The Dialectical Dilemma in DBT: Validation and Radical Genuineness
This presentation is an excerpt from the online course “DBT Secrets No More: Animated Role Plays“.
So this next section is therapy-interfering behavior. It highlights, illustrates, therapy-interfering behavior which occurs in the session.
So, although this is only the second session, we’re already having some interpersonal conflict. I want you to watch for my responses of self-disclosure and radical genuineness. I attempt not to get defensive as much as possible. The best way to not get defensive is to not be defensive. The best way to not sound defensive is to not be defensive. So in order to do that, I have to be able to simultaneously validate her perspective. I need to maintain a dialectical stance that’s a centered stance of validating her perspective and validating my experience at the same time, so both of our experiences are valid.
The previous bit of dialogue between us when I was doing the assessment involved her being on the side of the dialectical dilemma, emotional vulnerability vs self-invalidation. She was heavily on the emotional vulnerability side, meaning that she’s really bought into the idea that the environment is to blame. Here I am emotionally sensitive. I’m an emotional, sensitive person. I get easily emotionally dysregulated and other people need to be able to respond to me, to interact with me, in a way that minimizes the likelihood that I’m going to get upset. So that’s when the patient would be on the emotionally sensitive or vulnerable side of that dialectical dilemma.
The struggle is with who’s to blame? Who’s to blame? Is it me? Or is it the environment? So in this next interaction, she remains on the environment is to blame side. And what you can see is that I continue to be radically genuine and I’m asking, responding, with the hard questions. So, although this is a somewhat difficult interaction, I’m maintaining the stance that there is value to be gained in this conflict. I’m happy to be able to see what occurs in session with her previous therapists potentially actually occurring with me, so I can feel it out and start to discern what the actual problem behavior is and why and why it is for me. So what may be problem behavior for one therapist may not be for another.
So I’m really just trying to pay attention, use my observe and describe skills, while I participate in this discussion.
Dr. Vaughn: I mean, I guess I wish I could push a button and make it not but I suspect that I will probably have the same thing happen, if not worse. So I have a couple of questions. One –
Emily: So like are you saying it’s my fault then?
Dr. Vaughn: Is this one of those times? Is this one of those times that it happens?
Emily: I don’t know. I just feel like you’re saying it’s my fault.
Dr. Vaughn: Yeah. I feel like that if I say it is your fault then I would get in trouble. And I feel like if I say it’s not your fault then I would get in trouble in some way.
Emily: I just want to know what you think, like I just want to know the truth.
Dr. Vaughn: I don’t know what I think, not yet about this. But I know right now I feel like I’m on trial. You know what I mean?
Emily: So you’re saying like I already messed it up again?
Dr. Vaughn: A little. I mean, if you’re trying to make me like totally happy all the time, then yeah. But if you’re trying to actually talk about something and get it out, then no. It depends on how you look at it.
Emily: But that’s the thing. I just want to know what you think. Like is it my fault?
Dr. Vaughn: Yeah. I don’t know, I don’t know. It’s possible. Yes?
Emily: I mean, that just means that like I’m the one wasting all this money and time and dropping out of school and move home. Like it just means it’s all my fault.
Dr. Vaughn: So I’m super glad that this happened in this session because this I think is exactly what you’re talking about. And if we can go ahead and get that addressed, then you decide whether you’re going to work with me or not because clearly I have the same disappointing features that your other therapists have. And also, I must say a lot of times I’m worse I think because I’ll say if I don’t believe you. You may be 100% telling the truth and on my mind I’m having a hard time believing you. Like I would be that upfront and that would be super painful to hear I would imagine.
Emily: Yeah. I just feel like nobody is listening to me and nobody believes me of what happened and I just really – That’s what I feel like I need. I feel like I need someone to believe me but I don’t want them to [say that they] believe me if they don’t. I need them to believe me if they really believe me.
Dr. Vaughn: Yeah. You don’t want them to say that they believe you when they don’t. Besides, you would [be able to] tell that anyway.
Emily: No. Because then it’s just a lie. Yeah, it’s just a lie. Like I thought, like I don’t know. I thought I’ve gone over this time and time again. But it just always happens.
Dr. Vaughn: So this is something you’re going to have to think about. I mean, would you agree that I failed in the same way that your other therapists failed?
Emily: Yeah. But then it makes me feel like I failed.
Dr. Vaughn: Okay. But you just told me that I failed. That’s great, I mean, not that I failed. But you remember when you said that you might not talk about it like you might not tell me?
Dr. Vaughn: But you just did. So thank you. I really appreciate that in a weird way, in a super weird way.
