This feature by Donna Pattie, MSW, LICSW is Part 2 of 2 in a series about treatment strategies to help clients build the lives they want. In part one, Donna addressed the dialectical lens she uses with clients starting in session one, as well as a framework to help therapists and clients see the spectrum from misery and suffering to envisioning the life they want. Here in part two, she will explore linking DBT treatment strategies to client goals.
Research shows that people do not maintain steady states of commitment to behavior change. Rather, we commit and do the old behavior anyway, and then must recommit. Dialectics teaches us that everything is in constant change. DBT strategies serve to help clients change in the direction of skillful behaviors. The DBT assumption, “Clients need to do better, try harder and be more motivated to change,” rings true as we are paving the path to build this new life. The path is neither straight nor easy and requires the dialectical dance of acceptance and change strategies.
Commitment strategies are tools to be used in all aspects of treatment, to get and maintain commitment to DBT, and to support clients in building their lives. While it is important to develop these strategies in your own words, here are some statements and questions that I have found helpful.
Pros and Cons
Collaboratively look at what are the upsides and downsides to treatment, target behaviors, and skill use. “What are the benefits of acting on self-harm? What are the downsides?”
Devil’s Advocate
Lightly argue against a course of action once a person makes a commitment in an effective direction. Through the natural perspective of dialectics, the person starts arguing stronger for their perspective. “Are you sure you’re up for this treatment? It’s a lot.”
Foot in Door
Ask for a small commitment and link it to a lot. “What if I told you that you can have peace in your life if you use DBT skills and stop cutting. Would you be willing to stop for a month? Two months? A year?”
Door in Face
Start out asking for a lot, then ask for a lesser commitment that is easier to say yes to. “I can see cutting is ruining your life. Why don’t you just give it up for life? I can see that’s a lot. How about you just commit for the year?”
Connecting Present to Prior Commitments
“Have you ever done anything hard before and really succeeded? DBT will feel hard, and you have already done some hard things.”
Freedom to Choose and Absence of Alternatives
“It’s your choice. You can do that and what will your life look like?”
Generating Hope / Cheerleading
“This treatment really works for what you have. I have worked with lots of people who struggle like you and get better.”
Shaping
Reinforcing small steps toward effective behavior. “Just coming here today is taking a step to change your life.”
Remember that commitment strategies are designed to be integrated into all modes and components of DBT treatment.
Linking Specific Behaviors to Goals
“So how do you think being less suicidal will help your relationship with your partner?”
Diary Card Development
“How are each of these target behaviors getting in the way of you having peace, financial stability, housing, etc.?”
Diary Card Review
“I really appreciate how hard you worked on your skills. Do you think this is getting you one step closer to feeling more competent?”
Missing Links
“I know we keep talking about you wanting financial stability. Is that still the case? Let’s look at what might be getting in the way of paying your bills with a missing link.”
Behavior Chains
“Is this a behavior that is getting in the way of your goals? Do you still want ______? Let’s dig in and find some solutions to get you that life you want.”
Exposure
“The only way you will start to feel competent is for you to go out and try these skills in different situations. We need you to get new learning that you can approach hard situations and rely on your skills.”
Homework Completion
“I know homework is hard. The only way you are going to feel more competent is to practice these skills outside of sessions.”
Validation
“This is so hard. One step at a time.”
Shaping / Reinforcers
“What is one step you can take towards skills? What would be a reward?”
These strategies can help clients stay focused on their vision of the life they desire, giving them the drive they need to do the hard work of DBT. A recent graduate shared, “I am finally able to see what I want in life. I’m using my skills, going back to college, and getting a job. I learned that I could regulate my emotions with skills through exposure. When I first started, I couldn’t see this was possible. I fought it at every turn, ask Donna. She stuck with me when no one else would. For the first time in my life, I am proud of myself.” This brought tears to my eyes as you can imagine. There were many days on this journey that I didn’t think either of us were going to make it. It took every DBT strategy to help this client build the life she wanted. We both kept our eyes on the prize, and it worked!
For more on DBT skills, check out this blog on the role of experiential learning in DBT skills training.
Donna Pattie, MSW, LICSW is the DBT Trainer and Consultant for 15 DBT outpatient teams at Nystrom & Associates, Ltd across the state of MN. Donna is a Linehan Board Certified DBT therapist and DBT Team Lead in New Brighton, MN for a Linehan Board Program Certified Team. Read her full bio here.
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