Balancing Validation and Radical Genuineness in DBT
In the next segment, I’m attempting to balance validation with asking questions that could easily be perceived as being invalidating.
These are hypotheses, however, that I need to check out. And in doing so, I can paradoxically validate the patient simply by asking the questions. Asking if something that she did was like a “Screw you” to him can be very much the highest level of validation because of the fact that I even thought like that.
So it’s a radical genuineness on my part. This is similar to how I might have a conversation with a friend or a colleague when I’m being casual and not being very therapist-y. Being therapist-y can be one of the most invalidating things that you could do, so I’m trying to relate to her on a very genuine level. I’m peppering in some summarization of what she’s been saying. So, I’m doing some level 2 and 3 validation and going where angels fear to tread, as Linehan describes it.
Now, I am stepping into the therapy-interfering behavior of her failure to reach out to me for phone coaching as opposed to reaching out to her boyfriend. So I’m conducting a mini analysis within the analysis to find out her thought process and whether there were any contingencies which kept her from calling me rather than her boyfriend because she is aware that phone coaching is an option. She is aware that she is supposed to call me for phone coaching prior to engaging in self-harm or any other life-threatening behavior. And so not doing this is a therapy-interfering behavior.
Dr. Vaughn: So you feel a lot of like strength or power or competency or something with making that decision and doing it.
Julie: Yes and no. You know, like I do and I don’t. I have like four big gashes on my arms right now and I have to wear long sleeves and it’s like 95 degrees outside. I don’t like that about me either.
Dr. Vaughn: So in other words, it would be nice if you had a way to be able to feel like that without the consequences of big gashes on your arm and what other downside is there.
Julie: I mean, I can’t imagine it’ll look very good like 20 years from now.
Dr. Vaughn: Aesthetics, yeah.
Julie: Yeah. And like I don’t, like it helps in the moment. And I know how to like do it safely I guess but I don’t want to like really hurt myself. And my boyfriend hates it so I don’t want to lose him.
Dr. Vaughn: What about me?
Julie: Oh yeah.
Dr. Vaughn: I mean, I’m sort of half joking but, you know, you and I, we talked about working on taking it off the table as an option. It sounds like it was so fast though that it was difficult for you to intervene and like do something else. Did it occur to you to do anything else?
Julie: I thought about calling him back one more time, giving him one more chance. And then I hit this just f-it moment. And not really, not in that moment.
Dr. Vaughn: Did it occur to you to call me? I mean, I don’t mean to keep bringing me up here. I kind of do and I kind of don’t. But like you’ve got phone coaching. Did that occur to you and you put it aside? Or you just forgot?
Julie: I thought about it earlier. And at that point when I actually went from like all right, I don’t know what to do, razors, I did it, I didn’t think about you again. But I did think about it because I mean, I’ve been working on this assignment for like probably six hours to this point. I had gotten really stressed out a couple of times and thought about you then.
Dr. Vaughn: So I’m sort of thinking that you know I would’ve liked for you to call but just like how you said kind of yes and kind of no, I also would be afraid you know that I would say something very much like your boyfriend and set you off. Like I can totally imagine that I would say something trying to solve the problem and then you get pissed.
You’re smiling. What are you thinking?
Julie: I think you would do a little better than him. He’s ridiculous.
Dr. Vaughn: I think you’d be surprised at how badly I can do.
Rather than jumping into convoluted interpretations of her behavior, which would suggest she is deliberately not calling me, she didn’t want to call me, she was trying to make things worse, or some other pejorative interpretation of her behavior, it’s important to start with a very basic question, which is, “Did it occur to you to do something different?” Is this something that was even a possibility in her repertoire of choices or have we not gotten to that level yet?
The emotional intensity that she described suggests that it may not have occurred to her. However, we can, with repeated conversations about it, create a new association in which distress and the thought to call becomes associated with calling me. So I’m hoping that doing a role play is going to start building that association. But it is important that we don’t assume that she is not calling because she doesn’t want to get better or some other pejorative interpretation.