Emily: I mean, I guess.
Dr. Vaughn: Okay, all right. I don’t want to talk about that part anymore if that’s okay. I want to go back to talking about if you had any questions on the commitments especially about like the diary card or the 24-hour rule.
Definitely feeling like things have turned in this section of dialogue. It started with the question, “So are you saying it’s my fault?” I described it, at one point, as feeling like I was on trial.
And one of the reasons for this type of self-disclosure and radical genuineness is an attempt to get the patient to perspective take. Much of the reason why anyone really interacts in a way that is problematic is because they are unable to feel what the other person is feeling. They get caught up in their own thoughts and emotions, and they just start to react. So I’m attempting to get her to take some perspective and to see the immediate and direct result of her behavior. So I just plunged in when I asked, “Is this one of those times?” because I know right after she said, “Are you saying it’s my fault?” I felt like a deer in headlights. So I just ask, “Are we starting? Like, is this one of those times?” And I do it as a way to also try to bring in some humor and lighten the mood, which she does not respond to.
And then I just sort of lay out the facts. The facts are no one can dispute the way you feel. No one can dispute your thoughts. I have the thought that the moon is made of green cheese. I mean, they can dispute that the moon is made of green cheese, but they cannot dispute that you had a thought the moon is made of green cheese. So what I know to be true are my thoughts, my feelings, the fact that I had them, and that those thoughts definitely will impact the patient.
So in other words, when she asks, “Did I mess up again? So, I messed up again?” I so much, every fiber of my being that has been socially normed, what I’ve been taught is to say “No, no. You didn’t mess up,” and, “It’s fine.” And truly it is because this is only our second session and it’s really not that big of a deal if this is the only time. But that’s not what she’s asking. She’s asking, “In that interaction, did I interact with you in a way that chipped away just a little bit from a solid relationship?” And the fact is yes. So I had to suck it up because this isn’t a tea party, as I always say, and acknowledge that yes, a little bit. There was a bit of a subtraction from my good feelings toward this patient. So I say, “A little. If you’re trying to make me totally happy, yes, then you did mess up because you didn’t do it.”
And at the same time, we’re also trying to, just like I’ve mentioned earlier, we’re trying to actually discuss concerns that the patient has with me because I asked for it. I actually asked for her earlier to communicate to me when she felt resentment or when she wasn’t liking whatever interaction was going on between the two of us. And so she is obliging. She obliges. And yet, I don’t like that either. I mean, who’s the problem here? It sounds like it’s me really, that I don’t want what I’m actually asking for.
So, which way do I want it? Do I want her to not say anything or do I want her to say something? If those are our only 2 choices, we’ve got a problem. It’s both. I want her to say something and I don’t want her to say something. At the same time, what we’re looking for is that interpersonal skill. I want, I’m looking for—for us to maintain a relationship, there has got to be some softening of the way that she communicates. And throwing in some reinforcement would really be helpful.
So if I were to jump into change strategies at this point, I would go back and coach her through how she could’ve said what she said in a way that I found more palatable. Not that had she done that same interaction with somebody else it would’ve gone the same way. Not to say that she’s wrong, but to say if you want to dance with me, then this is how you do it. That’s not necessarily how you dance with someone else, but I’ve got two left feet. So in order to dance with me, who’s got two left feet, you’ve got to do it this way. So I’m going to own my part and I’m going to then model her owning hers and helping to reinforce her owning hers by modeling that.
So then, as we go along, I’m validating. I’m going back to the commitments again. I’m turning everything back to the commitments. I could take anything—in the second session, I’m going to take anything and bring it back to commitments if I don’t have one. I’m also pointing out the validity that I’m turning lemons, this conflict that we have together, into lemonade. I say, I point out that I’m happy that this interaction happened in session because basically, I know what I’m getting into now to some degree. And also, she could see what I’m like whenever she confronts me. So I take lemons and turn them into lemonade. That’s a style, a dialectical strategy in DBT.
So then, nearing the end of the interaction, I start to feel myself getting—I’m kind of over it. So rather than continue, and giving out more validation, and getting deeper into the discussion than I had intended, I explicitly say I don’t want to talk about that part anymore if that’s okay. I’m asserting, right? So I say I want to go back to talking about if you have any questions on the commitment. So, I am observing my own limits and I’m doing that oscillating of intensity that DBT talks about. Whereas, before, I’m validating and I’m upbeat and I’m maybe doing more warmth, now I’ve changed the intensity. I’m bringing it back to okay, now, let’s move on. And she responds very well.