Caller: When I am really honest, number 10 on the Code of Ethics is the hardest one for me: "I will not give my clients advice." And it seems as if the place where I'm susceptible to giving advice, is this inclination to tell people how to do The Work. I can share my own...
Katie (interrupting): OK now, see - that is OK - I mean, I mean, you know - that is not a breech of the (laughing) Code of Ethics - you know - people are going to slap it right back in your face.
Katie: But, but when I talk about advice - uhn - giving it would be like you're working w/someone that wants to divorce their spouse and you say: "Well, if it were me after hearing your worksheet, I would divorce them too." That's what I'm talking about.
Caller: O.K. that's clear
Katie: But in the Candidates Forum, when you're not working with - uhn - those of you not working with outside clients, you're just working with candidates, and the mentors, etc. - you know - just people enrolled in the Institute for The Work, then - uhn - you know - we're gonna - we're learning, we're growing. But these Code of Ethics is no more - it's no more and no less than you're going to have in any coaching - uhn - company or - or - uhn - or, if you had trained for years to be a psychologist, a psychiatrist - you know - you're gonna get exactly this - you know - it's - it's just a standard - uhn - really way of - of being with people that is natural for all of us and we work through the rest and when we breech it - you know - I'm just so here to - uhn - to talk.
But what - HONEY - what you're talking about - like giving advice to people about how to do The Work or to SHUT UP - you know - they're not your clients - it's all family here and (laughs) is that - Oops! - you know - uhn - I'm sorry I said to SHUT UP. And, I'm gonna work through that and then we do it and we learn a lot and then we go back and say how can I make it right? And if we owe an apology - uhn - in the forum - we do it. I mean - you know - just to clean it all up. And, nothing serious here, as far as us all together learning. But, I love that we're all conscious of what is right and wrong within ourself. We all know what that is.
'.The term 'Invalidating Environment' refers essentially to a situation in which the personal experiences and responses of the growing child are disqualified or "invalidated" by the significant others in her life. The child's personal communications are not accepted as an accurate indication of her true feelings and it is implied that, if they were accurate, then such feelings would not be a valid response to circumstances. ....an Invalidating Environment is characterised by a tendency to place a high value on self-control and self-reliance. Possible difficulties in these areas are not acknowledged and it is implied that problem solving should be easy given proper motivation. (quoted from article below)
Dialectical Behaviour Therapy is based on a bio-social theory of borderline personality disorder. Linehan hypothesises that the disorder is a consequence of an emotionally vulnerable individual growing up within a particular set of environmental circumstances which she refers to as the 'Invalidating Environment'.
An 'emotionally vulnerable' person in this sense is someone whose autonomic nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to baseline once the stress is removed. It is proposed that this is the consequence of a biological diathesis.
(Note that many LGATs require people to sign release of liability forms and advise against participating if one has a condition that requires medication. This seems to acknowledge that the LGAT requiring such paperwork is aware it is capable of creating a stressful environment. If part of that stress consists of invalidating what a subject considers to be his or her identity and personal history, that would be very stressful indeed--hence the need for the form.(Corboy)
The term 'Invalidating Environment' refers essentially to a situation in which the personal experiences and responses of the growing child are disqualified or "invalidated" by the significant others in her life. The child's personal communications are not accepted as an accurate indication of her true feelings and it is implied that, if they were accurate, then such feelings would not be a valid response to circumstances.
'Furthermore, an Invalidating Environment is characterised by a tendency to place a high value on self-control and self-reliance. Possible difficulties in these areas are not acknowledged and it is implied that problem solving should be easy given proper motivation.
'Any failure on the part of the child to perform to the expected standard is therefore ascribed to lack of motivation or some other negative characteristic of her character. (The feminine pronoun will be used throughout this paper when referring to the patient since the majority of BPD patients are female and Linehan's work has focused on this subgroup).
Linehan suggests that an emotionally vulnerable child can be expected to experience particular problems in such an environment.
She will neither have the opportunity accurately to label and understand her feelings nor will she learn to trust her own responses to events. Neither is she helped to cope with situations that she may find difficult or stressful, since such problems are not acknowledged.
It may be expected then that she will look to other people for indications of how she should be feeling and to solve her problems for her.
