DBT Assumptions about Patients

In Marsha Linehan's Cognitive-Behavioral Treatment of Borderline Personality Disorder (The Big Red Book of DBT), there are eight assumptions about patients and therapy; the DBT assumptions about therapy will be discussed in an upcoming post.  This section can be found on pages 106 to 108 of the Big Red Book of DBT.  

Shari Manning and Kelly Koerner have published that there are seven assumptions about clients and many DBT assumptions about therapy, so right now we'll focus on the DBT assumptions about the patient or client.  Before we look at the assumptions, let's look at the terms.

To clarify, assumptions are not facts, so these assumptions might not fit with every client 100% of the time.  They do, though, set the context for the for treatment planning (Linehan, 1993, p. 106).  

Also, the terms in the Big Red Book (1993) and the Skills Training Manual (the Little Red Book; 1993) differ in how the text refers to the individual in treatment.  The Big Red Book uses the term patient, while the Little Red Book uses the term client.  To address this, Marsha Linehan's response in the Skills Training Manual is that "a case can be made for using either term" (1993, p. 7).  In this blog, the terms will be left as they were written by the author.  While this can be confusing to have inconsistencies, I would like for the author's direct terms to be left intact. 

First, patients are doing the best they can.  This is why the terms resistant and self-sabotaging are not used to describe the patient.  Metaphorically, individuals with borderline personality disorder can be described as having very thin emotional skin or having third degree burns, so the slightest touch, be it criticism or general comment, can be very painful.  This heightened sensitivity can lead to pain and suffering, so they look for something to deal with these emotions, thoughts, and physiological responses.  

"In my experience, borderline patients are usually working desperately hard at changing themselves.  Often, however, there is little visible success, nor are the patient's efforts at behavioral control particularly obvious much of the time.  Because their behavior is frequently exasperating, inexplicable, and unmanageable, it is tempting to decide that they are not trying. . . The tendency of many therapists to tell these patients to try harder, or imply that they indeed are not trying hard enough, can be one of the patient's most invalidating experiences in psychotherapy" (p. 106).  

Second, patients want to improve. "Assuming that patients want to improve, of course, does preclude analysis of all factors interfering with motivation to improve. . . The assumption by therapists that failures to improve sufficiently or quickly are based on failure of intent, however, is at best faulty logic and at worst one more factor that interferes with motivation (Linehan, 1993, p. 106).  

Kelly Koerner adds that the first two assumptions, that patients are doing the best they can and they want to improve, "lead us back to examine factors that interfere with needed behaviors" (Koerner, 2012, p.23). 

Third, patients need to do better, try harder, and/or be more motivated to change.  "The task of the therapist, therefore, is to analyze factors that inhibit or interfere with a patient's efforts and motivation to improve, and then to use problem solving strategies to help the patient increase her efforts and purify (so to speak) her motivation" (Linehan, 1993, p. 107).

How do we do this?  We can help them stay motivated through reinforcement and validation; coaching the patient to self-validate and find skillful ways to reinforce himself/herself is a way for the patient to build mastery and work toward the life worth living goals.

Fourth, patients may not have caused all of their own problems, but they have to solve them anyway.  "A borderline patient has to change her own behavioral response and alter her environment for her life to change. . . Improvement will not result from the patient's simply coming to a therapist and gaining insight, taking a medication, receiving constant nurturing, finding the perfect relationship, or resigning herself to the grace of God.  Most importantly, the therapist cannot save the patient. . . Surely if we could save patients, we would save them" (p. 107).  

Fifth, patients' lives are unbearable as they are currently being lived.  "Given this fact, the only solution is to change their lives" (Linehan, 1993, p. 107).  What do we do with the knowledge that his or her life is unbearable?  We look at the dialectic, acknowledge that it is unbearable, and work together about how to make it bearable (Manning & TIC, 2013).

Sixth, patients must learn new behaviors in all relevant contexts.  "Times of stress are the times to learn new ways of coping" (p. 107).  

Seventh, patients cannot fail in therapy.  "When patients drop out of therapy, fail to progress, or actually get worse while in DBT, the therapy, the therapist, or both have failed" (p. 108).  Prior to Stage 1 treatment, the client makes a commitment to therapy for a specific number of months.  

Dropping out is the only way for a client to leave DBT.  If the client misses four individual sessions or skills group sessions in a row, the Four Miss Rule comes into effect.  So as therapists, we need to motivate and encourage the clients to come back to group.  Participating in group and individual therapy is often mentally and emotionally taxing.  Look for creative ways to keep the clients and therapists motivated.  

Marsha Linehan's eighth DBT assumption about patients and therapy is that therapists treating borderline patients need support.  We will look into this in an upcoming post.