This feature by Cedar Koons is Part 2 of 2 in a series about observing limits during the time of the pandemic. In the first part, we looked 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. In part 2, Cedar further examines the last three procedures.
In my last blog post (read here), I discussed the importance of observing limits to improve therapeutic relationships, reduce therapy interfering behavior and avoid burnout. We reviewed the first two observing limits procedures Linehan describes in her treatment manual (1993): monitoring limits and being honest about limits. In part 2 of this discussion I’ll cover the last three procedures, which are temporarily extending limits when needed, being consistently firm, and combining soothing, validating and problem-solving with observing limits.
Temporarily extending limits when indicated is an important observing limits procedure. We stretch limits, for example, when a patient in suicide crisis is using skills and needs more coaching contact to avoid acting on urges. The problem arises when temporary extension goes on longer than we can tolerate or when our own needs must take precedence such as during an illness. Many of us extended our limits with patients in March at the beginning of the COVID-19 pandemic without knowing how long this emergency would last. We scrambled to provide services to patients in ways they could access more easily. For example, we may have offered evening or weekend sessions, allowed the patient’s children to be in the room during session or significantly reduced fees to amounts we can’t sustain. Now that we know this situation might extend for months or even years, we may need to consider how to bring our limits back within a range we can more readily tolerate for the long term.
Patients may react quite negatively to therapists’ observing their limits by complaining and perhaps threatening. Once the limit is expressed (without resorting to blaming the patient for our limit), it is important not to give in to demands to reconsider, which could reinforce more demands, or punish the client for their reaction which could damage the therapeutic relationship. Instead, the therapist “states his or her position calmly, clearly and firmly.” For example, when withdrawing from an extension of limits we might say, “I know you appreciated that I was willing to see you on Saturdays in April, May and June, and I was glad to do it. I cannot continue, however, because I need my Saturdays back now. Beginning on this date I can see you at one of these week day times.” Linehan recommends using the broken record strategy from the interpersonal effectiveness skills.
Finally, DBT therapists offer validation, soothing and problem-solving around unwelcome limits. For example, it is reasonable for a client to want us to tolerate multiple interruptions to therapy sessions caused by her children wanting her attention. She is home alone with her children and is unaccustomed to saying no to them when they interrupt her for food or to settle an argument. She may lack skills to manage these interruptions, and we may have allowed them to go for a variety of reasons. Maybe we didn’t realize how disruptive the interruptions would be, or we didn’t know how to coach her to manage them better. Perhaps we didn’t want to ask her to do one more thing she obviously found difficult. By the time we realize the problem and observe our limit about the interruptions we will need to provide problem-solving around the limit and offer validation and soothing for the difficulty our limit poses to her.
Observing limits procedures are challenging to apply because they involve both mindfulness to limits and applying contingencies. Observing limits is especially difficult when treating suicidal behaviors and when utilizing telephone coaching. To observe limits effectively in these areas, it is helpful to consider how central the strategy is to conducting DBT to fidelity. In both situations, the consultation team can help us to balance our needs and limits with the needs and demands of our patients.
At times of crisis, our personal limits sometimes relax, only to firm up again when we adjust to the new normal. We are beginning such a time of adjustment to the crisis of pandemic now. It is important not to neglect any indications that we are at risk of burn out because we have either not observed or overextended our limits earlier in the spring. When interacting with clients and an “old familiar feeling” of irritation arises, it is likely that therapy interfering behavior of some type is happening. Not all therapy interfering behavior crosses our personal limits. But when it does, perhaps especially in times like these, it is important to address the behavior with observing limits procedures.
Want to read more about the role of DBT during this pandemic? Read here for an excerpt of a discussion between Tony DuBose, PsyD, Chief Training Executive at Behavioral Tech, and Esequias Caetano, a psychologist in Patos de Minas, Brazil about “DBT Skills in the COVID-19 Pandemic.”
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.