Therapy-Interfering Behavior in DBT 9781462555949, 9781462556205

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Therapy-Interfering Behavior in DBT

Guilford DBT Practice Series Alan E. Fruzzetti, Series Editor This series presents accessible, step-by-step guides to essential components of dialectical behavior therapy (DBT) practice. Delving deeply into different aspects of DBT implementation—phone coaching, validation, chain analysis, family interventions, and more—series volumes distill the latest clinical innovations and provide practical help based on sound DBT principles and good science.

Phone Coaching in Dialectical Behavior Therapy Alexander L. Chapman Chain Analysis in Dialectical Behavior Therapy Shireen L. Rizvi DBT Teams: Development and Practice Jennifer H. R. Sayrs and Marsha M. Linehan Therapy-Interfering Behavior in DBT Esme A. L. Shaller

Therapy-Interfering Behavior in DBT ESME A. L. SHALLER

Series Editor’s Note by Alan E. Fruzzetti

The Guilford Press New York

London

Copyright © 2025 The Guilford Press

A Division of Guilford Publications, Inc. www.guilford.com All rights reserved Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number: 9 8 7 6 5 4 3 2 1 LIMITED DUPLICATION LICENSE These materials are intended for use only by qualified mental health professionals. The publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which photocopying permission is specifically granted in a footnote. This license is limited to you, the individual purchaser, for personal use or for use with clients. This license does not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video or audio recordings, blogs, file-sharing sites, internet or intranet sites, and handouts or slides for lectures, workshops, or webinars, whether or not a fee is charged). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications.

The author has checked with sources believed to be reliable in her efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the author, nor the editor and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources. Library of Congress Cataloging-in-Publication Data Names: Shaller, Esme A. L., author. Title: Therapy-interfering behavior in DBT / Esme A. L. Shaller. Description: New York : The Guilford Press, [2025] | Series: Guilford DBT practice series | Includes bibliographical references and index. Identifiers: LCCN 2024034902 | ISBN 9781462555949 (paperback ; acid-free paper) | ISBN 9781462556205 (hardcover) Subjects: LCSH: Dialectical behavior therapy. | Borderline personality Disorder—Treatment. | Emotions. Classification: LCC RC489.D48 S53 2025 | DDC 616.89/142—dc23/eng/20240924 LC record available at https://lccn.loc.gov/2024034902 Guilford Press is a registered trademark of Guilford Publications, Inc.

About the Author

Esme A. L. Shaller, PhD, is Clinical Professor in the Department of Psychiatry and Behavioral Sciences at the University of California, San Francisco (UCSF), which she joined in 2007. At UCSF, she helped build the Wavefront Dialectical Behavior Therapy (DBT) Clinic, for which she serves as Clinical Director. Both Dr. Shaller and the Wavefront DBT Clinic are certified by the DBT-Linehan Board of Certification. Dr. Shaller’s central passions are teaching and dissemination of DBT, particularly for adolescents and families. She devotes a large percentage of her time to teaching and training, both within UCSF’s residency and fellowship programs and across California and the United States. She has worked with other members of the Wavefront team to implement comprehensive DBT for low-income teens in three Bay Area counties. Dr. Shaller is past president of the International Society for the Improvement and Teaching of DBT (ISITDBT) and a cofounder of the ISITDBT Anti-Racism Committee.

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DIALECTICAL BEHAVIOR THERAPY: LEARNING AND GROWING In this fourth volume in the Guilford DBT Practice Series, senior clinician Esme Shaller focuses on how to manage client and therapist distress, emotion dysregulation, diminishing motivation, and other insession problems. This book series was developed to meet the increasing needs of therapists to learn how to practice dialectical behavior therapy (DBT) in an adherent and competent way. This fantastic book is an important addition to our series. DBT was developed originally to meet the needs of suicidal and/ or self-harming patients with borderline personality disorder (BPD) and other problems related to chronic and severe emotion dysregulation. Although the DBT treatment manual (Linehan, 1993a), the revised DBT Skills Training Manual (Linehan, 2015b), and the DBT Skills Training Handouts and Worksheets (Linehan, 2015a) provide therapists with the entire treatment protocol, other aspects of comprehensive DBT have been developed further since these earlier books were published. These include chain and solution analyses; validating principles and procedures; telephone and other types of skill coaching; DBT parent, couple, and family interventions; DBT consultation team principles and procedures; using dialectical strategies effectively; and more. It is for this reason that we developed this series, with the support of Marsha Linehan, to help practitioners enhance and refine their skills and deliver DBT to their patients more effectively, according to present DBT standards and practices, and to enjoy doing DBT without burning out. vi



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Recent data have demonstrated that “better” DBT (i.e., when therapists adhere more closely to the principles, strategies, and procedures of DBT) produces superior outcomes (Harned et al., 2022). This further highlights the ongoing need to help therapists understand DBT practices that are adherent and effective and to provide guidelines, examples, and practices to help them achieve high levels of fidelity. In general, this practice series provides this kind of guidance, and this book particularly focuses on helping therapists in the here and now manage their sessions more effectively, especially when various problems interfere. Indeed, as we learn more and more about what “adherent” DBT includes (and doesn’t include), it becomes essential for all DBT practitioners to have resources like this book to improve our fidelity in treatment delivery. When the young psychologist Marsha Linehan and her colleagues at the University of Washington in Seattle began developing DBT in the 1980s, it was not at all clear whether it would be successful, both (1) in terms of treatment efficacy for the chronically dysregulated, suicidal, and self-harming people (often meeting the criteria for BPD) for which the treatment was developed; and (2) in terms of being accepted and adopted for use by the therapeutic community, which had struggled to treat people with these problems effectively for many years without much success. To put this book and this book series in context, we briefly examine how they fit into the overall structure of DBT treatment, and the treatment context for severe emotion dysregulation, BPD, and related problems that have evolved over time. Looking back more than 30 years, it is stunning to see the impact that the work of Linehan and her colleagues has had on the field. Before DBT became widely disseminated and accepted, suicidal and/or self-harming people with BPD faced rampant stigmatization, a sense of hopelessness about recovery, and a complete absence of empirically supported treatments. Needless to say, at that time people with BPD faced a bleak prognosis. DBT was available only in one small clinic, located at Marsha’s center at the University of Washington. There was no treatment manual or skills manual; there were no clear ways to teach, disseminate, or implement the treatment effectively. Where are we now? Stigma has been significantly reduced, hope has increased, there is a general recognition among professionals that BPD and related problems are treatable (although there is still a long way to go), and an impressive volume of studies demonstrate strong support of DBT’s efficacy and effectiveness. There is a widely read treatment manual (Linehan, 1993a), and both an original (Linehan, 1993b) and

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an enhanced and updated skills manual (Linehan, 2015a, 2015b). Welltrained teams in outpatient, residential, partial hospital, and other settings treat thousands of people every day with DBT, not only across the United States, but in dozens of countries and on every continent. Many of these treatment providers have demonstrated both their commitment and their abilities by becoming certified as DBT therapists, which requires rigorous demonstration of their skills as DBT providers (DBT– Linehan Board of Certification). In addition, other effective treatments, generally also nonpejorative toward people with BPD and related difficulties, have been empirically established or are under development. Moreover, applications and adaptations of DBT have been successfully developed for a host of problems in addition to BPD per se (i.e., other severe problems related to emotion dysregulation), and across a variety of treatment—and more recently, prevention—settings. What these applications have in common is dedication to the principles of the treatment, including treating problems with emotion dysregulation at their core. DBT is an integrative treatment program that includes a whole set of interventions that serve five functions and are typically delivered in different modes (see below). In all DBT modes of delivery, DBT therapists integrate the techniques and scope of acceptance-oriented therapies (e.g., support, warmth, encouragement) with the strategies and precision of behavior therapies and emotion science (e.g., precise treatment targets, scientific analysis of behavior: emotions, judgments/ thoughts, and actions) and a focus on psychological and social skills as solutions to a range of problems. Dozens of controlled studies (and hundreds more studies with varying designs) support the effectiveness of DBT in creating safety, stability, and self-control while minimizing treatment dropout, as well as improving mood; relationships; family, school, and job functioning; self-esteem; and so forth. Largely due to stable outcomes and reduced relapse, costs of DBT compared to alternative treatments are also significantly reduced in the long term. DBT model/theory. The treatment model views emotion dysregulation as the core of a variety of emotional, cognitive (thinking), relational, identity (self-concept), and behavioral problems. Emotion dysregulation increases or exacerbates behavioral dysregulation (out-of-control actions, including impulsivity), cognitive dysregulation (trouble thinking and problem solving), interpersonal dysregulation (difficulties in relationships), and self-dysregulation (problems with self-esteem, identity, negative self-views). Consequently, many common co-occurring problems (suicidal and nonsuicidal self-injury, depression, anxiety, eating disorders, posttraumatic stress disorder, substance abuse, aggression,



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problems in relationships, etc.) are similarly understood either as dysfunctional attempts to regulate emotion or as natural consequences of chronic emotion dysregulation. The overarching goal of DBT is to help people create lives worth living by helping them learn psychological, attention, emotion, and social skills to regulate or manage their emotions; earlier in treatment tolerating and reregulating secondary emotions; and later in treatment identifying, accurately labeling, allowing, expressing accurately, and managing primary emotions. Much of the treatment is built around these principles. Chronic and severe emotion dysregulation is hypothesized to result from an ongoing transaction between the person’s emotion vulnerabilities and invalidation from others in the social and family environment, which often promotes self-invalidation as well. Emotion vulnerability is influenced by temperament, conditioning, biological well-being (e.g., sleep, pain, exercise, drugs), and present biological disposition resulting from learning and current circumstances, and manifests as emotional sensitivity and reactivity, along with often slow return to emotion equilibrium. Invalidating responses can take a variety of forms, from the obviously critical and emotionally abusive to well-meaning misunderstandings that occur because of temperamental differences, inaccurate expression, or miscommunication between people and their family members, and others. Five core functions of comprehensive DBT. DBT consists of components or modes that address the five essential functions of treatment: 1. Help people learn new psychological, emotional, and social/ relationship skills, typically via skill training groups (skill acquisition). 2. Help people generalize those skills to their real, everyday lives, in situations that have elicited less skillful responses in the past, which includes detailed planning, in vivo coaching, and practicing skills in the “real” world (skill generalization; see Chapman, 2018). 3. Help people collaborate on their treatment targets and enhance their motivation to replace overlearned dysfunctional behaviors with more skillful alternatives, primarily through individual psychotherapy and also in other ways, depending on treatment setting (motivation to replace dysfunctional behaviors with skillful alternatives). This typically occurs in individual DBT therapy, and includes chain and solution analyses, commitment work, dialectical interventions, and lots of validation of client experiences (and “wise mind” behaviors; see Rizvi, 2019).

