On the occasion of Mental Health Day, Dr. Luis Alvarez, psychiatrist and child psychiatrist at the American Hospital in Paris, explains the benefits of “dialectical behavioral therapy” (DBT). A psychotherapy used today in 23 countries and almost unknown in France.
Paris party. He uses Dialectical Behavior Therapy (DBT) to treat his patients. How did you discover this form of psychotherapy?
Dr. Luis Alvarez. I follow many pregnant women with borderline personality disorder at American Hospital. With my team I noticed that we managed to stabilize the patient’s mood during her pregnancy, but that our care systems (psychotherapy, pharmacology) were very insufficient after the birth of the child (postpartum), and in the relationship with the child. So I looked for other methods and thus discovered that the TCD was especially indicated in this difficult-to-treat pathology. I have been using this therapy with my patients for four years and I would not go back for anything in the world!
In what other pathologies is this therapy indicated?
DBT also treats anxiety and mood disorders (including major depression and bipolar disorder), post-traumatic stress disorder, addictions, eating problems, and attention disorders. It is not effective in cases of autism or psychosis.
It is not the unconscious that leads the dance, it is the emotion!
Can you explain how this psychotherapy is a different approach from psychoanalysis or cognitive behavioral therapies?
DBT is part of the “third wave” therapies, in which emotion plays a central role. The paradigm shift is here. For psychoanalysis, it is the unconscious life that governs us. For second-wave cognitive-behavioral therapies, it’s thinking, cognition. For DBT, third wave behavioral therapy, it’s emotion that leads the dance! This therapy treats “emotional dysregulation”.
Psychoanalysis is a great tool, but it is insufficient
What do you mean by “emotional dysregulation”?
It is the mechanism by which an intense emotion (hyperemotivity) is activated, making the person suffer terribly, without having any connection, however, with the reality of the facts. For example, a person having a panic attack is convinced that she is going to die when there is no real event that corresponds to this emotion. The problem is that dysregulated emotion will produce dysregulated thinking, which will lead to problematic behaviors in the person over time, making the situation worse. Psychoanalysis is a formidable tool for self-knowledge, but it is insufficient. It is not because one is doing the archeology of his past that one stops being emotionally activated. By treating this difficulty or inability to manage their emotions and behaviors, despite efforts, DBT first relieves the person of their suffering, which then allows them to learn to suffer no more. That is why this therapy is very effective!
The patient must be the actor of his day of care, he is the one who has the power
How’s the therapy going?
It is a very structured device, scientifically validated and supported by a team of therapists. Includes individual and group therapy sessions and telephone coaching. It is a true investment of the care relationship because the patient must be the actor of his journey. Therapists pass on a series of tools, but it is the patient who has the power. During a first phase, which lasts between six and twelve months, patients are oriented towards getting out of suffering and gaining quality of life. They learn, according to their needs, the emotional regulation skills that they did not acquire during childhood. They apply techniques to silence the sympathetic system (which activates emotions) and enhance the parasympathetic system (which allows us to focus, find solutions). It’s neuroscience applied to everyday life! When an anxious person says, “I felt the emotion come to life, but this time I got over the panic attack,” they are really experiencing it as a revelation. When an 8-year-old boy, whose behavior terrified his family and his class, comes into a consultation and tells me, “I am no longer a slave to anger,” it is very moving.
In Germany, this therapy is developed and even reimbursed
What is the second phase of care?
Second, in individual therapy we deal with everything traumatic. We build with the patient new ways of functioning that replace the problematic behaviors forged over time. We accompany him towards the achievement of his goals, that is, towards what gives meaning to life. While the patient suffered from anxiety attacks, avoidance, alcoholism or scarification, it was very difficult for him to achieve his goals. That is why he is first taught not to lock himself in suffering.
Why is this care device, established in particular in the United States, the United Kingdom and Germany, not developed in France?
First, the institution that oversees the certification of doctors and therapists, based in Seattle, is very demanding. Training is arduous and represents a cost. So, France is still very suspicious of the Anglo-Saxon world. There are obstacles of a cultural nature in the conception of mental care, which is still, in our country, mostly psychoanalytic. The movement of cognitive and behavioral therapies has grown in the last forty years, but we are lagging behind the most recent, those of the “third wave”. In Germany, this therapy is developed throughout the country and is even reimbursed by social security! I find it regrettable that in France, suffering patients are deprived of a scientifically validated method.
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