Targeting – select a target at the start of every session
DBT primary therapists use individual therapy to target behaviours
In every individual session the therapist will select a target behaviour to work on during that session. To do this the therapist will consult the patient’s diary card to find a target behaviour that has occurred in the period since the last therapy session. As there could be a number of dysfunctional behaviours that are to be reduced, there are guidelines on how the therapist selects the target:
- If a life-threatening behaviour has occurred this must be targeted. Life-threatening behaviours include deliberate self-harm and urges to engage in self-harm. Harm to others takes precedence over harm to self. An actual act of harm takes precedence over an urge. A potentially lethal overdose would take precedence over minor scratches.
- If there are no life-threatening behaviours the therapist will move on to target any therapy-interfering behaviour that has occurred since last session. This is anything that prevents the therapist delivering the treatment to the client, including behaviours that de-motivate the therapist.
- If there are no therapy interfering behaviours the therapist will target a quality-of-life interfering behaviour. This means any severe de-stabilising condition that has been identified as significant for this client and is being tracked on the diary card, e.g. severe depressed episode, psychotic episode, alcohol binge.
Once a target has been identified the therapist will spend the session doing a detailed chain and solution analysis, rehearsing with the client more functional behaviours that could replace the dysfunctional links in the chain.
Q. Is there any time when the therapist would NOT target a life-threatening behaviour first?
A. Only if there was a potentially therapy-destroying behaviour. For example – if the client had missed three group sessions in a row and the next miss would result in her being thrown out of therapy under the four-miss rule. The therapist must try to keep the patient in the therapy so will start the session by addressing this potential drop-out, then quickly move on to deal with the life-threatening behaviour.
Q. My client says she will quit if I make her do another chain of self-harming behaviour. As this would be potentially therapy-destroying, should we focus on her urges to quit?
A. The danger here is that you would reinforce the behaviour that you don’t want – refusing to do the chain. Link the doing of the chain to her ultimate goals and stay focussed on the target behaviour. Problem-solve difficulties (such as high shame) as they crop up. Soothe and validate but don’t back off.
Q. My client very occasionally has a week with no self harm. As it is so likely that the behaviour will occur again the following week should we just continue focussing on self-harm until she has had a number of weeks without harming herself?
A. No – On any week that the client has not self-harmed you go down to the next target. If on a subsequent week she has self-harmed again at that point you target the self-harm incident. The target behaviours are always selected from the current diary card. The only exceptions are therapy-interfering behaviours that have arisen without warning.
Q. How would you target something like alcohol abuse?
A. Work hard to define your targets in pre-treatment. For example, if the person wanted to be alcohol free you would agree to target the very first drink on the diary card. This is because as soon as she has had this one drink she has already crossed the line from abstinence to drinking. You would do a chain on what led up to her having that drink. It is easy to be distracted by the day she had ten drinks – but the real question is, how did she come to have the first one? Over time the client will learn to question herself over that first drink.
If the client has decided on an alcohol limit, you would target the drink that took her over the predetermined limit.
Q. My client has anorexia, isn’t this potentially life-threatening?
A. Yes, but not imminently so. The idea of the life-threatening behaviour category is things that could cause your client to die before you even get the chance to see her again. Remember, if you targeted the eating restriction in that first category you would never be able to talk about therapy interfering behaviour (e.g. lateness to therapy) until she was no longer restricting her food.
Targeting a behaviour for reduction is always easier than trying to increase a behaviour. To target the non-appearance of a behaviour is quite hard, so you need to identify when the behaviour SHOULD occur. For example, if my client restricts her food, I get her to track breakfast luch and dinner each day, she has to put yes or no on the card for each meal. My target for the week’s session (if there is no higher order target) is the FIRST mealtime where she has recorded ‘No’. We chain what led up to that mealtime, what her thoughts actions and urges were
Q. ’m targeting cutting behaviour which occurs every day with my client. The chain is always the same; somebody says something to upset her, she gets angry, goes off by herself and cuts. Do we have to keep doing a chain when we know it so well?
A. This is a very general chain and lacks the detailed specificity that is required in DBT. Although there may well be similarities, each session has to focus on the detailed thoughts, feelings and events that led up to the target on that particular day. The client may also believe that every event is the same, rather than understanding that each occasion is slightly different and a new opportunity to practice skills. It sounds like anger is a key link in the chain and so solutions to regulate anger will be helpful. Try to approach each chain picking out the thoughts, emotions and events that made it unique, whilst also drawing on your insights into those common links. Be very careful not to merge one chain into another because they are so similar. Asking the question, “is that what happened on this day?” can be helpful to avoid getting caught up in the story of a previous, but similar occasion.
If the chains are very similar then you can start to track whether your client implemented the skills you suggested, and what the outcome was. For example – ‘did you remember to walk away and get your temperature down, what got in the way of you doing that on this occasion?
Q. Is it ok to target anger as my client’s quality-of-life interfering behaviour?
A. Anger is a normal human emotion. You would need to decide what specific problematic behaviour you are trying to reduce. If your client becomes violent to others when angry you would target specific acts of violence (which may come into the category of ‘life threatening behaviours if they are severe). If your client drinks to excess when angry you would target the drinking as a ‘quality-of-life threatening behaviour.’ In either case anger is just a link in the chain and not a target in its own right.
Q. My client hates being alone, and will avoid it at all costs. Is this a quality-of-life interfering behaviour?
A. No, this is not a severe destabilising condition or diagnosis that would be worthy of a referral to a mental health service or other government agency in its own right. Instead it is probably a link in the chain leading up to other more serious target behaviours. As such you will still get to talk about it and find solutions for it in session – in fact it may crop up quite a lot. It may even be a key link in the chain to many target behaviours. But it is not a target per se.
Q. Shouldn’t I use individual therapy to check up on how the client is using her skills, and whether she understands her homework for skills group?
A. Individual therapy is for targeting behaviour; doing a detailed chain and solution analysis and rehearsing new functional behaviour takes up a lot of time. You will get a chance to rehearse skills with your client as solutions to links in the chain. Your job is not to do an overview of general skills acquisition. Leave this to the skills trainers.
Q. My client wants to talk about other things in therapy. It is difficult to keep her on track. Can’t we deviate once in a while?
A. Whilst you do want to take your client’s agenda seriously, you want to help her gain a sense of perspective on the things that really threaten her life and her wellbeing. We do not diversify into other items if there are target behaviours to work on. Intermittently reinforcement is likely to result in more deviation from therapy. Reassure her that when no target behaviours appear on the card there will be an opportunity for her to talk about those other things – or if she works well in therapy there may be time left at the end for discussion. We really want the client to understand how these target behaviours get in the way of her having a life worth living.