Courageous Conversations in Evidence Based Treatment

Previously, I’ve written about the framework DBT provides to help therapists address therapy interfering behaviors in session with their clients.

But what if the client feels the therapist is engaging in behaviors that interfere with treatment? How do you have these conversations? DBT offers some guidelines about this as well. (Frankly, these strategies may help you have courageous conversations with ANYONE important in your life.)

1. Remember: In DBT the therapist and client are considered to have a relationship between equals. This suggests that it is reasonable – perhaps even EXPECTED – that if you have a problem with the other person, you will talk about it.

This is true in most relationships, why should the therapy relationship be different?  Find a nonjudgmental/compassionate way to understand the therapist’s behavior. Try to remember that your therapist is on your side, that she or he is human, and that we all make mistakes. In DBT we call this “phenomenological empathy.”

2. Before having the conversation, do some prep work. This is not a conversation to take lightly, and it requires some thinking-through before executing.

Clarify the issue in your mind: What exactly is the problem you want to discuss with your therapist? Make it behavioral and objective. For example:

• You are wondering if your symptoms are improving.
• You would like your therapist to give you more validating statements.
• It would help for the therapist to push you harder and focus on change.
• You want your therapist to start sessions on time.
• Your therapist said something in the last session that has left you feeling judged and confused.

Practice your emotion regulation and distress tolerance skills to effectively manage your emotions.

3. Consider putting the issue on the DBT session agenda. If you need to have a difficult conversation with your therapist, add it to Target 2 when setting the agenda for the session. This puts it out in the open and decreases the possibility that you will run out of time (or avoid bringing it up in the first place). In session, observe and describe the behavior and why you see it as a problem. Consider using your Interpersonal effectiveness skills.

4. Ask for collaboration on what to do about it. Can we talk about how to best handle this? And Reinforce your therapist for collaboration. Thanks for hearing me out… Thanks for being willing to work on this with me…  It really means a lot to me….  (even therapists need to hear some positive words).

Remember that you can practice having this conversation in your DBT skills group or get some coaching from your skills group leader. If you are not in a DBT skills group, find one; it will change your life.

Go forth and have courageous conversations!