Marsha Linehan Conducts Dialectical Behavior Therapy
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DR. MARSHA LINEHAN: How often would you say you hit her?
PATIENT: I did—I didn't keep a—I don't count that way
DR. MARSHA LINEHAN: Yeah, yeah. But like, once a week? I mean—
PATIENT: But why, why is it so important to know about—to know this? As I told you already, she was hitting me, as well.
DR. MARSHA LINEHAN: Mm hm.
PATIENT: Why—why should this be an issue?
DR. MARSHA LINEHAN: An issue with you?
PATIENT: Yeah.
DR. MARSHA LINEHAN: Well, OK. So let's stop for a moment. I don't have her in therapy.
PATIENT: No.
DR. MARSHA LINEHAN: If I had her in therapy, I might be talking to her. And you had left her. I might be talking to her, trying to help her figure out why you left her.
PATIENT: Yeah.
DR. MARSHA LINEHAN: But she's not here.
PATIENT: No.
DR. MARSHA LINEHAN: OK.
PATIENT: No. And the other therapist made an issue about this, and I told them—and I was honest about it.
DR. MARSHA LINEHAN: Yeah, yeah.
PATIENT: And then they made abuse of it.
DR. MARSHA LINEHAN: Yeah, OK. So you're worried I'm going to do the same thing?
DR. MARSHA LINEHAN: If you noticed, he had asked me previously, why is it that I'm not talking more about her instead of just about him? And I told him that the reason was because he's the only one in therapy. So now, I'm going to continue talking about therapy, and start discussing what therapy is and clarify his goals for treatment. To be sure that we're on the same page.
PATIENT: I don't know you.
DR. MARSHA LINEHAN: Mm hm.
PATIENT: You're a total stranger for me.
DR. MARSHA LINEHAN: Yeah, yeah.
PATIENT: Because I'm talking about my intimate life, about my life.
DR. MARSHA LINEHAN: OK.
PATIENT: To a total stranger.
DR. MARSHA LINEHAN: Yeah, yeah.
PATIENT: I'm not sure what you are doing, what you are thinking.
DR. MARSHA LINEHAN: Right. That's true. You're not. How could you be? OK, so you're worried about what I'm thinking? Right?
PATIENT: Yeah.
DR. MARSHA LINEHAN: OK.
DR. MARSHA LINEHAN: Now, you noticed that I said "right, well that's true, you're not, how could you be?" In other words, I'm validating the client's point of view. It's very important in DBT to validate, but even more important than validation is you validate the valid, you don't validate the invalid. That's critical. You don't validate things that aren't true or that are dysfunctional. So you don't validate everything. But it's essential in DBT that a therapist find things to validate that can be validated. So you'll notice me doing that quite a bit in this session with this client.
DR. MARSHA LINEHAN: Well, let me tell you what I'm thinking about this particular thing, OK? One thing that you need to be clear is that if you were in a relationship right now, with a child or an older person, and you hit them, I might have to report it. So you could worry about that. OK?
If you're in a relationship with a woman your age, and you're hitting her, your hitting her is going to stay confidential in here. But what I'm going to think about you hitting a woman is that that's probably going to create problems in the relationship. So listening to you talk, and hearing that you've hit her, my opinion is that's probably going to cause a lot of problems.
And so if you decide you want to work with me, my guess is that one of the things that you and I would have to work on is for me to work with you to help you not hit women. Because there's almost no relationship that can tolerate physical hitting, no matter how good your reason is. Just listening to you, I can tell you right off the bat that one of the things you and I would have to work on in therapy would be for me to help you find ways to relate to women that don't involve hitting.
DR. MARSHA LINEHAN: What you've noticed here is a very matter-of-fact approach to telling a client, one, I might have to report your behavior if it's serious and violent. And two, not fragilizing the client as I tell him that this is a behavior that's going to have to change if he wants to reach his goals. In other words, you can't really have a relationship with a woman if you keep hitting her. So it's very matter-of-fact, and this is very typical in DBT to both be matter-of-fact, but also not to fragilize clients.
DR. MARSHA LINEHAN: And so, does that makes sense, what I just said?
PATIENT: Yes, it makes sense.
DR. MARSHA LINEHAN: OK.
PATIENT: [INAUDIBLE] On other hand, I think she could do anything she wanted. She could hide from me, she could be silent.
