Selected Strategies for Clients With Complex and Multidiagnostic hating Disorder Presentations

In this section, we describe four key DBT interventions and their application to patients with EDs who also present with multiple problem behaviors. Using case examples and scripted dialogues, we review (a) therapist stance and patient assumptions, (b) facilitation of client commitment to treatment, (c) prioritization of multiple problem behaviors, and (d) implementation of contingency management strategies. Although these four interventions are foundational, we want to highlight that they are only a part of the full DBT treatment approach that we use in our treatment program. The full treatment involves the use of validation, structural, stylistic, and additional change strategies that can be found in Linehan's (1993a) original text as well as Koerner's (2012) more recent publication.

Therapist Stance and Assumptions About Patients

Whether a counselor is working at a higher level of care or in an outpatient setting, the therapeutic stance in DBT is foundational and essential to successful treatment delivery. In DBT, individual therapists (and the entire treatment team) make a commitment to practice a nonjudgmental, dialectical stance in their practice. They also accept the DBT assumptions about clients, therapy, and therapists (Table 16.1) and use them to guide their clinical decisions (Koerner, 2012; Linehan, 1993a). Using these assumptions can be challenging when working with clients who display such behaviors as purging three times per day, water loading to artificially increase weight before being weighed, and maintaining a dangerously low body weight. Therapists may feel anxious about the clients physical health and frustrated at a perceived lack of behavioral change. Their initial response might be to label the clients behaviors as manipulative or as proof that she or he is unmotivated. Similarly, therapists might communicate disapproval nonverbally (e.g., a look of frustration, short or curt answers). Instead, from a DBT perspective, discussing these behaviors would be important, including therapists' reactions to them, in a matter-of-fact manner free of judgment and assumptions. A nonjudgmental position moves away from labeling experiences, emotions, thoughts, and behaviors as good or bad. Instead, everything simply is as it is. Maintaining a nonjudgmental stance models adaptive behavior for the client, lessens emotion dysregulation (on the part of both client and therapist), and helps to maintain a strong working alliance. The therapist's nonjudgmental response to even the most egregious behaviors will be quite different from how people typically respond to the client, which serves to decrease polarization and increase collaboration and openness on the part of the client.

Additionally, all members of the DBT team agree to adopt a dialectical worldview. To do so means to accept that no one person has a lock on the

Table 16.1. Dialectical Behavior Therapy (DBT) Assumptions About Clients, Therapy, and Therapists

Assumptions about clients

• Clients are doing the best they can.

• Clients want to improve.

• Clients cannot fail in DBT.

• The lives of suicidal clients (and those with multidiagnostic eating disorder presentations) are unbearable as they are currently being lived.

• Clients must learn new behaviors in all relevant contexts.

• Clients may not have caused all of their own problems, but they have to resolve them anyway.

• Clients need to do better, try harder, or be more motivated to change.

Assumptions about therapy and therapists

• The most caring thing therapists can do is to help clients change.

• Clarity, precision, and compassion are of the utmost importance in the conduct of DBT.

• The relationship between therapists and clients is a real relationship between equals.

• Therapists can fail to apply the treatment effectively. Even when applied effectively, DBT can fail to achieve the desired outcome.

• Therapists who treat individuals with pervasive emotion dysregulation need support.

Note. From Doing Dialectical Behavior Therapy: A Practical Guide (p. 22), by K. Koerner, 2012, New York, NY: Guilford Press. Copyright 2012 by the Guilford Press. Reprinted with permission.

absolute truth. Instead, the team agrees to accept that multiple opinions, experiences, and truths can coexist. In DBT, rather than getting stuck when the team is polarized, the team works to celebrate differences in opinion and recognize them as opportunities to find new solutions. For instance, a skills group leader may state in a team meeting that she or he is feeling frustrated by a client's lack of progress and poor attendance in skills group. The dietician might report feeling similarly burnt out by the same client's argumentative style during meals. The individual therapist, however, might argue that the client has been working very hard to get to treatment on time, has reduced the overall number of absences over the past month, and has made progress in other domains such as weight gain and reduced self-injury. From a dialectical stance, the question is not about who is right and who is wrong; rather, the question is what is valid about each person's perspective and how does the team develop a treatment plan that includes all valid points. The same tensions arise quite frequently with clients. A client may want to live and want to die at the same time. Another client can hold the desire to start a family alongside her wish to starve herself to death. Although the urge might be to challenge one thought as maladaptive, a dialectical position acknowledges the validity in both points of view and seeks to find a synthesis. Change (whether on a team or with a client), therefore, occurs as the result of the synthesis between opposing forces.

Finally, those working within the DBT framework also agree to adopt a consultation-to-the-client approach. DBT strongly emphasizes teaching clients to take greater responsibility for their actions and their lives, which can be an especially difficult position for therapists to take when working with multidiagnostic clients who present with severe ED symptoms (e.g., low body weight, medical instability) and other life-threatening behaviors (e.g., recurrent self-injurious behavior). A therapist's initial urge, especially a therapist who subscribes to the medical model, might be to coordinate treatment, talk to the family, communicate the client's needs to other team members, and problem solve on behalf of the client. These practices are common in many inpatient hospital settings. In the consultation-to-the- client approach, however, therapists do not speak for or act on behalf of their clients; instead, clients are encouraged to take primary responsibility for themselves and adopt a more proactive stance. Although circumstances may certainly call for treatment providers to advocate for their clients (such as when the client's life is in imminent danger and he or she is not willing to contract for safety or use skills), it is essential that therapists not treat clients as fragile or incapable of acting skillfully. Our approach, rather than solving clients' problems, calls for therapists to help clients learn new ways of managing their life circumstances. This approach might mean only speaking with the family or other treatment providers with the client in the room, having the client call the dietician during a session to schedule an appointment, or role playing with the client on how the client can get his or her needs met with other team members.

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