Is DBT potentially patronising for some patients?

[PsychiatryAndCats]

Hello all, I'm a 3rd year psych registrar (my country's equivalent of resident) in Ireland and have an interest many of the therapies. I recently had a few introspective and articulate patients with EUPD/BPD who found some aspects of DBT patronising.

(I don't personally practice DBT, but work on teams that provide it.)

I have to say I completely understood where they were coming from. One lady felt that using mindfulness techniques when distressed made her more distressed. Another felt the interpersonal skills were extremely basic and although she would have done most of the recommended things instinctively, they failed whenever she hit conflict no matter how religiously she used them.

A few mentioned they found many of the distress tolerance and emotional regulation skills were extremely useful for the very small things, but less so for the more significant things, and as one gentleman pointed out, many 'skills' were things anyone could find on a quick google search for 'how to have a mental health day.'

I discussed this with some medical and nursing colleagues across different teams and catchment areas, who were inclined to see where our patients were coming from. People often felt patronised, and crucially, invalidated by some of the techniques taught.

I'm just wondering if anyone else has come across similar cases or if anyone has any musings on the matter.

Where I am, DBT is seen as a panacea and schema therapy or MBT are not easily available. My feeling would be that DBT isn't always as suitable as we'd like, but I'm open to other ideas.

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[splik]

DBT is not a panacea. And it is definitely a cult and some people think you can CBT/DBT everything to death. I prefer MBT myself. On the other hand, these patients who regard it as patronising are failing at life. These skills are not making them feel more distressed or extremely basic for them. If that were the case then they would be such a cluster**** in the first place. I know some psychiatrists who say as much to their patients. The more narcissistic patients often regard cognitive-behavioral treatments as "remedial" but that doesn't mean it is not what they need. Help-seeking/help-rejecting is part of the dynamic of their personality. don't get sucked into the primitive defenses the patients use. Most borderline patients will reject DBT and say they've learnt it all/it's too basic/it's invalidating etc. Yes its true the crux of it is basic, but these patients are completely unable to use these basic attempts to regulate their emotions. You need to confront the hell out of these patients and their BS.

it is however possible the therapists were invalidating, if they were not well trained. but DBT itself is not invalidating. In fact it was developed specifically because existing treatments were unrealistic for these patients, and is based on the premise that chronic invalidation of certain temperaments leads to the cluster of symptoms we call borderline personality. Validation (and lots of it) is a key part of the treatment.

Edit: personally, I've found it particularly hard to engage adolescents in DBT and prefer to use more dynamically informed approaches in this population but the data does support using DBT in adolescents (and their parents!)

 

[PsychiatryAndCats]

Thanks for the reply, Splik. I love your cat. I also prefer MBT.

I'd agree such patients clearly lack skills in the four areas, but I'm not sure the skills taught necessarily tackle the deficiencies. In my (admittedly limited) experience, it doesn't seem to help many 'higher functioning' people too well.

I know you'll always get the 'nothing works for me doctor' crowd too, but for want of a better way of phrasing this, I don't get that feeling from this group.

To give an example, one of the above people used become acutely suicidal whenever she had any kind of argument, had a history of DSH and was an extreme self-doubter, but was a successful business owner and lucky enough to have a supportive life partner. It probably didn't help that she was in a group with people who were of a very different socioeconomic group and had a much lower level of education.

I'd also have my doubts on the environmental aspect of some of it - all the polite, mindful and respectful communication in the world only goes so far with some people. So the DBT candidate can take it on board very well and still not get too far.

And just to take a slightly different angle, if I were inclined to personally carry a soothe bag, I'd imagine developing a revulsion to some of my favourite things.

Just a disclaimer, I'm known for my soft attitude towards people with personality disorders (which is a constant source of amusement on my team).

 

[Bartelby]

First, I would say that DBT could be patronizing for some patients. I am a big believer in matching treatment to a formulation of the patient sitting in front of you. Some of the higher functioning individuals might benefit from a short course of ACT, or longer insight-oriented therapy, or traditional CBT with prolonged exposure, and so on. If you are working with a CEO who has mild depressive and anxious symptoms who wonders why she keeps falling for abusive men, then DBT is probably not the way to go!

