This feature by Cedar Koons is Part 1 of 2 in a series about observing limits during the time of the pandemic. In this first part, we look at why it is important to observe limits at this time to maintain equilibrium and avoid burnout, as well as the kinds of demands that may currently make life more strenuous for DBT therapists and our patients.
The demands on therapists who provide stage 1 DBT to patients have always been high. Working with patients with severe behavioral dyscontrol is very stressful work under the best of circumstances. In the time of pandemic and economic meltdown, however, the demands on DBT therapists and our patients are becoming even more strenuous.
In addition to the problems that brought our patients into therapy, they are now coping with significant societal stressors. We therapists are also struggling to accept unwelcome changes the virus has wrought in our lives. How, under these circumstances, can we maintain our equilibrium and avoid burnout? A key element to our balance is the ability to observe our limits with our patients.
In her original treatment manual, Linehan (1993) tells us that, “observing limits is essential to DBT.” In my experience as a consultant to DBT teams and individual therapists I have found that therapists’ failure to observe their limits is one of the most common factors I see as contributing to burnout and treatment going awry.
Linehan (1993) describes observing-limits procedures as a part of contingency management that treat the specific therapy interfering behaviors of patients which cross the therapist’s natural or personal limits. It is the responsibility of the therapist to observe their limits and to communicate about their limits “before it is too late,” i.e., before therapists “burn out, terminate therapy or otherwise harm the patient.”
With the exception of the four-miss rule and the observation of all professional and ethical standards, therapist limits are rarely arbitrary in DBT (Linehan 1993). Instead, therapist limits are personal and vary from therapist to therapist even on the same team and over time. Thus, the therapist must take “personal responsibility” for their own limits and consult with the team regarding their limits and treatment (Linehan 1993). Observing limits procedures include 1) monitoring limits; 2) being honest about limits; 3) temporarily extending limits when needed; 4) being consistently firm; and 5) combining soothing, validating and problem-solving with observing limits (Linehan 1993).
Many factors make monitoring our limits more difficult during the time of pandemic. Because of social distancing we are providing DBT on a computer screen and often dealing with the connectivity challenges, eyestrain and fatigue associated with using a video platform. Sometimes we cannot tell what is really going on with patients in group or individual sessions because it is easier for distressed patients to “hide” on line. We ourselves may be working from home in a less than ideal “office” with family, roommates or the dirty kitchen just on the other side of our door. The commute or other afterwork downtime has been removed and with it our opportunity to decompress before returning to home life. We are likely very worried about any number of things including finances, our children’s well-being, civil unrest, and a thousand other concerns. Patients may be skipping out on sessions, arriving late, calling because they are bored or texting inappropriately, complaining more, or displaying more anger. But because we are distracted with our own stressors it can be hard to notice our emotions, sensations, and thoughts that ordinarily alert us to the fact that our patient is crossing our limits. Noticing how these behaviors affect us and which ones cross our limits before we feel burned out by them is the first step.
What gets in the way of being honest about limits?
Sometimes we can’t bring ourselves to acknowledge that we, the strong, well-adjusted therapists, have limits. Given it is so much harder for our patients, shouldn’t we keep extending our limits indefinitely?
As Linehan (1993) acknowledged, therapists sometimes “feel guilty or somehow untherapeutic if they attend to their own desires and needs.” On the other hand, therapists who are honest about their limits communicate respect for their patients (Linehan 1993). By taking responsibility for their personal limits they are likely to reduce repeated limit crossings and the accompanying resentment that accrues from them. Patients can benefit from the modeling therapists provide when they are honest about their limits, especially those limits that affect therapist and patient in similar ways.
Read here for Part 2 of this blog post, in which I will discuss observing limits procedures including temporarily extending limits and soothing around unwanted limits.
Cedar Koons, MSW, LISW, is a DBT consultant and the author of The Mindfulness Solutions for Intense Emotions: Take Control of BPD with DBT. Check out her blog at www.cedarkoons.com. Read Cedar’s full biography on the Behavioral Tech website here.