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Series Editor’s Note 4. Help people manage their social and family relationships to build better relationships; elicit more support, understanding, and validation; and help family members become more validating and supportive of loved ones’ skillful behaviors, through family interventions (structure the social and family environments to promote improvements). Sometimes DBT interventions are extended to school or additional treatment environments as well. 5. Provide ongoing support, validation, problem solving, and skill building for therapists to enhance their motivation and skills through regular team consultation meetings (increase skills and motivation for DBT providers; see Sayrs & Linehan, 2019).

The present volume by Esme Shaller serves an essential need for DBT practitioners across all five functions (and multiple different modes of intervention): how to manage dysregulated emotion and behavior that show up in the treatment (or consultation) process. In DBT we label this set of behaviors as “treatment interfering” (TIBs) because, descriptively, that’s exactly what they do. Esme takes an inspiringly nonjudgmental approach to understanding, identifying, assessing, and addressing TIBs across all DBT modes. DBT skills. Learning key psychological, emotional, and social skills is believed to be central in helping patients learn to regulate their emotions, build satisfying relationships, and thrive. Thus, DBT skills are almost always necessary components of managing, reducing, and/ or eliminating TIBs. These include skills to: 1. Increase attention control and nonjudgmental awareness and build a more positive self-concept or identity (mindfulness), including the ability to move from conceptual (imaginary, judgmental, hypothetical) to descriptive reality. 2. Understand emotions, increase positive emotions, decrease vulnerability to negative reactions, accept negative emotional experiences, and change negative emotional experiences (emotion regulation skills). 3. Build empathy and improve relationships while balancing assertion with self-respect (interpersonal skills). 4. Tolerate highly distressing experiences without doing things impulsively that increase dysregulation, impulsivity, or other behaviors that likely worsen the situation overall (distress tolerance skills). 5. Balance competing goals, interests, and perspectives, and build



Series Editor’s Note xi cognitive and emotional flexibility to make effective choices (dialectics, along with “wise mind”).

Over time, some additional skills have become part of the DBT lexicon, such as dialectical (or “middle path”) and validation skills for patients and their families, specific skills for people with substance use problems, and so on (cf. Fruzzetti, Payne, & Hoffman, 2021; Miller, Rathus, & Linehan, 2007). Of course, learning principles are at the core of any behavior therapy, including DBT. In particular with skills, there are three overlapping phases of learning: (1) acquisition phase, in which the basics of the skill are learned, typically in skill training groups designed to be optimal learning environments; (2) strengthening phase, in which the person practices the skill, typically in planned ways, in groups or with the therapist, or at home; and (3) generalization phase, in which the person’s skill has become robust enough that the person can employ it when needed in their life, often spontaneously. Of course, in addition to the teaching/training and coaching that occurs in skill training groups and in individual sessions, in outpatient settings in vivo coaching can help to generalize skills (mostly by text or telephone) and manage between-session problems. Acceptance and validation. Throughout DBT, treatment providers strive to understand and validate the primary emotional experience of their patients, along with other valid behaviors, and help clients validate themselves. We do not validate things that are not, in fact, valid. This is a complex task, learning to discriminate the valid aspects of any given behavior from the invalid ones. For example, certain impulsive and/or destructive behaviors (e.g., self-harm, substance use) typically are primary targets for change because they are invalid ways to solve problems or enhance quality of life long term. Yet, they are valid in the sense that they do often “work” to reduce, avoid, or escape painful negative emotional arousal, albeit briefly. Understanding and validating what is valid, even in the most dysfunctional behavior, is a key therapeutic activity that helps the client feel understood (validated), increases motivation for change, builds the therapeutic relationship, and thus increases collaboration for change. Consequently, therapist validation not only has value in itself (feeling understood, cared about, etc.), it also helps regulate the person and promotes change (Fruzzetti & Ruork, 2018). Change, problem solving, and behavior therapy. Within a therapeutic context based on understanding, acceptance, and validation, the therapist targets dysfunctional behaviors for change, pushing patients

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to substitute skillful alternatives for the problematic reactions and dysfunctional behaviors for which they sought treatment. Utilizing a carefully constructed treatment target hierarchy, DBT therapists and the DBT team can employ all the components of learning and behavior therapy: (1) careful assessment, using chain analysis; (2) development of solutions on the chain, replacing dysfunctional “links” in the chain that led to a dysfunctional or undesired behavior with a skillful alternative (this includes learning skills, noted above); (3) behavioral rehearsal and other commitment strategies to foster the difficult change process; and (4) all the techniques of behavior therapy to help the person actually use the skill when needed (e.g., stimulus control, reinforcement/contingency management, exposure and response prevention). Of course, these same procedures are employed in all modes of DBT (individual therapy sessions, family therapy, when coaching, on the consultation team, and so on). Dialectics. Balancing acceptance and validation with change and problem solving/behavior therapy is complicated, and there are no algorithms to guide us because each context is unique. Rather, the therapist must balance these dialectically in the service of effectiveness. Every strategy in DBT has an “opposite” of equal value that must be considered and balanced in order to help people change in the ways they want to change: Just as acceptance and validation must be balanced with change and problem solving, intervening on behalf of clients is balanced by consulting with clients to empower them to intervene on their own behalf; communicating in warm, genuine, and caring ways must be balanced with irreverence, insistence, and matter-of-fact communication—emotion must be balanced with reason (and vice versa). Interventions in the social and family environments. Although an important component of DBT from the beginning, this area has shown enormous growth and development since the first wave of DBT was developed and implemented. For example, fully developed applications of DBT have been shown to be effective with parents, couples, and families, and in school systems, and are being used to prevent the development of emotion dysregulation problems or to intervene early to help clients avoid full-blown problems related to emotion dysregulation. All these DBT efforts utilize the core principles of DBT but necessarily have expanded the strategies and techniques to be effective in these new domains. Their growth and development are a positive testament to the coherence and effectiveness of DBT in the beginning. What is DBT and what is it not? Given the strong empirical foundation for DBT, it is no surprise that many clinicians want to offer DBT as part of their therapeutic toolbox. However, DBT is complex and



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requires considerable time, effort, and dedication to learn well. So, it is also not surprising that a wide range of treatments are offered under the DBT “label” but are of varying DBT quality. This is confusing for consumers at best, and of course fraudulent at worst. Imagine if your surgeon thought, “I’ve never had the training to do this procedure but I read a little bit about it, so I can advertise myself as an expert in it.” No one would want this surgeon performing a procedure on them. Fortunately, a certification process for DBT therapists and their DBT teams has now been available in the United States and in several other countries for nearly 10 years, and more and more DBT therapists and programs have become certified. This is a significant positive development both for people who need treatment (they can know that they really are getting worthy DBT, a “version” of the treatment has the best chance of helping them) and for DBT therapists (they have achieved a measure of achievement in DBT expertise according to empirically derived standards). How does this book series fit into the development of DBT? DBT is, at least metaphorically, a living, breathing, and always growing and evolving treatment. It expands and changes in a dialectical manner: We use the therapy according to the model (the “thesis” or “proposition”); DBT therapists continue to innovate within the treatment to improve DBT interventions (“antithesis” in which we employ theory and science to develop something new). In response to data/research findings about these innovations, we find that some things show incremental improvements and others do not; ultimately, some new strategies or interventions become established and integrated with the old synthesis, now established treatment, and stay that way until a situation arises in which better methods are established. Then further innovation (a further antitheses) is engaged. The original text (Linehan, 1993a) remains relevant and wise, and includes an enormous amount of thoughtful and effective guidance. And DBT has evolved since 1993 to include many more things (applications in new settings, extensions of principles and strategies, new skills, etc.) that could not have been anticipated at the time the book was written. This book series presents DBT as it is today, a new synthesis of the older and the newer, built on the original treatment manual. For example, the first book published in this series (Chapman, 2018) focuses on telephone consultation with clients/patients. This idea of coaching suicidal and self-harming clients by telephone between sessions was an innovative notion and was initially greeted by many therapists as a potential barrier to learning and practicing DBT. Would clients abuse their phone privileges, intrude on therapists’ lives, and

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make for never-ending demands on therapists’ time? Chapman shows how to observe therapeutic limits, coach but not provide treatment, and use phone time to effectively advance treatment. He also presents details about how coaching might differ for teens compared with adults, and other aspects of phone coaching that have emerged over time with much innovation and empirical evaluation. Similarly, Shireen Rizvi’s (2019) book on chain analysis provides details and nuance well beyond early iterations of DBT. Chain and solution analyses are the core method of understanding clients’ experiences and problems and thus provide opportunities for validation. In addition, they are the foundation for change strategies, allowing the therapist and client to “swap out” dysfunctional thoughts, reactions, and so forth, and “swap in” skills as alternatives. Doing one or more chain and solution analyses is part of every individual DBT session. Rizvi expertly highlights not only the ins and outs of doing chains and solutions but also the complex dialectical process that goes into completing a successful chain and solution analysis, including validating key behaviors on the chain, shaping, managing TIB, and developing and implementing solutions that are effective and efficient. Although consultation teams have been a sine qua non of DBT since the beginning, Jennifer Sayrs and Marsha Linehan’s (2019) manual on how to build and run a DBT consultation team effectively includes enormous innovation and establishes new standards for teams. Sayrs is able to pull together many years of experience and innovation to suggest structures and strategies on teams to maximize their effectiveness on both targets of DBT consultation teams: (1) enhancing therapist motivation joy, well-being (low burnout) via active support, validation, and so on; and (2) improving therapist skills and adherent treatment delivery via problem solving, teaching/ learning, practice, or rehearsal (e.g., role plays). Just having a weekly consultation team in DBT with the therapist’s behavior as the target is a rather different approach from most treatments, and thus how to do this is not necessarily obvious. This volume continues the series’ tradition by providing sophisticated yet practical help in how to use updated practices in DBT to reduce reduce client—and sometimes therapist—TIBs. Esme employs the principles and honors the standards and traditions of DBT (e.g., Linehan, 1993a) and, at the same time, provides guidance on how to manage TIBs across all modes of DBT. Moreover, this book could be invaluable to therapists who practice cognitive-behavioral therapy or other modalities who are interested in addressing TIBs in a nonjudgmental and principle-based way.



