavioral therapy recognizes the importance of interpersonal relationships to people struggling with depression, substance abuse, and other behavioral problems. “DBT teaches teens how to ask for what they need, how to say no, and how to cope with conflicts with parents and peers,” explains Sandy MacDonald, Clinical Director at SageWalk. “Using DBT skills, we help teens reach their goals without damaging their relationships or losing self-respect.”

Through assertiveness training, DBT therapists help people determine when to say yes and when to say no, and offer guidance on how to accomplish their goals. DBT teaches people to gently and calmly communicate their feelings and make requests, while taking into consideration the other person’s interests and needs. In order to avoid damaging the relationship, people learn to avoid attacks, threats, or judgments and to show a genuine interest in the other person’s point of view. To maintain self-respect, DBT trains people to be fair to themselves and the other person, avoid excessive apologies, stay true to their values, and be honest about their needs and feelings.

DBT in Action

SageWalk is one of the first programs to introduce these four DBT concepts into the wilderness setting. Used in combination with cognitive behavioral therapies, the Stages of Change by Prochaska and DiClemente, and the 12 Steps, DBT is a highly effective method of reaching out to troubled teens.

“In traditional talk therapy, kids sit down with a counselor one hour a week and try to understand why they have a problem. But these teens also need real-life skills that will actually solve those problems. If you dig up painful feelings without learning the skills to cope, you’re more likely to use drugs or act out to numb the pain. That’s where DBT comes into play,” says MacDonald.

DBT teaches skills that are well-suited to the wilderness setting. At SageWalk, therapists walk each student through a chain analysis of problem behaviors. If a teen yells at the field staff, throws a log, or runs away from camp, a therapist begins an immediate chain analysis by asking detailed questions about what triggered that behavior and what techniques he or she could have used to respond differently.

“DBT is a great tool to help teens learn life skills in the wilderness,” says Flaherty. “By taking kids out into the wilderness where they are exposed to the elements and a new peer group, we can figure out how each teen deals with stressful situations. Teens are used to their parents, friends, and therapists at home responding to their problem behaviors in a certain, predictable way. At SageWalk, our wilderness instructors catch them off guard by taking a different approach than traditional talk therapists. In the field, our staff can call out problematic behaviors and provide specific instruction on healthier ways to resolve conflicts right on the spot.”

Through group skills sessions and one-on-one support, SageWalk therapists help teens get better control over the behaviors that are destroying their lives. At SageWalk, parents learn the same skills as their teens, so when their child returns home, they’re speaking the same language. Through parent workshops, parents learn how to model and reinforce positive behaviors and DBT skills like emotional regulation and distress tolerance. Rather than starting an argument by simply saying yes or no to a request, they can open a dialogue about the rationale behind a given rule or opinion. Using DBT, parents and teens learn to take a break when they are angry and find ways to avoid making difficult situations worse.

With programs lasting up to two months, SageWalk provides initial skills that students can build upon at home or at a boarding school or residential treatment center. “It all starts with getting teens committed to their own treatment,” says Wilmot. “When teens arrive at SageWalk, they often are rebellious and defiant and need a wake-up call to realize they have a problem, and that’s what wilderness provides. When teens are thrown into a completely new environment, they are forced to think of things in a new and different way. By building their confidence and motivation and then providing them with skills to achieve their goals, teens learn positive techniques they can use at home or in the next stage of treatment.”

Since introducing dialectical behavioral therapy into the SageWalk curriculum, the feedback has been overwhelmingly positive. According to a survey, students felt they were able to successfully learn and apply problem-solving and emotional regulation skills over an 8-week period. For more information about SageWalk and wilderness therapy, please call (800) 877-1922 or visit www.sagewalk.com.