Do “volun-told” clients benefit?

A common misperception regarding mental health treatment is that unwilling clients can benefit from therapy.  To be honest, therapy requires a level of willingness. Even medication effects are influenced by placebo and nocebo effects. Treatment is more likely to work if one believes it will.  On the other hand, treatment is less likely to work if a client believes it is not going to work.

While there are strategies and skills to increase commitment and willingness, DBT remains a voluntary treatment. Both the client and therapist must agree to work together with clear expectations and rules for treatment. Clinicians cannot be expected to talk someone out of suicide, as no client ever comes in asking for help to not kill themselves. If a therapist can offer to help a client build a life worth living through skills application, the client must agree to commit to staying alive long enough to do so, even if it means suffering through the change. Since therapeutic failure for clients at this point in their life increases hopelessness and risk for suicide, it is unethical for a therapist to begin working with someone they did not believe could commit to the intensity of this kind of treatment.

This is complicated in adolescents because parents obviously do not want to experience their child suffer and are motivated to bring about an end to at risk behaviors. However, a clinician also needs to find a willing client in the adolescent. Being forced into treatment rarely works, unless the adolescent miraculously decides they want to work hard for this change for themselves, not just because their family expects it.  

In general terms, a workable client has reached a place where they know some part of them does not want to die, but they have suffered too much to continue living as they have been.  They are aware that their current level of suffering is worse than their fear of change.   

Timing sometimes IS everything. Entering treatment too early and you may not find willingness to work as hard as they must to change.  Entering treatment too late increases the risk of worsening self-destructive behaviors and traumatic experiences from at risk behaviors. There are difficult times ahead when families bring clients into treatment who aren’t ready. Continuing to work with clients against their will worsens relationships in the family, burns out staff, and risks the client experiencing an abuse of power in treatment, increasing the odds they will drop out and not return at a future time when they might be ready.   

The episode below has information regarding primary targets in DBT.

All Therapists are Jerks, and . . .: AODA 5: Treatment Hierarchy (libsyn.com)