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Esme provides extremely clear guidance, and her book will instantly become the “go-to” guide for TIBs. It is comprehensive and still totally accessible. Esme is empathic, direct, descriptive, nonjudgmental, and thorough. She takes the reader step-by-step in defining TIBs as those behaviors that, in the moment, interfere with treatment progress because they (1) interfere with the client actually receiving the therapy effectively, (2) interfere with other clients (and their abilities to receive the therapy), and/or (3) interfere with the therapist’s joy/ satisfaction/motivation and have the potential to burn out the therapist. This way of thinking about TIBs in DBT is thorough and descriptive and focuses our attention, dialectically, on both how it makes sense that the client (or therapist) is doing something problematic right now, and how to go about changing the TIB by utilizing DBT principles and practices. It is also fairly unique in the mental health field, in that DBT therapists recognize that TIBs are just additional, albeit sometimes provocative, behaviors to be curious about and, when needed, to shape. We don’t assume ill intent or threaten to end treatment when patients engage in problematic behaviors. Instead, we seek to “target” them: assess (often via chains); intervene with coaching, skills, or other means that utilize all DBT skills and strategies; seek consultation from DBT team members; and so on. Perhaps just as important, Esme recognizes that therapists also can engage in TIBs, and that we need to take the same curious, nonjudgmental approach to reducing these behaviors to the benefit of both client and therapist. Dialectically, Esme recognizes that just calling something a TIB in DBT requires entering a transactional way of understanding the client’s behavior, and our own, and intervening in that transaction with acceptance-oriented or change-oriented strategies. Or, of course, doing both. Esme provides regular and compelling examples to bring difficult clinical situations to life and transcripts (synthesized from many real-life situations) to guide the reader with specifics, and she employs an engaging style to keep our motivation through what could become treatment-destroying situations if not managed effectively. It is likely that both novice and expert readers will return again and again to her explanations and her examples for guidance. Her enthusiasm, irreverence, empathy, nonjudgmental stance, target clarity, and deep knowledge of this topic will inspire DBT therapists to utilize the principles and practices that she explicates. Following her expert recommendations likely will both reduce therapist potential for burnout and improve consultation around TIBs, ultimately leading to more effective outcomes for our clients.

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Of course, the material in this book is entirely consistent with core DBT competencies, adherence in DBT, and Linehan’s (1993a) initial treatment manual. The entire series intends to update and augment, rather than replace, earlier core DBT manuals (Linehan, 1993a, 2015a, 2015b), and this volume truly enhances and extends our thinking about and practices in difficult clinical situations in all modes of DBT. Every book in the series, like this one, illustrates many new developments guided by both clinical innovation and sound research that are DBT today.                       Alan E. Fruzzetti, PhD

REFERENCES Chapman, A. L. (2018). Phone coaching in dialectical behavior therapy. New York: Guilford Press. Fruzzetti, A. E., Payne, L. G., & Hoffman, P. D. (2021). DBT with families. In L. A. Dimeff, S. L. Rizvi, & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications across disorders and settings (2nd ed., pp. 366– 387). New York: Guilford Press. Fruzzetti, A. E., & Ruork, A. (2018). Validation principles and practices. In M. Swales (Ed.), Oxford handbook of dialectical behaviour therapy. Oxford, UK: Oxford University Press. Harned, M. S. (2022). Treating trauma in dialectical behavior therapy: The DBT prolonged exposure protocol. New York: Guilford Press. Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford Press. Linehan, M. M. (2015a). DBT skills training handouts and worksheets (2nd ed.). New York: Guilford Press. Linehan, M. M. (2015b). DBT skills training manual (2nd ed.). New York: Guilford Press. Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. New York: Guilford Press. Rizvi, S. L. (2019). Chain analysis in dialectical behavior therapy. New York: Guilford Press. Sayrs, J. H. R., & Linehan, M. M. (2019). DBT teams: Development and practice. New York: Guilford Press.

Preface

M

y family teases me because I cry every day (though it’s mostly at funny or touching things). I suppose being a “big emotions” person drew me to DBT, as did countless other things: I like complex clinical presentations, I like teenagers, I like science, I like radical genuineness (or rather I’m really bad at not being radically genuine, so DBT works for me). Most of all, I like chaos! I like the chaos itself, but I also love finding and creating order amid chaos. This has been true my whole life. Most of the things I love or do have a certain level of chaos: the Muppets, live music, marching band, theater, student government, free-form college radio, volunteering with the Girl Scouts, activism . . . all of these require a baseline interest in (or tolerance for) chaos. At the same time, they all benefit from a little bit of order. This book is thus for all of you who have learned to love and tolerate the chaos and order of DBT. As is the case with the other books in the Guilford DBT Practice Series, I assumed my readers would have basic DBT knowledge prior to coming to this book, so DBT-relevant terms are not explained in great detail. I sincerely hope this book deepens your engagement with DBT and with the things that challenge us as DBT clinicians. This brings me to therapy-interfering behavior (TIB). I think I love the concept of TIB so much because it names the particular kind of chaos we all experience in the business of psychotherapy: Things get in the way! Even in ideal circumstances, change is hard, and clients and therapists do stuff that makes it harder. This is normal. The shift that Marsha Linehan created by putting this normal stuff on our therapy agenda was immeasurable. Before I learned DBT, I discussed the things that were getting in the way of therapy with my colleagues and supervisors. After learning DBT, I discussed these things with my clients. What an idea! So simple, and so transformative. My sincerest xvii

xviii Preface hope is that after you read this book, you will feel more confident and empowered to have these conversations to directly address the chaos of TIB and make a little order from it. I start with an overview of TIB and some reasons for you to love and appreciate the opportunities it gives us in our work, while highlighting some overall principles of working with TIB to keep in mind. I then move on to orienting your clients to the concept, assessing it thoroughly at the outset, and addressing it effectively throughout your work with a given client. Throughout the text, I have included helpful “TIB Tips” to provide reinforcement of key concepts, as well as worksheets to help with the assessment of TIB and examples of both challenging and straightforward client–therapist dialogue to model what these conversations might look like in the therapy room. While we are on the topic of client–therapist dialogue, let me highlight that all clients in this book are fictional composites, and are not based on specific clients with whom I have worked. By the time you’re finished reading this book, I hope you have lots of ideas of how to improve and increase your TIB targeting and that you’ll feel more confident in doing so. How did I get here? Unlike many of the authors in this series, I am not a Marsha Linehan insider. I am, however, very persistent, and I have managed to somehow convince many DBT luminaries to work with me and let me learn from them over the years. Here’s a chaotic (yet also orderly!) list of people I’d like to thank for teaching me about DBT in general and TIB in particular: • The first patient I ever saw in the training clinic at Stony Brook University, who had borderline personality disorder and caused Sue O’Leary to hand me a copy of Cognitive-Behavioral Treatment of Borderline Personality Disorder. Thank you. • Adam Payne, who gave a fellow Stony Brook alum a chance and had me co-lead a multifamily group with him for an entire year and supervised me in individual and family DBT. I owe you my willing hands forever. Adam, you taught me everything I initially knew about DBT (I will now finally admit I have learned a couple things since). Thank you for being a model for how to be a clinician educator while also being a rather Muppet-y human. Chaos and order, again. • Ali DeGeorge, Sasha Izen, and Sara Steinberg, who watched me learn (and struggle with!) DBT in real time and still wanted to hang out with me, even though I was a pretty big jerk about mindfulness at first. • A big thank you to all of the DBT hotshots I have had the pleasure of learning from in workshops and working with through ISITDBT, in no special order: Alec Miller, Jill Rathus, Jennifer Waltz, Aditi Vijay, Melanie Harned, Lizz Dexter-Mazza, Kelly Koerner, Charlie

Preface xix Swenson, Jim Mazza, Katie Dixon-Gordon, Maggie Gorraiz, Nick Salsman, Marcus Rodriguez, Vibh Forsythe Cox, Erica Tan, Clerissa Cooper, Maggie Mullen, Faria Kamal, Carla Chugani, Shireen Rizvi, and of course, Marsha M. Linehan herself. • Thank you especially to Alan Fruzzetti, who responded positively to my DEAR MAN asserting that I should write a book in this series, and to Jennifer Sayrs, who suggested I do the DEAR MAN in the first place (among so many other wonderful and helpful behaviors from you both!). From there, huge thanks go to Kitty Moore, Samantha Grossman, Katherine Sommer, and everyone else at The Guilford Press who has just been a delight (and so reinforcing!) through this whole process. Thank you also to Mimi Melek for her fantastic editing and enthusiasm. • I come from a long line of teachers and I am, first and foremost, a teacher. I have had the privilege of working with an embarrassment of incredible trainees in my career, and have learned so much from each of you. Thanks for making it so much fun and making me a better teacher. If this book is useful to anyone, it’s because of you. • For every DBT patient I have ever had, and all of the parents, too: You are the bravest people I have ever met and working with you during some of your toughest times is a privilege I never take for granted. Thank you for working so hard and for putting up with all of my TIB. You have taught me more than anyone else. • Finally, to all of my DBT teammates past and present at UCSF: You are all so brilliant and kind and dedicated! I pinch myself every day that I got to/get to work with you. How am I so lucky? A special shout-out to Alison Yaeger for hiring me in the first place and teaching me how to be a big girl licensed psychologist. Nothing but love and gratitude to her and also to Barbara Stuart, Auran Piatigorsky, Samantha Fordwood, Anya Ho, Natalie Todd, Sabrina Darrow, Sarah Forsberg, Ashley Maliken, Lindsey Bruett, Joan Jou, Lauren Jung, Julia Charalel, Melissa Wei, and Anthony Daggett. You’re all incredible. And finally, some non-DBT thanks: As a former college radio DJ and training director (listen to KALX 90.7!), I am tempted to list a long and pretentious list of the music I listened to while writing this book, but in the spirit of radical genuineness I will admit that no music gets me to a higher word count faster than the irreverent third-wave ska of Reel Big Fish, who have been helping me complete writing assignments since 1996. Thanks, guys. Gary, Keely, and June: I can’t be dialectical and nonjudgmental about the three of you because you are the absolute best in the world. Your routines give me outright, prolonged laughter (yes, of course I’m crying!). I love you.

