Treating the therapist

Just as therapists treat clients’ therapy-interfering behaviours, so too must they treat their own behaviours that stop or reverse the progress of the treatment. Examples of such therapy-interfering behaviours include invalidating the valid, failing to target properly, not engaging the client in active problem-solving, treating the client as overly fragile or reinforcing suicidal behaviour. These behaviours may result from some combination of the therapist’s personal issues, clinical skills deficits, strong emotions or cognitive distortions during the session, or contingencies imposed by the system. Often, the prompt for the therapist’s problematic behaviour is the client’s therapy-interfering behaviour. One therapist who had a habit of lecturing clients analyzed this pattern of behaviour and discovered that it tended to occur when a client had remained unresponsive for a prolonged time. The therapist identified the assumption that she had not explained things clearly enough as the intervening link. Once the therapist recognized this pattern, she mindfully let go of the assumption and focused instead on using DBT to treat the client’s unresponsiveness. Just as the therapist shapes the client’s behaviour, so the client shapes the therapist’s behaviour. With some clients, in particular, the transaction between client and therapist may be such that the client punishes therapeutic behaviour and rewards iatrogenic behaviour. For example, one can easily imagine that if a client became verbally aggressive every time the therapist tried to address a presenting problem, the therapist may become less likely to target that problem.

A strong emphasis on therapists applying the treatment to themselves to reduce their own therapy-interfering behaviour characterizes the treatment. Therapists employ the full range of problem-solving strategies, including skills practice, exposure, contingency management and cognitive restructuring to change their own problematic behaviour and associated links. For example, if intense anger leads to overtly hostile behaviours, a therapist might act opposite to the emotional urges by identifying something about the client to validate. If interpretations of the client’s behaviour partially caused the anger, challenging the interpretations may prove useful. If the anger results in desirable self-validation, the therapist might try to block that reinforcing consequence. Perhaps most critical is conducting therapy as mindfully as possible. Mindfulness requires the therapist to attend to this moment and be effective, to let go of distracting thoughts and urges and to refocus on solving the problem at hand. The mindful therapist is less likely to have therapy-interfering behaviour, more likely to notice when it does occur and more effective in changing the behaviour.

Changing therapy-interfering behaviour usually first requires an acknowledgement of the behaviour. Therapists often identify their own problematic behaviours during a session, and many clients will capably assist their therapists in this endeavour. Role-playing or listening to session tapes during consultation team meetings can help the team to detect behaviours that the therapist missed. Acknowledging the problem may lead directly to generating and implementing solutions, but some problems will require more thoughtful analysis by the therapist or assistance from the consultation team.

Though the consultation team generally functions to treat therapist-interfering behaviours and otherwise support the therapist, it can also become a context for consultation-interfering behaviours. Common behaviours include missing consultation-team meetings, not adhering to the treatment model and violating consultation-team agreements. The consultation team treats these behaviours just as an individual therapist treats therapy-interfering behaviours. For example, a therapist missed several consultation teams in a relatively short period of time. When the team highlighted the problem and suggested analysing it, the therapist simply responded that she had an unusual number of demands at the moment. The team persisted in obtaining a detailed behavioural chain analysis to determine what specifically had caused the therapist to decide not to fulfil her commitment to the consultation team and to schedule conflicting meetings. The analysis revealed two important sets of variables. First, the therapist did have an unusually high number of demands at the moment because she unmindfully had agreed to a number of requests, fearing what others might think of her if she said no. The team helped the therapist to develop a Wise Mind response in these circumstances, rehearsed saying “No” to requests and planned how the therapist could cope with any negative response to the “No”. Second, the therapist experienced little anxiety about skipping the consultation team, partly because she did not view her attendance as important. In response to these links, the team described the negative consequences of her absence on them and also highlighted possible aversive consequences for her clients if she did not receive the required amount of consultation.

Despite the notable problems caused by these consultation team- interfering behaviours, therapists often hesitate to address these problems. As described in Chapter 12, having an identified observer can help. Even observers will hesitate, however, if they worry about how others will respond. If the facts do not warrant such worry, challenging the worry thoughts and approaching rather than avoiding the task usually proves an effective combination. As part of challenging the worry, therapists may want to consider whether they really think of their colleagues as more fragile or volatile than their clients or as less capable of receiving feedback. In approaching the task, therapists should use the same variety of strategies that they use with clients, starting with describing the problem behaviourally. Addressing consultation-interfering behaviours may also require the observer first to manage his or her own judgements, interpretations, other cognitions or emotions. If a member of the team does have a history of responding in a problematic way to critical feedback, then the team has the task of treating this consultation-team-interfering behaviour as well.

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