Whose Therapy is it Anyway? DBT, Psychoanalysis or Both

“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