“My
dear if you could give me a cup of tea to clear my muddle of a head I should better
understand your affairs.” ~Charles Dickens, “Mrs. Lirriper's Legacy”
Today
at our weekly conference on Borderline Personality Disorder a question arose
about whether a therapist would make a cup of tea for their patient. The well
attended conference provided a smorgasbord of responses with the strict
analysts saying no, the more dynamic types saying yes, but with an exploration
of the meaning for the patient, the supportive psychotherapists saying yes and
the DBT therapists saying yes and making a cup for themselves!
I
made myself a cup of tea after today’s conference which got me reflecting on my
experience attending the gathering over the years. In certain ways, the
conflicts that arose years ago between our clans, the “behaviorists” and the
“analysts,” are the ones that continue to arise, although today the effects of
theoretical interbreeding and cross-pollination has led to a more nuanced
analyses and treatment of our complicated patients. Nevertheless, in the face
of what appears to be enduring skepticism, it is a perplexing juxtaposition
that I would comfortably (and have done) refer a difficult to treat patient
with BPD to any other seasoned clinician in the room, whether or not I agreed
with their theoretical stance. There is something about inherently knowing that
despite differences in style and orientation, there is particular wisdom and compassion
in the room that any patient would find holding and useful.
Even if it were not within my nature to be curious, as a DBT
therapist my training requires me to not be certain that I know it all. It compels
me to recognize that the “truth” often has opposing points of view, and that
there is wisdom in mulling the tension of any disagreement, listening without
judgment, while working towards a clearer synthesis, a newer way of thinking.
It seems to me that at times we get too stuck in the certainty about how we see
things. This stuckness that has less to do with imagining each other as
incapable and more to do not listening with open curiosity. Why not make the
cup of tea? Or why make it? How is what we do helping the patient and what
evidence do we have that it is helping? Do we get so rigid in our approach that
any nod to a dissenting perspective automatically casts us from our clan? On
the other hand, having a free-for-all approach and doing whatever pleases each
one of us makes little sense.
Each patient is unique, just like all the others. The same goes
for each one of us. We do the treatment that works for us and the patient, and
in most cases things work out. It is when therapy does not work as we intended
in the cases that we present that ego appears to arise within our group of
dedicated and expert clinicians and the sense that “I” could have done better
permeates, sending those of us who have failed, feeling judged and scurrying
back to our dens to get support from our clan. And it is here that the conflict
arises. That initial judgment imprints, particularly in young minds leading to
an enduring mistrust that is hard to shake.
What about
integration?
Another manifestation of dialectical tension in our work with
patients is that a psychodynamic approach works with the “truth” that the past
determines present behavior and that it will inform future behavior. In theory,
understanding the past empowers the patient to do things differently going
forward. Through a thorough exploration of how a person comes to be stuck in their
way of thinking, the ensuing insight offers liberation from the repetition of
maladaptive interactional styles. On the other hand, DBT recognizes the “truth”
that simply focusing on the past can be an unproductive exercise, one that
drains time, energy (and money) from more immediately changing problematic
behaviors and cognitions. Because living in regret about the past or worry
about the future is a major source of suffering in people with BPD, DBTs
emphasis on staying in the present moment while developing the skills to deal
with painful emotions makes sense. If we cannot see the wisdom in these two
approaches then what is it like for our patients, caught in the confusion of
therapies that each promise a way out. We become bickering parents, inflexible
in a rigid stance. This rigidity indignifies the undertaking of our collective
purpose.
What about science?
A
fair argument could be made about using the scientific method to test competing
approaches to a specific problematic behavior. The research data strongly indicates
that DBT is very effective in dealing with suicidality and self-injury,
particularly in adolescents. If my child were severely self-injuring I would
want them to be in a DBT therapy. But it is not the impulsive, dysregulated
behavior and emotions that keep a person in therapy. It is self-constructs like
self-loathing, unworthiness and insignificance that perpetuate misery and these
don’t yield their grasp all that easily, and certainly not to standard DBT. In
DBT parlance effectiveness is doing what is required. The evidence is the
health of our patient. A therapist integrating an exploration of the past as a
means of understanding entrenched, potentially unconscious patterns of thinking
and behavior together with the teaching of new, present focused behavioral
skills including mindfulness combines the best of what all of us have to offer.
Let us all be open to that.
So
back to the tea! Eliot’s (The Love-Song
of J. Alfred Prufrock) distant musing captures the spirit of our endeavor at
our weekly conference:
Time
for you and time for me,
And
time yet for a hundred indecisions
And
for a hundred visions and revisions
Before
the taking of a toast and tea.
And
surely we can all agree to that!
If you are interested: Our Mindfulness Book for BPD
Or the new edition of BPD in Adolescents
