There is a clear and open emphasis on the limits of behavior acceptable to the therapist and these are dealt with in a very direct way. The therapist should be clear about his or her personal limits in relations to a particular patient and should as far as possible make these clear to her from the start. It is openly acknowledged that an unconditional relationship between therapist and patient is not humanly possible and it is always possible for the patient to cause the therapist to reject her if she tries hard enough. It is in the patient’s interests therefore to learn to treat her therapist in a way that encourages the therapist to want to continue helping her. It is not in her interests to burn him or her out. This issue is confronted directly and openly in therapy. The therapist helps therapy to survive by consistently bringing it to the patient’s attention when limits have been overstepped and then teaching her the skills to deal with the situation more effectively and acceptably.
It is made quite clear that the issue is immediately concerned with the legitimate needs of the therapist and only indirectly with the needs of the patient who clearly stands to lose if she manages to burn out the therapist.
The therapist is asked to adopt a non-defensive posture towards the patient, to accept that therapists are fallible and that mistakes will at times inevitably be made. Perfect therapy is simply not possible. It needs to be accepted as a working hypothesis that (to use Linehan’s words) “all therapists are jerks”.
The Commitment to Therapy
This form of therapy must be entirely voluntary and depends for its success on having the co-operation of the patient. From the start, therefore, attention is given to orienting the patient to the nature of DBT and obtaining a commitment to undertake the work. A variety of specific strategies are described in the Linehan’s book (Linehan, 1993a) to facilitate this process.
Before a patient will be taken on for DBT she will be required to give a number of undertakings:
- To work in therapy for a specified period of time (Linehan initially contracts for one year) and, within reason, to attend all scheduled therapy sessions.
- If suicidal behaviors or gestures are present, she must agree to work on reducing these.
- To work on any behaviors that interfere with the course of therapy (‘therapy interfering behaviors’).
- To attend skills training.
The strength of these agreements may be variable and a “take what you can get approach” is advocated. Nevertheless a definite commitment at some level is required since reminding the patient about her commitment and re-establishing such commitment throughout the course of therapy are important strategies in DBT.
The therapist agrees to make every reasonable effort to help the patient and to treat her with respect, as well as to keep to the usual expectations of reliability and professional ethics. The therapist does not however give any undertaking to stop the patient from harming herself. On the contrary, it should be make quite clear that the therapist is simply not able to prevent her from doing so. The therapist will try rather to help her find ways of making her life more worth living. DBT is offered as a life-enhancement treatment and not as a suicide prevention treatment, although it is hoped that it may indeed achieve the latter.