Reflecting on DBT Assumptions about Patients and Therapy (Part 3)

June 24, 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 3 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 our first two parts we examined the assumptions that “Patients are doing the best they can,” that “Patients want to improve,” and that “Patients need to do better, try harder, and be more motivated to change.” In this third part, we take a closer look at three more assumptions about patients with Borderline Personality Disorder and therapy described in the treatment manual. First, that patients may not have caused all of their own problems, but they have to solve them anyway. Second, that the lives of suicidal, borderline individuals are unbearable as they are currently being lived. And finally, that patients must learn new behaviors in all relevant contexts.

As a Training and Development Specialist for Behavioral Tech Institute, I frequently field questions from people who are just learning about DBT. For those who are beginning to learn about DBT, one of the fundamental aspects to understand is how our core DBT assumptions affect how we treat our clients. As a Training and Development Specialist for Behavioral Tech Institute, this is a subject I come back to time and again and about which I frequently field questions.

In this four-part blog series, I am examining eight assumptions of DBT. The first blog covered the first assumption that patients are doing the best they can (you can go back and read that here). In the second blog, I addressed the second and third assumptions, that patients want to improve and that they need to do better, try harder, and be more motivated to change (read about assumptions two and three here). Now let’s move on to our fourth, fifth, and sixth assumptions!

Patients May Not Have Caused All of Their Own Problems, but They Have to Solve Them Anyway

“The fourth assumption simply verbalizes the belief in DBT that a patient with Borderline Personality Disorder has to change her own behavioral responses 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 consistent nurturing, finding the perfect relationship, or resigning herself to the grace of God. Most importantly, the therapist cannot save the patient. Although it may be true that the patient cannot change on her own and that she needs help, the lion’s share of the work nonetheless will be done by the patient. Would that it were not so! Surely if we could save patients, we would save them. It is essential that the DBT therapist make this assumption very
clear to the patient, especially during crises.”

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

Many people have a negative reaction to being asked to solve a problem they didn’t create. The judgment “unfair” often springs to mind. Depending on how you describe unfair, it might be unfair. And, from my perspective, this assumption is here to remind us that we do not have to invest time in that idea. The decision that must be made is about whether solving the problem will get us closer to or farther away from our goals. In a situation where your goals involve limiting your work to tasks that are directly assigned to you, you may choose not to solve certain problems. My experience is that more often, we are motivated to solve problems we did not create by the fact that we are the ones who will experience the negative consequences if the problem goes unsolved.

I often tell clients and other therapists the story of my broken car window. I was late to an appointment on a rainy day. I was rushing to get where I needed to be and got to my car only to find that someone had smashed the car window and taken a few items. I still vividly remember the willfulness I felt in that moment. I did not want to have to solve that problem. My opinion was that I did not cause that problem. However, my opinion did not matter. No matter what or who was to blame for this particular problem, I was the one who needed to solve it. I did not have to find who broke my car window. The more efficient route to solving my problem was to look at my goals, and what I needed to do to be able to get to them. I believe this is one of the assumptions of the treatment to help us orient our clients to doing the same.

It can be true that we did not cause a particular problem AND devoting time and attention to the fact that we did not cause the problem takes time and attention away from the behaviors that will solve the problem. So, like the other assumptions, this assumption helps us orient our attention. It may help us step out of conversations about why we shouldn’t have to solve certain problems and invest that energy in the things that need to be done to help our clients get closer to their goals. 

Problems rarely get solved without action.  As it is written in the manual, this assumption has emphasis on the fact that the therapist cannot save the patient. I take this to mean that the patient is the one who must take the needed action. The therapist can help to highlight action that is needed, teach new skills, and provide guidance, and I believe it is our responsibility to encourage the client to act as their own agent of change. For me, this is not related to ideas of fairness. I understand this position to be a reflection of the fact that problem solving requires a set of skills and capabilities, and by solving our clients’ problems for them we take away valuable opportunities for them to learn and practice those skills and inhibit their ability to gain those capabilities. Maybe even more importantly, we risk preventing them from having the experience that they can be effective agents for change in their own lives.

“The Lives of Suicidal, Borderline Individuals Are Unbearable As They Are Currently Being Lived”

“The fifth assumption is that [patients with Borderline Personality Disorder’s] frequently voiced dissatisfactions with their lives are valid. They are indeed in a living hell. If patients’ complaints and descriptions of their own lives are taken at all seriously, this assumption is self-evident. Given this fact, the only solution is to change their lives.”

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

This saves us from the pitfall of focusing too narrowly on keeping clients alive. Our clients are often in excruciating misery, and from that position, the prospect of living looks like a commitment to more misery. I understand this assumption as a reminder not to ask our clients to commit to misery. We have to remember that our clients cannot live their lives as they have been living them. For clients who have contemplated suicide or made one or more attempts they see this very clearly, and in order to effectively help them, we have to see it clearly, too. We must understand the problem before anyone should trust in our ability to help them solve it. The problem, for many of these clients, is that their life is unbearable as it is currently being lived. Agreeing to these assumptions means acting as though these premises are true. Acting as though it is true that a client’s life is unbearable as it is being lived helps us remember the fallacy of asking for commitments in the absence of a plan to relieve some of the suffering. For our clients’ sake, we as DBT therapists must plan, problem solve, teach, and encourage as though their lives cannot be borne without change. The behaviors that follow this assumption generalize farther than commitments not to attempt suicide, or not to self-harm.

