Reciprocal communication, by definition, is about sharing with the client: giving and taking in the interaction, being warm and genuine, and treating the client as an equal. This includes the often-controversial strategy of therapist self-disclosure.
THERAPIST SELF-DISCLOSURE
Carew (2009) defines self-disclosure as making statements to the client that reveal personal infor-mation about the therapist and notes that this remains controversial. Depending on your previous training, the idea of self-disclosure may be counterintuitive and even scary. In more traditional therapies, therapists sharing personal information with clients is viewed as inappropriate; rather, it is thought that the therapist should be neutral, providing the blank slate clients need in order to sort out their problems.
However, the idea that therapist self-disclosure can be helpful isn’t new. For example, Beck, Freeman, and associates (1990) suggested that there is a place for therapist self-disclosure in CBT—
that by revealing personal reactions toward clients, therapists can help them understand the impact they have on other people within the safety of the therapeutic relationship. Along these lines, Carew (2009) notes that CBT clinicians regularly employ self-disclosure as a way of encouraging reciprocity in clients who are inexperienced in sharing their personal stories with others.
Therapist self-disclosure is also supported by humanistic therapies as a way of engaging the client in an authentic relationship. For example, Carl Rogers (1961) put forth the idea that the therapeutic relationship will be more genuine and real when therapists can simply be who they are, rather putting on a facade for the client.
Even more so than in other therapies, in DBT it’s important that the therapist-client relationship be strong and positive. Linehan (1993a) notes that the effectiveness of many DBT strategies relies upon the strength and genuineness of the relationship. In addition, at times the relationship will be what helps the therapist maintain a working alliance with the client, especially when the therapist’s reaction might otherwise be to lash out or abandon therapy with the client (Linehan, 1993a).
Linehan (1993a) notes that in DBT self-disclosure serves a variety of functions: It can be used to validate or normalize the client’s experience (e.g., the therapist might share that she had a similar situation in which she felt the same way); to problem solve (e.g., the therapist might disclose solu-tions that she’s tried to handle a similar problem); or to model how to engage in self-disclosure, teaching the client how to share her own experiences in an appropriate way.
Therapist self-disclosure is also used as exposure therapy and contingency management when the therapist uses self-involving self-disclosure—disclosing her reactions to the client’s behavior (Linehan, 1993a). In this type of self-disclosure, the therapist identifies her own internal reactions to the client, communicating them directly to the client. A common example might be a client who isn’t complet-ing her Behavior Trackcomplet-ing Sheets regularly. In response, the therapist might say, “I understand that the tracking sheets can be a pain to fill out, but you say you understand how important they are.
Each time you come to session without them completed, I feel less motivated to work with you.”
GUIDELINES FOR SELF-DISCLOSURE
Of utmost importance to point out here is that you must use validation in conjunction with self-disclosure, especially when providing self-involving self-disclosure. Remember the dialectical
DBT Strategies for the Individual Session
55 tension between these two: you can’t only push for change; you have to accept clients as they are (validate) and push for change at the same time.
We also have to remember that while there are times when self-disclosure is helpful and even necessary, we must always be thinking about what will be most helpful—and what could be harmful—to the client and the therapeutic relationship. Linehan (1993a) reminds us that decisions about what we disclose to our clients must always be based on what will be most helpful and the relevance of the disclosure to the current topic of discussion. For example, one of my clients has a long history of binge-eating disorder, and we’ve been working on this behavior that interferes with her quality of life regularly in our individual sessions. Recently, the client asked me if I had ever struggled with eating problems. Understanding that she was looking for some reassurance and hope that she could successfully reduce her bingeing, I told her that I had had a period in my life when I struggled with my weight and was able to get it under control. I also let her know that I’m a chocoholic and therefore could relate to her urges to eat. I shared some techniques that had worked for me, and we then went on to look at more skills to help her with these issues.
My self-disclosure served a specific purpose: it was validating for the client to hear that someone she looks up to has had struggles similar to her own, and letting her know that I understand and have had similar experiences helped strengthen our relationship. Of course, there’s a dialectical dilemma:
as therapists, we need to balance self-disclosure with observing our limits. If, for example, I’d once had an eating disorder and it was too uncomfortable for me to acknowledge this even if it might have been helpful to the client, I would need to observe this limit and not engage in self-disclosure.
The key is to aim for balance. Many therapists come from a background that labels therapist self-disclosure as inappropriate. If this is you, keep in mind that just because it feels uncomfortable to disclose something, that doesn’t mean you shouldn’t do it; it just means you need to think about it carefully and weigh the possible benefits against the possible discomfort you might experience.
You can also ask yourself why it’s uncomfortable. Is it because you think you shouldn’t disclose, or because this is something personal you’d rather not share with the client?
