DBT Principles and Difficult-To-Treat Clients

DBT Principles and Difficult-To-Treat Clients

Expert DBT trainer Ronda Reitz shows how the principles of DBT can be used to develop new ways to respond to difficult-to-treat clients.

What are some ways to activate the WISE mind or grounding when the client goes into a mode that makes it hard for her to hear anything else (stuck in her thoughts).

Thank you for posing this question - it is such a tough spot in therapy for everyone involved!

Our first job in this common situation is to notice what we are bringing to the transaction with the client. For therapists, it can be difficult to remain "curious" enough to do a good assessment. When feeling blocked, we sometimes charge forward with change, leaping to assumptions about the client's intent and... we begin to polarize. This can be despite our best intentions--in fact, our good intentions may be a part of the problem! Our body language, facial expression, voice tone and words may convey to the client that they are a "problem to be solved", rather than a collaborator in solving a problem.

Carefully observe your own response to the client. What do you notice in your body, your emotions, and in your thoughts? Take a couple of deep breaths and just notice any places of hardness, heat and tension. Sometimes I notice a small stone of willfulness in the center of my chest and particular areas of muscle tension in these situations. My team has worked with me enough that I can usually sense what I am conveying with my facial expression, posture, and voice. What are your cues? If you notice muscle tension, impatience/frustration, urgency, etc, try to bring a relaxed sense of curiosity to these experiences. Practice some opposite to emotion action. Relax the hard areas of your body, slow your breath, half-smile. Your team can help you identify any primary emotions that may be occurring, and do a solution analysis to help you reduce any therapist-therapy interfering behavior.

For therapists well practiced in mindful self-reflection and who have spent time in addressing internal barriers to treatment, this can be a rapid process. Once your are in proximity to your own wise mind, you can begin to assess the client. This is a direct and collaborative process as you describe the observable behaviors that you have noticed and ask them questions about what they are experiencing. It is a behavior chain and solution analysis of what is happening in session. Page 495 in the 1993 LInehan book, Cognitive Behavioral Treatment of Borderline Personality Disorder provides an overview of the assessment and treatment of therapy interfering behaviors.

The process of behavior chain analysis is a terrific beginning in helping a client access wise mind. A curious use of mindful observing and describing often serves to reduce emotion mind without any additional intervention. Using a matter-of-fact, non-judgmental approach, we take the client through the same process we use with ourselves to describe physical sensations, emotions, and thoughts. Reflecting on their life worth living goals, we can then ask them to do something as simple as "Breathing in, say 'wise', breathing out 'mind'. If there's a particular action they are trying to find in order to be effective in the moment, allow them some time to breathe and see what answer arises without forcing an answer. When clients are more practiced in wise mind, you can elicit it by asking, "What does wise mind say about this?"

Hi Ronda, I work with ACT mainly but would like to introduce some DBT skills especially to clients with trauma. Which would be the first / most compatible with ACT skills you would recommend including? Thanks!

While ACT and DBT are often used to optimize each other, one caveat I feel compelled to make before digging into the question is this: when two or more empirically based treatments are combined, we may no longer have an empirically based treatment. I'm unaware of any studies that have directly investigated outcomes when ACT and DBT are combined in any systematic way. Thus, in the interest of informed consent for our clients, it's important to be mindful when making decisions about how much to amend your primary intervention with elements of other treatments, if you are interested in maintaining fidelity to a particular model.

The next consideration when turning to the selection of specific DBT Skills is the presentation of the client. Some clients come to us in significant crisis arising from recent trauma, chronically high crisis arising from historical trauma, and too often, some of both. When crisis behaviors include impulsive or dangerous behaviors, I would recommend implementing a full course of DBT prior to doing any direct exposure work with the traumatic material. This does not preclude immediate intervention when symptoms of trauma are acute, as this is a common focus of DBT, especially early in treatment or when traumatic events occur during treatment. However, the general approach is to build a foundation of skills that help the client regulate enough to stay safe throughout the often emotionally intense process of exposure to traumatic material. Two relatively new DBT models of intervention are DBT-PE developed by Melanie Harned and DBT-PTSD developed by Martin Bohus. These interventions show benefit in combining DBT with prolonged exposure prior to the completion of a full course of comprehensive DBT.

When clients present with less acute dysregulation, such that they can learn and transfer information between sessions, pose limited danger of loss of life, and can largely maintain awareness of goals, then DBT skills may be a helpful adjunct to a variety of other treatments. Future research will be required to confirm this with certainty--and I hope you will collect data and share your outcomes if you do this!

