Dr. Vaughn: The ultimate goal in DBT is for the patient to have and achieve a life
worth living.
The idea being that the patient who continually attempts suicide engages in
life-threatening behavior has a life that is currently not worth living and we have
got to work on changing that.
In order to do that, we have to be able to understand what their life would
be.
The assessment of these goals can be difficult.
In this case, it's a little difficult getting started, but eventually the
patient gets the plan and starts to really participate.
It can be dysregulating for some patients.
So you don't want to necessarily press this.
I'm reading Emily's response and trying to assess whether or not she's getting
emotionally disregulated.
She doesn't seem to be, it seems to be able to lighten the mood nearing because I
know we're coming up on the end of session and I don't want to get into very heavy
material or
get into another conflict just prior to ending the session.
I'm not avoiding conflict.
I think that's important to point out because if there's any time that I need to
be able to engage in interpersonal conflict, it's in those first few
sessions.
So again that the patient has the information they need to be able to make
an educated decision.
Are they going to be able to stand me in future sessions?.
Am I going to be able to tolerate and stretch my limits with this patient?
The exploration of the life worth living goals is an important one because we've
got to be able to see the endgame.
It's just like saving for a rainy day or saving for a long-term vacation, they're
going to be some sacrifices that this patient is going to be making it's going
to be a painful journey.
And what's the point if we don't see the light at the end of the tunnel?
If we don't know why we're doing what we're doing.
So I'm going to be able to take these life worth living goals and remind her of those
when times get hard.
I'm going to need to track those as if they change I'm going to need to show her
her progress along the way in getting closer to those and keep those in mind.
Yeah,
that's hard to think about which makes me wonder.
What is the end goal?
What's the end game for you?
What's your life worth living?
What will or what does make your life worth living?
Emily: I don't know anymore, like I thought it was him.
But I feel like before starting this treatment, I just feel him getting more
distant and I live with my mom.
Dr. Vaughn: So was getting out of your mom's house one of those life worth living
goals.
Emily: Yeah, she loves me so much and she cares for me so much, but it's so hard
like she's so mean to me when stop happens like if I'm having a panic attack.
Dr. Vaughn: Shift gears for me, shift gears for me for a second, because I want
to get a good picture of where you're going.
I think you're kind of going into what the problems are now and I've really got to
see the in picture.
I mean, when do you say get out of your mom's house are you thinking like you're
going to get your own apartment or moving in with your boyfriend?
What does that look like?
Emily: I mean I want to end up with my boyfriend.
I can't imagine my life without him, but I don't know if he wants to be with me.
Like really really wants to be with me.
Dr. Vaughn: Okay, so just imagine I want you to imagine do me a favor.
Just humor me.
So imagine what is this place look like that you live in is it small as big as
picket fence?
Emily: Honestly, we could live anywhere as long as we're together.
Dr. Vaughn: Oh, that's super nice.
Okay, so on and put y'all in a motor home and you're gonna drive around the whole
country
Emily: That's fine.
Okay.
Dr. Vaughn: So you like travel?
Emily: Yeah, I really like to travel more but you know everything okay, but don't
but it's okay.
Dr. Vaughn: So travel would be a thing.
What about animals, do you have dogs?
Do you have cats?
Emily: I have a dog
Dr. Vaughn: Do you like it?
Emily: Yeah, he's kind of lazy.
I would like him to be more active.
But I guess it's kind of nice when he's lazy because if I don't feel like leaving
the house that day it's fine.
Dr. Vaughn: So will your dog be with you in this imaginary scenario?
Emily: Oh, no, it's kind of my mom's dog is I'm living with her right now, but I'd
probably get my own.
Dr. Vaughn: Okay.
Do you have a type of dog that you would want?
Emily: I really like retired Greyhounds.
Dr. Vaughn: Nice, okay
Emily: Because it's like I gave him like another life.
Dr. Vaughn: Yeah.
Emily: Yeah, and they're really cuddly
Dr. Vaughn: They seem skinny like super skinny.
Emily: Yes, but they're so Dopey and cute and their personalities are great.
I like them.
Dr. Vaughn: All right, so I'm getting somewhat of a picture.
What about like job-wise or career?
Emily: I don't really know.
Dr. Vaughn: Are you going to be stay-at-home mom or like what is...
Emily: I don't know right now like I'm in college for history, but I don't know what
I'll do with it.
I just want to finish college.
Dr. Vaughn: Okay.
So life worth living is you got your college degree.
And then whether you do anything without or not is subject to the circumstances
Emily: Yeah, I mean, I would feel really guilty if I went to college and that
didn't work, but I don't know what I'll do if I just pick something I was interested
in and so.
Dr. Vaughn: During this assessment of the life worth living goals I'm using some
redirection and contingency management.
So the first instance is when I interrupt her and say "Shift gears for me" because
she starts to get off track.
You can tell that she starts to get in her head and I just interrupt and you know,
gently coach her back into what we were doing.
I do that also by looking really, really interested in her in her life.
So I want to know what her life worth living is and I'm so interested in it that
I'm willing to interrupt her and say "Come back on track, don't leave me now".
So that's using contingency management.
I don't want to reinforce this getting off track and jumping around topics.
I do it again when I say, "Okay, but don't but" so I'm starting to also introduce her
to the idea of you know, getting rid of the but and sticking with the topic at
hand to the end.
At one point she talks about , she has a dog and I say "Do you like it?"
I think that's important to point out because I'm using a little irreverence,
but I'm also not judging that.
I'm not imagining that I know how she feels or what she expects.
Just like when someone comes in and says " I'm getting a divorce" you don't say " Oh,
I'm so sorry."
You basically ask "Is that a good thing or a bad thing?"
I mean you have to ask how the person expects or wants you to respond because
depending on circumstances, of course, it could be a good thing or a bad thing.
She may not like the dog.
And in fact she responds in a sort of, you know apathetic way and she talks about
wanting a different breed of dogs.
So had I have jumped in with "Oh, that's so great.
You have a dog and how wonderful and now you go on about and live happily ever
after", well, that could be extremely invalidating.
So I want to make sure that I don't assume how she feels if I don't have the data on
that.
So I get her life worth living goals are to finish college, she wants to have a
retired Greyhound.
I'm not reading into a bunch of things.
There's a point where she says, "I like retired Greyhounds cuz it's like I gave
them another life".
A therapist
would really read into that.
"And what does it mean to you that you would give someone another life?"
Would you like to give yourself another life"
Let's just, be with the topic, and the topic is what's your life worth living
look like and on a practical level you want a greyhound, so great.
What else?
So I'm not going to read into everything.
I'm going to be real.
I'm not going to dig into all of the barriers.
She definitely says that she would feel guilty if she went to college and didn't
work.
There's all these layers of things that I could explore, but I'm just trying to
reinforce her generating ideas right now and she can always change her mind.
And in fact probably will but I'm helping her to also see a future beyond just today
and the pain that she may be in.