1. Acceptance & change:
DIALECTICAL strategies
Balance acceptance and change; teach patient to be dialectical
1 therapeutic relationship: be aware of dialectical tensions
2 in all interactions, teach and model dialectical behaviour patterns

2. Acceptance & change:
DIALECTICAL strategies

3. Dialectical strategies
1 Entering the paradox
Eg koans
Refuse to step in with logical explanation to
allow the client to step out of the struggle
‘Both-and’ not ‘either-or’

4. Dialectical strategies
2 Using metaphor
Stories are easier to remember
Metaphors can communicate difficult stuff-e.g.
the effect of client’s behaviour on others
Useful metaphors: marathon not sprint; rescuing
vs visiting; use e.g.s from client’s interests
Keep a metaphor book

5. Dialectical strategies
3 Devil’s advocate
Therapist presents thesis (extreme maladaptive
belief)
Client presents antithesis
Eg T:‘if you offend anyone it is a mortal
catastrophe. You should be deported form the
country and all your assets seized’ C:’ well, I’m
not that bad’

6. Dialectical strategies
4 Extending
Take the patient more seriously than she takes
herself
Take anticipated consequences literally then
respond to seriousness
E.g. ‘I see, you really can’t carry on with DBT, we
must take that seriously…do you think we really
need to consider ending therapy?’

7. Dialectical strategies
5 Activating wise mind
Convince client she can do this
Can use ‘Well’ metaphor/floating on cloud/etc
‘What do you know in your wise mind to be
true/right?’

8. Dialectical strategies
6 Making lemonade out of lemons
‘I got the sack’
‘Wow now we have a chance to practise distress
tolerance big time’
‘was (the homework) hard?
‘yes’
‘good, now we know you can do hard things’

9. Dialectical strategies
7 Allowing natural change
Change, development and inconsistency are
inherent in any environment and are allowed to
proceed naturally
The client is encouraged to learn to tolerate and
adapt to change rather than keep environment
stable

10. Dialectical strategies
Dialectical assessment
?is the problem a fatal flaw in the client or a fatal
flaw in the social fabric?
Be aware of the oppressive/problem-producing
nature of some therapeutic rules, styles and
systems

11. Dialectical Skills
Enter the Paradox (both – and)
Metaphors
Lemonade out of Lemons (what a great
opportunity….)
Devil’s Advocate (you may find this too difficult...)
Extending (this is serious – perhaps we/you should..)
Wise Mind (taking both your emotions and knowledge,
what do you know in your gut/heart to be right?)

12. STYLISTIC STRATEGIES
Reciprocal style:
responsiveness
staying awake
considering the client’s agenda, clients’
desired session content.

13. STYLISTIC STRATEGIES
Self-disclosure
orient patient to what types of self-disclosure will
occur from the therapist
self-involving self-disclosure (reactions to
patient, heart to heart, ‘when you do X I feel Y’)
personal information: qualifications, experience

14. STYLISTIC STRATEGIES
Warm engagement:
observing limits
coping with rage at the patient
use of touch

15. STYLISTIC STRATEGIES
Genuineness
Being a ‘real’ therapist
Having a ‘real’ relationship
Be yourself

16. STYLISTIC STRATEGIES
Vulnerability
This is a high-power-low-power relationship
Because the therapist could not bear to be
more/equally vulnerable than client
Also, because the focus must be on the client

17. STYLISTIC STRATEGIES
Irreverent style:
1 reframing (in unorthodox manner)
E.g. ‘so, what you’re saying is that you’d rather
suffer from anxiety for the rest of your life than
do this one hard thing?
2 where angels fear to tread
E.g. ‘I’m sorry, we just have no success with
corpses’

18. STYLISTIC STRATEGIES
Irreverent style (contd)
3 confrontational tone
E.g. so what the hell have we been doing all
these months?
4 calling patient’s bluff
e.g. ‘OK so I am no good as a therapist,
perhaps you should sack me?’

19. STYLISTIC STRATEGIES
Irreverent style (contd)
5 Intensity and silence
E.g. look long at client and say nothing
6 omnipotence and impotence
E.g. ‘that can always be sorted’
Or ‘well I am completely helpless here’

20. Environmental intervention (consultation to staff/the
wider care system): keep to minimum; do only when patient
is unable, when environment is high power, to save life, when
humane, when minor issue.
Consultation to the patient strategies: effective self-care,
decrease ‘splitting’, how to manage other professionals.
Consultation to the therapist: consult group: meeting
agenda, consultation agreements, cheerleading, dialectical
balance, staff splitting, unethical behaviour, confidentiality.
CASE MANAGEMENT
strategies

21. CONSULT GROUP: APPLYING DBT
WITH OURSELVES
Environmental events and context are just as
important in shaping therapeutic behaviour as in
shaping clients’ behaviour, laws of human
behaviour apply to us as well!

22. Consult Group Agreements
Dialectical agreement; consultation to the client;
consistency; observing limits, phenomenological
empathy; fallibility.

23. Consult Group Agreements
Dialectical agreement; consultation to the client;
consistency; observing limits, phenomenological
empathy; fallibility.

24. Consult Group Agendas:
Supervision Meeting:
Mindfulness
Problems with treatment, review at least one case
Skills trainers tell individual therapists what skills being taught and individual
issues in skills training
Chain Analysis of lateness/absence
Institutional limits on client behaviour.
Staying DBT adherent
Review an aspect of DBT

25. Business Meeting
Mindfulness
Client tracking
New referrals
Allocation
Audit
Service issues (referral criteria)
Managing the wider system]

26. Consult Group Cheerleading
Therapist demoralisation: seeing the wood for the
trees
Hopeless thoughts
Validation and problem solving therapist mistakes.

27. Providing Dialectical Balance
Applying DBT strategies with one another
Over-protectiveness, rage, validate and reframe

28. ‘Staff Splitting’
Arguments among staff are seen as failures in
synthesis
Staff splits staff, client does not
Become aware of what precipitates disagreement
and of ‘wave patterns’ of attachment

29. Unethical or Destructive
Therapist Behaviour
Minimum levels of competence, ethics and non-
defensiveness not met: elephant in the room

30. Confidentiality
Therapist disclosures are confidential to consult
group
Case discussion may be disclosed judiciously to
client