Given that both ACT and DBT take into account experiential avoidance as a key symptom of interest, for clients who present prominently with this issue, it may be important to begin with a focus on the Core Mindfulness skills, combined with the Crisis Survival Skills of the Distress Tolerance unit. An example of a client for whom this approach might be helpful is one who uses substances to block or reduce the impact of emotional intensity. Crisis Survival skills, which are relatively self-explanatory and brief to use offer the client concrete actions they can take in the face of acute crisis to decrease both emotional arousal (quickly) and the likelihood of acting in such a way as to compound the crisis (e.g., drinking). These skills offer a quick way to give clients a feeling of competence in managing their most troubling urges and behaviors. Thus, I often give such clients the handouts covering these skills during a first session or two and briefly review their use in the face of urges to engage in experiential avoidance, in this example, substance abuse. This group of skills offers both direct interventions to reduce the intensity of arousal (e.g., intense exercise, breathing, and use of cold water to elicit the "mammalian diving response") and distraction (incompatible activities, or self-soothing strategies). Crisis Survival skills allow the client to practice doing something incompatible with escalating into their problem behavior.

Mindfulness skills were designed to build the capacity of clients to remain in the presence of their own internally arising cues (i.e., emotions, sensations, thoughts) for longer periods of time and with decreased sympathetic arousal. Building client competence in Core Mindfulness skills generally takes longer than with the Crisis Survival skills, thus it's important to begin teaching them early in treatment. It is wonderful to help clients who have been conditioned to fear/invalidate/suppress their own internal experience learn to pause before acting to banish that experience, sit in the presence of their sensations, emotions, and/or thoughts, and begin to trust themselves for internal direction.

Of course, the Emotion Regulation and Interpersonal Effectiveness skills modules offer helpful skills for this type of client as well, and may be a good starting point for some. However, for most clients we tend to begin with skills focused on tolerating pain without acting impulsively to escape it (Crisis Survival) and those skills that help clients learn to understand and navigate their own internal landscape (Core Mindfulness).

Hi - wondering about fidelity to the model when using skills training in adolescents? we currently run a 16 week skills class in the schools, train school staff in the skills so they can utilize in the front lines of the schools. We are often faced with in consult how much to adhere as its not BPD

It is wonderful to hear that you are working in schools with DBT! You can provide DBT to fidelity with diverse clinical groups. DBT has been shown to benefit individuals with a broad range of diagnoses. Shorter applications of DBT (e.g. 16 weeks) has studied in clinical populations of adolescents

While we have strong evidence that a comprehensive DBT model is effective with adolescents in an outpatient clinical setting, little work has been done focusing on DBT applications with adolescents in non-clinical settings until recently.

Informal adaptations of the DBT model have proliferated in school settings. Students identified as having social-emotional issues by the school have most often been the recipients of these adaptations. The programs range from comprehensive DBT provided in the school (with individual, skills group, skills coaching, and consultation team being held on campus) to groups of select students receiving a subset of skills. Preliminary research and descriptive studies have shown some promise for these types of interventions (e.g., https://www.tandfonline.com/doi/abs/10.1080/01933922.2013.834402), however, many of these programs have not been evaluated for effectiveness.

You may be familiar with the work of Dr. James J. Mazza and Dr. Elizabeth Dexter-Mazza who have developed a program called DBT-STEPS-A. Their book DBT Skills in Schools: Skills Training for Emotional Problem Solving for Adolescents (STEPS-A) was co-written by Alec Miller, PsyD, Jill Rathus, PhD, and Heather E. Murphy, PhD. and was published in 2016. STEPS-A is the only formal adaptation to DBT for use in schools that has been published and has undergone evaluative research. It was designed to be taught by school personnel during the course of the school day and school year. It can be applied flexibly to students across the range of psycho-social adjustment.

"DBT STEPS-A is not a therapy program. Rather it is a skills training component of DBT modified for students of middle and high school age, to be delivered as a universal social-emotional learning curriculum." (pg 4 of the text).

This model is undergoing rigorous research internationally and has shown promising results (decrease is office referrals, suspensions, and out of classroom time for discipline, etc). You can learn more about this model at https://www.dbtinschools.com/ and the Dr. Mazza-Dexter welcomes inquiries at lizz@dbtinschools.com.

