Treating the client's therapy-interfering behaviour

As within any relationship, tensions will arise between the therapist and client. Chapter 3 describes examples of such tensions. As illustrated in that chapter, DBT therapists attempt to resolve such conflicts by searching for syntheses, particularly those that validate both sides and move the treatment toward agreed-upon goals. When therapy tensions have not been successfully resolved they often result in therapy-interfering behaviours. For example, if a therapist simply confronted a client about abusing drugs but never offered alternative solutions that could achieve the client’s goal of regulating affect, the client may begin to lie to the therapist about taking drugs.

Whether as the result of a specific conflict with the therapist or of more general psychological factors, clients with BPD frequently engage in therapy-interfering behaviour. The frequency of such behaviour may partly explain why clients with BPD have tended to have poorer outcomes in traditional treatments when compared to clients without personality disorders. Linehan (1993a), however, particularly attended to these behaviours when she developed DBT. Therapy-interfering behaviours include behaviours that directly interfere with the application of the treatment (e.g. not attending the session, arriving drunk at a skills training group, leaving sessions early, not completing diary cards) and behaviours that decrease the therapist’s motivation to apply the treatment (e.g. pushing the therapist’s limits, frequently complaining about the therapist to other clinicians, constantly criticizing the therapist). DBT does not consider therapy-interfering behaviours simply as obstacles to avoid or overcome so that therapy can proceed. Instead, it treats them as examples of the behaviours that occur in clients’ lives outside of therapy and as the most immediate opportunities to change those behaviours.

For example, an analysis of not completing the diary card may reveal that the client experiences intense shame when acknowledging behaviours on the card and thus avoids the card. If a similar pattern of shame and avoidance appeared in the analysis of a life-threatening or quality-of-life threatening behaviour, then treating the shame leading to avoiding the diary card may also help to decrease the other target behaviour.

When therapy-interfering behaviours occur, the client’s individual therapist applies the standard DBT strategies, with a particular emphasis on the problem-solving strategies. Generally, the therapist would begin to treat the behaviour by describing the behaviour, without judgement or inferring intent, to the client. For example, a therapist would say: “You just threatened to harm yourself if I don’t extend the session”, rather than, “You’re trying to manipulate me”, or: “I’ve noticed that you seldom complete your homework”, rather than, “I think that you’re sabotaging the therapy”. The therapist may then try to increase the client’s motivation to change the behaviour by highlighting the aversive consequences of the behaviour (including the impact on the therapist) and linking a change in the behaviour to the client’s ultimate goals. For example, the therapist might say, “When you phone me inappropriately it makes me want to stop all phone contact. You have also said that many of your friends have withdrawn from you because you have pushed their limits. Maybe if we solve the problem in therapy, you can use the same skills to keep your friends”. The therapist would then conduct a brief behavioural and solution analysis of the behaviour and immediately implement solutions to change the behaviour. In the case of unwarranted shame leading to the avoidance of the diary card, the therapist would primarily apply exposure with the support of mindfulness and perhaps other CBT solutions. Many clients respond with “I can’t” when a therapist suggests practising a new skill. This single response, however, has many possible reasons, and as the reasons vary so will the solutions. Some clients genuinely cannot use a skill because they have not learned it well enough, in which case more skills coaching may solve the problem. Alternatively, other clients have some ability, but they also have some fear of being overwhelmed with embarrassment while practising the skills. In the face of unwarranted fear, exposure may prove effective. Other clients have the ability, but they also have a bias toward assuming poor outcomes (e.g. “I can’t do anything. I always fail”) or other negative cognitions that interfere with using skills (e.g. “I shouldn’t ask for anything for myself”). In these cases, therapists might utilize mindfulness or cognitive restructuring or both. Finally, clients may have the skill but they want to stop the solution analysis altogether and believe that “I can’t” will stop it. Therapists may then apply contingency management, ending the solution analysis only after the therapy- interfering behaviour has ended.

As with other target behaviours, the treatment of therapy- interfering behaviours often involves multiple CBT procedures in a single solution analysis. In one case, a client would try to change the topic whenever the therapist started to generate solutions for the client’s bingeing. A brief behavioural chain analysis revealed that in response to the therapist’s solution generation, the client would immediately think, “I should have thought of that. I’m so stupid”. These thoughts elicited shame that led to the client self-invalidating by oversimplifying the difficulty of stopping the bingeing. She would then think, “I can’t change”, and begin to feel despair. At this point she would try to change the topic to avoid the shame and despair. Whenever the client expressed judgements during the behavioural chain analysis, the therapist had her mindfully notice them and then describe the relevant facts. Mindfulness also helped with the selfinvalidating statements. To reinforce this practice of mindfulness, the therapist validated the actual difficulty of decreasing bingeing. The therapist prompted the client to use Wise Mind to determine if not having solved the bingeing problem herself warranted shame. To address the “I can’t” statements, the therapist suggested a combination of mindfulness (particularly noticing and focusing on effectiveness) and cognitive restructuring (particularly generating alternative explanations for not having stopped bingeing). After completing the analyses of the therapy-interfering behaviour, the therapist applied exposure to treat the unwarranted shame by continuing to re-present the cue of solution generation for bingeing until the client’s shame peaked and naturally subsided. During this procedure, the therapist blocked any attempts to change the topic. The client also learned to act opposite to the emotional urges by thoughtfully evaluating and trying the solutions for bingeing and even by asking the therapist to generate more solutions. Though the therapist utilized validation and praise to reinforce the client’s collaboration and hard work, the actual decrease in shame most strongly reinforced her use of skills and other interventions. Also, when the client began to fully participate again in the solution analysis of the bingeing, her despair disappeared.

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