The Importance of the Experienced DBT Therapist
The success of treatment is dependent on the quality of the relationship between the patient and therapist. The emphasis is on this being a real human relationship in which both members matter and in which the needs of both have to be considered. Linehan is particularly alert to the risks of burnout to therapists treating these patients and therapist support and consultation is an integral and essential part of the treatment. In DBT support is not regarded as an optional extra. The basic idea is that the therapist gives DBT to the patient and receives DBT from his or her colleagues. The approach is a team approach.
The therapist is asked to accept a number of working assumptions about the patient that will establish the required attitude for therapy:
- The patient wants to change and, in spite of appearances, is trying her best at any particular time.
- Her behavior pattern is understandable given her background and present circumstances. Her life may currently not be worth living (however, the therapist will never agree that suicide is the appropriate solution but always stays on the side of life. The solution is rather to try and make life more worth living).
- In spite of this she needs to try harder if things are ever to improve. She may not be entirely to blame for the way things are but it is her personal responsibility to make them different.
- Patients can not fail in DBT. If things are not improving it is the treatment that is failing.
In particular the therapist must avoid at all times viewing the patient, or talking about her, in pejorative terms since such an attitude will be antagonistic to successful therapeutic intervention and likely to feed into the problems that have led to the development of BPD in the first place.
Linehan has a particular dislike for the word “manipulative” as commonly applied to these patients. She points out that this implies that they are skilled at managing other people when it is precisely the opposite that is true. Also the fact that the therapist may feel manipulated does not necessarily imply that this was the intention of the patient. It is more probable that the patient did not have the skills to deal with the situation more effectively.
The therapist relates to the patient in two dialectically opposed styles. The primary style of relationship and communication is referred to as ‘reciprocal communication’, a style involving responsiveness, warmth and genuineness on the part of the therapist. Appropriate self-disclosure is encouraged but always with the interests of the patient in mind. The alternative style is referred to as ‘irreverent communication’. This is a more confrontational and challenging style aimed at bringing the patient up with a jolt in order to deal with situations where therapy seems to be stuck or moving in an unhelpful direction. It will be observed that these two communication styles form the opposite ends of another dialectic and should be used in a balanced way as therapy proceeds.
The therapist should try to interact with the patient in a way that is:
- Accepting of the patient as she is but which encourages change.
- Centered and firm yet flexible when the circumstances require it.
- Nurturing but benevolently demanding.