Reflecting on DBT Assumptions about Patients and Therapy (Part 2)

June 10, 2019
CATEGORY: DBT Assumptions

“The most important thing to remember about assumptions is that they are just that—assumptions, not facts.”

Cognitive Behavioral Therapy for Borderline Personality Disorder; Marsha M. Linehan, Ph.D, 1993

This feature by Vibh Forsythe Cox, PhD is Part 2 in a series of four blogs about DBT assumptions. In DBT, we adhere to several assumptions that help us organize our behavior towards our clients. In this second part, we take a closer look at two of the assumptions about patients with Borderline Personality Disorder and therapy described in the treatment manual: that patients want to improve and that patients need to do better, try harder, and be more motivated to change.

As a Training and Development Specialist for Behavioral Tech Institute, I frequently field questions from people who are just learning about DBT. In the learning phase, we are often working through how our core DBT assumptions affect how we treat our clients.

In the first part of this series, we took a closer look at the assumption that patients are doing the best they can. This is the first assumption, and you can go back and read it here to familiarize yourself with it. Now let’s move on to our second assumption.

Patients Want to Improve

“The second assumption is a corollary to the first, and is similar to the assumption therapists and crisis workers make with suicidal patients: If they are calling for help, they must want to live. Why else would they call? [Patients with borderline personality disorder] are so used to hearing that their behavioral failures and difficulties with therapeutic interventions stem from motivational deficits that they begin to believe it themselves.
Assuming that patients want to improve, of course, does not preclude analysis of all of the factors interfering with motivation to improve. Fear- or shame-based inhibition, behavioral deficits, faulty beliefs about outcomes, and factors that reinforce behavioral regressions over improvement are all important. 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.”

Cognitive Behavioral Therapy for Borderline Personality Disorder; Marsha M. Linehan, Ph.D, 1993

In my opinion, there is a theme among the assumptions. The theme is that these assumptions orient the therapist toward a position that will help them stay alert to continuing to fight alongside the client instead of getting polarized and finding themselves on the other side of a perceived tug of war.

Even worse than the tug of war itself may be the potential consequence that the therapist ends up feeling frustrated and resentful toward the client. The assumption that patients want to improve is an important foothold in the climb away from the pitfalls of believing that people are seeking treatment in order to get attention or that they enjoy their own suffering.

I have heard people talk about suicide attempts and self-harm as being “cries for help,” and I have always wondered: if someone is crying for help, why wouldn’t we answer them? Also, why would they be crying for help if they did not want help?

When I have heard therapists say of their clients “they don’t want to get better,” I have conceptualized this as an escape thought on the part of the therapist. It is a way to help get relief from the fear that our efforts may not be enough to help someone see and walk the pathway out of their own suffering and that we might lose them in that wilderness. If it were really the case that the client didn’t want to get better, then we would have permission to stop fighting to help them find a way out. Our hopelessness would be explained, and our guilt would be absolved.

Much of this treatment relies on careful behavioral assessment. As sharp as we may be as therapists, we cannot assess intent even if clients say they do not have motivation or aren’t trying their hardest.

Many of us understand confirmation bias and the threat it poses to the scientific method. We talk about how DBT is a treatment that is based in the principles of behavioral science. For this reason, it is important that we attend to and address the potential for bias in our assessment. As there is no hope for any person living to operate completely without bias, especially when it comes to our interpretations of and responses to the behavior of others, we can try to exert some control over the direction in which our bias takes us. Rather than have a negative bias which we will seek evidence to confirm, we will adopt a belief and open ourselves to an interpretation that helps us help our clients keep moving toward their goals.

Again, the assumptions are here to guide us by relieving us of the struggle inherent in trying to access what we will accept as “truth” and instead lead us with an assumption that will orient us toward the needed behavior. If we can agree to believe that our clients, like all people, want to improve, we can have a counterbalance for judgments that may arise that can help us find the synthesis and understand how best to move forward. For example, if I can hold both a “cry for help” with “a desire to improve” as true at the same time, I might be more likely to assess how these ideas relate to one another and may be interacting in a way that maintains the client’s problems.

Take for instance the client who is suffering with incredible loneliness. Talking about her sadness and suffering may be the only time when she has the experience of someone’s undivided attention, sincere concern, and offers to do things that help her feel soothed and connected. It would of course make sense that this person would keep seeking conversations (including therapy conversations) focused on conveying her problems to others in a way that engages others in helping to solve them. Attention, in this person’s case, is providing deeply desired relief. It would fail this client to say she just wants attention. She wants so much more. If we could offer this person a way to feel longer-term relief, and longer-term support and connection, we have no reason to believe that she wouldn’t be interested. We cannot lose sight of the fact that our clients want a different life than the one they currently have. “Just wants attention” suggests that there is no rhyme, reason, or rationale. But if we take the stance that all people want to improve, we are open to looking for what she may be trying to improve or find relief from with the skills she has in this moment. Asking for help may be her strongest skill. She may be looking for someone to pay attention to her pain, her suffering, or her life that is unbearable as it is currently being lived, in the hopes that that attention might lead to relief.

If that is the case, we could offer that person a way to resolve that aching loneliness in the long run, and not just in the moments that someone is listening in a therapy session or when a friend is listening on a late-night phone call about how terrible life is (which may ultimately result in burning out friends and losing those relationships).

