THE CASK OF MARIA: A DIALECTICAL APPROACH
Maria presents with both Axis I and Axis II concerns. Her symptoms include depression with suicidal ideation, interpersonal difficulties, and a trauma history related to suffering emotional and physical abuse. She displays severe impairment in her social and occupational functioning. She experiences feelings of self-doubt and concern that there is something wrong with her. She often feels scared and angry about the way she was treated by her husband and feels rejected by her family. She is currently experiencing perpetual emotional crisis and seems to fear being perceived by others as inadequate and unacceptable.
Maria has submerged herself in work in an effort to feel good about herself but feels little relief from her depression from this coping method. She feels lonely, depressed, suicidal, and unlovable and tends to perceive others as against her. She has developed a pattern of behavior that avoids interpersonal relationships. For Maria, it seems she would prefer to miss an opportunity for a close relationship than to risk the possible consequence of abuse or rejection.
Course of Treatment
Maria's daily symptoms of depression are debilitating and have resulted in frequent crying spells, sleep and appetite disturbance, and reduced effectiveness with parenting and at work. She will be assessed for medication and may be prescribed antidepressants by a physician to assist in the management of daily symptoms.
The first four sessions of DBT are intended to obtain a comprehensive history and familiarize the client with treatment. By the fourth session, Maria and her counselor should mutually determine treatment goals, including increasing her ability to make decisions despite not knowing if the "right" solution has been chosen; decreasing fear and avoidance in relationships; increasing the ability to tolerate criticism from her family; and developing a lasting, intimate relationship. Reducing suicidal ideation would also be a target. Diary cards would be introduced to track targets on a daily basis (Linehan, 1993b).
It is projected that in the early stages of treatment, Maria will demonstrate an overall willingness and ability to articulate goals for counseling. However, she may remain ambivalent about her own efforts and pessimistic about the possibility of change. An important part of treatment will include what is called informal behavioral exposure in standard DBT. For Maria, informal exposure is designed to help her learn new responses to classically conditional fear of being hurt or abandoned. Because DBT involves frequent feedback from the counselor, it will be explained to Maria that there will be many opportunities for informal exposure practice during the sessions themselves. After explaining the rationale of the need to practice receiving feedback/criticism because Maria's difficulty in doing so interferes with relationship development, the counselor will look for times during sessions when his or her comments were experienced as criticism/attack by Maria and use those moments to practice behaviors different from Maria's urge to escape or avoid. Thus, the counselor will have to be watchful for changes in Maria's affect during sessions and be willing to shift briefly to exposure practice before going back to the topic at hand.
The steps of exposure technique for Maria might look something like this: The counselor notices a change in Maria's emotional presentation and interrupts the conversation using immediacy and asking if she feels as if she is being criticized.
• Maria will be asked to try and identify what resulted in this emotional reaction.
• Maria will be asked to identify her emotion and consider what she needs to experience the emotion rather than avoid the emotion.
♦ Maria will be asked to verbalize her automatic thoughts, such as "she thinks I am being stupid."
♦ Maria will be asked to continue to focus on the sensations associated with the emotion until it starts to recede.
Each informal exposure lasts from 1 to 5 minutes and ideally starts and ends with a rating of Maria's distress on a scale of 1 to 100. In addition, it is important for the counselor to support Maria's willingness to participate and validate the possibility of change.
Once the skills associated with in-session informal exposure are learned, homework assignments will be given to help facilitate growth in all relevant contexts. Examples may include practicing confiding in others, increasing social behaviors, or noticing criticisms of others and letting them go.
The primary goal of treatment is to help Maria get her behavior under control, including reducing her suicidal ideation. Other treatment targets include addressing behaviors that compromise her quality of life, such as withdrawal from interpersonal relationships. Flexibility in blending acceptance and confrontation to change is needed. The counselor may alternate between validation and pushing Maria toward change by offering critical feedback. At the same time, the counselor will improve Maria's capacity to change by teaching her skills to tolerate painful feelings.
A warm communication style and use of validation will balance the focus on change- oriented strategies. In accordance with the DBT model, the counselor may occasionally use an unorthodox communication style in an effort to move toward change. Irreverent communication or an offbeat style may be used to shift Maria from her extreme affective responses. The counselor may also use the strategy of playing the devil's advocate to help Maria gain a sense of control and to help her see a different point of view.
The dilemma for the counselor is that a focus on changing Maria's behavior may be experienced as invalidating. Simultaneously, an overemphasis on therapeutic warmth and validation may leave Maria feeling that there is no escape from her misery. The counselor must seek to validate Maria's efforts to change, the difficulty in making change, and the pain stemming from believing that others are critical of her efforts. At the same time, the counselor will push Maria to do more. The counselor will use praise to support her efforts to change behavior and balance this by confronting Maria about ongoing dysfunctional behavior. The counselor will offer insight into Maria's behavior in an effort to help her notice patterns in her behavior. The counselor will also focus on finding solutions to problematic behaviors such as challenges to her dysfunctional belief that others are constantly rejecting her. The counselor will work to help Maria refrain from acting impulsively by encouraging her to act in a manner that is consistent with her personal goals.
A fundamental premise of the DBT approach is that problems in regulating affect represent the core dysfunction. Strategies are oriented toward addressing emotional dysregula- tion. Interventions in DBT focus on the various elements of the emotion response system, including emotions, cognitions, expressive-motor behavior, and action tendencies. The primary goal of the first stage of DBT is to treat out-of-control behaviors that threaten the individual's life, treatment, and quality of life and more generally to help achieve balance in behaviors and emotional experiencing. A number of secondary, complex pattern of behavior have the potential to interfere with treatment and may need to be addressed. Core behavioral patterns include emotional vulnerability and self-invalidation. The DBT counselor uses a number of specific techniques to directly enhance emotional regulation. These include exposure-based procedures, emotional validation, and the enhancement of capabilities, such as paying attention to experience, shifting attention away from cues associated with negative emotion, and learning to observe, describe, and understand the function of emotions.