Successful therapy requires balancing two opposing tasks: on the one hand, acceptance of the patient as they are, with their often traumatic history and currently limited coping skills, and on the other hand, change and movement towards a life worth living.

The first imperative requires a focus on 1) accepting and validating the patient’s often traumatic history and guiding them to come to terms with it and with their personal shortcomings, 2) a compassionate, unrushed, unconditionally supportive comportment maintained by the clinician, and 3) sometimes even an empathizing with the unfairness of other people’s actions or of life in general.

The second imperative requires different interventions, which may include 1) motivational enhancement, 2) validation and presumption of the patient’s agency to learn and change, 3) skill training, 4) identifying and mobilizing other resources in the patient’s life, and 5) coaching the patient towards their goals.

So, the biggest reason for ineffective psychotherapy is a lack of balance between these two imperatives. Some therapists, kind souls that they are, remain in the realm of the first task. They spend session after session commiserating with the patient on how many problems they have and how unfortunate it all is. They often start off the therapy session with a question such as, “So, how was your week,” and patiently listen to the many stories of woe that occurred until therapy time is up. And they end the session with, “OK, we’ll pick up again next week,” when the process repeats itself. BTW, I am not making light of our patients’ often very difficult lives as much as I am of the ineffective approach taken by these kinds of therapists.

Another group of therapists makes the opposite error: they move immediately into review of last week’s homework assignments and of upcoming tasks for next week. Of course, many (most?) times, the patient did not complete their homework assignment. Given the frequency of this outcome, these therapists are usually adept at focusing on the factors that got in the way of completing the assignments. The resolution of these impediments then becomes the focus of their problem-solving efforts until therapy time is up. Often there is no next session because many patients feel misunderstood and put-upon and opt out of treatment.

One therapy from which we can learn about effective therapeutic approaches, irrespective of therapy type or orientation that we practice, is dialectical behavior therapy (DBT). Marcia Linehan, its developer, was a trained behavioral therapist and researcher before developing DBT as we know it to be today. Through her work with patients, she came to realize that either approach (acceptance and change), taken in isolation, usually leads to stagnation in therapy and lack of progress towards goals. She realized that the patient must feel heard, understood, and validated as they are now, in all their strengths and weaknesses and struggling with their myriad intractable life problems, before they are willing to move to a stance of change. As Dr. Linehan writes in a 2015 review article on the origins of DBT*:

Initially, treatment focused on teaching clients effective problem-solving strategies. However, treating such a high-risk and complex population [of patients at chronic suicidal risk] moved the therapists to apply treatment strategies that required clients to make very difficult life changes. This focus on problem-solving was experienced as extremely invalidating by clients. Often, clients responded with hostility by lashing out, often at their therapist, or dropping out of treatment altogether. In response, treatment shifted dramatically to focus on warmth and acceptance. Clients were equally frustrated by this treatment, saying it was not doing enough to solve their problems.

When Dr. Linehan attended to the poor patient outcomes and sources of treatment failure of the therapy as initially conceived, she came to realize that both acceptance and change are necessary and are, in fact, so central to treatment success, that she incorporated the term “dialectic” into the name of the therapy. (The treatment started out being called CBT for chronically suicidal patients.) The term dialectic refers to the synthesis that is to be achieved between these two differing, often opposing, poles of therapeutic interaction. But such a synthesis is easier said than achieved. In particular, successful integration of acceptance and change requires specific stances from the therapist and the patient.

The therapist, because she or he is interacting with a highly affectively unstable, resource-poor, and chronically suicidal person, needs to develop a nuanced approach that requires perceiving the patient’s moment-by-moment capacity to engage, learn, and change. Within the therapy, a “spaciousness of the therapist’s mind to ‘dance’ with movement, speed and flow” is required. And further, the acceptance offered by the therapist must be of a certain kind; it must be a “radical acceptance.” This type of acceptance is characterized by viewing “the client as is, with a slow and episodic rate of progress and the constant risk of suicide” and as always doing the best they can, given the nature of their (limited) capacities for problem-solving, emotional regulation, distress-tolerance, and interpersonal effectiveness.

The patient, even when such a flexible dialectical approach is taken by the therapist, remains at risk of treatment failure and, ultimately, of death by suicide. Thus, as Dr. Linehan explains: “this synthesis of acceptance and change was troubling for clients as well. Given the complexity of the clients’ problems, asking them to temporarily tolerate distressing experiences to focus on other treatment goals proved difficult if not impossible. For many clients, the pain from the past was intolerable and elicited dysfunctional behaviors.”

Thus, something more was required of the patient to improve chances of success. First, the patient also must be guided to nurture radical acceptance of themselves, that is, a full acceptance of what happened to them in the past, of their capacities as they are in the present, and a realistic view of the future, including of what will be possible and what is likely to remain out of reach. This means that a life worth living will probably never be a life free of pain or conflict or of missed opportunities. The damage done in the past will never be fully undone.

And second, the patient must also learn to tolerate distress, often at high levels, without acting destructively to reduce that distress. Destructive acting out includes substance use, non-suicidal self-injury, violence towards others, impulse or ill-considered sexual activity, and placing one’s self at high risk, such as through driving drunk or picking fights.

Another important lesson derived from DBT is that not everything can or needs to be addressed at once. The most important things must be addressed first, and an explicit hierarchy of what takes priority is a part of the treatment protocol. At the top of the hierarchy requiring intervention are any factors that increase the risk of suicide or self-injury or that interfere with engagement with the treatment. Only after these are addressed – and they are reviewed and addressed at every session – can other factors that decrease quality of life be addressed.

*Reference: Linehan, Marsha M., and Chelsey R. Wilks. “The course and evolution of dialectical behavior therapy.” American journal of psychotherapy 69.2 (2015): 97-110.

Thanks and take care.

Dr. Jack

Language Brief

“In my early professional years, I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” ― Carl R. Roger

“Life is not the way it’s supposed to be, it’s the way it is. The way you cope with it is what makes the difference” ― Virginia Satir t

“Each morning when you wake up, bow three times before the mirror and say, “The world is a better place because I am here.” ― Virginia Satir

“There were nights when I left the sessions physically and emotionally drained after hearing the anguish pour out like blood from a gaping wound. Don’t let anyone ever tell you different – psychotherapy is one of the most taxing endeavors known to mankind; I’ve done all sorts of work […] and there’s nothing that compares to confronting human misery hour after hour and bearing the responsibility for easing that misery using only one’s mind and mouth.” ― Jonathon Kellerman