Consulting to the client
Consultation to the client represents the change end of the dialectical approach to case management within DBT. In itself, a defined approach to case management is a distinctive characteristic of the treatment. Most CBT approaches, indeed most psychotherapies, do not provide principles to assist the therapist to manage interactions among the various therapeutic interventions clients receive or among the treatment providers delivering these different interventions. The absence of case-management guidance may occur simply because most psychotherapies were developed for uncomplicated Axis I disorders, which require fewer interactions and involve less conflict between treatment providers. For clients who have a diagnosis of BPD combined with multiple other diagnoses or social problems, receiving multiple interventions from multiple treatment providers occurs frequently. Also, given the frequent tendency for these clients both to request and to require help from their therapist in negotiating these myriad interventions and treatment providers, a treatment for this population requires some principles to guide therapists in managing their cases.
DBT aligns the case-management strategies with consultation to the client providing change and environmental intervention representing acceptance. The central guiding principle is straightforward: the DBT therapist intervenes in the environment on behalf of the patient if, and only if, the short-term gain of an intervention by the therapist is worth the long-term loss in learning for the client. In all other circumstances the therapist coaches the client on how to intervene in the environment to solve the problem him- or herself. Many other forms of psychotherapy describe similar principles to help clients manage interpersonal problems with family, friends and work colleagues. DBT, however, uniquely applies this principle to assist clients in negotiating care and resolving problems with other healthcare professionals. For example, a client discussed with his DBT therapist dissatisfaction with his consultant psychiatrist and her prescribing practices. Rather than initiating a discussion with the consultant about appropriate medication for the client, the therapist worked with the client on expressing his concerns to his consultant and appropriately requesting changes in medication. The therapist also assisted the client to tolerate the dissatisfaction with his medication regime in the short term, while trying to change the consultant’s behaviour in the long term. In another case, a client with a comorbid eating disorder required regular monitoring of her blood potassium levels. Rather than the therapist writing to the client’s general practitioner to request the medical intervention, the DBT therapist had the client make the request herself. Consulting to the client about his or her treatment also aims to increase the client’s capacity and motivation to act as an agent in obtaining appropriate health and social care for him- or herself. Pragmatically, therefore, consultation to the client potentially reduces the amount of time professionals need to divert to communicating with each other rather than working with the client.
In principle, many mental-health professionals would willingly endorse consulting to the client. In practice, however, mental-health services frequently operate according to different principles and practices that emphasize regular direct communication between mental-health professionals, especially around risk and treatment planning. Practically, then, the DBT stance of consultation to the client requires a significant change in practice for many DBT therapists and also for those clients who previously have not had the responsibility of communicating with other professionals about their treatment. To ensure effective implementation of the strategy and to decrease misunderstandings in the transition to this approach, comprehensive orientation of clients and the system to the principle forms a useful first step. Subsequent elaboration of the rationale for the approach and its practical consequences may prove necessary in any given interaction to provide clarity to the client and his or her network. In discussions with the client, the therapist monitors the
CONSULTING TO THE CLIENT balance between environmental intervention and consultation to the client and, especially as treatment progresses, pushes the client to be more active in negotiating and obtaining appropriate care.
The consultation-to-the-client principle guides the therapist in how to respond when another treatment provider requests information or consultation about a client or asks the DBT therapist to solve a problem with the client. With regard to requests for information from the client’s treatment network, generally the DBT therapist may give information about the treatment programme but will not discuss the client or his or her treatment without the client present. Likewise, DBT therapists do not write letters or make phone calls to other professionals about the client without the input or presence of the client. The principle of consulting to the client also determines how and whether the DBT therapist provides advice to other therapists, both DBT and non-DBT, about how to interact with the client. For example, if a non-DBT case manager asks the DBT therapist about how to proceed with a mutual client, rather than making suggestions about how the case manager should proceed, the DBT therapist would simply support the case manager responding according to the case manager’s normal practice. Finally, just as the DBT therapist does not intervene to solve problems with other professionals on behalf of the client, the DBT therapist does not intervene with clients on behalf of other professionals. For example, a member of nursing staff complains to a DBT therapist on an inpatient programme that she is irritated with the client for breaking the smoking rules. The DBT therapist would target this behaviour only if there were no other higher targets and the complaints risked burning out the therapist or jeopardized the client’s place on the unit.
Applying the consultation-to-the-client approach presents particular challenges for the therapist when he or she disagrees with the client’s preferred course of action. In dealing with this situation, the DBT therapist explains the reasons for his or her disagreement with the client’s decision; he or she may also encourage the client to review the pros and cons of the decision. If the client persists with the original decision, the DBT therapist assists the client to pursue his or her chosen course of action as skilfully as possible. For example, a client during a particularly stressful period experienced increased suicidal urges. In the past she had often been hospitalized under such circumstances, and, unfortunately, hospitalization had reinforced suicidal behaviour. After the last hospitalization, the client and therapist had agreed that together they would endeavour to avoid hospitalization as a solution to crises in the future. Now in an impending crisis, the client’s resolve wavered. The DBT therapist reminded her of previous experiences and their agreement and then reviewed their previous pros and cons analysis. The client remained adamant that she wanted hospitalization. Therefore, the DBT therapist switched to problem-solving with the client how the client could most effectively obtain hospitalization while minimizing the likely reinforcing effects of this course of action. Notably, the therapist did not intervene to obtain hospitalization for the patient.