If you are choosing the correct patient population, though, then as splik points out these patients often need to start in a quite basic and stabilizing way. DBT is good for that, especially if you use the intended format in which the patient attends a group for "teaching" skills and then meets with an individual therapist to work through individualized concerns, working from life-threatening behavior to therapy-interfering behavior to quality of life issues in each session. In the examples you gave, you might explore how the patient is using mindfulness and why it makes her feel worse. When I hear "using mindfulness techniques when distressed made her more distressed," I wonder if she is using mindfulness as if it were a PRN benzo instead of a systematic and deliberate way to gradually increase her ability to control her focus and cope with heightened emotion in an accepting manner (to be fair, I see some therapists teaching misuse of "mindfulness" as a way to escape bad feelings, which it certainly isn't!). When I hear "'skills' were things anyone could find on a quick google search for 'how to have a mental health day.'," I don't disagree. I'm guessing you can find many suggested skills online. So what about its implementation is working, and what isn't? The payoff doesn't come from being able to recite a list of skills, it comes from finding what works for you personally and implementing it with the goal of *gradual* improvement. Also keep in mind that while stabilizing suicide attempts and serious self-injury needs to be a concern in the short-term, "resolving" personality issues is certainly a long-term task (most likely over the course of several years to even decades), and it is a task that might never be fully completed. Finally, once the person is not scaring their therapist with weekly self-mutilation or suicide attempts, maybe more space can open up for each side to take a breath and start talking about things that are more meaningful to the patient!

When a patient tells you the treatment is invalidating, that is extremely important to hear and discuss. We also have to be open to the fact that DBT is not the right approach for everyone. Be aware, though, that sometimes a treatment might feel patronizing AND might still be helpful and even necessary (see what I did there?)!

 

[pizzicarella]

I work as a perinatal mental health nurse in a mother-baby inpatient psychiatric unit and we have quite a high proportion, almost a third, of patients who are referred on to DBT following their inpatient admission. Of the third who are referred on to DBT about half meet criteria for a diagnosis of EUPD. Most of the staff on the DBT program also work in the inpatient setting, and this provides good continuity for our clients. I've only been in psych nursing for past two and a bit years, so at the moment I am only working as a co-facilitator in one of the outpatient groups - and I have a case load of four women that I see for individual therapy. Please do take into account that the population I work with is a little different in that all of the women were referred following inpatient treatment following childbirth, only a half will have a diagnosis of EUPD, and that in addition to reduced SI/suicidal behaviours, we really emphasise attachment between parent and child as a goal of therapy.

I like DBT, it's why I've spent so much time training to be able to be a DBT therapist. I think that DBT as it was intended and validated - as a six month course with skills group, individual therapy, and phone coaching - is an amazing therapy to be able to offer to a population that is suffering immensely and who can be very rewarding to work with. I've seen DBT work fantastically for some people. Specifically, I've seen it work fantastically for the people that it was targeted at helping (provided that they are willing to change). And others, I've seen diligently come to every appointment, and every group session with their homework done appropriately and insightfully, and they have no improvement - and at best they are wasting their time, and at worst their mental health is declining. DBT is not the be all and end all for people with EUPD or whatever mental health problem they've been referred for therapy for. It can be a great fit, but there are other therapies that may suit somebody better. In my area, we are lucky to have very easily accessible ACT, and I refer people on to these psychologists if I don't feel at intake that DBT will be the right fit. There are a couple of private psychologists that offer other therapy that may be appropriate like schema, or occasionally CPT etc. but they are much more expensive. A full course of DBT is a huge commitment on the clients part, and I never want to take someone on if they are not going to benefit.

There are plenty of people that I see who find the therapy condescending, patronising, or invalidating. And that's a really important thing to know, and to discuss, because it isn't always a reflection on the therapy. I usually talk a lot at intake and then write into our therapy contract that the person already has every single skill that we teach (they just might not have a name or acronym 😉 for it yet), and that every person has areas where they are strong, and others where they may need to improve - and that sometimes it will seem really really basic and silly, and that's when they are learning something they were already adept at, and sometimes they will find it very challenging and that might highlight to them an area where they need to work on in individual more. I also try to emphasise that not every skill will suit them - I've had plenty of people tell me that they hate mindfullness that focuses on the breath or that they find deep breathing distressing, and we normally talk about that and find out that perhaps they are uncomfortable with concentrating on the body or that they just have a preference for visualisation exercises. In terms of invalidation though a number of clients react very strongly to the radical acceptance skill - which is often due to a trauma history, and as much as we can tout the "acceptance is not approval" line, it can be very difficult to challenge these beliefs.