Contents CHAPTER 1

Destigmatizing and Demystifying Therapy-Interfering Behavior: Guiding Principles1

CHAPTER 2

What Behaviors Are Therapy-Interfering Behaviors?

12

CHAPTER 3

The Skills and Principles Needed to Address Therapy-Interfering Behavior

28

1

CHAPTER 4 Assessing Therapy-Interfering Behavior

45

CHAPTER 5 How to Address Therapy-Interfering Behavior

64

CHAPTER 6 Addressing Therapy-Interfering Behavior in Skills

79

in Your Client

Class, Coaching Calls, and Family Sessions

CHAPTER 7

Using Contingency Management to Address Therapy-Interfering Behavior

102

CHAPTER 8 When and How to Address Therapy-Interfering

129

CHAPTER 9 The Dialectics of Therapy-Interfering Behavior

153

References

169

Index

171

Behavior in Yourself

Purchasers can download and print enlarged versions of the worksheets at www.guilford.com/shaller-forms for personal use or use with their clients (see copyright page for details).

xxi

CHAPTER 1

Destigmatizing and Demystifying Therapy-Interfering Behavior Guiding Principles

E

very client and therapist I have ever met engages in therapyinterfering behaviors (TIBs): behaviors that interfere with the work that brings clients closer to their therapeutic goals. This may strike some as a nondialectical statement—we’re not supposed to use “evers” and “everys” in dialectical behavior therapy (DBT), right? I begin this book with the idea that all types of TIB are normal and routine. They can even be wonderful opportunities for you and your client to deepen your work together and move closer to achieving your client’s goals. In her original treatment manual, Cognitive-Behavioral Treatment of Borderline Personality Disorder, Marsha Linehan (1993) notes: “The aim of DBT is to create contingencies, enhance capabilities, and reduce inhibitions so that the probability of a patient’s and therapist’s continuing together in therapy is enhanced” (p. 129). What a beautiful notion. Yet again and again in teaching and training clinicians in DBT, I find that addressing TIB creates frustration, confusion, and even fear in clinicians. As you can tell by the title, this book is grounded in DBT. My primary goal is to help DBT therapists improve their ability to work through TIB. Yet every client and every therapist will engage in TIB 1

2

Therapy-Interfering Behavior in DBT

from time to time. Over many years I have taught trainees from a variety of professional backgrounds and therapeutic orientations how to systematically and nonjudgmentally address TIB in their clients, regardless of the treatment plan. Some were working with clients in DBT, but many others were practicing short-term stabilization on an inpatient unit, managing monthly medication dosages, and practicing cognitive-behavioral therapy, or other forms of psychotherapy. The tools and principles in this book should enhance your ability to have frank conversations with your clients about what might be getting in the way of your most effective work together. A quick reminder before I truly begin that TIB is addressed early and often in DBT. Our treatment hierarchy for individual therapy (see Figure 1.1) requires that we address TIB in most sessions, whenever it is present. We prioritize life-threatening behaviors (LTBs), then TIBs, then quality-of-life–interfering behaviors (Linehan, 1993). It’s super important.

DEFINING THERAPY-INTERFERING BEHAVIORS Because TIB is so common, the definition is broad. TIB is any behavior on the part of the clinician or the client (and sometimes of other people in either party’s sphere) that gets in the way of Linehan’s central goal: that the therapist and client continue to work together. TIB can also reduce the overall effectiveness of the work of a client and therapist, even when both remain committed to the treatment. As in other forms of behavior analysis, the intent behind TIB does not matter. TIB can be purposeful and even vindictive, and also entirely unintentional. As a DBT therapist, I am generally agnostic to whether a person means to engage in a TIB. When I encounter TIB, the most important fact is that something is getting in the way of our treatment and we need to figure out how to address it in order to continue our work together. For example, I met with a relatively new client for the second time. She was a 19-year-old woman with an extensive trauma history. I had some general information about her trauma, but not the full story. Since we were early in our work, the first order of business

Destigmatizing and Demystifying Therapy-Interfering Behavior

3

LifeThreating Behavior TherapyInterfering Behavior Quality of LifeInterfering Behavior

FIGURE 1.1. Treatment hierarchy for individual therapy. From Linehan (1993). Copyright © 1993 The Guilford Press. Reprinted by permission.

was to get to know her and address her suicidality and current safety. I was wearing a yellow dress that day; basically I was dressed in bright yellow from head to toe. In contrast to our first session, the client could barely speak. She appeared dissociated and confused; at one point she spoke in her native language, which she had barely used since early childhood. I learned almost nothing about her that day—we simply used distress tolerance skills together. Later in our treatment I learned that the color yellow played an enormous role in her childhood trauma for many years. It was no wonder that she couldn’t focus. Of course, I did not rub my hands together in front of my closet the morning of that session with an evil glint in my eye, thinking, “What outfit would be most unsettling to my new client?” I’m also sure she did not think, “This therapist dares to wear yellow? I shall punish her.” An entirely arbitrary decision on my part caused an entirely involuntary behavior on her part (dissociating and becoming dysregulated). Both of our behaviors interfered with the therapy; we couldn’t get to the work we needed to do to help her build her life worth living. Of course, some TIB may be less “innocent” on the part of both

4

Therapy-Interfering Behavior in DBT

the therapist and the client. I address intentional TIB the same way: descriptively, nonjudgmentally, and with the utmost compassion for the suffering that is bringing our clients to see us in the first place.

WHY ADDRESS THERAPY-INTERFERING BEHAVIOR? If you are holding this book, you probably already think addressing TIB could enhance your work. There are many reasons addressing TIB is effective, probably more than I discuss in this book. The top eight reasons to address TIB include the following: 1. Addressing TIB helps your client meet their treatment goals. All of our clients are working toward creating a different life—one that is more worth living than their current life. If we are doing our job as DBT therapists, we have a clear road map for how they can get there, and the route winds through our DBT program. If they are doing something that slows down or gets in the way of that work (e.g., not doing their diary cards, missing sessions due to poor calendaring), that will make the path to their goals that much longer and harder. TIB could also increase their hopelessness and decrease their motivation. We want to avoid all of these outcomes, and addressing TIB early and often helps us do that. 2. Addressing TIB in therapy helps your client in other areas of their life, too. Whatever TIB your client is engaging in with you, there’s a good chance it is also a relationship- or life-interfering behavior in another context. Is your client missing appointments because things aren’t written in their calendar? Guess who is likely to cancel on their friends and family or miss job commitments? Are they not filling out the diary card? Guess who likely isn’t turning assignments in on time? What other daily follow-through might they be dropping, thus disappointing someone else in their life? When behaviors similar to their TIB show up in real life, clients are often limited by them, which can delay reaching their goals. In addition, these behaviors in their daily lives can elicit judgments and stigmatizing language from others, potentially leading to shame and guilt. Addressing TIB mitigates these problems.



Destigmatizing and Demystifying Therapy-Interfering Behavior 5

3. Addressing TIB helps prevent burnout in the therapist. As DBT therapists, we work very hard on behalf of our clients’ goals—in turn, we hope to shape our clients so that they reinforce this hard work in us. When left unaddressed, TIB slowly chips away at the reinforcement therapists receive from their clients, the most powerful of which is, of course, the client meeting their goals. Slow progress is hard for therapists to tolerate for many reasons: we get discouraged, we lose the forest for the trees, we can get pulled in to a client’s hopelessness. The central work of DBT already moves slowly, and TIBs that slow it down even more can be really hard for therapists to tolerate. We are also better therapists when we are engaged with our clients’ lives—when we look forward to seeing them and when we bring our best attention to sessions. When we fail to address TIBs, such as not completing homework, shutting down, or name-calling, our emotions can get in the way of bringing our best selves to the work. Frustration, annoyance, and even dread can accompany us to session, which hinders our best therapist selves. Addressing TIB improves the therapeutic alliance and has the potential to increase reinforcement for both therapist and client, as they work to solve a problem together. An example may help. I began writing this at the tail end of the COVID-19 pandemic, at a time when many of us were shut in our homes, doing teletherapy. In the thick of it, a teenager I was seeing refused to turn their camera on. They just didn’t want to. They told me they were mad at their parents and thus would only “half” come to session. I was already tired of telehealth. I hate it enough on its own, without this teenager refusing to let me do my job. Did this refusal to accept my current reality and judgment of my client help me do my job? Spoiler alert: It did not. The ability to directly address TIB as a target and have open conversations about it opens up whole worlds to us as clinicians. We have tools to directly address the client behaviors (and our own behaviors) that most directly contribute to our burnout. In this case I had options—I could work on my own radical acceptance and distress tolerance while we had no choice but to do telehealth. Eventually, we could switch to in-person work, which was much better for this client. Once in person, they shared that the computer screen felt

6

Therapy-Interfering Behavior in DBT

like a fence between us that made it easier for them to pretend that I didn’t care about them and wasn’t a real person. However, if I kept judging the client for their challenges with telehealth, we would not have been able to address the issue effectively. Turns out in person I liked them and they liked me. This isn’t just about telehealth. Addressing TIB helps us shape our clients so that they are more reinforcing to us—that is, we will enjoy working with them more. It also allows our clients to shape our behavior to be more reinforcing to them and their progress. This two-way street of reinforcement can increase satisfaction for both the therapist and the client. Not only can it keep a client in treatment but this higher level of therapist satisfaction can contribute to our overall longevity in the field. Therapists who feel good about their work are less likely to drop out and become florists. 4. Addressing TIB reduces shame in the long term and keeps clients from burning bridges. While we have made many strides toward mental health representation in our society, stigma continues to have a great impact. Our clients’ histories and diagnoses can affect how they are treated. Many of our clients’ behaviors cause problems for them not just in close interpersonal relationships but can even block them from participating in large groups or organizations. For example, I have had many clients exited from their schools because the school was worried about their safety (private and faith-based schools in the United States can dismiss students at will, while public schools are federally mandated to provide a suitable learning environment for all students). Sometimes they also exit them because of the impact the client’s behavior is having (or could have) on other students. Many a psychiatry or psychology department, my own included, has expressed trepidation about housing a DBT program that caters specifically to chronically emotionally dysregulated individuals. Clients in our DBT program have yelled in our peaceful waiting area, thrown chairs in conference rooms, and lied in extreme and invalidating ways to other group members, for example. By addressing these behaviors openly and honestly and making clear behavioral plans to reduce them, we give our clients the opportunity to stay in programs and other organizations that



