TBIs of the Therapist: Balancing Change and Acceptance
This presentation is an excerpt from the online course “DBT in Practice: Mastering the Essentials”.
- All therapists engage in some therapy-interfering behavior at some point.
- Some examples of TIBs of the therapist include: being late, frequent rescheduling and failure to return messages.
- Therapy-interfering behavior of the therapist is addressed by the peer consultation team.
Patients aren’t the only ones who can engage in therapy-interfering behaviors. Therapists are human too. And as the DBT Fallibility Agreement states we agree ahead of time that we are each fallible and make mistakes, that we have probably either done whatever problematic things we’re being accused of or some part of it so that we can let go of assuming a defensive stance to prove our virtue or competence.
Some factors that contribute to therapy-interfering behavior of the therapist are life stress at home or work, illness or sleep issues, time demands, compartmentalizing clinical work so that the therapist is trying to do clinical work on certain days and perhaps research work on other days so that intersession contact or clinical duties feel intrusive, insecurity about one’s skills as a therapist, fears of being sued and panic that a patient will commit suicide. So each of these things can lead to therapy-interfering behaviors of the therapist.
So what are some of the most common problematic things?
Well, these can be things that concern respect for the patient. That may be session scheduling. If a therapist is late, forgets or misses appointments, ends sessions early. So we want to make sure that we are demonstrating respect for the patient by being on time, starting and ending on time, appearing prepared. We want to have our policies and expectations as consistent as possible. So if the rules are changing a lot, those rules with phone coaching or payment, etc., those things need to be in place as much as possible.
Intersession contact issues. If a therapist doesn’t return messages, delays in calling back, plays games with the patient in just sort of punishing them not in a behavioral sense, not in a clinical sense but just to get back at them or something. A disorganized appearance or being disorganized or forgetful, that’s by losing files or notes, failure to read notes, repeating one’s self as a therapist, forgetting really important information, making promises that you don’t keep when you say that you’re going to send something or you’re going to email or you’re going to call, you’re going to check up and that not happening. Be careful what you promise. Don’t make promises in session that you can’t keep, you know, as much as possible.
In the environment. So having an unprofessional or messy environment, not closing the door or having an area that’s loud and there are interruptions, doing other work or taking calls or messages while you’re supposed to be doing therapy, being distracted, watching the clock a lot. I’ve even heard of therapists falling asleep, appearing tired, having an appearance that the patient is not particularly important. And finally, other issues that concern respect for the patient are having a manner that’s patronizing or maternalistic or paternalistic, talking down to the patient. I’ve seen therapists or heard about therapists continually revamping the plan and having patients write their own notes, talking about therapy-interfering behaviors like it’s the patient’s fault, seeming like the expert on them, basically demonstrating a lack of respect for the patient.
So other types are those that concern balance or maintaining the balance within the therapy delivery. So we want to keep that dialectical balance between change and acceptance. And as cognitive behaviorally trained clinicians, we often can weigh far too heavy on the change side at times and we’re pressing the patient for change and we’re not doing enough of the acceptance. So we’re trying to make sure we’re balancing between both of those in session. We may lean too heavily on the side of acceptance and not challenge a patient on something because it’s just too uncomfortable for us or we’re not feeling well that day and so we’re just going to do a heart-to-heart session and we’re going to do some heart-to-heart talks instead of sticking to the plan. Not doing a good job of balancing that reciprocal communication where we’re validating with the irreverent communication and we’re throwing the patient off track and not taking ourselves too seriously and not tiptoeing around, so weighing too heavy on one or the other of those. Not balancing the nurturing versus demanding characteristics. We need to be able to provide a balance of compassionate and caretaking and being nurturing in moments when it’s necessary versus really challenging the patient to continue expecting more of themselves and challenging themselves.
We also want to maintain a balance between flexibility and stability. So we do have those rules, those DBT rules like we need to bring a diary card and we need to talk about life-threatening urges and actions. We need to do behavioral chain analysis. There are rules about attending and all of that. And we need to also be able to be flexible. So take the example of a patient who comes in and she’s not filled out her diary card and the therapist finds out she’s not filled out her diary card. And the immediate response is okay, well, you’re going to need to fill this diary card out here in session. That may be an intervention that’s helpful and I can certainly imagine that it would be and I have done something similar before. But let’s say that this patient has had a history of never bringing a late diary card and today she shows up without it or she’s extremely tearful. And instead of being a human being and asking, hey, what’s going on? I’ve never seen you like this when I first saw you and you always bring your diary card, instead of being a human, then we just go back to robotics of you need to fill this diary card out. And it turns out that the patient has just got in a car wreck or just found that her mother had died or her house had burned down or something. And so we’ve got to keep in mind that we need to be able to maintain that flexibility and adhere to these principles at the same time. We want to go with the spirit of the law as much as possible instead of always with the letter of the law so to speak. I’m definitely guilty of this. Another way that therapists have therapy-interfering behavior is the inability to tolerate a patient’s communication of suffering in the present. So it’s very difficult when a patient is continually expressing lots and lots of emotional distress, lots and lots of emotional pain and that happens repeatedly, session by session. We can inadvertently, accidentally reinforce dysfunctional behavior. We can accidentally make things worse if we’re not able to tolerate their suffering in the present, if we’re jumping into change things or we’re providing more session time or we’re taking more phone calls. And there are a lot of different ways that we can accidentally reinforce dysfunctional behavior.
So we’ve got to be able to have that team approach, that peer consultation team and bounce things off of them and be open to our peers in questioning. Is it possible that the way that you’re responding to the patient is actually making things worse? So we’ve got to be open to looking at our own behavior and considering whether we’re not being dialectic, whether we’re engaging in behavior that shows a lack of respect for the patient and be open to discussing that and changing it. So we can have therapy-interfering behaviors too.
Key Points: All therapists engage in some therapy-interfering behavior at some point. Some clear examples of therapy-interfering behaviors of the therapist include being late for sessions, frequent rescheduling of sessions and failure to return messages. Therapy interfering behavior of the therapist is addressed by the peer consultation team.
More DBT In Practice: Mastering the Essentials presentations
- 3 Types of Validation in DBT: Emotional, Behavioral, and Cognitive Validation
- 4 Tips for DBT Therapists About TIBs
- 6 Levels of Validation in DBT: From Awareness to Radical Genuineness
- DBT Agreements and Commitment Strategies: Pre-treatment and Beyond
- DBT Emotion Regulation Skills: Emotion Psychoeducation & Mindfulness
- History of DBT: Origins and Foundations
- Mindfulness Skills in DBT: The 3 States of Mind
- Observing Limits, Liability, and Other Concerns in DBT Intersession Contact
- Roleplay: Assessing Life Worth Living
- Using Validation in Therapy
- Validation in DBT: Basics and Purpose
- Dialectics in DBT: Balancing Acceptance and Change
- The Biosocial Model in DBT: Emotion Dysregulation and Invalidating Environments
- The Structure of Standard DBT: The 4 Skill Modules
- The 4 Stages and Targets of DBT Treatment
- DBT Assumptions About Patients, Therapists, and Treatment
- Stage Targets and Goals in DBT: Creating a Life Worth Living
- DBT Skills Group: Rules and Resources
- DBT Distress Tolerance Skills: Tip Skill, Stop Skill, and More
- The Role of the Individual DBT Therapist
- Intersession Contact and Telephone Coaching in DBT
- Telephone Coaching in DBT: Applying Skills to Prevent Full-Blown Crisis
- The DBT Hierarchy: Prioritizing Treatment Targets