This post is getting a bit long, so I might leave it at that, but I'll respond if there's any more.

 

[PsychiatryAndCats]

Thanks for all your replies. To clarify, I actually rather like DBT and am deciding whether or not to train. Pizzicarella your job sounds very intense!

MBT is another option. I'd be interested in schema therapy, but not too many opportunities here.

And I work with children and adolescents (over here have to do a few years of adult psych too) and our service really uses DBT with teenagers above other modalities, so it'd be overall the most convenient to learn.

All food for thought. Thanks.

 

[splik]

I would train in both if you have the opportunity! It's easier to train in MBT because it's not really a therapy but a way of informing your therapeutic approach. DBT is definitely cult like but there is a lot there of value. Many psychiatrists have found it of value in their own lives (which make it even more hollow when borderlines claim they know it all already). The real work happens in the individual not group sessions but you will learn the most by facilitating the skills group.

 

[SeniorWrangler]

I try to address this a bit in advance when I refer patients to DBT or even CBT, using phrases like "personal training for your brain" and "Jedi mind tricks" and so on. Trying to de-mystify it.
Often when people feel patronized, it's because they have a good intellectual grasp on the material but are having trouble making it work for them.

 

[Shikima]

I try to address this a bit in advance when I refer patients to DBT or even CBT, using phrases like "personal training for your brain" and "Jedi mind tricks" and so on. Trying to de-mystify it.
Often when people feel patronized, it's because they have a good intellectual grasp on the material but are having trouble making it work for them.

So it's the messenger and message?

 

[smalltownpsych]

DBT skills in and of themselves are not patronizing. Either the trainer is patronizing or the patient is just being defensive. Either way, it is the job of the the person providing psychotherapy to help patient work through it and it ties directly into the interpersonal difficulties the patient has. Too many people only focus on self harm behavior and trying to use the skills as coping to stop the self harm. That is not DBT that is just another control dynamic playing out. Focusing on difficulties with interpersonal conflict and how to improve with that is where the real work almost always is.

 

[DD214_DOC]

Perhaps these patients are ... splitting?


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[DD214_DOC]

My biggest issue with DBT, based upon my understanding of it, is that it was a treatment modality created by a borderline that enables borderline-related pathological behaviors through encouraging poor boundaries to foster the development of a codependent relationship. Several studies have demonstrated that it's not bad for decreasing suicidal thoughts and self-injurious behavior, but really no different than treatment as usual for addressing the other symptomatic features of BPD. I'm going to hypothesize that its efficacy in reducing the SI and NSSI is due to the .... codependent relationship with the DBT therapist. The exact type of relationship borderlines attempt to create in their personal lives that ultimately end up disasterous because of the absence of unconditional acceptance.

 

[pizzicarella]

HooahDOc, I am not sure that I agree. DBT has been fairly well validated for sustained benefit in not only suicidal/para-suicidal behaviour and hospitalisation, but also other symptom clusters. Granted, there are few studies that have follow-up periods beyond 12-24 months so it's hard to say with certainty if there's benefit for five years, or twenty years, but it is reductive to suggest that the benefit is reliant on the therapeutic relationship - yes, people benefit from having somebody hear them out and validate them each week in therapy, but the skills taught in DBT are just as important and a large part of the individual therapy is working on how to apply the skills to themselves. I'd also question the idea that allowing a close therapeutic relationship is necessarily a negative thing, as it underpins psychodynamic theory and also TFP (which is getting more and more evidence base for tx of people with bpd). Personally, I think exploration of transference is incredibly important when working with this population because it invariably highlights an area where we can discuss the need for change or skills development and keep relating back to DBT (and maintaining boundaries that are set up in the therapy contract).

 

[Salpingo]

My biggest issue with DBT, based upon my understanding of it, is that it was a treatment modality created by a borderline that enables borderline-related pathological behaviors through encouraging poor boundaries to foster the development of a codependent relationship. Several studies have demonstrated that it's not bad for decreasing suicidal thoughts and self-injurious behavior, but really no different than treatment as usual for addressing the other symptomatic features of BPD. I'm going to hypothesize that its efficacy in reducing the SI and NSSI is due to the .... codependent relationship with the DBT therapist. The exact type of relationship borderlines attempt to create in their personal lives that ultimately end up disasterous because of the absence of unconditional acceptance.