Destigmatizing and Demystifying Therapy-Interfering Behavior 7

are important to their goals (e.g., schools, faith communities, volunteer organizations, and jobs). 5. Addressing TIB makes us more culturally competent and humble. If therapists are unaware of their own implicit or explicit cultural biases, they will not be much help to their clients. TIB’s important place on the DBT treatment hierarchy reminds us that we need to pay attention to it, and thus gives us a template for paying attention to cultural missteps and challenges related to cultural noncongruence with our clients. I give more specific examples throughout the book. For now, I highlight that if I am treating someone from a background that is different from my own or new to me, it is my job as the therapist to make sure I get consultation on how to support that client as best as possible. Not doing so would be TIB on my part. The concept of TIB also reminds us to stay curious and not make assumptions about our clients based on any personal characteristics. 6. Addressing TIB makes us better therapists overall . . . There are a million subtle and not-so-subtle ways that different behaviors can get in the way of achieving therapeutic success. As a clinician, it is always my goal to improve my own skills so that I can help my clients reach their goals quickly. Building the skill set and habits required to effectively address TIB in my clients helps me become more effective at facilitating them reaching their goals. Building the humility and observation skills that allow me to address my own TIB—this is even better for my future clients. It’s a win–win. 7. . . . and better at DBT, specifically. Within DBT, addressing TIB allows us to align ourselves strongly with our Therapist Agreements and our Consultation Agreements (see Linehan, 1993, pp. 115–119). Targeting TIB helps us keep all of these agreements in mind. I can’t think of another part of the DBT treatment hierarchy that is as closely aligned with so many of the things we pledge to do for our clients. 8. Addressing TIB saves lives! We know that people seeking treatment for suicide, self-harm, borderline personality disorder

8

Therapy-Interfering Behavior in DBT

(BPD), and other forms of mood dysregulation are suffering. If they weren’t experiencing extreme suffering, they would not be engaging in the behaviors that have brought them to treatment. We all want to bring our clients relief as quickly as possible. By addressing TIB, we can get them back on track to address the things that matter most, thus keeping them alive another day to fight for their life worth living.

THE PRINCIPLES OF ADDRESSING THERAPY-INTERFERING BEHAVIOR You already read that the intention of the TIB doesn’t matter but it is such a crucial part of addressing TIB that I mention it repeatedly throughout this book. We do not care much about why a client (or a clinician) is engaging in TIB. “Why” clients (or you) are engaging in TIB may lead to a particular problem-solving strategy, of course. And yet, when we name TIB it simply matters that the behavior is getting in the way of the therapy. I have had many teenage clients who have arranged their own transportation to sessions over the years. Some are 20 minutes late because they have to take three connecting buses in San Francisco’s infamously inefficient and unreliable Municipal Rail System (sorry MUNI: I love you, but it’s true). Some are 20 minutes late because they were cruising the Haight–Ashbury neighborhood with their friends and simply did not want to come to session (and are happy to tell me this directly!). The outcome for these clients is identical: We now have only 30 minutes to work on enhancing their motivation, chaining behaviors, and teaching skills (instead of our usual 50 minutes). Thus, these are equally important TIBs to target. You might be thinking to yourself—but wait, the context matters! The client who is working so hard to get to session and is foiled by public transportation is clearly more dedicated to the treatment than the client who was trying on vintage tie-dye. Right? As with so many things in DBT, the answer is “it depends.” From the observations above I don’t really know yet. We’re going to do some behavior chains and we’ll learn more. Maybe my discussion with the client stuck on public transportation will be very quick (“sounds like you



Destigmatizing and Demystifying Therapy-Interfering Behavior 9

have to leave even earlier?”) and maybe my discussion with the procrastinating client will be much longer. Nonetheless, my goal is for both of them to walk away from the conversation with a plan to attend 100% of our next session. We need every precious minute. When orienting clients to addressing TIB, it is incredibly important to convey this idea clearly and thoroughly from the very beginning of your work. People in DBT are prone to shame, and any hint that they are “getting in trouble” can be a signal to shut down or run for the hills. Below are some general principles that I will return to again and again in observing and describing TIB for ourselves and our clients (see Table 1.1). 1. Think behaviorally. You are going to be descriptive and precise. You are also going to do careful behavior chains and missing link analyses to figure out how to address a given TIB. We will use positive reinforcement of progress and improvement every chance we get. We will use extinction in the form of blocking and ignoring and also tolerating when we can’t reinforce. We will hardly ever use punishment and we will be extremely careful when we do, consulting with our team at every step. 2. Be grounded in and aware of our assumptions. We keep in mind our DBT assumptions about both clients and therapists. We will also consider our larger assumptions, the ones we can’t always see so clearly. We will consider our own backgrounds, our clients’ backgrounds, and any and all systems of oppression that may affect each of us in different ways. We will lean on our team and relevant outside consultants when we need help growing in these areas. TABLE 1.1.  Principles for Addressing TIB 1. Think behaviorally. 2. Be grounded in and aware of our assumptions. 3. Be curious. 4. Normalize, normalize, normalize. 5. Listen closely to the TIB. 6. Exposure works on therapists, too!

10

Therapy-Interfering Behavior in DBT

3. Be curious. We will watch our small, in-the-moment assumptions as well. We will use mindfulness to guide our assessment and interventions around TIB. When we are in emotion mind and/or judging our client and their behaviors, we will lean on our team and search for wise mind before proceeding. 4. Normalize, normalize, normalize. We will work to contain our anger, frustration, and other aversive emotions and thoughts about our clients when they engage in TIB. We will use our own DBT skills. TIB is an expected part of treatment. Clients are seeking help and we have skills to work through these behaviors. TIB is also normal; change is hard. Motivation waxes and wanes in all people, and our clients are no different. I am a creative and imaginative person, so much so that I spent most of my childhood indoors and never really learned how to extract natural reinforcement from physical activity. Do I want to be physically healthy? Of course. I want to live a long life and be here for my children and my husband. Does that mean I got up and went for a run this morning when my alarm went off? It does not. My behavior and my dedication do not always line up with my values. 5. Listen closely to the TIB. We have much to learn from it. There are kernels of truth in client TIBs that we as clinicians need to listen to. My teenage client who was cavorting around the Haight didn’t have much other reinforcement in her life. We desperately needed to target that in session. I helped her find more daily reinforcement outside of session time and worked to get her parents to allow her regular time with peers. Once that was established, I was able to help her prioritize our session time. Remember, addressing TIB is an important part of the treatment, it’s not an impediment to the treatment. 6. Exposure works on therapists, too! The more you address TIB, the better you get at doing it, the easier it will be, and the more rewarded you will be by the outcomes. I will address both clinician fears about TIB and clinician anger about TIB throughout the book (and while I’m at it, shame and guilt about TIB, too). I promise your



Destigmatizing and Demystifying Therapy-Interfering Behavior 11

exposure to all of these emotions and your deliberate practice managing TIB will improve your overall therapy and confidence. Working with TIB is my favorite part of DBT. Anyone who has worked with or trained with me knows I say that about a billion different parts of DBT but working with TIB is at least in my top five. What a revolution to give both clinicians and our clients permission—no, a mandate—to respond to difficult-to-address behaviors. It’s freeing, it’s essential, and it works. When we get TIB out of the way, we can focus on creating more space for therapyenhancing behaviors of all types. It’s reinforcing, sometimes hilarious, and always important. Let’s get started!

CHAPTER 2

What Behaviors Are Therapy-Interfering Behaviors?

I

trust the first chapter has convinced you that you need to take TIB seriously. This chapter delves deeper into the major categories of TIB as outlined by Linehan (1993). Exactly which behaviors are we targeting? And which behaviors may masquerade as TIB?

THREE CATEGORIES OF THERAPY-INTERFERING BEHAVIORS FOR CLIENTS Linehan defines three broad categories of TIB: behaviors that interfere with receiving therapy, behaviors that interfere with other clients, and behaviors that burn out therapists. I will spend some time on each. 1. Behaviors that interfere with receiving therapy. As therapists, we must get our clients an adequate dose of our treatment, and to do so, they need to be present. Clients may engage in several different types of behaviors that prevent them from receiving therapy. Linehan categorizes them as nonattentive, noncollaborative, and noncompliant behaviors. a. Nonattentive behaviors. Have you ever been to a lecture, or even a movie, and realized you missed everything that was just 12



What Behaviors Are Therapy-Interfering Behaviors? 13

said in the last 15 minutes? Or is this just me? This is, of course, a common human experience. We often miss things that happen right in front of us. Yet when what our clients are missing is DBT, they are missing some life-changing or even lifesaving information. We must do everything we can to understand the behaviors that are leading to both physical and psychological nonattention and work to reduce them. These behaviors can be as simple as missing sessions and as complex as having a panic attack or dissociating during session. When clients share suicidal plans with people who have the legal power and the inclination to hospitalize them (an emergency room [ER] nurse, a medical provider not on your DBT team), this TIB would likely result in missing both skills group and individual session that week. Each of these behaviors are examples of nonattendance and each should be targeted to optimize the dose of DBT that your client is getting. b. Noncollaborative behaviors. Of course, collaboration is a requirement of nearly all forms of psychotherapy. There is a strong dialectic here, as collaborative behaviors are challenging for many clients with chronic emotional dysregulation to sustain. Increasing collaboration is an active goal of treatment and noncollaboration in DBT is considered a TIB. It is common for the teenagers I work with, for example, to respond with “I don’t know” when I ask about their emotions on a behavior chain. I believe, in fact, that many of them legitimately don’t know what they were feeling. Nonetheless, this also gets in the way of us doing the work we need to do, so we target it as a behavior to increase (accurate observing and describing of emotions) and to decrease (the TIB of not labeling emotions). c. Noncompliant behaviors. Noncompliance refers to specific times when clients in DBT refuse to do what has been agreed to as essential to the treatment (and in line, therefore, with their long-term, wise-mind goals). Accountability and followthrough are essential in DBT, and failure to do what both client and therapist have agreed will help is a TIB that needs to be addressed.

