way. Yet the nature of traditional psychotherapy
renders it vulnerable to such problems of passivity.
It is even possible that the active, vigorous quality
of cognitive-behavioral methods and the analogous
attitude that this forces upon the therapist may be
responsible for a measure of patient improvement
beyond that caused by the specific procedures
employed. An active therapist may be reassuring,
exciting, or encouraging to some patients (in con-
trast to a passive, contemplative, noncommittal psy-
chotherapist who often has little to say or suggest).
It is also worth repeating that behavior therapy
is the undisputed leader in“manualizing”its treat-
ments so that empirically supported techniques
can be administered in a standardized fashion. Not
only does this facilitate conducting research and
providing effective treatment but it also facilitates
the training of future clinical psychologists to
administer these effective treatments.Symptom Substitution. As much as anything,
CBT will have a secure and valued position in the
history of psychology because it helped lay to rest
the hallowed notion ofsymptom substitution. It not
only demonstrated that there are alternatives to the
psychodynamic view of pathology but also effec-
tively attacked the medical model of pathology
and its cherished notions of illnesses and symptoms.
After years of research and clinical experience, it is
now clear that not every patient’s complaint can be
labeled as a symptom of some underlying psychic
illness—an illness that will surely return in the formBOX14-7 Focus on Clinical Applications: Excerpts from Sessions of Dialectical Behavior Therapy (DBT)The client was a 30 year-old woman with borderline
personality disorder who had been hospitalized at least
10 times in the previous 2 years for treatment of sui-
cidal ideation and who had engaged in numerous
instances of self-harm behaviors including drinking
Clorox bleach, cutting and burning herself, and one
suicide attempt (Linehan & Kehrer, 1993).
In this segment (Linehan & Kehrer, 1993, pp. 428–
429), the DBTtherapist(T) explains the DBT program
and goals to theclient(C):
T:Now, the most important things to understand is that
we are not a suicide-prevention program, that’snot
our job. But we are a life enhancement program.
The way we look at it, living a miserable life is no
achievement. If we decide to work together I’m
going to help you try to improve your life so that it’s
so good that you don’t want to die or hurt yourself.
You should also know that I look at suicidal behav-
ior, including drinking Clorox, as problem-solving
behavior. I think of alcoholism the same way. The
only difference is that cutting, burning, unfortu-
nately, it works. If it didn’t work, nobody would do it
more than once. But it only works in the short term,
not the long term. So quitting cutting, trying to hurt
yourself, is going to be exactly like quitting alcohol.
Do you think this is going to be hard?
C:Stopping drinking wasn’t all that hard.T:Well, in my experience, giving up self-harm behavior
is usually very hard. It will require both of us
working, but you will have to work harder. And
like I told you when we talked briefly, if you
commit to this it’s for 1 year. Individual therapy
with me once a week, and group skills training
once a week. So the question is, are you willing to
commit for 1 year?
C:I said I’m sick of this stuff. That’s why I’m here.
T:So you’ve agreed to not drop out of therapy for a
year, right?
C:Right.
T:And you do realize that if you don’t drop out for a
year, that really does, if you think about it, rule
out suicide for a year?
C:Logically, yeah.
T:So, we need to be absolutely clear about this,
because this therapy won’t work if you
knock yourself off. The most fundamental mood-
related goal we have to work on is that, no
matter what your mood is, you won’t kill yourself,
or try to.
C:Alright.
T:So that’s what I see as our number one priority, not
our only one but our number one, that we will422 CHAPTER 14