This year I have been working full-time as a psychology resident at a specialized healthcare setting for mental health. It has been a challenging but certainly rewarding journey.
One of the rotations I am working in is the Borderline Personality Disorder clinic. The recommended treatment for BPD is dialectical behaviour therapy – a form of therapy that I did not have experience with prior to beginning this residency.
However, I have been very lucky to work with several leading experts in dialectical behaviour therapy and treatment of BPD. They have been such incredible sources of wisdom and knowledge in this area.
In this post, I provide 10 key clinical lessons from my DBT supervisors from our supervision:
1. There is always something valid about a person’s thoughts and feelings
Folks with BPD spend a lot of their lives feeling invalidated – that they shouldn’t feel the feelings that do. This can make it hard for them to trust their own thoughts and feelings.
Therefore, providing validation is a very important part of being a DBT therapist (and for being a therapist in general). However, I have learned that validation does not mean just agreeing with everything that the client says. Rather, it is about finding the ‘grain of truth’ that we can validate without reservation.
For example, I might not agree with a client wanting to assault another person or using alcohol to cope with unpleasant emotions. However, I can validate them feeling betrayed by a close friend lying to them, or that it makes sense for them to want to get away from feelings of shame by using alcohol.
My supervisors like to note that all behaviours are reinforced and make sense in some way – even if not to me. Therefore, I have learned to ‘validate what is valid’ to show that I really understand the client’s situation. Afterwards, I can work with the client to change what is not helpful or effective in the situation.
2. Prioritize the underlying emotion
As someone from a cognitive behavioural background, I used to primarily focus on the thought or behaviour in different situations. However, I often found that naming the thought did not always allow me to get into a deep connection with my clients. Moreover, I often felt stuck in those moments.
My supervisors encouraged me to go a little deeper and ask about the emotion. For example, sitting with feelings of shame when a client is talking about “being a failure” because they feel like they haven’t done enough in life.
The reason that this was important is because there is a way of thinking about behaviours in DBT. That all ‘unhelpful’ behaviours (like self-harm or alcohol use) are ways to get away from uncomfortable emotions.
Therefore, by sitting with the emotions, I found that this helps clients learn to notice these patterns and tolerate bad feelings. This then gives us space to be able to process emotions and use more effective DBT skills to manage emotions in a healthier manner.
For identifying emotions, I learned that I needed to be more aware of whether the emotion is ‘primary’ or ‘secondary.’ Primary emotions are our response to a situation whereas secondary emotions are our emotions to the emotion.
Let’s clear this confusing idea up with an example. Let’s say Jane is talking to her best friend Amanda. Amanda says something nasty to Jane. Jane’s first emotion is sadness because she feels betrayed that a close friend would say something so hurtful. She then thinks: “How dare she say that about me?” – which then promptly turns into anger.
In this case, sadness would be the primary emotion and anger would be the secondary emotion. To work with Jane, we would focus on the primary emotion of sadness rather than sitting with the anger. This is important because secondary emotions sometimes come in to protect the primary emotion. For example, shame is very uncomfortable and makes us feel vulnerable, but anger is a powerful emotion. However, we need to learn to sit with the shame and understand where it comes from. Only by being able to tolerate these feelings, can we truly move forward.
3. Get as precise as possible
Instead of theorizing what might be going, my DBT supervisors have encouraged me to get precise as possible about what is going on in a situation. Usually, this means identifying a specific situation where a client was having difficulties and really getting into the nitty-gritty. The reason to get precise is that if we do not know what is going on, we cannot provide the right skills to support the client.
For example, a client might report that they were struggling with procrastination. However, there are hundreds of reasons why a person may be procrastinating. Therefore, we want to get into the details of the situation.
The following might be a possible ‘chain’ of events that happen during the procrastination:
- Thought: “I’m thinking about going my work”
- Emotion: anxiety
- Thought: “I’m not going to understand the material”
- Emotion: Shame
- Judgmental thought: “I’m so stupid and worthless”
- Emotion: hopelessness
- Behaviour: Give up and do something else
With this much more precise understanding, we can see possible contributors to procrastination, like the feelings of shame or predictions of “not understanding the material.”
We can then find areas where we can target to break this chain of events. For example, sitting with the feelings of shame or challenging unhelpful thoughts like “I’m not going to understand.”
4. Change comes with cost
Some folks come to therapy with the expectation that change is necessary and it is always a good thing. However, one lesson that my supervisors have really emphasized that there always a cost to change and it is important to have this discussion with the clients.
For example, one of my clients was seeing some real progress in their life during therapy: they had started school, was holding down a steady job, and was keeping to a generally healthy routine.
