Sunday, 17 August 2008

dialectics of psychological therapy

Georg Wilhelm Friedrich HegelDialectical Behavior Therapy - DBT - is said to be 'dialectical' because it moves back and forth between i) a stance of acceptance or validation of the client and their experience as they are on the one hand, and ii) a stance of helping them to change on the other. I don't really see that this is 'dialectical' in any particularly interesting theoretical way, but perhaps I'm missing the point -and I should say, I don't have Linehan's original book... (This in any case isn't a critique of DBT, only a question about the pertinence of its name.)

There is however a dialectic that seems important to me to cultivate in any therapy. This is between i) engaging with 'the part of' the client that is an agent, desiring change, can feel hopeful, and ii) engaging with 'the part of' the client that is a patient, fears change, feels hopeless. Managing this dialectical encounter appears important. And this is because if I just engage empathically and acceptingly with the hopeless part of my client, then they will feel accepted and cared for, but ultimately remain helpless and powerless. If, on the other hand, I just engage with the part of my client that feels hope, wants to change, dares to be brave, then I risk losing them when they don't feel brave, are scared, hopeless, powerless. I risk too not hearing their distress and coming across as unempathic.

In my work I am experimenting with being as honest about these two parts of the client as I can be. Discussing the dialectic (not usually in those terms!) with the client themselves. Wondering with them where they are at, whether they feel heard and which part of them is doing this hearing. I have the idea that the tension between these parts is what keeps the therapy itself alive. I also have the idea that the agent can be recruited as a reconditioner (in the sense of behaviour therapy) for the patient parts of the client. I mean to say that, if there is a need to change habitual patterns of feeling, activity, and thought, then the way to do this may not be directly (cognitively or affectively), but from the ground up (behavioural conditioning), and the (agentive part of the) client can be recruited as the self-directing provider of this therapy in their daily lives. (You know, like practicing the violin: you make yourself do it and eventually the requisite neural pathways get layed down for spontaneous expressive access in the future.) I am suspicious that this is too active a model of successful therapy, since it focuses far more on what I do than on who I am. But that is a topic for another day.