“Patients Must Learn New Behaviors in All Relevant Contexts”

“[Individuals with Borderline Personality Disorder] are mood-dependent, and thus they must make important changes in their styles of coping under extreme emotions, not just when they are in a state of emotional equilibrium. With some exceptions, DBT does not generally favor hospitalization even during crises, since hospitalization takes individuals out of the environment where they need to learn new skills. Nor does DBT particularly favor taking care of patients when stress is extreme or seems unbearable. Times of stress are the times to learn new ways of coping. Not taking care of a patient does not mean that a DBT therapist does not take care of the patient. The task of the therapist during crises is to stick to the patient like glue, whispering encouragement and helpful suggestions in her ear all the while. Such an approach, in which the therapist is biased toward producing self-care from the patient during crises rather than taking care of the patient, can result in a number of risky encounters for the therapist. Acceptance of the possibility that the patient may commit suicide is an essential requisite for conducting DBT. The other alternative, however— in which the patient stays alive, but within a life filled with intolerable emotional pain —is not viewed as tenable.”

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

For me, this assumption holds echoes of the assumption that patients will need more than insight to solve the problems in their lives. The skills deficit model on which this treatment is built posits that our clients need to learn and practice needed behaviors. It is not enough for the patient to learn and practice the skills within their individual therapy session or skills training group. Our clients come to us to change the lives they are living outside of therapy, and for this reason we need to make sure we help them build competence and confidence to navigate a variety of contexts. 

To see the full scope of this assumption, we must remember that context is made up of multiple factors. Context includes more than where the client is and who they are with. Context also includes their emotional state. It might be that your client is more likely to do behaviors that are disruptive to their goals in the context of intense emotional distress. In fact, this is the most likely scenario. So, in order to get rid of the barriers this can place between them and their goals, we need to help them be able to use skillful behavior even when they are under conditions of intense emotional distress.

As you might imagine, talking isn’t enough. Teaching someone these skills is much like teaching someone how to swim. You can tell someone all of the steps of swimming: turn your head, breathe” you can describe the strokes in exquisite detail, and this actually might do very little to help them learn how to swim. We can talk about how when the client is in high emotion they need to be able to do certain behaviors, and that is not a substitute for their executing those moves while they are in the emotional distress that they have been training for. In this way it might be more accurate to think of the therapist not just as a swim instructor, but as a swim coach. The therapist helps prepare for the context in which the skills will be needed and moves alongside the client to give feedback and encouragement as needed to help the client become stronger and move more efficiently toward their goals. If I may indulge in continuing this metaphor, the session is like training or practice. There might be certain topics that raise emotional distress for the client to even think about, and those moments are opportunities to coach them on how to navigate that emotion to identify their goals and the skillful behavior that will get them there. Life outside the session is like the swim competition.  Even at the Olympics, which are considered by many to be the highest level of competition (as a suicide crisis urge can be considered the highest level of distress), you will find the coaches with their athletes. Those coaches cannot swim the events for their athletes, it is unlikely they are saying anything for the first time on the day of the race, and there is purpose in their presence.

The idea of a stance that does not favor hospitalization is concerning for many as they are learning DBT. I think the assumptions help to make the rationale for that position clearer. If we assume that learning to cope with intense distress will be needed for our clients to be able to cope with even the most difficult situations in life without seeking escape (through death, substances, or other self-damaging behavior) then removal from the stressful context can be seen as a lost opportunity to gain the needed skill and, by extension, a pathway to increased risk if a belief develops that escape is the only viable solution.

In fact, as therapists we must bear in mind what we communicate with our behavior. If we choose to hospitalize a client, we might inadvertently communicate that we are out of ideas, out of skills, or, worse yet, out of hope. Even when a client of mine makes the decision to go to the hospital, I do what I can to help them learn something that will move them toward their goals (which rarely include a life inside of the hospital). For example, we sometimes focus on how to make the gains they need to get out as quickly as possible or how they can use the time to reduce their need for the hospital in the future by practicing their skills (like self-advocacy).

When therapists agree to this assumption, I believe we are agreeing to actively seek and favor building needed skills in every available context.

Having now covered the first six DBT assumptions about patients and therapy, we see the complexity but also how these assumptions work together to give us a framework to organize our behavior toward our clients. In the last part of this blog from Vibh, she will address the final two 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.


Disclaimer: The Behavioral Tech Institute blog is designed to facilitate the sharing of ideas, experiences, and insights related to Dialectical Behavior Therapy (DBT). The content and views expressed in the articles, comments, and linked resources are those of the individual authors and do not necessarily reflect the views, policies, or positions of Behavioral Tech Institute or staff. Content is provided for information and discussion purposes only and is not intended as professional advice. Contributors to the Behavioral Tech Institute blog are independent, and their participation does not represent an endorsement by Behavioral Tech Institute.