Reflecting on DBT Assumptions about Patients and Therapy (Part 4)

Jul 5, 2019 | DBT Assumptions

“The most important thing to remember about assumptions is that they are just that—assumptions, not facts.”

Cognitive Behavioral Therapy for Borderline Personality Disorder; Marsha M. Linehan, Ph.D, 1993

This feature by Vibh Forsythe Cox, PhD is the fourth and final part in this series of blogs about DBT assumptions. In DBT, in order to organize our behavior towards our clients, we adhere to certain assumptions. Through the first three parts of this blog series, we examined the assumptions that “Patients are doing the best they can,” that “Patients want to improve,” that “Patients need to do better, try harder, and be more motivated to change,” that “Patients may not have caused all of their own problems, but they have to solve them anyway,” that “the lives of suicidal, borderline individuals are unbearable as they are currently being lived,” and that “patients must learn new behaviors in all relevant contexts.”

In this fourth part, she will shine a light on the last two assumptions: that “Patients cannot fail in therapy” and that “Therapists treating borderline patients need support.”

In this four-part blog series, I am examining eight assumptions of DBT. As a Training and Development Specialist for Behavioral Tech Institute, I often work with people who are just learning about DBT. For those new to DBT, one of the fundamental aspects to understand is how our core DBT assumptions affect how we treat our clients.

The first blog covered the first assumption that patients are doing the best they can (you can go back and read that here). In the second blog, I addressed the second and third assumptions that patients want to improve and that they need to do better, try harder, and be more motivated to change (read about assumptions two and three here). In the third blog, we looked more closely at the fourth, fifth, and sixth assumptions: that patients may not have caused all their own problems, but they have to solve them anyway, that the lives of suicidal, borderline patients are unbearable as they are currently being lived, and that patients must learn new behaviors in all relevant contexts (read about assumptions four, five, and six here). Now let’s move on to our final two assumptions!

Patients Cannot Fail in Therapy”

“The seventh assumption is that when patients drop out of therapy, fail to progress, or actually get worse while in DBT, the therapy, the therapist, or both have failed. If the therapy has been applied according to protocol, and the patients still do not improve, then the failure is attributable to the therapy itself. This contrasts with the assumption of many therapists that when patients drop out or fail to improve, it can be attributed to a deficit in their motivation. Even if this assumption is true, the job of therapy is to enhance motivation sufficiently for the patients to progress.

Cognitive Behavioral Therapy for Borderline Personality Disorder; Marsha M. Linehan, Ph.D, 1993

I believe that this is the assumption that elicits the most consternation when I am training. The idea that clients cannot fail in therapy seems to kick off a threat response in many providers. It might be useful to ask what is the threat? What do we lose by assuming the client cannot fail?

The word “fail” seems inextricably linked to negative connotation. Thankfully, DBT has also encouraged me to be mindful of my own responses and judgements and to seek behavioral specificity. My ability to deliver this treatment improved considerably when I stopped viewing “failure” as an evaluation of a person and their efforts and instead interpreted the word as a descriptor for whether a set of behaviors did or did not reach the intended goal. Definitions of “fail” that I found from the Merriam Webster dictionary included “To miss performing expected service or function for” or to “disappoint trust or expectation.” It has helped me and my clients to be specific about the goal or expectation we failed to achieve when we say we failed.

My main expectation in delivering this treatment is that my clients seek treatment because they need help to make things go differently in their lives. A person cannot fail at needing help. My understanding, based on the other assumptions of the treatment is that our clients are people who are suffering, want to improve, and need to learn how. If we can understand how our clients’ skills deficits have interfered with their ability to achieve their goals then we can understand that benefiting from treatment is another goal endangered by those same deficits.

Beyond understanding, this treatment is organized to help target treatment-interfering behavior, because we expect that these same deficits have the potential to interfere with receiving the full benefit of treatment. Therefore, even treatment-interfering behaviors cannot accurately be described as a failure to meet expectations.

Often clients and therapists will surmise that a client wasn’t motivated or couldn’t do what was required to benefit from the therapy. I would highlight that part of the functions we strive to meet with comprehensive DBT are to increase the motivation and capability of our clients. So, if they do not have the motivation and capability to continue in the treatment and benefit from it, we have failed in our goal to meet that function. This represents a failure on the part of either the therapy or the team applying it. 

For me, it has been helpful to remember that assessing treatment failure is not about assigning blame.

In terms of this treatment, we have a more important focus. When we fail to meet a specific goal, it can be helpful to assess what were the factors that contributed to the goal not being met. People diagnosed with cancer are typically prescribed treatment that has evidence suggesting it has worked with other patients with that diagnosis. If that client’s cancer does not remit in response to the treatment, we rarely say that patient “failed” cancer treatment.

My understanding of the assumption that patients cannot fail treatment is that it is a prompt for us to think the same way about this treatment. We have hope that it will work and we do our best to apply it according to the standards of available evidence. If it does not work for our patient, we strive to identify changes in our treatment delivery, or in the treatment itself that would be needed to increase the likelihood that it might work for this client or for the next person who presents with similar problems. 

“Therapists Treating Borderline Patients Need Support”

“As noted throughout this book, [patients with borderline personality disorder] are one of the most difficult populations to treat with psychotherapy. Over and over, therapists seem to make mistakes that interfere with the patients’ progress. Some of the problem stems from the patients’ intense cries for immediate escape from suffering. Often therapists are capable of soothing the pain, but giving such relief frequently interferes with providing help for the longterm. Therapists get caught between these demands for immediate relief and for long-term cure. Many other factors make it difficult for therapists to remain therapeutic with borderline patients. A co-supervision group, a treatment team, a consultant, or a supervisor is important for keeping therapists on track.

