Carmen’s case example will help demonstrate how to set the agenda for an individual session.
Carmen, a twenty-year-old woman, was referred by her probation officer. She had a diagnosis of depression and general anxiety disorder with panic attacks and had been using illegal drugs over the last two years. She probably also had symptoms of PTSD from different events that had occurred since she started using drugs. Carmen had been living with her boyfriend, who was also a drug user, and a fight between them led to Carmen being charged with assault. She was sen-tenced to two years of probation and wasn’t allowed to return to her boyfriend’s apartment. When we began working together, Carmen was living in a women’s shelter and was on social assistance.
Carmen regularly experienced thoughts of suicide but had never made an attempt and repeat-edly told me that she didn’t want to die. However, she had a history of self-harm. The first time she met with me, she informed me that it had been about eight months since she had cut herself. She had also reduced her drug use but was still using crack once or twice a month. This often led to having sexual relations with strangers, sometimes two or three different men in one night, without using protection. She regularly drank alcohol, at least three or four times weekly, and was aware that her drinking often led to urges to use crack, but she was ambivalent about stopping or even reducing her alcohol use.
Carmen had been seeing a psychiatrist since she was about fifteen and told me that she took her medication regularly but her anxiety continued to be a problem. She was having panic attacks regularly at the time of assessment and found that drinking often helped her feel calmer and also helped with her low self-esteem and feelings of worthlessness. Carmen reported that she didn’t really have friends, although she did go to a bar with a group of guys about twice a week.
In our eighth session, Carmen arrived at my office almost ten minutes late and gave me her Behavior Tracking Sheet. The tracking sheet indicated that she hadn’t made any suicide attempts, but her suicidal thoughts had increased from a 2 to a 4, and her self-harm urges had increased from a 3 to a 4 since our previous session. Her drinking had remained the same, and she had used crack once during the last week. Based on all of this information from the tracking sheet, here’s how I structured this session with Carmen (note that this doesn’t include an in-depth discussion of how these behaviors were addressed):
1. Behaviors that interfere with life: Because Carmen didn’t record any suicidal behav-iors, we first looked at her suicidal thoughts. Because those thoughts had increased recently, we needed to check this out, which we did with a behavior analysis. Next, we looked at the increase in self-harm urges. We didn’t need to do a full BA here, as the reasons for the increase were the same as for the increase in suicidal thoughts.
2. Behaviors that interfere with therapy: Carmen was ten minutes late for her session, which interfered with her ability to get the most out of therapy, so we addressed this next.
Preparing for the Individual Session: What You Need to Know
37 3. Behaviors that interfere with quality of life: First, Carmen was still in temporary
housing (an immediate problem), so we needed to work on getting her housing situa-tion stabilized to ensure she could remain in therapy. Second, we had previously identi-fied that her drug use almost always led to an increase in suicidal thoughts and also led to engaging in other self-destructive behaviors, such as having unsafe sex with strang-ers, which was a threat to her health, so we looked at her drug use next. If there had been more time in the session, we would probably have looked at Carmen’s anxiety next, as it seemed to be at least one of the reasons she ended up drinking. Since Carmen hadn’t identified reducing her alcohol use as a goal, this didn’t go on the agenda.
However, this came up in future sessions; I continued to point out how drinking was interfering with her quality of life and how it was connected to her drug use and other problems.
Of course, skills training is interwoven throughout this process, so we weren’t simply analyzing the behavior without trying to do anything about it.
Once target behaviors are under control, clients are ready to move on to the second stage of therapy. As noted earlier, the focus of this book is on stage 1, so the discussion of the remaining stages will be brief.
Stage 2: Reducing Post-traumatic Stress
DBT doesn’t focus on PTSD symptoms until clients have the necessary skills. When clients are regularly engaging in or experiencing urges to engage in suicide, self-harm, substance use, and other self-destructive behaviors, not only are they not ready, it’s actually unsafe to do this kind of work. Of course, as Linehan (1993a) notes, that doesn’t mean the client’s trauma history is ignored during stage 1. If the client brings up these issues in session, the therapist validates the pain and suffering the client has experienced, but the focus remains on the present—how the trauma is probably contributing to problem behaviors and the skills the client can use to help reduce these behaviors.
In stage 2 this changes. The trauma becomes the focus and exposure therapy is used to emo-tionally process past traumas. Swales and Heard (2009) note that, because not all clients have a history of trauma, stage 2 may also focus on negative relationship experiences related to the client’s emotion dysregulation and subsequent lack of interpersonal skills. While these might not be desta-bilizing experiences, they can nonetheless contribute to ongoing pain and problem behaviors if left unresolved.
Stage 3: Increasing Self-Respect and Achieving Individual Goals
In stage 3, the goal becomes helping clients work on trusting, valuing, and respecting them-selves, as well as continuing to work on generalizing the skills they’ve learned in therapy to the rest of life. Linehan (1993a) points out that it’s not unusual for clients to move between stages in a nonlinear way; for example, moving from stage 1 to stage 2, back to stage 1, then jumping to stage 3, and so on. She also emphasizes the importance of taking breaks when needed; for example, before moving from the relative stability of having completed stage 1 work to beginning the trauma work in stage 2.
WRAPPING UP
This chapter has covered what you need to know to get started using DBT in individual sessions:
the DBT assumptions about clients, guidelines for observing limits, and consultation to the patient, all of which help reduce therapist burnout and increase motivation to work with the client. This chapter also examined the structure of therapy as embedded within the stages of treatment for borderline personality disorder. In the next chapter, you’ll learn the basic concepts of behavior theory you need to know to effectively provide DBT to clients. I’ll also provide a detailed discus-sion of the behavior analysis, which is used to do an in-depth analysis of a problem behavior.