14

Therapy-Interfering Behavior in DBT

2. Behaviors that interfere with other clients. Beyond their own treatment, people in DBT can get in the way of others receiving the treatment they need. Linehan notes “openly hostile attacks” are the most common way that one client can interfere with another’s treatment, given the exquisite sensitivity of those with BPD and thus their tendency to perceive even carefully given feedback as an attack. We have seen many other ways of interfering with other clients’ treatment in our clinic over the years, including but not limited to lying to another client about their background in order to gain trust, bringing up triggering content in skills class such that other clients become dissociated or dysregulated, and sowing doubts about a specific therapist’s commitment to their client. 3. Behaviors that burn out therapists. Last, I focus on behaviors our clients engage in that can contribute to our burnout as therapists. Of course, everything in DBT is context dependent and idiosyncratic— a behavior that is likely to cause burnout in me may not do so in you. Linehan points out that addressing burnout-inducing TIBs is a process closely tied to the Observing Limits Agreement—a therapist must know and understand their own limits in order to understand whether a behavior is likely to bring them closer to burnout. Thus, it is essential that this category of TIB is examined anew in every therapist–client dyad. That said, Linehan identifies some broad categories that are most likely to lead to burnout. These include behaviors that push the therapist’s personal limits, behaviors that push organizational limits, behaviors that decrease the therapist’s motivation, and behaviors that reduce milieu or group members’ motivation. a. Behaviors that push the therapist’s personal limits. All boundaries are context dependent—there are no “right” or “wrong” boundaries. However, clients commonly exhibit behaviors that bump against the majority of therapists’ personal limits. Most commonly, this TIB occurs when a client refuses to use the strategies that have been identified to help them make progress in therapy. However, this type of behavior can also be direct threats or name-calling to a therapist, demanding extra sessions or coaching calls that the therapist cannot give, or a lack of gratitude expressed for the work the therapist is doing on



What Behaviors Are Therapy-Interfering Behaviors? 15

behalf of the client. It is essential that these TIBs are viewed as interactions between the therapist’s limits and the client’s current behavior, not as something objectively “wrong” or “inappropriate” that the client is doing. As a person who works with teenagers, I have been called a lot of creative names over the years. None of them particularly cross my limits. That said, I’m aware that as a white, heterosexual, and cisgender person, there are few (if any) names that carry the weight that a racial or homophobic slur can carry for my lesbian, gay, bisexual, transgender, queer/questioning, plus (LGBTQ+) colleagues and colleagues of color. Our different limits as therapists are context specific and have to be addressed as such. b. Behaviors that push organizational limits. Many hospitals, office parks, and outpatient clinics have been hesitant to house DBT programs over the years. Some of this is a result of stigma, pure and simple. Sometimes, however, it is due to the actual behavior of our clients in these spaces. Yelling or shouting at therapists or reception staff can make those around the client feel uneasy. Sometimes organizations are also concerned about liability and keeping the environment safe enough for clients in DBT themselves. When clients “behave themselves”—that is, behave in a way to not draw concern or ire from a larger organization like a hospital or university—this is therapy-enhancing behavior. The extent to which clients can act in a way that doesn’t draw negative attention to them is therapy enhancing. Engaging in organizational limit-pushing behaviors is therapy interfering. I’d like to be crystal clear that the idea that these behaviors help or hinder therapy says nothing about the fairness or appropriateness of large organizations having these limits. Our clients are entitled to help, even when they engage in behaviors that push organizational limits. It is simply true that when they do so, it has the potential to interfere with their treatment. c. Behaviors that decrease the therapist’s motivation. DBT therapists work hard. We are invested in our clients and make ourselves available during many hours of our personal lives in order to support them in reaching their goals. It is essential that we, as therapists, have a good idea about what keeps

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us motivated. It is also important for us to observe our limits with our clients and help teach them how to motivate us. “Yes butting,” or shooting down skill ideas, is a common motivation killer but a client may only be expressing their doubts or hopelessness and have no idea that these behaviors are having a negative impact on their therapist (and likely other people in their lives). Many therapists on my team get frustrated when clients don’t thank them. Others feel de-motivated when the client never calls for coaching and appears disengaged. d. Behaviors that reduce milieu or group members’ motivation. There are many layers to a DBT skills group or milieu. There are leaders, other clients, possibly residential staff, and depending on the age of participants and the setting, their caregivers and/or other family members. At least 50% of these people are, by definition, exquisitely sensitive, and in our experience that number is even higher. Things are bound to come up! Group members can be distressed by other members’ behavior (whether it be considered insensitive or rude or whether it is simply too similar to their own behavior and thus upsetting). They can also be distressed by the way we as DBT therapists run the group. Group members may also push back against organizational or program policies. For example, in our multifamily groups, we have people put their cell phones on “phone vacation” during group, in order to be more mindful. Some people love it, some people hate it. While these types of struggles are an opportunity to use skills, there are times that behaviors that reduce others’ motivation can really get in the way of treatment. Simply put, a group member who is so irritated by others’ behavior in the group may not want to attend, and thus, may miss learning important skills that they need.

WHAT BEHAVIORS ARE NOT THERAPY-INTERFERING BEHAVIORS? From the list above, you may be starting to think that almost everything can be a TIB. There are a few behaviors that are often mislabeled as TIB that are worth highlighting separately here.



What Behaviors Are Therapy-Interfering Behaviors? 17

1. Behaviors for which clients need treatment are not generally viewed as TIB. Our clients engage in a wide variety of extremely challenging behaviors and many of them are the exact reasons they are coming to us: suicidal threats and behaviors, self-harm, problems with anger, risky sexual behavior, binge eating . . . the list is long. However, the mere existence of these problems does not make them TIB. In fact, these are often our primary targets for change. That said, they often contain nuances of TIB. Consider the following examples: a. As Marsha Linehan has noted many times, you can’t teach new behaviors to a corpse. Killing yourself is the ultimate TIB, functionally speaking. At the same time, the fact that our clients are struggling with self-harm urges and suicidal ideation (SI) is generally what they are seeking help for. Having suicidal thoughts is not a TIB—lying about it, or discussing those suicidal thoughts with someone who may hospitalize you (and therefore take you out of your DBT treatment) is. b. Similarly, a client skipping meals is not, in and of itself, a TIB. This behavior is a target of our interventions. However, if a client has skipped many meals and has so little nutrition in their system that they cannot learn and take in information from therapy or skills class, this is also a TIB. We can say the same about drug use more generally and coming to treatment while high. The former is a regular target of DBT, the latter is both a target and TIB. c. Therapists may find themselves getting angry or frustrated at clients for continuing to engage in the behaviors they are attempting to help them stop. These emotions, while valid and understandable, are our TIB, as therapists. It is upon us to use our team to come back to a place of empathy, tolerate slow progress, and reenergize ourselves to fight these behaviors alongside the client. The DBT assumptions tell us our clients cannot fail in DBT. If someone is still cutting 3 months into the treatment, the responsibility to help them stop lies with us (and also with DBT itself). 2. Slow progress is a feature of work that attempts to change many complex and entrenched behaviors. Slow progress in and of itself is not

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a TIB, though some forms of TIB may in fact be slowing progress down (e.g., not attending sessions, not completing therapy homework, “yes, butting”).

THERAPISTS ENGAGE IN THERAPY-INTERFERING BEHAVIORS, TOO Of course, as therapists we are not innocent here. As human beings, we also get in the way of our clients’ therapy from time to time, even when we’re working very hard not to. The major types of TIB therapists tend to perform involve imbalances and disrespect (see Table 2.1). 1. Interpersonal imbalances. Every interpersonal dyad has its share of imbalances. My daughters are 30 years younger than I am and they did not experience the 1990s (poor things). My editor has probably forgotten more about DBT than I will ever know (thanks for your mentorship, Alan!). A key to successful relationships (and thus, successful treatment) in these scenarios is to acknowledge the imbalances that occur both naturally within the relationship and those that can develop over the course of a given session and to address them as effectively as possible. In this way, we can work to stop them from capsizing our therapeutic canoe. These imbalances include acceptance versus change, and imbalances in power, information, and emotion regulation. a. Acceptance versus change. By far the most common imbalance I have seen in all of my years of doing, teaching, and supervising DBT is in the therapist not using acceptance and TABLE 2.1.  Types of Therapist TIB 1. Imbalances a. Interpersonal imbalances b. Power imbalances c. Information imbalances d. Emotion regulation imbalances 2. Disrespect



What Behaviors Are Therapy-Interfering Behaviors? 19

change strategies judiciously and as needed. The vast majority of therapists feel at least slightly more comfortable leaning toward change or leaning toward acceptance. Take a minute and do a personal inventory by answering the questions in Table 2.2: Where do you fall? If your answers included irreverence, clarifying contingencies, and providing hard truths, you likely lean toward change. If your answers included validation, comforting, and allowing clients to come to their own realizations, you likely lean toward acceptance. Whether you lean toward acceptance or change, you have likely used that strategy at a time when your client needed the other one. Within acceptance and change, there are several more specific imbalances that can occur: flexibility versus stability, nurturing versus demanding change, and reciprocal versus irreverent communication. i. Flexibility versus stability. DBT contains many rules. Many have pointed this out, including novice therapists learning DBT, teenagers in the program, and outright critics of the approach. I suppose one can see DBT as rule filled but most therapies have their share of rules. The key with this dialectic is to note the principles and flexibility underlying the rules. DBT therapists must both adhere to the rules when required, and be flexible when it is not necessary to follow the rules. We must be stable and consistent in pushing for change that by its nature will take time, while also not switching strategies so often that there is no way change can take root. We need to respect the rules while not getting caught up in rules for rules’ sake. TIB occurs here when we follow the letter of the law as opposed to the spirit of the law. TIB Tip Anytime a DBT therapist is following the letter (form) of the law instead of the spirit (function) of the law is a time to watch out for potential TIB.

