by: Kira Yanko, MS, LPC | Northwest Passage III Therapist
Don’t Have a Cow?!
For therapists like me, thankfully DBT is highly structured. There are times in every clinician’s work that we are challenged and these difficulties lead to self doubt. In addition to hashing this out through consultation, DBT’s stages and targets allow for grounding and focus in session. They provide a framework to approach clients and guide treatment. This is especially important when working with clients who are emotionally dysregulated because often they will enter session with a new “COW” (Crisis Of the Week) that they would like to discuss. Often these are chaotic and crisis ridden problems that are loosely related to the overall goals of treatment. As such, it would be easy to spend each week addressing these COWs and never get to the gestalt, to the greater pattern of underlying distress, and the need to build a live worth living. Avoiding COWs is a term I heard in a training several years back. In my own practice, I tend to refer to these as “shiny objects” because it is easy to become super distracted by them in session. The stages and targets of DBT help provide a framework to make COWs or “shiny objects” less clinically alluring. They also offer guidance to what problems areas and issues should be addressed when – something that can be of use even outside of the therapy office.
DBT moves in stages, each with their own specific goals. In the first stage, the focus is helping the client move from an out of control to in control life behaviorally. The aim of this is very basic: to ensure normal life expectancy. Within this stage, the first goal addresses problem areas that could lead to the client’s death. It is impossible to engage in therapy with a client who has not succeeded in this area due to suicidal behaviors or self harming actions. (It always feels morbid and a little harsh speaking about this but it is a reality that Marsha is very firm on.) The next goal in this area is to address issues that could lead to premature termination of treatment or therapy interfering behaviors. If a client drops out of therapy the potential for progress ends. If a client never completes homework, regularly goes off topic, misses sessions repeatedly, or is disruptive in group these would be considered interfering with therapy. While it’s certainly a step better than not attending at all, it also makes it very difficult to gain any value from the session. Finally within the first stage, a client focuses on the acquisition of new skills and behaviors to decrease the use of actions that are destroying their quality of life. Traditionally this would occur in group by learning DBT skills. Individual therapy would then target a client’s use, misuse, or lack of use of these skills.
Beyond the walls of the therapy session, this hierarchical framework can help shape any interactions with a client who is emotionally dysregulated. No matter what COW or shiny object is brought to the table, issues are always addressed and treated the same way: first issues endangering physical life, then issues negatively affecting participation in treatment, and then the acquisition of new skills to manage underlying distress. If we use this framework then we are able to respond with greater neutrality to clients, not providing any unintentional secondary positive reinforcement for maladaptive behaviors. Additionally, the application of this structure can decrease feelings of being emotionally overwhelmed when initially presented with a multitude of new crises each meeting. As we respond with decreased emotional arousal, we model effective emotional regulation and provide an anchor to our clients.
Stage two moves the client from “quiet desperation to full emotional experiencing.” According to Behavioral Tech, this is the stage in which Posttraumatic Stress Disorder would be treated. Stage three helps clients to live a life with the regular ups and downs we all experience. The fourth and final stage helps clients reach spiritual fulfillment. Unfortunately for me, I generally never get to any phases beyond the first (sometimes a tiny bit into phase two) because by the time a client is able to maintain physical safety, regularly and effectively participate in treatment, and has learned a strong, new adaptive skills base then they are also able to return to the community to continue their treatment.
Wrap it Up Kira…
Most focus when speaking about DBT centers around the skills. Use of Distress Tolerance, Mindfulness, Interpersonal Effectiveness, and Emotion Regulation are certainly techniques that can help any human to more effectively and joyfully exist. Often, however, the other components of DBT that are just as applicable to everyday life live in the shadows of these all-star skills. In working with emotionally dysregulated clients whose daily lives are often filled with highs and lows and push-pull interactions, employing the core tenets of DBT is not only useful but vital for remaining grounded and effective. Creating strong therapeutic relationships through the articulation of both validation and encouragement for change, resisting compassion fatigue through mandatory self-care and consultation, and maintaining balance and focus by following the hierarchy of the first stage of treatment can all serve to assist in helping our clients find their self worth and inner confidence to take control of their lives.