It probably depends on the person practicing it. If you follow the strict, behaviorist model of DBT, then there should be very clear boundaries in the relationship. Stuff that would send the average psychiatrist into the dramatic tizzy, like cutting and vague suicidality, would be met with short but clear instruction so that negative behavior isn't positively reenforced with attention (which would be the other explanation for its success here, at least when practiced in the research setting).

Psychiatry in general has a codependent relationship with severe borderline personalities, with our intense fear of lawsuits and suicide leading to endless hospitalizations and interminable treatment.

 

[splik]

My biggest issue with DBT, based upon my understanding of it, is that it was a treatment modality created by a borderline that enables borderline-related pathological behaviors through encouraging poor boundaries to foster the development of a codependent relationship. Several studies have demonstrated that it's not bad for decreasing suicidal thoughts and self-injurious behavior, but really no different than treatment as usual for addressing the other symptomatic features of BPD. I'm going to hypothesize that its efficacy in reducing the SI and NSSI is due to the .... codependent relationship with the DBT therapist. The exact type of relationship borderlines attempt to create in their personal lives that ultimately end up disasterous because of the absence of unconditional acceptance.

not really. while the individual therapist in the traditional model is technically available 24/7 (and in reality therapists choose how available they make themselves) this is only for emergencies. Linehan is well known for hanging up on her pts 99% of the time with the terse words "this is not an emergency." The point is not to foster codependency but to reward patients for help-seeking adaptively rather than self-harming. the problem is the way regular public services are structured (you basically have to actively suicidal to get any help) encourages everyone to become borderline!

 

[deleted343839]

Several studies have demonstrated that it's not bad for decreasing suicidal thoughts and self-injurious behavior, but really no different than treatment as usual for addressing the other symptomatic features of BPD.

"Not bad": Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder

Suicidality and self-injury are fairly important outcomes in the borderline population, no?

 

[DD214_DOC]

"Not bad": Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder

Suicidality and self-injury are fairly important outcomes in the borderline population, no?

Where did I suggest these outcomes weren't important?

 

[deleted343839]

Where did I suggest these outcomes weren't important?

I could have misinterpreted, but in the context of your comment you seemed to minimize a robust effect on the cardinal outcomes in this population: "it's not bad for decreasing suicidal thoughts and self-injurious behavior, but really no different than treatment as usual..."

I'm going to hypothesize that its efficacy in reducing the SI and NSSI is due to the .... codependent relationship with the DBT therapist.

I disagree. Linehan's group published a study not long ago specifically looking at the incremental effect of the individual therapy component. Based on that study (and others), if I were forced to choose skills training alone versus DBT individual therapy (as opposed to the standard approach using the two concurrently), I'd opt for skills training. The literature on mechanisms of change in DBT and related treatment approaches points to improved emotion regulation. I doubt this mechanism of change is unique to DBT, though DBT may be relatively efficient.

 

[Nasrudin]

I would train in both if you have the opportunity! It's easier to train in MBT because it's not really a therapy but a way of informing your therapeutic approach. DBT is definitely cult like but there is a lot there of value. Many psychiatrists have found it of value in their own lives (which make it even more hollow when borderlines claim they know it all already). The real work happens in the individual not group sessions but you will learn the most by facilitating the skills group.

I use the universality of the skills training to de-patrronize, or de-stigmatze the material. Interpersonal negotiation skill is universal. Show me a highly functional, highly intelligent, well adjusted physician who is also hyper-agreeable and uber-conscientious, and I'll show you a ****ty negotiator. You can scale the skills to examples that suit the user. For a low functioning patient that might mean negotiating that no one else eats his box of cheerios before the whole house descends into relational chaos resulting in a presentation to the psych ER. For the group leader, such as I was, it might mean, negotiating the emergence of my own clinical identity and asserting the boundaries of it in a healthy way.

I disagree about what you're saying about work not happening in groups. There is a metacognitive, communal, network structure of human relations happening in groups that is very much alive and part of their work and ours. DBT is about negotiating the intrapsychic and the interpersonal.

I don't disagree that it's cult like. But I also believe some approximation of a cult is the right Rx for the job.

