Unfortunately, premature termination of therapy is not at all uncommon in clients with emotion dysregulation. Linehan (1993a) notes a study by Parloff, Waskow, and Wolfe (1978) that demon-strated a link between the use of pretreatment orientation strategies and a reduction in therapy dropout rates. Given that the dropout rate for these clients tends to be high, the first several indi-vidual sessions in DBT focus on having the client and therapist make a decision as to whether they are willing and able to work together. In these early sessions, the therapist also helps the client modify any beliefs or expectations about therapy that might lead to a negative outcome in treat-ment, such as premature termination (Linehan, 1993a). In addition, the therapist works on com-pleting an assessment with the client, providing psychoeducation about the client’s diagnosis, and obtaining a commitment to therapy in general as well as to specific goals.
Stage 1: Attaining Basic Capacities
Once therapist and client have committed to working together, therapy enters stage 1, which focuses on behaviors that pose a direct threat to the client’s safety and stability (Swales & Heard, 2009). The goal in this stage is to reduce suicidal behaviors and thoughts, as well as other behaviors that are destabilizing, self-destructive, or otherwise unhealthy, and to address skills deficits (Linehan, 1993a).
As discussed in chapter 1, in traditional CBT a lot of time would be spent jumping from one crisis to the next, making it difficult for the therapist to find time to teach the skills the client needs for managing emotions. To address these issues in a productive way, DBT organizes the individual session in a methodical way that provides much-needed structure for clients with emotion dysregu-lation. This structure is provided by the client’s Behavior Tracking Sheet, which is a short-form way of journaling. There are different types of tracking sheets, and you can personalize them for spe-cific clients. I’ve included a copy of the one I use later in this section; feel free to photocopy it and use it in your practice. From this tracking sheet, behaviors are addressed in the following order (Linehan, 1993a):
1. Behaviors that interfere with life 2. Behaviors that interfere with therapy 3. Behaviors that interfere with quality of life
Linehan (1993a) notes that, with highly dysfunctional and suicidal clients, it may take over a year of therapy to reduce behaviors that interfere with life or interfere with therapy. However, she says that by the end of the first year of therapy, “patients should also have at least a working knowl-edge of and competence in the major behavioral skills taught in DBT” (p. 170). Keep in mind that having a working knowledge of the skills doesn’t mean clients can apply them to all of their problems!
BEHAVIORS THAT INTERFERE WITH LIFE
In individual sessions, the first items to be addressed are behaviors that interfere with life, in the following order:
1. Any suicidal behaviors
2. Nonsuicidal self-harming behaviors, such as cutting or burning 3. Intrusive suicidal or homicidal urges or communications 4. Suicidal ideation
When these kinds of behaviors occur outside of session, they become a priority for discussion in the next individual session. In DBT, the tool most commonly used to address these kinds of behaviors is the behavior analysis (BA). The BA helps therapist and client take an in-depth look at the variables that lead to a target behavior and cause the client to continue engaging in the problem behavior. I’ll discuss the BA in detail in chapter 3.
Linehan (1993a) notes that suicidal thoughts that are regularly or constantly present like back-ground noise are not always directly addressed in the individual session, as this could prevent therapist and client from working on other problem behaviors. The DBT assumption is that this type of suicidal thinking is related to the low quality of life that results from emotion dysregulation, so the focus on enhancing quality of life (which is the third target on the agenda) will address this problem.
BEHAVIORS THAT INTERFERE WITH THERAPY
The second topic to be addressed is behaviors that directly interfere with the client’s therapy in some way, in order from most destructive to least destructive. These behaviors can present in many different ways and may be engaged in by both client and therapist. Examples include the
Preparing for the Individual Session: What You Need to Know
31 client or therapist arriving late or canceling appointments, not being properly prepared for sessions (e.g., the client hasn’t completed her tracking sheet or the therapist hasn’t reviewed her notes to remind herself of what homework was assigned), taking phone calls during sessions, and so on.