I have a client eager for skills in managing outburst - we've been working for a couple years on this pattern of feeling hijacked by envy and acting out, desperate for attention from others, followed up subsequent shame and remorse. where is a good place to start?

The word "hijacked" certainly describes the feeling many of our clients have in the face of powerful emotions--swept up without warning and too far into the intensity to make effective decisions before they know what has happened. This is the point at which many of our clients engage in behaviors that make their lives immeasurably worse. In DBT we quicky offer such clients the Crisis Survival Skills--a part of the Distress Tolerance unit in Marsha Linehan's Skills Training Manual. These skills are designed to help a client quickly regulate an out of control nervous system, and get back to their lives. The approach employs a variety of strategies to help the brain shift focus using such things as cold water, intense exercise, breathing strategies, distraction, and self-soothing activities.

These skills are primarily for use during the intensity of crisis. Once the body is regulated in the short term, other skills are brought to bear that serve to reduce emotional dysregulation in the long-run. Core mindfulness skills are taught throughout treatment in small but consistent doses. These skills build a greater capacity for self-awareness and the ability to create a calmer emotional baseline. The emotion regulation unit teaches skills aimed to directly reduce episodic emotional intensity by reducing vulnerability to emotion (self-care and routine), critically evaluating the thoughts and situations driving emotion, problem solving and knowing when to act opposite to emotional urges. The reality acceptance portion of the distress tolerance unit helps clients learn how to accept life on it own terms when it can not be changed. The interpersonal effectiveness unit is a values-based decision making model that brings logic into intense relationship issues and helps clients make strong long-term decisions, when they might otherwise act on impulse.

In short, all of the skills will ultimately help a client like the one you describe but you are likely to offer relief the fastest with the crisis survival and mindfulness skills.

How does DBT help a client manage an external situation they are stuck in that is directly contributing to symptoms (e.g. the home environment) when that external situation is logically/rationally an issue (i.e. not a perceived one)?

This is such a tough situation--especially when there is high pain associated with the situation and there doesn't appear to be a way out for our client. This is often the case with younger clients or even adults with guardians. When the "power of the environment is too great" for problem solving skills to change it, then we have too look at the four options for solving any problem and take available skillful action:

  1. Solve the problem--change the situation, avoid, leave, or get out of the situation for good.
    If there is no reasonable escape from the situation, then other skills will have to be used.

  2. Feel better about the problem--change or regulate your emotional response to the problem. Emotion regulation skills. This is when the situation "fits the facts", and you still don't want to be miserable. For example, many LGBTQ individuals experience persistent invalidation by others at home, school, work, or other environments and it isn't possible to stop this from happening.
    All of the emotion regulations skills can be brought to bear to some extent--self-care makes the
    person less vulnerable, coping ahead may help them avoid confrontations, etc. But still the person
    may ruminate on past or anticipated invalidations and can be miserable even out of the presence of the immediate cues. The specific methods will vary by situation, but in general, we would have them behave opposite the urges of the primary emotion. If sadness dominates and their natural urge is to shut down/avoid social situations, we would have them engage in behavioral activation in carefully selected social contexts, and throw themselves into connection. If anger is prominent for them, we would prescribe gently avoiding those who invalidate, and focusing on areas of in which they don't experience this.

  3. Tolerate the problem--Accept and tolerate both the problem and your response to the problem. Use distress tolerance and mindfulness skills. Practicing radical acceptance in the situation above can be a combination of the emotion regulation skill of "Mindfulness of Emotions" and the reality acceptance skills of willingness and turning the mind. First, noticing the sensations of the moment of emotion, we would coach the client to be aware of that pain and to accept that it exists. Turning the focus away from thoughts and feelings of outrage and despair, we give the emotional experience a good long look with gentle attention. This is validation of ourselves and can be the most effective step in reducing painful emotion. It's a paradoxical truth that the most profound change may occur in the presence of deep acceptance of a situation. Not to say we approve of the situation, just that we notice it exists.

  4. Stay miserable (or make it worse) and use no skills.

Of course, this is just one example of a situation in which the client is objectively helpless and just a few thoughts about a skills approach that might be used. It doesn't stop at the use of a single skill or even a sequence of skills. We might notice that as the client engages in one or two skills, they become more capable of using others, and so the process continues. I often notice that as clients are able to fully accept their situation (e.g., "I have a person(s) who makes frequent belittling statements to me") they are able find solutions, where none appeared before. When non-judgmental stance is used to describe the situation, they can sometimes find a kernel of understanding for the perpetrator.