An example may help: In DBT, we require our clients to fill out diary cards. You might call it a rule. I once had a client

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TABLE 2.2.  Personal Inventory Questions • Do you gravitate toward irreverence, or do you love to validate? • Do you enjoy clarifying contingencies, or do you prefer to comfort? • Do you lean toward providing “hard truths,” or do you want the client to come to realizations on their own?

who was engaged in DBT in almost every way: She was on time, eager to do behavior chains, and able to use coaching appropriately. She just could not do her diary card. It became more and more therapy interfering, and I wasted precious session time attempting to get her to complete her diary card. Finally, I came to understand that this client’s severe learning disabilities and attention-deficit/hyperactivity disorder (ADHD) were getting in the way of completing her diary card. The card itself was too overwhelming and the effort of writing it down and making sense of her day was too great. This challenge triggered shame, and the benefit of self-tracking was thus completely lost. When we finally figured this out, she began leaving me short daily voicemails with her ratings (by looking at a modified diary card with only one row on it). We listened to the messages together at the beginning of our sessions and we were ready to set our agenda, without 20 minutes or more of verbally wrestling over the diary card. The letter of the law for DBT is “all clients must do a diary card.” But, the spirit of the law is “clients need to learn to use their mindfulness; self-monitor their emotions, behaviors, and skill use; and think about DBT when they are out in the world, living their lives.” We finally followed the spirit of the law (though I delayed this a great deal with my own TIB). ii. Nurturing versus demanding change. Our clients have suffered a great deal, and as DBT therapists, we want to help them. Sometimes we help too much, and sometimes we don’t help enough. For example, many of my clients have a hard time talking with their psychiatrist. They don’t feel heard at times, and they worry that their psychiatrist won’t take their concerns seriously. If their psychiatrist is a colleague of mine, it would be



What Behaviors Are Therapy-Interfering Behaviors? 21

very easy for me to walk down the hall and talk with them about what I feel would be most helpful to my client. This would also be completely against the DBT principle of “consultation to the client,” and would not help my client learn to self-advocate effectively. Consider another example about session process. Sometimes it can be tempting to “rescue” our clients from strong emotions, even when it would be more effective to let them feel their feelings. As people, we want to make those around us feel better, so we may have the urge to comfort a crying client rather than let them notice that they are crying and try to connect with and understand the emotion. It’s hard to know when our shut-down, overwhelmed clients can step up to the plate and when they may need us to advocate for them. We may provide more help than is truly necessary by allowing them to avoid challenging topics, or texting them to remind them to do their diary cards rather than troubleshooting how they can follow through on important interventions. Conversely, we might say things like “If he really wants to change, he’ll do X, like we agreed.” In waiting for him to do behavior X, we may miss the fact that the client lacks those skills and needs our support/scaffolding to even attempt X. iii. Reciprocal versus irreverent communication. Both irreverence and therapeutic warmth, or reciprocal communication, are strategies in DBT. They are used to soothe and validate a client to keep them regulated (reciprocity) and to shake them up or surprise them (irreverence)—to keep them “off balance” and also to aid memory. Both stylistic strategies help the client and therapist avoid slipping into an emotion–mind abyss in session (and risk not accomplishing anything on the agenda). Yet both strategies have their pitfalls when applied mindlessly by therapists. Self-disclosure and warmth can be overused and reinforced by a client such that the therapist’s personal information becomes central to a given therapeutic interaction, even though it is irrelevant to therapeutic goals. In extreme situations, this can become therapy-destroying behavior, such as in

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the case of romantic and/or sexual relationships between therapist and client. Too much irreverence, especially when coming from a therapist’s frustration or own personal emotions, can also be therapy interfering. There is no excuse for cruelty or mean-spirited sarcasm in DBT. b. Power imbalances. By definition, as licensed professionals we are in a more powerful position than our clients. DBT is first and foremost a treatment for people who are chronically suicidal. Unfortunately, most mental health care systems are set up so that people who are chronically suicidal get hospitalized, often frequently. This means that many people—and their family members—who find themselves in DBT have had people in medical authority take something from them: guns, medications, independence, time alone, and in the most extreme cases (involuntary hospitalizations), all of their civil liberties. This could leave anyone suspicious of the power their therapist can wield over them and can be a barrier to trust that must be addressed for clients who have had these experiences. In addition, there are many personal characteristics that can confer additional power to the therapist: age, race, ethnicity, country of origin, and being able-bodied, cisgender, and heterosexual. All of these areas of potential privilege should be effectively acknowledged to attempt to address power imbalances early on in treatment. That way, if they become therapy interfering, you and your client are ready to dive in and discuss them, together. An example follows: TIB Tip Doing your own individual work as a therapist to understand your identity and acknowledge your privilege is an essential part of preventing therapist TIB.

Therapist: There’s one more thing I want to talk about related to TIB, and that’s the power imbalances in our relationship. Client: What do you mean?



What Behaviors Are Therapy-Interfering Behaviors? 23

Therapist: Well, for instance, I know you’ve been hospitalized a number of times, right? Client: Yeah . . . Therapist: And who wrote the orders for those hospitalizations? Client: Mostly random people in the ER, but one time it was my last therapist. Therapist: Exactly. I know that you know that legally, I could do that. Hypothetically, if I felt hospitalization would be helpful. Client: But you said you don’t think hospitalization is helpful! Therapist: That’s true, I don’t! And I will show you over time that you and I are going to work together to make sure we avoid that. At the same time, the truth is that I do have legal power to hospitalize you, and you don’t have that power over me. I just want you to know I see that, and I hope we can work together to make that reality irrelevant in the context of our work together. Client: I’m not sure what you mean. Therapist: Well, I have no desire to use that power, but I also think it would be perfectly reasonable of you to be a little suspicious of me about this topic for a while. And I hope we can talk about it if it comes up. Client: Oh, OK. That sounds good. Therapist: Great. There are also some other ways that you may perceive I have more power, and I think we should be honest about those, too. Client: Like what? Therapist: Well, these things have different effects on different people, but my age, for instance. As a young adult, you probably have a lot of older people telling you what to do. Client: For sure. Therapist: I’m also a cisgender straight white lady, and you are not.

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Client: Ha! Nope. Therapist: So, there are some circumstances where I wield more power than you because of my race and other personal characteristics—and I’m going to work hard to try to make sure that our work together is not one of those places. And this means I really want feedback about this stuff. So if you think I’m throwing my “white lady-ness” around and missing something about your experience as a Latino dude, I need you to call me on it. Client: Yikes. OK. That might be hard. Therapist: Oh, for sure, that’s why I’m going to make sure to put it on the agenda to invite you to give me that kind of feedback, so we don’t lose sight of it. Do you think that would help? Client: Yes, actually—if you say I need to give you feedback about this kind of stuff, then I think I will be more likely to. Therapist: Perfect! Are there any other power imbalances between us, do you think? c. Information imbalances. We often have more sources of information about our clients than they do about us. We may get this information without even asking—family members or referring providers leave us messages, hospitals send us discharge summaries. To reduce my own TIB as much as possible, I try to decrease this information imbalance by orienting my client’s community that in general, I will not hold secrets from them. We also know more about DBT than our clients do (at least when they start the treatment). One thing I love about DBT is that we do not withhold information from our clients. There is no supposition that I have access to knowledge to which only therapists are privy. I have had clients and families read books about DBT, even the treatment manual, and I am thrilled for them to get as much information as possible. My goal is to be transparent with my clients to empower them to take control of their own lives. Nonetheless, I acknowledge and am honest with them about our information imbalance at the beginning of treatment and along the way.



What Behaviors Are Therapy-Interfering Behaviors? 25 TIB Tip The transparency required by DBT works to level power imbalances that could result in TIB.

We have another information imbalance in our therapeutic relationship as well, though. My client will always have more real information about themselves than I will ever have. They are the only one living their life at every moment. Making this clear to our clients from the start, that I respect their expertise in their own experience, and that I want them to tell me if I get something wrong, helps regulate this imbalance and keeps us on the right track. d. Emotion regulation imbalances. Our clients generally have lots of shame for not being able to get their emotions under control and for acting in a dysregulated way in many areas of their lives. Due to the invalidating environment, they have also internalized a lot of messages indicating that emotion regulation “should be” easier than it is, and that they are uniquely failing for having the big emotions (and the resulting big behaviors) that they have. On average, DBT therapists at the very least appear to be much more globally regulated than their clients. We have to work to overcome this imbalance in the current experience of emotion dysregulation to bridge the gap with our clients—to show them that all people can and do have big emotions and that everyone gets dysregulated sometimes. That said, the imbalance of therapists having more emotional control than their clients (or at least appearing so) remains. There is an argument that this imbalance is useful—who would trust a hairstylist with a terrible haircut? Our clients likely don’t want us to be as dysregulated as they are, or they might have little faith in our abilities to help them. Still, being aware of this imbalance and attending to the potential shame associated with it is important. 2. “Disrespect.” The choice to put the term “disrespect” in quotation marks is a deliberate one. In DBT, we look at everything in context. As there are no empirically “correct” personal boundaries, there are no behaviors that are inherently disrespectful. As with