DR. MARSHA LINEHAN: Yeah.
PATIENT: She could not speak. She was allowed to do anything.
DR. MARSHA LINEHAN: yeah, yeah. Right. So one of the things to do would be to learn how to be in a relationship with a person who does those things. Given that you loved her and wanted to stay in it, right? Even though she did all that, you still wanted to be in the relationship, right? So the question would be how—if a person does that, how could you be in a relationship and react in such a way that they continue to want to stay with you? Because that's really what you want, isn't it? For her to also want you?
PATIENT: Yeah.
DR. MARSHA LINEHAN: OK. So it seems like one of the things we would need to work on in therapy would be, if you wanted to do therapy, would be how to be in a relationship with someone and react to them in such a way that they want to stay with you. Is that something you want to work on?
PATIENT: Yeah.
DR. MARSHA LINEHAN: OK.
PATIENT: In one way, it sounds reasonable.
DR. MARSHA LINEHAN: Mm hm.
PATIENT: And the other way, it makes me feel some resentment, because—
DR. MARSHA LINEHAN: Right. It's not fair.
PATIENT: No, it's not fair. Why should I change? Because the others betrayed me?
DR. MARSHA LINEHAN: Right, exactly. Yes.
PATIENT: It's not fair.
DR. MARSHA LINEHAN: Right. I totally, I totally understand that.
PATIENT: Because the—
DR. MARSHA LINEHAN: So on the one hand, you feel like, I need to change, there must be something wrong with me.
PATIENT: Yeah.
DR. MARSHA LINEHAN: Because these women keep leaving me. And on the other hand, your sort of everyday view is that they're doing things that are very upsetting, and why should you change, why shouldn't they change?
PATIENT: Yeah.
DR. MARSHA LINEHAN: Right. So you sort of think both ways?
PATIENT: Yeah.
DR. MARSHA LINEHAN: OK, so the trick would be to figure out sort of the truth in both sides. There's probably some truth that you need to change, and there's probably some truth that it's not fair. So I assume when you start thinking it's not fair, then you get angry, right?
DR. MARSHA LINEHAN: So up until that last statement, I've been clarifying goals, making sure we're on the same page. And then, as you see, I made a synthesizing statement, where I brought together two different points of view. So that would be a dialectical statement, which is also common in DBT.
DR. MARSHA LINEHAN: OK, all right. Now what I want to do now is go back to something else. I want to find out how suicidal are you feeling right now? This minute?
PATIENT: This minute, I don't feel suicidal at all.
DR. MARSHA LINEHAN: OK, good. Now what I want to do, at least, is have an agreement. That although it is perfectly true that you could kill yourself later, if the therapy doesn't work, that at least for the moment, we could agree that you're not going to kill yourself without—before we really give this treatment a chance.
So can you agree not to kill yourself? If you kill yourself, this therapy will not work.
PATIENT: Obvious.
DR. MARSHA LINEHAN: So you gotta stay alive to give the therapy a chance. OK? So what I want to know is, if you've already agreed that you are willing to really try to make some changes, you're going to explore whether I'm the right person, but I want you to agree to now—I want us to agree. I'm perfectly willing to agree to stay alive for myself. So I want to know whether you'll agree not to kill yourself before we give it a chance.
You're not speaking.
PATIENT: No.
DR. MARSHA LINEHAN: Yeah, so speak.
PATIENT: Do I have to say [INAUDIBLE]
DR. MARSHA LINEHAN: You have to—I want to find out whether you agree. Do you? Agree not to kill yourself before giving the therapy a chance?
DR. MARSHA LINEHAN: You noticed that I asked the client to commit to not killing himself before giving therapy a chance. This is really important, that you ask clients for that commitment. But it's equally important to notice that DBT is not a suicide prevention program. It's a life worth living program.
So the actual goal you're asking the client to commit to is the goal of trying to develop a life worth living, instead of killing themselves before they try to do that.
PATIENT: Do I have to make an oath?
DR. MARSHA LINEHAN: No.
PATIENT: No?
DR. MARSHA LINEHAN: I'm just trying to find out whether you do agree. You just have to tell me what's going on in your mind. Either yes, I agree. No, I don't.
PATIENT: Yes, I agree.
DR. MARSHA LINEHAN: Thank you. OK. I'll stay around, you stay around.
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