Confronting and being irreverent

Irreverent strategies provide the dialectical contrast to the reciprocal communication strategies of warmth, genuineness and self-disclosure. The therapist employs irreverent strategies when the client or client and therapist become stuck in a dysfunctional pattern of emotions, thoughts or behaviours. Metaphorically, therapists use irreverence when the therapy train appears in imminent danger of crashing at high speed into the buffers, and only diverting the train will avert an accident; irreverence is the verbal equivalent of changing the points. Although irreverence differs substantially from the reciprocal strategies, it also must arise from genuine compassion towards the client, not from a position of frustration and anger. Irreverence aims to help the client alter his or her perspective and let go of rigidly held views. Employing irreverence in anger reduces the likelihood of a shift in perspective by the client and increases the possibility that the client will hold more firmly to the very perspective that the therapist hopes to change.

DBT as a therapeutic approach recognizes the heightened sensitivity and vulnerability of individuals with a BPD diagnosis; however, the treatment also acknowledges that individuals with the diagnosis have a degree of robustness that is often underestimated. Irreverence addresses these non-fragile aspects of the client. Line- han (1993a) described several different types of irreverence. Some of these strategies are based primarily on tone. Most commonly, the therapist uses a matter-of-fact tone with the client when most therapists would become more validating or warm. For example, when a client reports a wish to die, professionals and non-professionals alike tend to respond with increased warmth, concern and interest. For many clients with a BPD diagnosis, over time this response has reinforced suicidal communication as a way of expressing distress.

The DBT therapist’s absence of an increase in warmth and maintenance of a matter-of-fact tone in response to such communications represents the most basic level of irreverence. The unexpected nature of the response may grab the client’s attention and assist the client to consider more effective ways of communicating distress. By using a matter-of-fact tone, the therapist begins to extinguish suicidal communication by removing a historical reinforcer of the behaviour. Thus, as with many strategies within the treatment, irreverence can function to manage contingencies within the therapeutic relationship. The therapist may move beyond a matter-of-fact tone and increase the intensity of the irreverent response by becoming more directly confrontational. For example, a client called her therapist following a last-minute cancellation by a friend of a meeting for coffee. The client threatened suicide saying, “Everything is hopeless— everyone always leaves me”, and began to rehearse past endings of relationships. The therapist quickly blocked this behaviour with, “Stop catastrophizing and focus on solving the problem”.

Beyond irreverent strategies based more on tone, DBT encourages the use of irreverent strategies that rely even more on the content of the statement in addition to the tone. Two of these strategies are plunging in where angels fear to tread and reframing the client’s communication in an unorthodox manner. In using the strategy of “plunging in where angels fear to tread” the therapist simply says directly and clearly what many would consider unsayable, without “beating about the bush” or “hedging bets”. For example, a therapist conducting a chain analysis with a client who had self-harmed by mutilating her genitals asked matter-of-factly whether the client had found the act sexually arousing.

In reframing the client's communication in an unorthodox manner the therapist responds to the client’s communication in an “off-beat” completely surprising way. For example, a young female client with a history of sexual abuse complained bitterly each week in individual therapy about male members of her skills group looking at her during the session. She also reported increasing frustration with young men looking at her outside of the therapy context. The client was a striking young woman who dressed in a way that was likely to

CONFRONTING AND BEING IRREVERENT attract attention. The therapist discussed a number of strategies to address the problem (e.g. the client changing her style of dress, radical acceptance that men tended to look at her, restructuring of her judgements about the observation that she attracted the attention of others), all to no avail. The young woman continued to complain yet remained unwilling to either tolerate the difficulty or implement strategies to solve the problem. Then one week when the client began her usual complaint and combined it with a threat to drop out of skills group, the therapist said, “I know, it’s impossible—the only solution for you is to live in a convent—maybe that’s what we should work on this week—how to get you into a closed order!” The young woman immediately saw the point and became more willing to implement the previously suggested strategies.

On occasion, an irreverent strategy can widely miss the mark and, instead of assisting the client to change, exacerbate his or her difficulty or distress. In such circumstances, the therapist moves rapidly to change strategy and if appropriate apologize and repair the relationship. Interactions of this type provide an opportunity for the therapist to model how to recover from an interpersonal rupture without being overly defensive, apologetic or overwhelmed by affect.

When the client shifts from an entrenched position to a more flexible consideration of his or her circumstances and options, the therapist switches rapidly back to the reciprocal strategies. In part, this switch reinforces the client’s movement. Therapist movement between both poles of the stylistic dialectic also enables clients to tolerate the inherent challenge in the irreverent strategies. The constant movement between the two poles provides some of the momentum within the therapy and is a distinctive characteristic of the treatment in its own right.

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