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

Disconnecting what you think is real from what is real

The happiness of your life depends upon the quality of your thoughts: therefore, guard accordingly, and take care that you entertain no notions unsuitable to virtue and reasonable nature.

Marcus Aurelius 

Nearly two thousand years ago the Roman Emperor Aurelius noted this wisdom, and it is as relevant today as it was then. This perspective has important implications in the treatment of borderline personality disorder (BPD) and that is because it is typical of brain function to look for evidence that supports an idea you believe to be true and to not pay attention to data that says the idea is inaccurate. Generally speaking this can be of trivial consequence, so you might wear your lucky cap to the ballgame in the belief that doing so will help your team win, and then you are likely to focus on the times when your team won when you were wearing your cap. At the same time you discount the times when they won and you weren't wearing the cap, or when they lost and you were wearing the cap. In order to change this perception you have to be aware that you have a perception that a belief you have is true, want to examine it and then decide if you want to change it. 

One simple way to do so would be to examine the evidence, by being a careful observer of the data at hand. You might take a note-book to future games and wear your lucky hat and plot the correlation between your hat-wearing and game outcome. It would be a fun thought experiment to have a friend loyal to the other team, and who has an equal belief in lucky-cap-wearing, to similarly track results.

In people who have BPD, the consequence of this particular function of brain activity can be decidedly destructive for two reasons that are characteristic of people with the condition: The first is that the thoughts and beliefs tend to be painful. "No one loves me", "people hate me", "I am toxic", "I deserve to die", and the second is that people with BPD tend to magnify these particular thoughts, and so the thought that "no one loves me" becomes universal, and without exception. Unfortunately the opposite is not true. If you have BPD, you don't tend to have self-compassionate thoughts and then if a compassionate self-thought pops into your mind, you don't tend to dwell on it and don't tend magnify it, instead rejecting it as false.

But the brain is constantly distorting information. It does so in order to make sense of the world. There are multiple examples of how the brain changes perception even when you are not aware that it is doing so. In many circumstances, if the trick or the perceptual distortion is not pointed out you continue to believe that what you imagine to be true is true. Here is a great little article on this very point. The examples in the article are of visual misperceptions, and as the article shows, in many circumstances there can be a simple solution to rectify the misperception. Thought mispreceptions tend to be far more complicated, and in people with BPD can be the ones that lead to the conclusion that suicide is the only way out.

Another characteristic of brain function is that continued practice and repetition of any thought or behavior, makes the thought or behavior increasingly hard-wired. And so if you repeatedly imagine an event occurring, and continue to ruminate on the thought that it will occur, your view of the likelihood of it occurring increases. If you have BPD and you worry and ruminate about an awful event, such as that your therapist hates you and wants to get rid of you, you are also increasing your perception that the awful event will occur. Whether it happens or not, the fact that you are thinking about it will add to your misery. And it all started because your brain created the thought and then repeated it over and over again. 

Sadly, it is possible that because you believe your perception to be true and factual, you might then act in ways that not only confuses the other person, in this case your therapist (for example you might attack your therapist for being uncaring because you thought she was being uncaring), and then because of the attack, the therapist decides that they no longer want to work with you and then the perception that they don't care and will leave you becomes a reality..

Stopping this kind of thinking is difficult. Again, this is because rumination is practice and the more you practice a painful thought, the more neuronal connections become dedicated to practicing the thought, the more hard-wired it becomes and the more you suffer.

When you feel something powerfully, the tendency is to act decisively and you behave in a certain way. However you can never have all the information about a particular situation so you tend to make decisions with the data that you have at hand. You tend not to realize that there is often information to which you are not paying attention. Here is a famous video by Daniel Simons proving the point. When certainty sets in, the task is to consider what information is being left out, to slow down consider that it is possible that you may have missed some critical facts. Going back to the imaginary situation with your therapist, if you are angry with her because she did not show up on time to your session, consider that it is possible that rather than the certainty that she doesn't care about you, that it is possible that you don't have all the information. Was she stuck in traffic? Was her child ill at home? Was she running late from a meeting with her boss?  In BPD in particular it is typical that the closer that you are to another, the more likely that strong emotions will distort interactions with that person. And with that the more powerful the certainty that resulting thoughts become "truths." Being curious about what happened and getting more of the facts will lead to more effective behavior. This does not invalidate the fact that you are angry, but it does allow for more adaptive interactions.

The problem is that when strong emotions, particularly anger and shame engulf your experience, there can be a misery-inducing loop where you make interpretations and assumptions about the behaviors of others. When you then behave in ways that are based on these interpretations, perceptions and assumptions, rather than relying on what you can actually observe to be true, the ensuing behaviors can lead to destroyed relationships and enduring shame and anger. Remember that you can never observe another's intentions. Intentions are in the mind of the other. The task here is to use the "observe" and "describe" skills of mindfulness (as taught by dialectical behavioral therapy (DBT)) to describe what you can actually see rather than making assumptions and interpretations of what you see.

So when thinking is causing you to suffer because you imagine your thoughts to be facts, the sooner you catch the thought spiral, the sooner you can deal with it and the quicker you can prevent your brain neurons from establishing long-lasting connections, which over time will become more difficult to undo. The skillful practice of noticing rumination through mindful awareness is the way out of enduring suffering. The fact that you have a thought does not make that thought a fact.

And so we go back to the wisdom of Aurelius who noted:

Very little is needed to make a happy life; it is all within yourself, in your way of thinking.

For more on targeting the struggles of dealing with BPD our book Mindfulness for Borderline Personality Disorder has been well received.