Rebuttal Rewrite- belladonna98

DBT Doesn’t Fail- Therapists Do

Therapists whose patients don’t improve with DBT complain that it doesn’t work in extreme cases of BPD and emotional dysregulation. In one case, Shireen L. Rizvi had a patient named Barbara whose condition was not improved, and whose disorder may have been worsened, by the improper application of DBT. Barbara had BPD, social anxiety, severe depression, PTSD, and was an abuse survivor. Rizvi’s treatment was incompetent.

Over the course of six months, Rizvi struggled to treat Barbara, later blaming her failure on the “therapy-interfering behaviors” of her patient such as asking her therapist very personal questions, calling her in crisis daily, and not making eye contact. Rizvi’s response to these behaviors is what makes her argument that DBT didn’t work here completely invalid. Rizvi admitted to outright ignoring some of Barbara’s behaviors in many ways. She failed to indulge in and therefore validate the behaviors. The very basics of DBT state that a patient must feel validated in order to receive treatment. Maybe partially answering a question or asking her why she didn’t make eye contact would have been an improvement. Rizvi instead 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) Rizvi’s 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 looked at Barbara and saw not a person but a set of symptoms: mistrust of authority, boundary blindness, disassociation, crippling anxiety. Well-administered DBT could have helped Barbara; her therapist did not.

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. Barbara may fit the criteria for rigorous DBT, but would not be able to handle it. She 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 not only have given the therapy more meaning to her, but 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. A user we’ll call Cabdriver gave a list of explanations on why DBT wasn’t working for him and how it was flawed. The list consisted of a combination of him not practicing his skills and his therapist punishing him for it. He found the skills boring and unhelpful, and would lie to avoid punishment and say that he did them when he hadn’t.

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 his 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 he is constantly fearing punishment. A person can’t fear his therapist; therapy is supposed to be a safe space where someone can admit to anything without judgement. He may be held accountable for his actions, but he shouldn’t have to fear a slap on the wrist. Patients are 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 he also must realize that the skills are there to help him, 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.

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. Reluctant patients shouldn’t be completely immersed in the therapy, or shut out like failures. 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.” She can simply give skills that pull from DBT and mention the name, intriguing the patient. Patients who recognize the value of DBT are receptive patients.

Patients have to believe that the skills will help them, and that they can implement them successfully. Emotional validation, as Robins and Rosenthal say, is one of four core principles of successful DBT. 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. But of course, the person has to practice the skills in order for them to help. If someone completely ignores their skills and makes no progress, then what?  Successful therapists guide their patients through that process, from belief, to validation, to empowerment, to practice. The unsuccessful, who treat their patients like children throwing fits, drive patients away.

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.