DIALECTICAL BEHAVIOUR THERAPY
The term 'dialectical' is derived from classical philosophy. It refers to a form of argument in which an assertion is first made about a particular issue (the 'thesis'), the opposing position is then formulated (the 'antithesis' ) and finally a 'synthesis' is sought between the two extremes, embodying the valuable features of each position and resolving any contradictions between the two. This synthesis then acts as the thesis for the next cycle. In this way truth is seen as a process which develops over time in transactions between people. From this perspective there can be no statement representing absolute truth. Truth is approached as the middle way between extremes.
The dialectical approach to understanding and treatment of human problems is therefore non-dogmatic, open and has a systemic and transactional orientation.
The dialectical viewpoint underlies the entire structure of therapy, the key dialectic being 'acceptance' on the one hand and 'change' on the other. Thus DBT includes specific techniques of acceptance and validation designed to counter the self-invalidation of the patient.
" These are balanced by techniques of problem solving to help her learn more adaptive ways of dealing with her difficulties and acquire the skills to do so.
The emphasis is to assist the person to develop insight and a realistic sense of personal agency by applying insight skills, not to invalidate the persons own story and identity but instead to analyse a difficult situation and identify areas for taking action.Quote
'In the course of a typical behavioural analysis a particular instance of behaviour is first clearly defined in specific terms and then a 'chain analysis' is conducted, looking in detail at the sequence of events and attempting to link these events one to another.
'In the course of this process hypotheses are generated about the factors that may be controlling the behaviour.
'This is followed by, or interwoven with, a 'solution analysis' in which alternative ways of dealing with the situation at each stage are considered and evaluated. Finally one solution should be chosen for future implementation. Difficulties that may be experienced in carrying out this solution are considered and strategies of dealing with these can be worked out.
'Dialectical strategies underlie all aspects of treatment to counter the extreme and rigid thinking encountered in these patients. The dialectical world view is apparent in the three pairs of 'dialectical dilemmas' already described, in the goals of therapy and in the attitudes and communication styles of the therapist which are to be described.The therapy is behavioural in that, without ignoring the past, it focuses on present behaviour and the current factors which are controlling that behaviour.
(Corboy) I suggest this is very different from BK Work which does ignore the past. (eg where would you be without your story?).
THERAPIST CHARACTERISTICS IN DBT
The success of treatment is dependant on the quality of the relationship between the patient and therapist. The emphasis is on this being a real human relationship in which both members matter and in which the needs of both have to be considered. Linehan is particularly alert to the risks of burnout to therapists treating these patients and therapist support and consultation is an integral and essential part of the treatment. In DBT support is not regarded as an optional extra. The basic idea is that the therapist gives DBT to the patient and receives DBT from his or her colleagues. The approach is a team approach.
The therapist is asked to accept a number of working assumptions about the patient that will establish the required attitude for therapy:
1. The patient wants to change and, in spite of appearances, is trying her best at any particular time.
2. Her behaviour pattern is understandable given her background and present circumstances. Her life may currently not be worth living (however, the therapist will never agree that suicide is the appropriate solution but always stays on the side of life. The solution is rather to try and make life more worth living).
3. In spite of this she needs to try harder if things are ever to improve. She may not be entirely to blame for the way things are but it is her personal responsibility to make them different.
4. Patients can not fail in DBT. If things are not improving it is the treatment that is failing.
In particular the therapist must avoid at all times viewing the patient, or talking about her, in pejorative terms since such an attitude will be antagonistic to successful therapeutic intervention and likely to feed into the problems that have led to the development of BPD in the first place.
Linehan has a particular dislike for the word "manipulative" as commonly applied to these patients. She points out that this implies that they are skilled at managing other people when it is precisely the opposite that is true. Also the fact that the therapist may feel manipulated does not necessarily imply that this was the intention of the patient. It is more probable that the patient did not have the skills to deal with the situation more effectively.
Patients with BPD frequently describe a history of childhood sexual abuse and this is regarded within the (theoretical) model as representing a particularly extreme form of invalidation.
Linehan emphasises that this theory is not yet supported by empirical evidence but the value of the technique does not depend on the theory being correct since the clinical effectiveness of DBT does have empirical support.
On the other hand they have internalised the characteristics of the Invalidating Environment and tend to show 'self-invalidation'. They invalidate their own responses and have unrealistic goals and expectations, feeling ashamed and angry with themselves when they experience difficulty or fail to achieve their goals.