Staying Balanced When Treating Patients at Risk for Suicide (Part 1)

July 26, 2019

A fundamental goal of consultation to the therapist is to provide balance for each therapist so that he or she can stay within the dialectical frame of the therapy.”

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

This feature by Laurence Y. Katz, MD is Part 1 of a two-part series about therapists’ need to stay balanced when treating patients at risk for suicide and how the framework of DBT facilitates this balance. In part 1, we start by examining the need for balance and the first two principles of how DBT fosters that balance.

For therapists treating clients at risk for suicide there are many dialectical tensions inherent in the task. The therapist must on the one hand completely invest herself emotionally in the relationship with the client, as the real nature of emotional connection between therapist and client is an essential element of facilitating engagement and the necessary change. At the same time that the therapist is fully throwing herself into the treatment she must also be aware that she may have to let go of her attachment to this relationship at any time for any of many reasons (including the client’s death). This tension and the often rapid back and forth between these two poles can leave the therapist with an almost vertigo-like experience.

Another principle that is relevant to this experience is that principles of behavior are universal, affecting therapists no less than clients. This refers to the often tense and conflict-laden experience of therapy in which the therapist is striving for change that is extraordinarily stressful for the client and yet necessary at the same time. Inevitably, the therapist will have experiences that are at a minimum not reinforcing and at times are frankly punishing. This will challenge any therapist to maintain a personal sense of balance in this context or as Swenson has put it:

“Treating individuals with chronic, severe emotional dysregulation, poor judgment, and impulsivity would challenge the capacities of any therapist to stay present, connected and involved.”

DBT Principles in Action: Acceptance, Change and Dialectics; Charles R. Swenson MD, 2018

To address this fundamental element of effective therapy a number of principles that are part of DBT can help the therapist to carry out the ongoing task of seeking balance (although I do not presume these are the only strategies that exist). First, the team approach of therapy for the therapist; second, the Zen principle of willingness to let go of attachments when that is effective; third, therapist mindfulness practice; and finally, the application of radical acceptance of having a career with the potential for experience of loss to death.

In Part 1 of this series, we will explore the first two principles.

The Team Approach of Therapy for the Therapist

Thank goodness that when Linehan developed DBT she came to the realization that the treatment needed built-in mechanisms to help therapists maintain their own personal balance if they were going to be able to stay balanced in providing the treatment.

This would explain my experience of gratitude for my DBT consultation team; over the last twenty plus years of providing DBT, my weekly team meetings have consistently been one of the favorite parts of my week. If we are going to maintain personal balance in the context in which we work, we need our team be sure that we are identifying times when we, or the treatment, are out of balance. If we are not aware it is the team’s role to move in.

The therapist’s personal sense of balance – or lack thereof – will manifest in the dialectics that play out during treatment such as acceptance versus change, flexibility versus rigidity, or nurturing versus withholding. The team can recognize when there is imbalance in the treatment and can assess for the factors that have contributed.

This means that given the inherent – and pretty much inevitable – event of me being out of balance, that the fallibility agreement (that “all therapists are fallible”) leads me to accept my vulnerability to such an event and hopefully help me to observe and describe the vulnerability to my team. Then the team can help me find the middle path back to balance.

This requires the team to apply DBT to one another, as this is the mechanism through which we effect change with each other.

Willingness to Let Go of Attachments

Another common source of imbalance is the result of difficulty in letting go of attachments.

One of the goals of Zen practice is to see reality as it is without attachment. Of course we all are prone to attachment (we are wired up for it) and as such the task in wise mind is to be aware when attachment is interfering in our awareness of reality and our capacity for skillful behavior.

This can manifest in many ways. Among the most challenging is when the therapist has to tolerate the anxiety of a client at risk and in crisis, when removing the client from the situation will reinforce dysfunctional behavior and actually increase long-term risk. For example, frequently when I am involved in a coaching call with an adolescent client that is in crisis there will come a choice point where the client has ongoing suicidal thoughts in their current environment and the option will be to push for change and drag new skillful behavior out of the client, or, alternatively, develop a plan to remove them from their environment to a “more immediately safer” environment. 

There is a risk here that my attachment to my client will shape me toward the “safer” option and thereby deprive the client of the necessary opportunity to practice skills in the very setting in which they are required. This can also result in my reinforcing the escalation of communication if the communication has been of suicidal thoughts as opposed to the need for coaching in managing a situation. This reinforcement of escalation actually increases the long-term risk. This will create tension between the therapist’s attachment to the client and the recognition of the need to allow for the opportunity for skill development.

Although the team can help a therapist to recognize these tensions and invoke various strategies to help the therapist, at the end of the day the therapist will have to find willingness to work toward the middle path.

I should also mention that this does not mean that we never opt to remove a client from the crisis environment due to insurmountable safety concerns but when we do so it is with the realization of lost opportunity and risk of reinforcing dysfunctional behavior.

In Part 2 of this blog, we will take a closer look at the two remaining DBT principles that can help the therapist to seek balance: therapist mindfulness practice and the application of radical acceptance. Click here for part 2 of this series from Dr. Larry Katz!

Laurence Katz, MD, FRCPC is currently Associate Professor of Psychiatry and a member of the Swampy Creek Suicide Prevention Team at the University of Manitoba, Winnipeg, Manitoba, Canada. He is a psychiatrist on the Intensive Child and Adolescent Treatment Service where he is the team leader of the adolescent DBT service, and also participates in the DBT service offered within the STAT program at the Health Sciences Centre. He is also a senior DBT Trainer with Behavioral Tech Institute in Seattle, Washington.


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