Cognitive Behavioral Therapy for Borderline Personality Disorder; Marsha M. Linehan, Ph.D, 1993

We are accustomed to the idea that grueling tasks like delivering a baby, running a marathon, putting out fires, or performing high risk surgery are best accomplished with support. I see the assumption above as helping orient us to the fact that the application of this treatment is no different.

Treating clients who present with life threatening behaviors, significant emotional dysregulation, or barriers to treatment is hard. It is a complex and high-stakes task. There are many prompts for emotion, and incredible pressure to soothe, benevolently demand, and problem solve in the right proportions and at the right times. The myriad thoughts and emotions associated with this work can pull our attention to different problems and crises and away from our treatment plans. The consultation team (and the other supports listed above) help us stay mindful of the plan we have created with our clients about what is needed to help them achieve their long-term goals and the strategies and principles of the treatment that help us navigate obstacles while staying in line with that plan.

My understanding is that in the context of this assumption, support is not synonymous with unconditional positive regard. In this context, I understand support to mean providing what is needed to help the therapist reach the goal of delivering the best possible treatment to their clients.

Both the therapist and their team must remember that support can take many forms. Getting feedback from others who understand the principles of the treatment is important because they can point out when more assessment is needed, when there may be a higher-priority target than the one we had been working to address, when there may be multiple explanations of behavior, and they can highlight principles to consider while addressing those behaviors. It is hard to imagine keeping a therapist on track and in line with the principles of the treatment without ever challenging an interpretation or prompting another way of looking at an issue. 

At the same time, keeping a therapist on track is about much more than pointing out what the therapist is doing wrong. The team is not only an avenue to point out the things the therapist is potentially missing. Needed behaviors can be unpleasant. Sometimes needed behaviors require regulating our own fear, shame, or frustration. We see this clearly when we as therapists are highlighting needed behaviors for our clients. Another important way the team provides support is by providing reinforcement for therapist behaviors that will benefit the client in the long run and may be hard to do in the moment.

DBT therapists rely on the support of the consultation team in much the same way that our clients rely on our support to approach needed behaviors. Just as we support our clients’ progress toward increasingly skillful behavior by celebrating the progress that others might not, I can honestly say that my team has been the one place where I can share victories and feel like the gravity of those accomplishments is fully understood.

As some of the other assumptions orient us toward compassion for our clients, I believe this one orients us toward compassion of DBT therapists. Therapists need support. Even when we offer corrective feedback, this assumption reminds us that it is in service of supporting the therapist. I like to think that helps orient us toward accompanying critique with validation, teaching, and ideas and practice to help the therapist enact a specific behavior change.

As behavior therapists, we understand that our behavior in response to a therapist’s request for support can serve as a reinforcer or a punisher for a therapist seeking the support of others. It is of the utmost importance that we do not punish therapists form seeking consultation.  If the consequence of bringing a topic to team is corrective feedback with validation and ideas for moving forward, it might increase the therapist’s likelihood of bringing agenda items to team in the future. Conversely, team members or supervisors responding with critique, disinterest, or problem solving without adequate assessment might reduce the likelihood a therapist will engage in needed discussions. At best this puts that therapist at risk of not having access to a valuable resource for improving their treatment and at worst puts the therapist at risk of making decisions in isolation and under high emotion.

We have now covered all eight DBT assumptions about patients and therapy. Taken together, we see the complexity of these assumptions, but also how they work together to give us a framework to organize our behavior toward our clients. These eight assumptions give us a way to reduce the distraction from treatment that it can present if we are struggling to get to a place of certainty or proof about our clients’ intentions. Behaving as though these eight assumptions are true helps us as therapists to stay on track in treatment.

Vibh Forsythe Cox, PhD, serves as the Training and Development specialist for Behavioral Tech Institute (BTECH), the training organization founded by treatment developer, Dr. Marsha Linehan. She serves on the team that creates content for BTECH’s training offerings, including the newly released Online Comprehensive Training in DBT. She provides consultation to newly forming DBT teams within the online learning platform. She works as a therapist at Cadence Child and Adolescent therapy, a DBT-Linehan Board certified DBT program in Kirkland, Washington. There, she provides DBT and other evidence-based treatments for teens and adults with emotion regulation difficulties. Dr. Forsythe Cox earned her PhD in Clinical Psychology at The Ohio State University, where her research focused on characteristics of Borderline Personality Disorder and interpersonal emotion regulation. During her time at The Ohio State University, Dr. Forsythe Cox participated in specialized training in DBT, and assisted the Director of the DBT program by providing supervision and consultation to new trainees. She was also the 2012 recipient of the Psychology Department’s Meritorious Teaching Award. Dr. Forsythe Cox has experience providing DBT in a variety of settings, including university-based research, inpatient and outpatient hospitals, forensics, and private practice facilities. She is a Clinical Instructor in the Department of Psychology at the University of Washington, where she provides individual and group supervision to doctoral psychology students in the Behavioral Research and Therapy Clinics (BRTC). Dr. Forsythe Cox has also been an invited speaker at high schools, community colleges, and the University of Washington. Dr. Forsythe Cox is licensed as a Psychologist in the state of Washington.


Disclaimer: The Behavioral Tech Institute blog is designed to facilitate the sharing of ideas, experiences, and insights related to Dialectical Behavior Therapy (DBT). The content and views expressed in the articles, comments, and linked resources are those of the individual authors and do not necessarily reflect the views, policies, or positions of Behavioral Tech Institute or staff. Content is provided for information and discussion purposes only and is not intended as professional advice. Contributors to the Behavioral Tech Institute blog are independent, and their participation does not represent an endorsement by Behavioral Tech Institute.

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