VALIDATION
The other major component of the reciprocal communication style is validation, which is the main acceptance strategy in DBT (Swales, Heard, & Williams, 2000). Linehan (1993a) defines valida-tion as communicating that the client’s responses make sense and are understandable given what’s currently taking place in her life. Validation means taking the client’s responses seriously, rather than discounting or minimizing them. Linehan (1993a) notes that effective validation requires that the therapist recognize and reflect back to clients the intrinsic validity in their reactions to situa-tions and events.
Early in her research, Linehan (1993a) discovered that using CBT to treat BPD was ineffective.
She attributed this to CBT’s focus on change, a focus likely to be perceived as invalidating by clients with difficulties regulating their emotions. As Swales and Heard (2009) point out, being told that you must change is invalidating in and of itself, even when you are able to see the truth in it.
This is the main dialectic in DBT: balancing pushing clients to make changes in life while at the same time accepting the way they are and the life they’re leading, as well as encouraging them to accept themselves. If the therapist pushes too hard for change and doesn’t focus enough on accep-tance, the client will feel invalidated and will be unable to work effectively in therapy. But too much acceptance and not enough push for change will create a sense of hopelessness, which will also result in an inability to work effectively in therapy (Swales et al., 2000).
Linehan (1997) outlines six different levels of validation:
1. Listening and observing: The therapist actively tries to understand what the client is saying, feeling, and doing, demonstrating genuine interest in her and actively working to get to know her. This entails paying close attention to both verbal and nonverbal communication and remaining fully present.
2. Accurate reflection: The therapist accurately and nonjudgmentally reflects back the feelings, thoughts, behaviors, and so on expressed by the client. At this level, the thera-pist is sufficiently in tune with the client to identify her perspective accurately.
3. Articulating the unverbalized: The therapist communicates to the client that she understands the client’s experiences and responses that haven’t been stated directly.
In other words, the therapist interprets the client’s behavior to determine what the client feels or thinks based on her knowledge of events. The therapist picks up on emotions and thoughts the client hasn’t expressed through observation and specula-tion based on her knowledge of the client. This type of validaspecula-tion can be very power-ful because, while clients often observe themselves accurately, they can also invalidate themselves and discount their own perceptions because of the mistrust fostered in them by their environment.
4. Validating in terms of sufficient (but not necessarily valid) causes: The therapist vali-dates client behavior in relation to its causes, communicating to the client that her feel-ings, thoughts, and behaviors make sense in the context of her current and past life experience and her physiology (e.g., biological illness). This level of validation goes against the belief of many clients that they should be different in some way (for example,
“I should be able to manage my emotions better”).
5. Validating as reasonable in the moment: The therapist communicates that the client’s behavior is understandable and effective given the current situation, typical biological functioning, and life goals. It’s important for the therapist to find something in the response that’s valid, even if it’s only a small part of the response (for example, letting a client know that it’s understandable she would resort to cutting herself because it provides temporary relief, even though it doesn’t help her reach her long-term goals).
6. Treating the person as valid—radical genuineness: The therapist sees the client as she is, acknowledging her difficulties and challenges, as well as her strengths and inherent
DBT Strategies for the Individual Session
57 wisdom. The therapist responds to her as an equal, deserving of respect, rather than seeing her as just a client or patient, or, worse, as a disorder. Linehan (1997) points out that level 6 validation involves acting in ways that assume the individual is capable, but that this must come from the therapist’s genuine self, and that at this level, almost any response by the therapist can be validating: “The key is in what message the therapist’s behavior communicates and how accurate the message is” (p. 379).
Swales and Heard (2009) note that, in addition to these different levels of validation, there are also two different types of validation: explicit verbal validation, which is the more direct validation that occurs in all six levels described by Linehan’s (1997), and implicit functional validation, in which the therapist validates with actions rather than words. For example, say a client comes in distressed over the end of a common-law relationship and reports that she has to find a new place to live as soon as possible because she can no longer tolerate the abuse she’s been experiencing from her partner. There are many ways of providing explicit verbal validation for the client in this moment, from a level 1 validation, staying in the present with the client and remaining interested and express-ing concern, to a level 6 validation, such as “I’m so glad you’ve finally been able to make this tough decision. I’ve been so concerned for you.”
In implicit functional validation, rather than validating with words, the therapist does so by means of her response to the client, moving directly to problem solving. As Swales and Heard note, “Sometimes the most validating response to a client’s dilemma is to help them to solve it”
(2009, p. 95).
Facial expressions and body language can also be implicitly validating. For example, if a client is telling you a very sad story, hopefully she will see in your facial expression that you feel sad as well. Or if a client comes in and shares a success story with you and you smile broadly and break into applause, that would be implicitly validating, as the message you are conveying isn’t verbal but is clear nonetheless.