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terms of normative functioning (level 5). Considered the highest level of validation (level 6) the therapist is radically genuine with the client, responding to her as an equal. Clients (and therapists) often view the client’s behaviors as “invalid,” weak, or bad. Validation requires the therapist to search for the validity in any client perception, feeling, or response, thereby acknowledging the inherent effectiveness of these reactions whenever possible and, more importantly, teaching the client to self-validate (Koerner & Dimeff, 2007). A client who punches a hole in the wall because she is angry could be validated in that the physical pain she experienced provided an immediate decrease in her emotional pain (so it makes sense that she hurt herself in the context of trying to decrease her emotional pain), but at the same time, injuring herself isn’t valid in that it isn’t a normative response and goes against her goal of coping in more effective ways. The case example at the end of the chapter provides an example of how the six levels of validation play out during therapy sessions.
s t a g e s o f d b t
DBT treatment is structured in stages that are behaviorally defined and have specific behavioral goals. Clients exhibiting the most severe symptoms of BPD require stage one treatment. In this stage, the goal is for the client to stabilize and achieve behavioral control. Target achievements in this stage include decreasing life-threatening behaviors (suicidal thoughts, suicidal behaviors, and self-harm such as “cutting”); decreasing therapy-interfering behaviors (such as quitting therapy, not doing homework, and not taking medications as prescribed); decreasing behaviors that interfere with quality-of-life (such as anger outbursts, missing work, sexual promiscuity); and increasing behavioral skills that can replace ineffective coping skills. DBT behavioral skills are typically taught through “skills groups” that provide detailed instruction on mindfulness, distress tolerance, emotion regulation, and interpersonal skills.
Stage two treatment commences when clients are no longer engaged in life-threatening behaviors. It focuses on replacing the experience of “quiet desperation” with full emotional experiencing. At this stage, posttraumatic stress disorder (PTSD) can be addressed since clients’ behaviors are under better control and they have also increased their behavioral skills. Traditional exposure work may be used as well.
Stage three treatment focuses on obtaining “ordinary” happiness and unhappiness and reducing ongoing problems with living. Clients who want more than ordinary happiness—they want a sense of connectedness to a greater whole—benefit from stage four treatment. The goal in this stage is to work on finding joy and freedom. The stage also focuses on resolving any sense of incompleteness.
c o m p o n e n t s o f d b t t r e a t m e n t
A comprehensive DBT program includes five components: (a) individual therapy; (b) skills training group therapy; (c) a consultation team for DBT therapists; (d) between-therapy coaching calls when indicated; and (e) supplemental services as needed (e.g., pharmacotherapy, case management). Individual therapy is typically offered on a weekly basis. Individual therapists help clients move through the stages of change described earlier. Therapists balance acceptance (validation) with encouragement toward change throughout DBT therapy. They motivate the client, reinforce skillful behaviors, and help extinguish unskillful behaviors and unhealthy behaviors. Clients may have been reinforced in the past for being symptomatic. Unfortunately, the mental health service system often withdraws support as clients get better. The opposite is often also true; as clients decompensate, support increases. This can be very problematic for clients who are not skilled at getting their needs met other than through dramatic and extreme measures.
For example, consider a client with poor coping skills and poor emotional regulation who says he wants to kill himself. His life may indeed be so miserable that he thinks he is better off dead. He may also have learned that in order to get people in his life to take him seriously, he needs to express his pain very loudly. His environment has reinforced his need to be “loud” in order to get support, attention, or help in solving his problems. Feeling suicidal is not the central problem; rather, the problem is poor coping skills and the lack of problem solving skills which leaves suicide as an attractive possibility.
Therapists use “behavioral chain analysis” to help clients understand any problematic behaviors they wish to target for change (e.g., suicidal ideation, “cutting,” suicide attempts, “blowing-up,” etc.). Behavioral chain analysis defines the problem behavior and spotlights its antecedents and consequences (both behavioral and environmental). The goal of behavioral chain analysis is to create a relatively complete account of what happens before, during, and after the problem behavior. As client and therapist create the chain analysis, dysfunctional responses can be highlighted, emotions/thoughts are noted, and patterns can be discovered that relate to other problem behaviors for the client. Client and therapist together look for places in the chain where skillful behavior was used, as well as what skills need to be used next time to avert engaging in the problem behavior. Client and therapist may also find that other changes need to be made, such as working on cognitive restructuring, exposure to emotions, or managing contingencies (consequences). In the example of the suicidal individual, a behavioral chain analysis may show that when the client states he’s going to kill himself, his girlfriend drops everything and attends to him. In this case, in order to extinguish this behavior, the client might focus on contingency management and ask his girlfriend not to attend to him the next time he says this (or they may come up with another plan, such as the client contacting his therapist for skills coaching or going to the emergency room if he truly is at risk of harming himself). The client then works on getting his need for his girlfriend’s support in other ways (possibly by using his interpersonal skills).
Skills training groups are 90–120 minutes in length and occur weekly. Skills groups are more like classes than a therapeutic process-type group. Skills training has several distinct components or modules. Mindfulness skills help clients observe and describe their thoughts and feelings in a nonjudgmental way. The significance of mindfulness is that if clients can’t get control of their attention, it will be difficult to apply the other DBT skills. Distress tolerance helps clients learn to cope with problematic emotions and events without making their situation worse. These skills can be likened to a lifeboat—for use in emergencies but not for coping in the long-term. Emotion regulation skills help clients learn how to change emotions they wish to change. Interpersonal skills help clients become more assertive or more accepting of help through the application of social skills. Clients also learn how to say no to unreasonable requests and ask for help in skillful ways.