 

[smalltownpsych]

I use the universality of the skills training to de-patrronize, or de-stigmatze the material. Interpersonal negotiation skill is universal. Show me a highly functional, highly intelligent, well adjusted physician who is also hyper-agreeable and uber-conscientious, and I'll show you a ****ty negotiator. You can scale the skills to examples that suit the user. For a low functioning patient that might mean negotiating that no one else eats his box of cheerios before the whole house descends into relational chaos resulting in a presentation to the psych ER. For the group leader, such as I was, it might mean, negotiating the emergence of my own clinical identity and asserting the boundaries of it in a healthy way.

I disagree about what you're saying about work not happening in groups. There is a metacognitive, communal, network structure of human relations happening in groups that is very much alive and part of their work and ours. DBT is about negotiating the intrapsychic and the interpersonal.

I don't disagree that it's cult like. But I also believe some approximation of a cult is the right Rx for the job.

The most successful treatment and a cult have a lot in common. In twelve step I have heard former addicts say that they were initially reluctant to get "brainwashed", but then realized their brain needed washing. I find that some of the problem with replicating DBT outside of Linehans program at UW is that you lose some of the power of influence that the cult factor provides.

 

[Nasrudin]

The most successful treatment and a cult have a lot in common. In twelve step I have heard former addicts say that they were initially reluctant to get "brainwashed", but then realized their brain needed washing. I find that some of the problem with replicating DBT outside of Linehans program at UW is that you lose some of the power of influence that the cult factor provides.

This aspect of our work is something I find fascinating. Partly because it suits my psychodynamic orientation. But also because it's taboo. I can't figure why we don't talk about it. Or research it. Placebo has technique and amplification and opportunity for multi-medium expansion. But...it's like we're aversive of unconscious influence for some reason. And the whole struggle of articulating psychological theory has done nothing to clear it up or imprison it in the realm of logical positivism. The behaviorists miss the art and rhythm and invisible inductive force of it. The religious cannot be abided because... well... just because ... obviously. We're afraid of getting kicked out of our medical tribe for being cooks and weirdos. So... we just ignore it. Except we engage in it. Regularly. As the invisible glue of therapeutic relation.

How are we not in the shamanic tradition? Our mojo and charisma and ritual enthusiasm is active, whether we like it or not.

 

[splik]

The most successful treatment and a cult have a lot in common. In twelve step I have heard former addicts say that they were initially reluctant to get "brainwashed", but then realized their brain needed washing. I find that some of the problem with replicating DBT outside of Linehans program at UW is that you lose some of the power of influence that the cult factor provides.

ah but her disciples are everywhere! they might even be more cultish!

 

[splik]

I disagree about what you're saying about work not happening in groups. There is a metacognitive, communal, network structure of human relations happening in groups that is very much alive and part of their work and ours. DBT is about negotiating the intrapsychic and the interpersonal.

don't get me wrong, i love groups they are very powerful! i actually prefer group work to individual therapy (which is to say with the right group it is a lot more fun with all the vertical and horizontal transferences)

 

[Nasrudin]

don't get me wrong, i love groups they are very powerful! i actually prefer group work to individual therapy (which is to say with the right group it is a lot more fun with all the vertical and horizontal transferences)

Yeah. I love groups too. It's amazing that a group is a like a unique meta-organism that reflects it's unique nodal-invidual composition. Like a band. Man... now that I'm thinking about it.... I have to figure out how to have a group as part of my career.

 

[smalltownpsych]

ah but her disciples are everywhere! they might even be more cultish!

They might be true believers or members of the cult but in isolation they tend to lose their influence although maybe not their dogmatic stance.

 

[splik]

Yeah. I love groups too. It's amazing that a group is a like a unique meta-organism that reflects it's unique nodal-invidual composition. Like a band. Man... now that I'm thinking about it.... I have to figure out how to have a group as part of my career.

consider attending the AGPA meeting next year. I've never been able to attend thus far as it's clashed with other things but have heard great things about it. If you go into pp, get mentorship from group therapists in pp on how to set up a group, or if you look for a salaried position, you can request time blocked off for group work in your schedule.

 

[Nasrudin]

consider attending the AGPA meeting next year. I've never been able to attend thus far as it's clashed with other things but have heard great things about it. If you go into pp, get mentorship from group therapists in pp on how to set up a group, or if you look for a salaried position, you can request time blocked off for group work in your schedule.

Thanks. I'll look into that.

 

[Salpingo]

I disagree about what you're saying about work not happening in groups. There is a metacognitive, communal, network structure of human relations happening in groups that is very much alive and part of their work and ours. DBT is about negotiating the intrapsychic and the interpersonal.

