Acceptance & change: DIALECTICAL strategies

Balance acceptance and change; teach patient to be dialectical1 therapeutic relationship: be aware of dialectical tensions

2 in all interactions, teach and model dialectical behaviour patterns

Acceptance & change: DIALECTICAL strategies

Dialectical strategies

1 Entering the paradox

Eg koansRefuse to step in with logical explanation to allow the client to step out of the struggle‘Both-and’ not ‘either-or’

Dialectical strategies

2 Using metaphor

Stories are easier to rememberMetaphors can communicate difficult stuff-e.g. the effect of client’s behaviour on othersUseful metaphors: marathon not sprint; rescuing vs visiting; use e.g.s from client’s interestsKeep a metaphor book

Dialectical strategies

3 Devil’s advocate

Therapist presents thesis (extreme maladaptive belief)Client presents antithesisEg T:‘if you offend anyone it is a mortal catastrophe. You should be deported form the country and all your assets seized’ C:’ well, I’m not that bad’

Dialectical strategies

4 Extending

Take the patient more seriously than she takes herselfTake anticipated consequences literally then respond to seriousnessE.g. ‘I see, you really can’t carry on with DBT, we must take that seriously…do you think we really need to consider ending therapy?’

Dialectical strategies

5 Activating wise mind

Convince client she can do thisCan use ‘Well’ metaphor/floating on cloud/etc ‘What do you know in your wise mind to be true/right?’

Dialectical strategies

6 Making lemonade out of lemons‘I got the sack’‘Wow now we have a chance to practise distress tolerance big time’‘was (the homework) hard?‘yes’‘good, now we know you can do hard things’

Dialectical strategies

7 Allowing natural change

Change, development and inconsistency are inherent in any environment and are allowed to proceed naturallyThe client is encouraged to learn to tolerate and adapt to change rather than keep environment stable

Dialectical strategies

Dialectical assessment

?is the problem a fatal flaw in the client or a fatal flaw in the social fabric?Be aware of the oppressive/problem-producing nature of some therapeutic rules, styles and systems

Dialectical Skills

Enter the Paradox (both – and)MetaphorsLemonade out of Lemons (what a great opportunity….)Devil’s Advocate (you may find this too difficult...)Extending (this is serious – perhaps we/you should..)Wise Mind (taking both your emotions and knowledge, what do you know in your gut/heart to be right?)

STYLISTIC STRATEGIES

Reciprocal style: responsiveness

staying awakeconsidering the client’s agenda, clients’ desired session content.

STYLISTIC STRATEGIES

Self-disclosure

orient patient to what types of self-disclosure will occur from the therapist self-involving self-disclosure (reactions to patient, heart to heart, ‘when you do X I feel Y’) personal information: qualifications, experience

STYLISTIC STRATEGIES

Warm engagement:

observing limits

coping with rage at the patient

use of touch

STYLISTIC STRATEGIES

Genuineness

Being a ‘real’ therapistHaving a ‘real’ relationshipBe yourself

STYLISTIC STRATEGIES

Vulnerability

This is a high-power-low-power relationshipBecause the therapist could not bear to be more/equally vulnerable than clientAlso, because the focus must be on the client

STYLISTIC STRATEGIES

Irreverent style: 1 reframing (in unorthodox manner)E.g. ‘so, what you’re saying is that you’d rather suffer from anxiety for the rest of your life than do this one hard thing? 2 where angels fear to treadE.g. ‘I’m sorry, we just have no success with corpses’

STYLISTIC STRATEGIES

Irreverent style (contd)3 confrontational toneE.g. so what the hell have we been doing all these months? 4 calling patient’s bluff e.g. ‘OK so I am no good as a therapist, perhaps you should sack me?’

STYLISTIC STRATEGIES

Irreverent style (contd)5 Intensity and silenceE.g. look long at client and say nothing 6 omnipotence and impotenceE.g. ‘that can always be sorted’Or ‘well I am completely helpless here’

Environmental intervention (consultation to staff/the wider care system): keep to minimum; do only when patient is unable, when environment is high power, to save life, when humane, when minor issue.

Consultation to the patient strategies: effective self-care, decrease ‘splitting’, how to manage other professionals.

Consultation to the therapist: consult group: meeting agenda, consultation agreements, cheerleading, dialectical balance, staff splitting, unethical behaviour, confidentiality.

CASE MANAGEMENT strategies

CONSULT GROUP: APPLYING DBT WITH OURSELVES

Environmental events and context are just as important in shaping therapeutic behaviour as in shaping clients’ behaviour, laws of human behaviour apply to us as well!

Consult Group Agreements

Dialectical agreement; consultation to the client; consistency; observing limits, phenomenological empathy; fallibility.

Consult Group Agreements

Dialectical agreement; consultation to the client; consistency; observing limits, phenomenological empathy; fallibility.

Consult Group Agendas:

Supervision Meeting:

MindfulnessProblems with treatment, review at least one caseSkills trainers tell individual therapists what skills being taught and individual issues in skills trainingChain Analysis of lateness/absenceInstitutional limits on client behaviour.Staying DBT adherentReview an aspect of DBT

Business Meeting

MindfulnessClient trackingNew referralsAllocationAuditService issues (referral criteria)Managing the wider system]

Consult Group Cheerleading

Therapist demoralisation: seeing the wood for the trees

Hopeless thoughts

Validation and problem solving therapist mistakes.

Providing Dialectical Balance

Applying DBT strategies with one another

Over-protectiveness, rage, validate and reframe

‘Staff Splitting’

Arguments among staff are seen as failures in synthesis

Staff splits staff, client does not

Become aware of what precipitates disagreement and of ‘wave patterns’ of attachment

Unethical or Destructive Therapist Behaviour

Minimum levels of competence, ethics and non-defensiveness not met: elephant in the room

Confidentiality

Therapist disclosures are confidential to consult group

Case discussion may be disclosed judiciously to client