Rebuttal Argument-belladonna98

DBT Doesn’t Fail- Therapists Do

Therapists themselves have had many failures in implementing DBT, stating that in some extreme cases of BPD and emotional dysregulation, it doesn’t work. In one case, Shireen L. Rizvi had a patient named Barbara who was not affected, and whose disorder may have been worsened, by DBT. Barbara had BPD, social anxiety, severe depression, PTSD, and was an abuse survivor.

Over the course of six months, Rizvi struggled to treat Barbara, often blaming her “therapy-interfering behaviors” such as not making eye contact, asking her very personal questions, and calling her in crisis almost daily. The response to these behaviors is what makes the argument that DBT didn’t work here completely invalid. Rizvi admitted to outright ignoring some of these behaviors, when the very basics of DBT state that a patient must feel validated in order to receive treatment. Instead of indulging in and therefore validating these behaviors, maybe partially answering a question or asking her why she didn’t make eye contact, Rizvi let them agitate her and obstruct her own practice.

While Barbara did overstep the patient-therapist line (she had had a romantic affair with a previous therapist, so she didn’t understand it in the first place) the response should have been one of understanding and willingness to help, not one of agitation and rejection. Rizvi admitted to being a “novice therapist”, but as someone who is not even a therapist yet, I can see that that is no excuse. She saw someone who clearly had a mistrust of authority and no concept of patient boundaries, and did not take that into account. The bottom line is, she didn’t try hard enough to understand Barbara as a person rather than as a set of symptoms. It is these therapists who most often fail with DBT. It is not the therapy’s fault; it is the fault of the therapist administering it.

Therapists need to take into account the state of their patients and how to best treat them. They cannot look at every patient as the same textbook set of symptoms, they have to see the patient as a whole person. Though a person may fit the criteria for rigorous DBT, the person may not be able to handle it. This is another issue with the Rizvi case. Barbara most likely would have done better under a less structured form of DBT, as one who has had little structure in her life to begin with. She is not familiar with such intense dedication to one thing, a thing which she is not even convinced is worthwhile yet. So, giving her small tidbits of DBT in her therapy sessions would have not only given the therapy more meaning to her, but may have made her more receptive to it.

Another example of DBT failure is one I found on a forum for people with BPD. This time, we see the patient perspective on the issue. User cabdriver gave a list of explanations on why DBT wasn’t working for them and how it was flawed. The list consisted of a combination of them not practicing their skills and their therapist punishing them for it. They found the skills boring and unhelpful, and would lie and say that they did them when they didn’t to avoid punishment.

Therein lies the problem, a therapist should never punish a patient. Apparently, cabdriver’s therapist would become irreverent or even take breaks from therapy when cabdriver didn’t practice their skills regularly. This is probably an extreme case, but it is troubling. Again, I reference that one of the key principles of DBT is validation, and a patient cannot possibly feel validated if they are constantly fearing punishment. A person can’t fear their therapist, therapy is supposed to be a safe space where someone can admit to anything without judgement. That isn’t to say that they won’t be held accountable for their actions, but they shouldn’t have to fear a slap on the wrist. They’re adults, treat them as such.

The solution here lies in both the patient and the therapist trying a bit harder. The therapist needs to try to convince cabdriver that the skills are worthwhile, as the punishment approach is ineffective and downright patronizing. Maybe cabdriver needs a new therapist altogether. But they also must realize that the skills are there to help them, and they aren’t as black-and-white as they seem. Cabdriver often said things along the lines of “Have a problem? Practice your skills!” However, “practice your skills” can simply mean applying a new approach to a situation or changing thinking. It doesn’t always mean sit and be mindful and all the world’s problems will disappear. In the end, everyone involved with DBT just has to be open minded and accepting, and go from there.

But obviously not all college students are Barbara or cabdriver and not all therapists are Rizvi. However, they may still have therapy interfering behaviors and not be the most eager to start DBT. That is why a very relaxed form of it is best. If someone doesn’t want to do something, it makes no sense to completely immerse them in it against their will, or shut them out like a failure. Introducing DBT slowly in small pieces makes much more sense. The therapist doesn’t even have to officially declare “We’re going to do DBT now.” They can simply give skills that pull from DBT and mention the name, intriguing the patient. If they see that these skills are helping them, and they know they come from DBT, they will be more eager to dive deeper into the practice.

But of course, the person has to be willing to use the skills in order for them to help. If someone completely ignores their skills and makes no progress, then what? That’s where the emotional validation comes in. As Robins and Rosenthal say, that is one of the core principles of successful DBT. Patients have to believe that the skills will help them, and that they can implement them successfully. The safer and more empowered a patient feels, the more likely they are to use therapy skills outside of the office, as I stated when giving cabdriver a solution.
The bottom line is, it all comes down to the proficiency of the therapist. If they look at patients as textbook sets of symptoms who all need the same thing, no progress is going to be made. However, if they change their style to meet each patient’s needs, looking at them as a human being, it makes all the difference. This kind of care could benefit everyone, from the most resistant BPD patient to the scared college student. Therapists just have to be willing to try.

Works Cited

Rizvi, Shireen L. “Treatment Failure in Dialectical Behavior Therapy.” Cognitive and Behavioral Practice 18.3 (2011): 403-12. Science Direct. 2011. Web. 13 Nov. 2016.

Robbins, Clive J., and Zachary Rosenthal. “Dialectical Behavior Therapy.” Acceptance and Mindfulness in Cognitive Behavior Therapy. John Wiley & Sons, n.d. Web. 30 Oct. 2016.

User Cabdriver. “DBT: How Is It Working for You?” RSS. N.p., 19 Sept. 2010. Web. 23 Nov. 2016.