Staying Balanced When Treating Patients at Risk for Suicide (Part 2)

August 13, 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 2 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 (read it here), we examined the need for balance and the first two principles of how DBT fosters that balance.  In this part, we will explore two more principles: therapist mindfulness practice and the application of radical acceptance.

One of the principles we explored in part 1 was the concept of willingness to let go of attachments. It can be a source of imbalance in therapy when the therapist has difficulty letting go of attachments. This is where Zen practice helps the therapist to see reality as it is and walk the middle path in treatment. As such, the second principle leads us to the third.

Therapist Mindfulness Practice

This tension – amongst many others – provides the rationale for therapist mindfulness practice.

It is hard to imagine having the capacity for therapeutic balance without therapist mindfulness practice. In trying to navigate the fine balance of acceptance and change at the heart of DBT and to do so with speed, movement, and flow requires the therapist to be centered and fully present.

Furthermore, to deal with the many emotions and distressing cognitions inherent in conducting DBT, mindfulness practice will assist the therapist in their own emotion regulation. Mindfulness as part of an overall therapist wellness plan is also recommended.

Application of Radical Acceptance of Having a Career with the Potential for Experience of Loss to Death

Although it is not always immediately necessary or at the forefront of our minds, a therapist’s radical acceptance of a career with the potential for the experience of loss to death may be helpful.

Of note, we cannot radically accept the actual death of a client that we are still working with (you cannot radically accept an event that has not occurred yet) but rather we radically accept that we currently have a job that includes those experiences.

This process is a specific application of letting go of attachments. Sometimes the source of therapist imbalance is fear of the experience of the death of a client. This is of course understandable and at the same time can paralyze the therapist and create imbalance in application of treatment strategies (e.g., too much acceptance and not enough change).

Once again, it is the role of the therapist and the team to identify this source of imbalance. It can have origins in the therapist’s past personal or professional experience of loss and will again require the therapist to be willing to enter into that vulnerability with the team.

The fear can also be rooted in medico-legal concerns, and again the team can help the therapist develop a plan of how to manage concerns in that context. This process may require that the team utilize various DBT change strategies (e.g., exposure) to assist the therapist back to the middle path.

The sources and experience of therapeutic imbalance are many and frequent. The common theme to the discussion in this series is that DBT is not just something that we practice with our clients; it is also something that we practice with our team, our system, and ourselves.  The application of DBT in all of these relevant contexts will help therapists and teams in the unending pursuit of therapeutic balance when treating clients at risk for suicide.

Interested in reading more about Zen Mindfulness in DBT? Check out this blog from Behavioral Tech Institute Trainer Randy Wolbert.

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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