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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 4 of 4. This is the beginning of the thread.
Posted by terrics on October 24, 2004, at 11:35:40
This is a question I really need answered by an unbiased person. In DBT irreverence is used quite frequently. Why would something like that work if we have spent our whole lives being subjected to it? Do you have personal experience with DBT? I cannot figure out how it could work, but it is my last ditch effort to getting well. Then I am giving up, really giving up. If you answer, thanks. terrics
Posted by gardenergirl on October 24, 2004, at 16:01:50
In reply to gg, DBT, posted by terrics on October 24, 2004, at 11:35:40
Hi terrics,
I'm glad you asked. I just attended a workshop on DBT with Eating Disorders that was very helpful. I don't have much experience with using it. I've used some elements of it in treatment with some clients, but unfortunately, I have not worked somewhere where there was a DBT experienced supervisor available.This is probably more than you are looking for, but here are some statements about DBT that made me think of you, as well as others on this board who have experienced it.
In no particular order: (and stuff is from the workshop presented by Lucene Wisniewski, Ph.D and also from Linehan's "Cognitive Behavioral Treatment of Borderline Personality Disorder".)
"DBT Assumptions about Patients" (Wisniewski)
-Pts are doing the best they can.
-Pts want to improve.
-Pts must learn new behaviors in all relevant contexts.
-Pts cannot fail in DBT.
-Pts may not have caused all of their problems, but they have to solve them..."DBT Assumptions about Therapy"
-It's caring for the T to help pts change in ways that bring them closer to pts own goal.
-Clarity, precision, and compassion are of the utmost importance in the conduct of DBT.
-The therapeutic relationship is a real relationship between equals.
-Behavioral principles are universal...they affect T too.
-Therapists need support.
-DBT therapists can fail.
-DBT can fail even when T's do not.I really liked these reminders. I think it's healthy for the T to see this and become more aware of the power differential. DBT seems to work to decrease that power differential by making the T and the pt more equal partners in the process and by showing that the T can be just as affected by the process and by behavior principles as the pt.
Regarding your question about irreverance and how it happened throughout your life...I am wondering if perhaps your T is not using irreverence in a skilled manner. Perhaps it is feeling like replaying an invalidating environment for you, which according to Wisniewski's workshop "pervasively negates or dismisses behaivor independent of the actual validity of the behavior."
Whereas irreverence, which is used "(1) to get the pt's attention, (2) to shift the pt's [emotional] response, and (3) to get the pt to see a completely different point of view. It is used whenever the pt, or both the pt and the T are 'stuck' in a dysfunctional emotional, thought, or behavioral pattern." (Linehan, pg.393).
Continuing from Linehan...To be effective, irreverence must have two components: 1) It must be genuine, coming from the T's center (and from this I infer that the T must be in a centered place during therapy...this can take effort, depending on each T), and 2) it must "be built on a bedrock of compassion, caring, and warmth."
Irreverent communication versus reciprocal communication, which is the more empathic and in tune with the client in the moment kind, is one of the "dialectics" of DBT. Dialectical means that two "opposites" are both true at the same time. So there needs to be a balance of both irreverent techniques, designed to challenge or catch the client off guard, and reciprocal techniques, designed to communicate validation and acceptance.
One thing I liked that Dr. Wisniewski said more than once was the word "And". She talked about how clients are doing the best they can AND they need to do better. This holds true for the T as well, which is why DBT also contains a consultation for the T component. This is really important, as it helps challenge the T on his or her own behaviors. The consultation team can use irreverent and reciprocal communication to the T to accomplish similar things...i.e. if the T is getting "stuck" in one way of thinking, the team may use irreverence to "push" the T into re-thinking and re-framing.
Is this making sense? From what I remember of your comments about your own experience with DBT, terrics, my sense is that your T uses irreverence in a non-therapeutic way, perhaps. In Linehan's book on pg. 394, there is a table which is a "checklist" for using irreverent communication. I won't re-type all that here, but at the bottom are three "Anti-DBT tactics". I thought were good to see written out, too.
-T uses irreverent communication in a mean-spirited way.
-T uses irreverent communication without awareness of effects on pt.
-T uses irreverent communication in a stilted or rigid manner.Do any of these resonate with you? I hope not, but I know you have been really unhappy with DBT so far. Is your T formally trained in DBT? What kind of supervision does she have?
Sorry so long...I get excited about these concepts. :)
Let me know if you have more questions.
gg
Posted by corafree on October 25, 2004, at 0:39:26
In reply to Re: gg, DBT (long and packed with quotes), posted by gardenergirl on October 24, 2004, at 16:01:50
Hi gg!
I went to see my DBT therapist, as do every Weds. I was very sad over three+ issues worrying about. As time was runniing out, my T, upon arising from her chair, and I mine, looked at me and w/ a slight weird smile said, "you need to toughen up!" It didn't hit me until 5m later what she'd said. Then, I became angry. I asked to speak to the director. Director not there. Asked to speak to my therapist, but busy w/ her next client. My group begins an hr after individ. therapy, so one of my group leaders, the most kind and seriously caring professional I've met there, said I could speak with her.
I told her how invalidated I felt when she said, "you need to toughen up", w/ her crooked smurk. She said, "I understand how you must feel." I said, yes, it was like having someone say to you, after the death of a loved one, "you'll get over it." And she nodded, yes, that she agreed.
Tomorrow is Mon morn and as of yet, I have not spoken w/ my T or the director. This is the first time (been in individ. therapy maybe 8 wks, group I think 4 wks) she has straight out been disrespectful of my feelings. I must speakup re: my feelings, but wonder if I should go straight to the supervisor.
Your post was very, very helpful. I knew that the relationship was to be one of a kind and caring one, and my T leans a bit away from that, not way away, but a bit.
I've been in regular 'talk about the goings-ons therapy' before and have had very poor, nonempathetic, therapists; and wonderful empathetic therapists.
This is my first experience with DBT and I was so looking forward to something that might just work.
At the time of this visit, I had asked her about seeing another therapist to just 'talk about the goings-ons' in my life; as my therapist and I concentrate on dissecting one issue into its emotion and function. She said that is not ethical.
Any feedback for my thoughts? tks cf
Posted by terrics on October 25, 2004, at 21:30:59
In reply to Re: gg, DBT (long and packed with quotes), posted by gardenergirl on October 24, 2004, at 16:01:50
Thanks GG, I will explain further when I am not so tired. Good Night. terrics
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