The person-centred approach to therapeutic care, developed by American psychologist Carl Rogers*, remains as relevant today as it was in the 1940s. It lies at the heart of the services offered by psychology experts across the world.
“The person seeking care is considered to be the ‘expert’ in seeking the desired solution or outcome,” says Sandy Lewis, head of psychological services at Akeso Clinics. “The voice of the patient is paramount in this model. Caregivers assist people to find their own way forward into health through listening, genuineness, congruence, empathy and ‘unconditional positive regard’ – a warm, non-judgmental approach. Person-centred care is our core treatment philosophy.”
Dialectical behaviour therapy (DBT) provides patients with new skills to manage painful emotions and decrease conflict in relationships. It is particularly suited to address borderline personality disorder, extreme suicidal and self-harming behaviours and addictions, as well as eating disorders.
“This type of therapy is suitable for the majority of our patients,” says Lewis. “Usually, when they, or their families, approach us for help, they are in acute pain. It’s a state that often precipitates a life crisis (one of many), and they are at risk of harm or even death.”
How dialectical behaviour therapy works
Marsha Linehan, who developed DBT, said, “People with borderline personality disorder (and those like them) are like people with third-degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement”.
DBT works in three ways: first, it aims to reduce the intensity of pain felt by the patient; second, it tries to engage cognitive functioning which is lost during periods of extreme emotional arousal; and third, it works on acceptance of both self and situation.
“To quote Linehan once again, ‘acceptance is the only way out of hell’,” says Lewis. “DBT helps people to learn skills to reduce the intensity of the pain they feel, to learn acceptance, to regulate their nervous system's reactivity to situations and introduce a range of positive emotions to balance the pain, and it also teaches skills to build and maintain relationships, an area where our patients really struggle. However awful a person may feel, you can learn to modulate those feelings so that you can make a decision about how you wish to behave. That is discipline of mind.”
DBT lends itself to any disorder characterised by intense, unregulated emotional pain, impulsive self-destructive acting out, and a lack of an ability to temper feelings with thoughts that would serve to slow down the behaviours that bring relief but that produce even more problematic consequences.
“It’s particularly effective with clients in the acute phase of illness, often characterised by crisis – relationship breakdown, job loss or threat of job loss, legal ramifications, breaks in studies, suicide attempts, binges and the like,” Lewis explains.
A concept at the heart of DBT theory is that of ‘wise mind’, notes Lewis. “When one is in a balanced, calm and mindful space, when one is capable of the process of mentalisation, then one is also in a place where one can draw on wisdom.”
For most personality disorders, DBT, along with its sister therapy, mentalisation-based treatment (MBT), is most effective. Developed in the UK by Peter Fonagy and Anthony Bateman, MBT is a model of therapy that helps patients to develop the capacity to reflect on and interpret thoughts and actions – to think about thinking and feeling or to be ‘mind-minded’. Mentalisation is essential to a consistent sense of self and a basic requirement for relationships.*
“This is particularly useful as many of our patients have dual diagnoses – and one of those diagnoses is, more often than not, personality disorder,” Lewis says. “These personality disorders were at one time considered to be largely untreatable, but DBT and MBT have given much hope in this regard, and that is why we favour them. They quite simply suit the vast majority of our patients.”
Modalities of therapy
While therapy is offered to individuals, families and couples, group therapy is the foundation of many Clinics programmes.
“This modality is extremely important because when we assess our patients on admission – using the World Health Organisation Disability Assessment Scale 2.0 – we find that the domains in which they struggle most are participation in society, getting along, and general life activities,” Lewis explains. Given that these are social activities, they need to be resolved in social settings like groups.”
The aim is to prepare patients to resume life in communal settings like families, work and friendship groups. They lack the skills to negotiate these spaces, and this is most often the reason for their deep sense of emptiness and despair, their sense of personal failure and the feeling of not belonging anywhere.
A multi-disciplinary treatment philosophy
A multi-disciplinary approach to therapy, says Lewis, results in the best understanding of, and decision-making around, the patient’s illness and the most effective treatment plan.
“We always consult with the multidisciplinary team along the patient’s journey to healing. This team comprises allied professionals or psychotherapeutic specialists, the psychiatrist and the nursing team. We aim for regular ward rounds where each patient is presented, and we also share records both in written and electronic form on a frequent basis. For us, mental health care is a ‘team sport’. We believe that the best care is when it’s offered as part of a comprehensive plan on a pre-determined path or journey, together, not in fragmented parts.”
What can inpatients expect once they are admitted?
Akeso Clinics offers inpatients a comprehensive orientation programme, so that each patient knows what to expect, and a regular daily routine to ensure structure. This prepares the patient for the return to work, family and society – right from the beginning. Patients are also encouraged to participate in exercise, relaxation, learning, creative expression, community building, leisure and fun programmes.
“What we offer is a microcosm of life outside the clinic,” says Lewis. “Groups are compulsory because that is where patients learn what they most need to reintegrate after being discharged. Time at the clinic is time out, but it is a temporary respite from the responsibilities of life – that is why discharge planning starts early. Our aim is to reduce avoidable readmissions and we work hard towards that goal, notwithstanding the fact that the disorders we treat are sometimes chronic.”
- Carl Rogers, Founder of the Centre for the Study of the Person, best-known books Client-Centred Therapy (1951), On Becoming a Person (1961) and A Way of Being (1980).
- Allan, J G and Fonagy P, Handbook of Mentalization-Based Treatment, Wiley, 2006
- Linehan, M, Cognitive Behavioural Treatment of Borderline Personality Disorder, Guilford Press, 1993
- Linehan, M, Dialectical Behaviour Therapy Skills Training Manual, Guilford Press, 2014
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