In my experience, DBT groups have run more like classes and less like traditional, psychodynamic-oriented group therapy. There may be group dynamics that are played out, but the role of the leader isn't to make those unconscious processes conscious. Instead, they need to convey the pertinent information, while maintaining structure/rules in a group of individuals being treated for impulsivity, mood lability and inability to maintain stable, healthy relationships. The goal is to convey needed skills, not foster interpersonal connections (which is more incidental). But I'm not Marsha Linehan, so I'm sure I could be wrong.

While there is value to creating a sense of community and shared experience, I have also heard a few nightmare stories of patients splintering off, meeting outside of the group, and cycling down into some very maladaptive behavior. While a typical group therapy for other psychopathology would encourage "working through" those experiences, DBT has set rules against it (which also applies for missing consecutive sessions, rude/aggressive language, "triggering" statements). I guess there's a little dialectic there -- you forsake a little of your individuality to participate in the group, but your individuality is needed to keep the group running (by providing your homework and examples of your personal life).

Anyway, the jury is out on whether or not combined group + individual is necessary over just individual (Effectiveness of combined individual and group dialectical behavior therapy compared to only individual dialectical behavior therapy: a preliminary... - PubMed - NCBI)

 

[Salpingo]

The most successful treatment and a cult have a lot in common. In twelve step I have heard former addicts say that they were initially reluctant to get "brainwashed", but then realized their brain needed washing. I find that some of the problem with replicating DBT outside of Linehans program at UW is that you lose some of the power of influence that the cult factor provides.

I think most successful psychotherapy has had some cult-like following, with prominent/charismatic figureheads (Starting with Siggy Freud, but then also Jung, Beck, Kernberg, Kohut, Fonagy, maybe Yalom although he has limited aspirations of bringing existential psychotherapy to academia) who have the guts and ingenuity to convince both patients and other practitioners that they hold "the truth," and that truth can be taught (for a nominal fee). Deviation cannot be tolerated, as it will dilute the brand, leading to quick excommunication of heretics (maybe less so with CBT, which has subsequently led to dilution of the brand).

 

[Nasrudin]

In my experience, DBT groups have run more like classes and less like traditional, psychodynamic-oriented group therapy. There may be group dynamics that are played out, but the role of the leader isn't to make those unconscious processes conscious. Instead, they need to convey the pertinent information, while maintaining structure/rules in a group of individuals being treated for impulsivity, mood lability and inability to maintain stable, healthy relationships. The goal is to convey needed skills, not foster interpersonal connections (which is more incidental). But I'm not Marsha Linehan, so I'm sure I could be wrong.

While there is value to creating a sense of community and shared experience, I have also heard a few nightmare stories of patients splintering off, meeting outside of the group, and cycling down into some very maladaptive behavior. While a typical group therapy for other psychopathology would encourage "working through" those experiences, DBT has set rules against it (which also applies for missing consecutive sessions, rude/aggressive language, "triggering" statements). I guess there's a little dialectic there -- you forsake a little of your individuality to participate in the group, but your individuality is needed to keep the group running (by providing your homework and examples of your personal life).

Anyway, the jury is out on whether or not combined group + individual is necessary over just individual (Effectiveness of combined individual and group dialectical behavior therapy compared to only individual dialectical behavior therapy: a preliminary... - PubMed - NCBI)

Those are good points. But I think group processes that I was thinking of are universal to group interaction. DBT or otherwise.

 

[birchswing]

This is kind of an out-there thought . . . I've thought that the people of some cultures tend to be so individualistic and reserved that they would be less likely to be viewed as having BPD is US culture and that some cultures are to the other extreme where people with collectivists values have a great need for loyalty which can easily be shattered and in which those with perceived loyalty are greatly welcomed/rewarded and those who fail to come through in slight ways can be shunned/cursed etc very easily.

The thought of this came up again in the context of reading about group therapy for DBT. It made me wonder if the cultures which have a high demand for loyalty that is very fragile have something in place in their culture for mediating the extremes, particularly whether the religions of those cultures would either reinforce or attenuate the interpersonal swings between security and drama. The cultures I'm thinking of are rather heterogeneous so it's something you could possibly look at nomothetically to draw broader conclusions and which you could also compare with the secular effects of DBT and other therapies and their relation to interpersonal behavior.