When our clients return to old behaviors that have been problematic in the past, it may not be out of a lack of motivation to improve. A more behaviorally-specific conceptualization might be that they have practice and success experiences with one way of solving the problem and it will remain difficult to take another path. Taking the new path only becomes easier when they have the knowledge or experience to make them believe that the new path will be just as effective or more so for the goal of getting something that they desperately need. Some change in their approach to solving their very real problems is often what is needed. This leads us into our next assumption.

Patients Need to Do Better, Try Harder, and Be More Motivated to Change

“The third assumption may appear to contradict the first two, but I do not think so. The fact that [patients with borderline personality disorder] are doing the best they can and want to do even better does not mean that their efforts and motivation are sufficient to the task; often they are not. The task of a 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.”

Cognitive Behavioral Therapy for Borderline Personality Disorder; Marsha M. Linehan, Ph.D, 1993

The idea that the client needs to do better, try harder, and be more motivated to change is what helps us understand this third assumption as one side of a dialectic. I often use “Patients are doing the best they can, and they still need to do better and try harder” as an example of a dialectic when I am teaching about DBT. I will often ask groups I am training how we can hold both assumptions as true at the same time. I would encourage people reading this blog post to take a moment to answer this question for themselves before reading how I answer. How could it be true that somebody both is doing the best that they can and needs to do better and try harder?

In my opinion, the therapy is the synthesis. Our patients are often stuck and suicidal because they see that they are doing the best they can and it isn’t enough to reduce their suffering. In fact, sometimes they end up suffering more as a result of their efforts. These clients are the same people who are told time and time again that they need to work harder and be more motivated to change. What we, as therapists, have the opportunity to show them is how to work harder, do better, and be more motivated to change.

For me, the synthesis is that they need new information about themselves and the world, to practice doing new behavior, and to experience successes as a consequence of that new behavior. I operate in line with the belief that these experiences are what will help them see that there are pathways out of hell. Hopefully we also help them see that they have the capability to follow those pathways to reach a life they experience as worth living. What we are proposing to our clients is a bridge between the life they have and a life they won’t want to end. Just as an engineer who builds bridges must be able to see and understand both sides, so must the DBT therapist.

I had a client who wasn’t getting a full dose of treatment because she was frequently late to session. Sometimes this client missed over half of our scheduled session time. She was one of my earliest DBT clients and we tried several strategies (unsuccessfully) to solve this problem. I knew that she needed to be more motivated but I was relying on all of the same strategies that other people in her life had been using for years. Thankfully, my supervisor prodded me to think about how many punishing experiences she had probably already encountered related to this behavior. That feedback helped me remember to treat her like someone who wanted desperately to improve. This moved me to reinforce her efforts and not focus exclusively on the outcome. She needed more from me to be able to improve. Part of what she needed to increase her motivation and capability was for her efforts to be acknowledged and valued. My supervisor helped me see the reinforcement value of my own behavior, and therein, the potential to give my client new learning experiences. My client and I did figure it out. When I brought my behavior back in line with the assumptions of the treatment, the change was swift and significant.  For me this was a valuable lesson.

If we accept that the assumption that more than the client’s current best is needed, our role becomes clear. We can start seeing it as part of our commitment to our clients to help figure out what they need to do better, try harder, and be more motivated to change, and to help them get it. What they need may be skills, encouragement, or a change in the contingencies of reinforcement in their environments. As DBT therapists, we build the bridge between people who are doing their best (and still suffering) and what it will take to make change happen.

As we learn more about DBT assumptions about patients and therapy, we see the complexity but also how these assumptions give us a framework to organize our behavior toward our clients. In part three of this blog from Vibh, she addresses the fourth, fifth, and sixth assumptions of patients and therapy!

Vibh Forsythe Cox, PhD, serves as the Training and Development specialist for Behavioral Tech Institute (BTECH), the training organization founded by treatment developer, Dr. Marsha Linehan. She serves on the team that creates content for BTECH’s training offerings, including the newly released Online Comprehensive Training in DBT. She provides consultation to newly forming DBT teams within the online learning platform. She works as a therapist at Cadence Child and Adolescent therapy, a DBT-Linehan Board certified DBT program in Kirkland, Washington. There, she provides DBT and other evidence-based treatments for teens and adults with emotion regulation difficulties. Dr. Forsythe Cox earned her PhD in Clinical Psychology at The Ohio State University, where her research focused on characteristics of Borderline Personality Disorder and interpersonal emotion regulation. During her time at The Ohio State University, Dr. Forsythe Cox participated in specialized training in DBT, and assisted the Director of the DBT program by providing supervision and consultation to new trainees. She was also the 2012 recipient of the Psychology Department’s Meritorious Teaching Award. Dr. Forsythe Cox has experience providing DBT in a variety of settings, including university-based research, inpatient and outpatient hospitals, forensics, and private practice facilities. She is a Clinical Instructor in the Department of Psychology at the University of Washington, where she provides individual and group supervision to doctoral psychology students in the Behavioral Research and Therapy Clinics (BRTC). Dr. Forsythe Cox has also been an invited speaker at high schools, community colleges, and the University of Washington. Dr. Forsythe Cox is licensed as a Psychologist in the state of Washington.


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