The targets and goals of DBT differ for each
stage of treatment but the overarching goal
in DBT is to help the patient create their
life worth living.
This goes along with the idea that patients’
lives are unbearable as they’re currently
being lived.
And it is the therapist’s job to help them
develop their life worth living rather than
ending life or simply bearing the unbearable
existence that they have.
As Linehan says, the therapist’s job is
to help the patient find a way out of hell.
She often describes the experience of patients
first coming in to DBT as that of being in
hell and having only a metal ladder to stretch
out beyond hell and the therapist is there
to help coax the patient onto the hot ladder
and out of the hell that they’re in.
The problem with helping someone get out of
a hot place using a metal ladder is obvious.
As the patient starts to climb out using his
or her skills, it is not uncommon for them
to slide back down due to the pain involved
in using the skills themselves.
In addition, assessment in the beginning of
“What does the patient view as being a life
worth living?” in and of itself, that exploration
can be dysregulating.
At the outset of treatment, patients may only
be able to list one or two things that they
would like to have present in a life that
they could see themselves living in, for example,
a house of their own, a job or a small white cat.
In stage 1 which is the most frequently discussed
and studied DBT stage, we are looking at eliminating
life-threatening behavior, reducing and potentially
eliminating therapy-interfering behavior and
reducing what is referred to as quality of
life interfering behavior.
So life-threatening behavior would be things
like suicide attempts, suicidal thoughts and
urges and any kind of behaviors that are absolutely
associated with suicide, anything that would
make it more likely that the patient would
be at risk for dying or substantial harm to
themselves.
It is important to differentiate between life-threatening
behavior and quality of life interfering behavior.
And sometimes, that can be difficult for therapists
to determine.
Quality of life interfering behaviors would
be things like substance abuse, impulsive
sexual behavior, impulsive spending, being
jobless, being homeless and other very difficult
but not life-threatening behaviors such as
eating disorders.
It is not uncommon for a new DBT therapist
to accidentally label a quality of life interfering
behavior as a life-threatening one.
The key to determining what is a life-threatening
behavior is to ask the question “Is the
behavior that the patient is engaging in imminently
a risk to their lives?”
So in the case of substance abuse or eating
disorders, we would characterize them as life
threatening if they were in fact imminently
life threatening today.
So for example, smoking or drug use would
not be considered an imminent life-threatening
behavior although it does potentially risk
the patient’s life in the long term.
So we want to eliminate life-threatening behaviors.
Self-harm is also subsumed under this category
because of the risk that the patient has to
accidentally harming themselves to the point
that their life is at risk.
In addition, the correlation between self-harm
and completed suicide is significant.
So beyond life-threatening behavior, we want
to reduce therapy-interfering behaviors.
And there is a variety of therapy-interfering
behaviors that we can work on.
Some are behaviors which literally interfere
with the process of therapy, for example,
missing therapy sessions or arriving late
to therapy sessions.
Those would literally interfere with receiving therapy.
We want to also work on behaviors which increase
the risk that the patient is either going
to drop out or be terminated from therapy.
And that may be arriving late.
It may also be things which literally interfere
with therapy such as arriving late but can
also include interpersonal styles of the patient
which interfere with the therapist’s willingness
to treat them.
It can also be behaviors such as failure to
bring homework or follow through on other
treatment recommendations that the therapist
finds extremely important or concludes to
be extremely important.
Therapy-interfering behaviors would also include
any issues with intersession contact such
as a patient calling too frequently or pushing
or challenging the therapists limits
Our third set of behaviors is the quality
of life interfering behaviors that were mentioned
earlier.
And we are not looking at completely eliminating
quality of life interfering behaviors but
we are looking at reducing.
In stage 1, we are also looking at increasing skills.
So not only are we trying to reduce things
but we’re also trying to increase things
as well.
And in group, this is where it happens that
the patient gets a psychoeducational experience
and skills.
So they are going to be learning how to self-validate,
how to communicate effectively, ways in which
they can regulate their emotions and how they
can tolerate distress.
In addition, they will be learning the formal
practice of mindfulness.
So the skills that they’re learning in group
are reinforced by the individual therapist
both in individual sessions and in intersession contact.
Another of the goals of DBT is to keep the
patient in the environment that they are in
rather than to create a false environment.
Sending a patient to a residential facility
or hospitalizing them would be an example
of an environment that was not a natural one.
So we want to try to help them use these skills
in the environment that they are in rather
than withdrawing them and putting them in
a structured environment that does not exist
in the outside world.
That being said, it is also not uncommon for
DBT patients to go to the hospital.
It’s just important to recognize that that
is not always a recommendation when a patient
is suicidal.
Another goal of DBT is to help the patient
stay motivated.
So it is the role of the individual therapist
particularly in the beginning and at various
periods throughout treatment to help motivate
the patient and cheerlead him or her in to
staying with the skills and to keep going.
So again, if we go back to the ladder analogy,
the therapist would coax, cheerlead, cheer
for and remind the patient why it is so important
despite how difficult it is to climb out of
hell using a hot metal ladder, how important
it is to keep going because the only alternative
is to continue staying on in the unbearable
environment that they are in.
Key points.
The key points to video 7 include:
DBT’s main goal is to help patients create a life
worth living.
There are three targets for an individual
DBT therapist in stage 1: To eliminate life-threatening
behavior, reduce therapy-interfering behavior
and reduce quality of life interfering behavior.
Life-threatening behavior includes suicidal
thoughts, urges and attempts as well as self-harm.
A behavior is life threatening if it imminently
threatens a patient’s life.
Therapy-interfering behavior is anything that
gets in the way of the patient receiving therapy
or makes it more likely treatment will end
prior to completion.
Examples of therapy-interfering behavior include
missing sessions, not completing homework,
calling a therapist too frequently and arriving
late for session.
Quality of life interfering behaviors are
anything which interferes with the patient
creating their life worth living.
Examples of quality of life interfering behavior
include substance abuse, impulsive sexual
behavior, impulsive spending and eating disorder
behavior.