 

[PsychiatryAndCats]

Thanks so much for all the replies, people. Some really interesting, considered responses and definitely food for thought.

 

[smalltownpsych]

In my experience, DBT groups have run more like classes and less like traditional, psychodynamic-oriented group therapy. There may be group dynamics that are played out, but the role of the leader isn't to make those unconscious processes conscious. Instead, they need to convey the pertinent information, while maintaining structure/rules in a group of individuals being treated for impulsivity, mood lability and inability to maintain stable, healthy relationships. The goal is to convey needed skills, not foster interpersonal connections (which is more incidental). But I'm not Marsha Linehan, so I'm sure I could be wrong.

While there is value to creating a sense of community and shared experience, I have also heard a few nightmare stories of patients splintering off, meeting outside of the group, and cycling down into some very maladaptive behavior. While a typical group therapy for other psychopathology would encourage "working through" those experiences, DBT has set rules against it (which also applies for missing consecutive sessions, rude/aggressive language, "triggering" statements). I guess there's a little dialectic there -- you forsake a little of your individuality to participate in the group, but your individuality is needed to keep the group running (by providing your homework and examples of your personal life).

Anyway, the jury is out on whether or not combined group + individual is necessary over just individual (Effectiveness of combined individual and group dialectical behavior therapy compared to only individual dialectical behavior therapy: a preliminary... - PubMed - NCBI)

I think up at Linehan's clinic they have both educational groups and psychotherapy groups and it probably depends on who is running the group. Haven't been there but that is what I inferred from the workshops of hers I have attended. Also comparing group to individual can be tricky because group dynamics maximixpze efffect whether positive or negative. So a bad group will show more negative effects than a bad individual therapist and vice versa so it tends to wash out.

 

[Nasrudin]

I think up at Linehan's clinic they have both educational groups and psychotherapy groups and it probably depends on who is running the group. Haven't been there but that is what I inferred from the workshops of hers I have attended. Also comparing group to individual can be tricky because group dynamics maximixpze efffect whether positive or negative. So a bad group will show more negative effects than a bad individual therapist and vice versa so it tends to wash out.

Hmmm. Interesting.

Although why would that be necessarily different from individual. I suppose we might be widening the risk. And allowing the affect chaos to enter the metaorganismal system.

So. Maybe Saplingo and whoever else has a good point. Short term measures might take a dive. But... if we're interested in emotional/behavioral wisdom. Maybe people who burden others with their self-harm and emotional chaos need to see it operate in a system. Maybe they need to be burdened themselves. Or see themselves advancing with the application of skills in relation to others. I certainly saw the more experienced more regulated patients helping the less reflective more emotionally labile ones in the course of even DBT didactic style groups.

I know i'm coming at this from an existential point of view but... the personality disorder clinic I worked at and am going back to had all kinds of groups. From free-form, psychodynamic, to instructive didactic DBT skills training. And they move people along in the right direction, globally.

 

[SeniorWrangler]

This aspect of our work is something I find fascinating. Partly because it suits my psychodynamic orientation. But also because it's taboo. I can't figure why we don't talk about it. Or research it. Placebo has technique and amplification and opportunity for multi-medium expansion. But...it's like we're aversive of unconscious influence for some reason. And the whole struggle of articulating psychological theory has done nothing to clear it up or imprison it in the realm of logical positivism. The behaviorists miss the art and rhythm and invisible inductive force of it. The religious cannot be abided because... well... just because ... obviously. We're afraid of getting kicked out of our medical tribe for being cooks and weirdos. So... we just ignore it. Except we engage in it. Regularly. As the invisible glue of therapeutic relation.

How are we not in the shamanic tradition? Our mojo and charisma and ritual enthusiasm is active, whether we like it or not.

Torrey laid it all out for us in the 80's. Everyone should read this book:
Witchdoctors and Psychiatrists
Amazon product ASIN 0876689713

 

[clausewitz2]

Torrey laid it all out for us in the 80's. Everyone should read this book:
Witchdoctors and Psychiatrists
Amazon product ASIN 0876689713

This book legitimately intrigues me, but given the author, I am a little afraid of "schizophrenia is an infectious disease" level foolishness. Is it any good?

 

[SeniorWrangler]

I believe it was written before his obsession with the toxoplasmosis hypothesis took root, it's much more about the philosophy and sociology of psychiatry.