However, they noticed that they were wanting to self-sabotage. When we started discussing where this feeling came from, they noted that it was scary to do well and that there were cons associated with improving. For example, they noticed getting less attention from family/friends and that there was less overall excitement (read: drama) in their lives.
Moreover, they realized that it was risky to do well – the higher the climb, the bigger the drop.
It was helpful for the client and I to have an honest discussion of what it means to change. Specifically, to identify the loss and to take some time to grieve the changes associated with improving. This was helpful for them to validate both the pros and cons of changing and make a commitment to change anyways.
5. Be willing to set the pace
I have a tendency to sometimes let the client set the pace of a session. However, this can sometimes be a disservice to clients because folks with BPD can be dysregulated. Without me framing the session, we can end up in all sorts of places and clients can feel confused, stuck, and hopeless.
I’ve often reflected why I am more willing to give the reigns in my therapy sessions at this particular clinic. In working with this population, I’ve sometimes felt a little less confident in what I was able to bring to the table. This made it harder for me to set pace and have the self-esteem to believe that I have something to offer. This uncertainty made it easier for me lose faith in my own effectiveness and let other people decide what is right or wrong to talk about. However, I have learned that it is important for me to be the person that extends hope to the client, model the way forward, and that I do have a number of clinical tools that can benefit their lives. This is an important gift I can provide for the clients.
6. Help clients distinguish what’s in the here-and-now, and what’s in the past
Oftentimes, clients have a sort of ‘trauma network’ that activates in different situations. For example, they may feel worthless when they do not do well on an exam because their mother always criticized the smallest mistakes when they were young.
When these ‘networks’ get activated in a client, it is helpful for us to understand where this reaction is coming from and help the client recognize the pattern. Clients can then ‘check the facts’ about the current situation and understand their feelings better. By sticking to the facts of the here-and-now, we become more grounded in reality and able to act effectively.
From my supervisors, I have found the question: “Where do you think this comes from?” helpful to guide clients to talk more about their relationship dynamics with parents and other important figures in their lives. I have also found this helpful to help with validation – helping the clients make sense of why they are feeling the way that they do.
7. Use your own emotions to guide you
My supervisors have encouraged me to take notice of my own emotions in the therapy room and to trust my clinical ‘spidey senses’ when something is afoot.
I have certainly had clients seemingly agitated or upset without me having said anything particularly offensive. In those moments, I have found it helpful to notice my own discomfort and check in on what was going on in the room. For example, saying something to the effect of “I’m noticing that we are not connecting like we usually do. I’m wondering if you are feeling the same way?”
This opens up an honest dialogue that allows to explore what is going on which can be an incredibly therapeutic conversation.
8. Look for the synthesis
There are many times where I felt like I had two options and neither felt quite right. For example, asking a client to radically accept a poor situation or asking them to change. The former might make them feel stuck and the latter is a potentially invalidating experience.
My supervisors have encouraged me to do my best to look for a synthesis. For example, perhaps there are some parts of a situation where we have to take an acceptance approach. However, there may also be areas that we can cope and effectively work on.
Folks with BPD often have an all-or-nothing way of thinking (e.g., “it’s either perfect, or I’m a failure”), so I have found it important to model the middle ground and find that proper balance.
9. Use metaphors
My supervisors really emphasize the use of metaphors. This is because metaphor creates a bit of distance for the client to observe their situation and take key lessons without feeling too involved in it themselves.
One metaphor I really like is the ‘beach ball’ metaphor. The beach ball metaphor is a lesson that teaches us about acceptance. When we try to suppress or reject something, it is kind of like pushing a beach ball down into the water with both hands. Although the ball is out of sight for a little bit, if often flops back up from time to time and we must keep using energy to push the ball back down.
Instead, accepting a situation is like letting the beach ball float around in the water. By doing so, we can spend our time enjoying the sights on the beach and use our hands and energy for something more fulfilling.
10. Be radically genuine
My supervisors encourage ‘bringing more of yourself’ into the therapy space. This has often been more challenging for a person like me who tends to be more on the reserved side. However, I have found it freeing at times to say what I think.
For example, I have found it therapeutic to let the clients know that I care for them and want the best for them. This is true even for the ‘hard truths’ – like telling my clients that if they keep doing what they are doing, then they will continue to feel stuck and not be able to move towards their valued lives.
The reason that it is important to be radically genuine is because folks with BPD may have often had experiences where people tip-toed around them. In this case, we do not wish to fragilize our clients and want to show them that we believe in their resilience.
Conclusions
My experience at the borderline personality disorder clinic has been fun and chaotic, enjoyable and anxiety-provoking, despairing and meaningful – all at the same time. It has been an incredible learning opportunity with excellent supervisors that have given me many valuable pearls of wisdom. I hope a few of these lessons were of interest to you.
Best wishes,
P
Photo by Ryan Graybill on Unsplash
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