These behaviors can also be more subtle, such as the therapist pushing the client too hard, invalidating the client, or reinforcing unhealthy behaviors in the client, or either the client or the therapist avoiding addressing difficult topics in session. Behaviors that interfere with therapy can also become more destructive (for example, the therapist not observing a limit with the client or the client threatening herself or the therapist in some way).
BEHAVIORS THAT INTERFERE WITH QUALITY OF LIFE
The final item on the agenda for individual sessions is addressing behaviors that interfere with the client’s quality of life. This could include comorbid mood, anxiety, or substance abuse disor-ders; inappropriate housing or financial difficulties; or lack of social support.
Because clients with emotion dysregulation usually have many of these additional problems in their lives, it’s important to decide which is the most important area to work on. Linehan’s guide-lines (1993a) are as follows: first, solve immediate problems, such as housing or getting into a reha-bilitation program; second, address problems that are more solvable and tackle the harder stuff later; and third, prioritize behaviors that are related to the two higher-order targets (behaviors that interfere with life, and those that interfere with therapy).
PUTTING IT ALL TOGETHER
To summarize the previous three sections and make the priority of treatment targets explicit, here’s a list of behaviors to address, from highest to lowest priority:
1. Suicidal behaviors and nonsuicidal self-harming behaviors 2. Behaviors that interfere with therapy
3. Suicidal ideation and “misery”
4. Maintaining treatment gains 5. Other goals the client identifies
As mentioned, I’ve included the Behavior Tracking Sheet I use. Take a look at this sheet, and then I’ll discuss a client example to help you understand how the agenda for an individual session would be set in DBT. Note that the client instructions refer to a handout listing emotions that clients can refer to if need be. You’ll find this handout in chapter 9. Feel free to photocopy the worksheet and handout for use in your practice.
BE H A V IO R T R A C K ING S H E ET
Name: Week of: Mon.Emotions How strong? 1-------5 1-------5 1-------5 1-------5Urges suicide self-harm
How strong? 1-------5 1-------5 1-------5 1-------5
Behaviors (number) suicide attempt self-harm Did you use a skill?Yes No If yes, which one(s)? Did it help? Yes No If you didn’t use one, why not? Tues.Emotions
How strong? 1-------5 1-------5 1-------5 1-------5
Urges suicide self-harm
How strong? 1-------5 1-------5 1-------5 1-------5
Behaviors (number) suicide attempt self-harm Did you use a skill?Yes No If yes, which one(s)? Did it help? Yes No If you didn’t use one, why not? Wed.Emotions
How strong? 1-------5 1-------5 1-------5 1-------5
Urges suicide self-harm
How strong? 1-------5 1-------5 1-------5 1-------5 Behaviors (number) suicide attempt self-harm Did you use a skill?Yes No If yes, which one(s)? Did it help? Yes No If you didn’t use one, why not?
Preparing for the Individual Session: What You Need to Know
33
Thurs.Emotions How strong? 1-------5 1-------5 1-------5 1-------5
Urges suicide self-harm
How strong? 1-------5 1-------5 1-------5 1-------5
Behaviors (number) suicide attempt self-harm Did you use a skill?Yes No If yes, which one(s)? Did it help? Yes No If you didn’t use one, why not? Fri.Emotions
How strong? 1-------5 1-------5 1-------5 1-------5
Urges suicide self-harm
How strong? 1-------5 1-------5 1-------5 1-------5
Behaviors (number) suicide attempt self-harm Did you use a skill?Yes No If yes, which one(s)? Did it help? Yes No If you didn’t use one, why not? Sat.Emotions
How strong? 1-------5 1-------5 1-------5 1-------5
Urges suicide self-harm
How strong? 1-------5 1-------5 1-------5 1-------5
Behaviors (number) suicide attempt self-harm Did you use a skill?Yes No If yes, which one(s)? Did it help? Yes No If you didn’t use one, why not? Sun.Emotions
How strong? 1-------5 1-------5 1-------5 1-------5
Urges suicide self-harm
How strong? 1-------5 1-------5 1-------5 1-------5 Behaviors (number) suicide attempt self-harm Did you use a skill?Yes No If yes, which one(s)? Did it help? Yes No If you didn’t use one, why not?