How would you utilise DBT to help a client where the opposing forces (e.g. desire to live and desire to die; desire to get help and desire to self-destruct) are so rapidly oscillating that they are stuck in a state of confusion?

Powerful ambivalence about living is a painful experience for our clients and can make for unpredictable terrain in therapy. For the therapist, it can be wearing to have a client in this position for any length of time and can impact the therapeutic relationship, as well as the morale of the therapist. A client who spends a portion of their time thinking about death is not able to fully commit to having a life worth living. For all of these reasons (and more) we work hard to side with the part of the client that has hope and wants to be alive. A great deal of our time at the beginning of treatment is spent helping the client find compelling reasons for living and then revisiting these reasons repeatedly throughout the course of treatment.

However, before any of this can happen we have to validate the pain of the client, as their life is currently being lived. This validation is not a simple nod in the direction of the pain, but is rather an exploration of and joining with the client such that there is little doubt in their mind that the therapist understands why they would want to die. Therapists who are anxious in the presence of the client's pain may rush this process or miss it entirely. It is imperative to be mindful of the client's pace and not attempt to change their perspective until they are clearly communicating a sense of being heard. Often, when this happens we will see the client's level of arousal dropping and openness increasing.

At the same time, if we continue to validate pain without opening a door to change, clients can become more hopeless. Thus, we take our cues from the client. We stand with them in dark places until we have a sense that they know we are with them, and then we begin to explore reasons for staying alive, suggesting that we see validity in the factual existence of that reality. At no point do we side with their wish to die, only with the feelings that give rise to those thoughts. Then we side whole-heartedly with life, and the certainty that treatment can help them find a life that is less painful and worth living.

Often we move back and forth between validation and change in this way multiple times in the course of an interaction and this work is revisited sometimes numerous times before the client is able to remain on course with their life worth living goals. Sensing what is needed in the moment with clients requires mindfulness, persistence, and a fluid use of commitment strategies on the part of the therapist.


What can I do when a difficult to treat client is struggling to practise and use DBT strategies outside of session and therefore reports frequent acute symptoms that are not managed independently?

It seems that we all struggle to translate what we know into daily behavior change--it's part of the human condition. Changing simple things like diet and exercise can feel impossible, but when habitual behaviors are driven by powerful emotions, it is even more difficult. Many of our clients can recite the skills, can reflect later on which skills might have been helpful in a situation, but do not implement them in the moment of most need. This is largely why we have clients self-monitor and record practice on diary cards, and we address non-collaborative behaviors second only to life threatening behaviors in treatment. We know that implementing change is heavy lifting and requires a lot of focus.

When this is happening it is important to move in quickly with assessment before discouragement and even hopelessness settles in for both therapist and client. "Missing links analysis" is used when the client did not complete an expected task, and behavior chain analysis when they engaged in target behaviors.

Here are some things to evaluate when considering where to begin to test out solutions:

  1. Skill Acquisition: Does the client actually know the skill? Sometimes when we question clients a little more closely about their understanding of skills, we find that they are missing important information about how or when to use them. Asking the client specifics about how they used a skill in a particular situation can reveal these gaps.

  2. Skill Generalization: Remember the assumption that "New behavior has to be learned in all relevant contexts". When clients learn a new skill they will likely know how to apply it only in a narrow number of situations. They will need to learn to apply the skill in each new situation they encounter. Thus, if a client is good at using a skill at home they may find it confusing to apply it at work or school. Learning to recognize the need for a skill and to use it subsequent contexts generally is easier and faster than the original learning, but it is still a necessary step. Ask your client if it occurred to them to use the skill in a situation of concern, and if so, did they know how to use it in this context? Then rehearse, rehearse, rehearse.

  3. Skill Strengthening: Even when a client has a good understanding of a skill and can apply it in numerous life situations, there are sometimes challenges to being able to do so. Some days they may be more vulnerable emotionally or physically, so it is difficult to apply the skill. They may be facing a very powerful or difficult environment and they find it hard to use the skill. In these situations, clients require help in practicing the skill in hard situations. Role playing situations that are slightly harder than the ones they face is one good way to strengthen skills.

Finally, remember to follow the hierarchy of targets in treatment and continue to treat those therapy interfering behaviors however persistently they appear. If the behavior continues to occur, then be assured you have not identified and addressed all of the factors giving rise to it. Not focusing on these behaviors when they happen may inadvertently reinforce (strengthen) them and cause them to occur more often

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