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behaviors of a client that convey disrespect, behaviors of the therapist that do so may be intentional or not, and may actually deliver the message of disrespect to some clients and not others. The important thing when addressing a client who has felt disrespected by us is to understand the impact our behavior has had on them and work toward the opportunity to repair. In many cases, our clients have not achieved successful relationship repairs in other contexts. The opportunity to be hurt in this way by someone and then to be able to find a way to still have an effective relationship is an enormous therapeutic opportunity. The following principles and guidelines can help us in understanding when a client has been “disrespected” by our actions. a. Intent versus impact. Put simply, your intent doesn’t matter. The impact is important. I am a joke-y, quip-y person, and this manner works well with many teenagers to ease them along and show them that I don’t think their entire lives are miserable or broken. I am reinforced for this way of speaking and interacting about 90% of the time, both in the therapy room and in my personal life. However, some clients do not like this. They think I am making a joke at their expense. They find my small asides unprofessional. That impact is therapy interfering, so I need to figure out a better and different way to interact with that client. Now, on the other side of the dialectic, might it be helpful for that client to learn to tolerate it when other people don’t behave the way they want them to? Maybe. And I am not going to get them there by being defensive and bringing that up when my actions have hurt them. One thing at a time. b. Microaggressions and implicit bias. Both microaggressions and implicit bias can contribute to conveying disrespect to our clients. A microaggression is a statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group (Sue et al., 2007). Implicit bias involves the unconscious attitudes or stereotypes that affect our understanding, actions, and decisions (Rae, Newheiser, & Olson, 2015). It is not our client’s job to point these out to us (though if they do, we strive to gratefully and graciously receive their feedback). As DBT therapists, we must



What Behaviors Are Therapy-Interfering Behaviors? 27

work with our teams to reduce microaggressions and be aware of our own biases and larger systems of oppression that may make us likely, even if inadvertently, to convey disrespect to our clients. c. Purposeful displays of anger, or “meanness.” As it turns out, DBT therapists are human. Sometimes we snap! Sometimes we are actually mean, short-tempered, or just generally ineffective in our words to our clients. When this happens, we acknowledge our ineffectiveness and make a repair. Remember, TIB can appear anywhere: in a milieu, in family or couple’s sessions, in skills class, and in individual therapy. It happens on coaching calls and during and between session skill practice, when the therapist isn’t even around. It takes a great deal of focus and mindfulness to root out TIB in all of its forms. In the next chapter, I focus on you, the therapist: How can you best equip yourself to address TIB in all the places in which it is imperative to do so?

CHAPTER 3

The Skills and Principles Needed to Address Therapy-Interfering Behavior

Y

ou now have a clearer idea of what TIB is and why it’s so central to our work as DBT therapists. Before we even get into the room with a client, we need to be clear about what skills and practices set us up for success in addressing TIB. This chapter should help you do just that.

THERAPIST TOOLS FOR ADDRESSING THERAPY-INTERFERING BEHAVIOR The principles of DBT provide the direction on how to proceed in assessing and targeting TIB. Three guiding principles will set you up for successfully changing TIB: mindfulness, behaviorism, and dialectics. These are what you’re going to do to target TIB. Of course, because it’s DBT, we also need some “how skills” for TIB. We need to address TIB with curiosity, humility, vulnerability, and genuineness. We go over each of these in more detail in the next sections.

“What Skills” for Therapy-Interfering Behavior Just like our “what skills” in standard DBT are what we do to get into wise mind, our “what skills” for addressing TIB are what we 28



Skills and Principles to Address Therapy-Interfering Behavior 29

use to effectively address TIB in yourself and in your clients (you may notice that these are also our three pillars of DBT more generally. Surprise!): 1. Mindfulness. Given we’re doing DBT, we first focus on mindfulness. I could write a whole book on how central mindfulness is to addressing TIB. Without it, we would be lost. Using an open mind to catch minute-to-minute changes in the therapy room is of the utmost importance. What micro expression has my client just displayed when I asked them to tell me more about a particular friend or family member? When my typically agreeable client storms out of session unexpectedly, how do I interpret their behavior? My use of all three of the standard mindfulness “how skills” (one mindfully, nonjudgmentally, and effectively) are essential so that I can be as accurate and specific as possible when describing TIB to my team. I need to be able to fully participate in sessions so that I can be aware of my own emotions (irritation in the form of the thought, “You didn’t do your homework again?!”), as well as my clients’ (shame expressed by looking down and not wanting to tell me about their weekend). When things are more chaotic, I may need to shift into describe to adequately capture the interaction playing out between me and my client. Cultivating my personal mindfulness practice also helps me be ready to employ those skills when a client’s TIB catches me off guard. I can slow down and ask myself, What is happening here? To what do I need to attend? What can I better understand about this therapeutic moment? 2. Behaviorism. While behaviorism is right there in the title of our treatment, it can be easy to lose our role as behavioral detectives when emotions are running high (as they so often are in DBT). What is reinforcing this TIB and how can I effectively reinforce an alternative behavior? I will return to behaviorism again and again as I discuss defining and assessing TIB. For now, know that it’s one of our most powerful tools. 3. Dialectics. Of course, we accept a dialectical philosophy in DBT. What are we leaving out? What makes sense about a given TIB? How might the TIB be helpful or functional for our clients?

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While my frustration, worry, or confusion might be valid, so too are my client’s thoughts and feelings about their behavior (or my behavior, for that matter). Dialectics help us stay grounded in finding what we are missing in order to better understand—and thus better address—TIB.

“How Skills” for Therapy-Interfering Behavior You know you need to apply these broad principles to address TIB effectively . . . but how? How do we approach tricky behaviors in order to maximize our effectiveness in addressing them? I think of the following as our “how skills” for TIB: 1. Curiosity. As we discussed in the previous chapter, often a TIB can be irritating or downright insulting the very first time it shows up. By practicing curiosity, we can approach TIB with more equanimity and openness, which can more quickly lead to understanding and thus a way to address it. Do not assume you know why a particular TIB is showing up. To quote Ted Lasso (and many Zen masters before him), “Be curious, not judgmental.” If a client keeps changing the subject when I ask her about her current romantic partner, I might assume it’s because she is avoiding the subject. This is one possible reason, but of course there are hundreds of possibilities. Her partner could be in the CIA; I don’t know! Leading with curiosity will make sure I don’t jump to conclusions while attempting to understand whether the client is changing the subject on purpose or not. 2. Humility. When we don’t make assumptions and remain curious, it’s a lot easier to remain humble. As much experience as I have gained in DBT, I will never know more about my client’s lived experience than they do. Ever. Remembering this and bringing humility to your work on TIB will make it easier for you and easier for your clients to tolerate. This is probably even more true when it comes to getting your clients to bring up your TIB. We can do this in many small and practical ways in DBT. Even saying short sentences like “You were there, I wasn’t.” and “Only you can tell me how it felt.” remind your client that they are the



Skills and Principles to Address Therapy-Interfering Behavior 31

experts on their lives. The DBT strategy of utilizing impotence also helps underscore this TIB how skill, reminding clients, “I only know what you choose to tell me.” 3. Vulnerability. We ask our clients to be incredibly vulnerable. If we are never vulnerable with them, it is highly unlikely we can address all TIBs effectively. This does not mean that every time we address TIB it is in the form of a heart-to-heart (more on overusing this strategy later). Rather, it involves displaying our own vulnerability to model and reinforce vulnerability that is so desperately needed in our clients if we are going to effectively join forces to reduce TIB. Frequently pointing out your own TIBs and modeling vulnerability also makes it more likely that your clients will do the same. Putting yourself on the agenda and saying directly, “I need to apologize to you for last week when I was so pushy and impatient. Just because I was doing it because I want to help doesn’t make it OK,” can help our clients see our vulnerability and our commitment to resolving all TIB, not only the ones they display. 4. With genuineness. I’m not going to lie—radical genuineness is my very favorite principle of DBT, most likely because I am truly terrible at not being myself. Lucky for me, clients in DBT generally respond well to this. They are tired of therapeutic posturing—the number one complaint my clients have about their previous therapists is that they were too “therapist-y.” Not exactly a behaviorally specific complaint, but I’ve come to understand this means that they saw their former therapists performing one or more of several “therapist behaviors,” and that my clients didn’t feel like they really knew who their therapists were. A common “therapist-y” behavior that can fuel client frustration is answering a question with a question. A client asks, “Are you married?” and the therapist responds with “Why do you ask that question?” This would never be our response in a nontherapy social situation. This doesn’t mean that DBT compels us to answer personal questions; it simply means that we respond to the question as we would in another social setting. For me, I would just answer, “Yes, I am.” This particular question doesn’t cross my own personal

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limits. Other people may not like to answer a personal question right away—those people can just say so: “We just met, and I usually get to know people a little better before answering questions about my life.” Both are genuine and are less likely to make clients feel like we are simply saying “what a therapist is supposed to say.” Another example of potentially nongenuine behavior can be when we rely too much on reflection, our second level of validation. Remember, our clients in DBT are exquisitely sensitive, and often not looking for a “cookie-cutter” therapy experience. When my client says, “I’m so enraged at my mom,” and I tell them “You’re really mad at your mom,” their response is often “That’s what I just said! Why are you just repeating me?” Using self-disclosure (“I know that feeling, when I get that angry my muscles tense up”) or higher levels of validation (“Everyone gets mad when their goals aren’t being met”) can help us avoid the TIB of “acting the part of therapist.” There are as many different ways to be genuine in therapy as there are of being human. The point is to bring your own real-life limits and comfort and your personality to the table so your client can see that you are who you say you are. Being genuine helps our clients trust and believe us when we bring up TIBs that need addressing.

KNOW YOUR CLIENT: USING FUNCTIONAL ANALYSIS TO UNDERSTAND THERAPY-INTERFERING BEHAVIOR We spend the entirety of Chapter 4 discussing how exactly to assess TIB in our clients. In a broader sense, when getting to know a new client, it can be helpful to get some general information about their reinforcement and relationship history. Here are some general questions that can help us in getting to know our clients before we even address TIB: • What do they find reinforcing? • What are the current contingencies in their life maintaining both target behaviors and potential TIB? • What TIB has shown up in other relationships? • What are the risks for your client of giving up a given TIB?



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I once worked with a client who was identified in early childhood as a “genius.” He was reinforced steadily and heartily across his early childhood for any display of intelligence. This included doing well in school but also many other behaviors: correcting people, sharing facts that were not germane to the conversation at hand, and “winning” academic arguments. Part of his invalidating environment, in fact, was that these were pretty much the only behaviors his immediate family reinforced or validated: They did not understand his emotions or understand how to support him in describing them. This meant that by the time I worked with him, when he was in his early 20s, he had precious little practice engaging with other people without instinctively trying to best them in a game of wits that only he was playing. It turns out that most 23-year-olds are not interested in having an argument in a bar about an obscure topic from British history: Most people, myself included, were turned off by his lecturing. Only by identifying his goals of connecting with others and making more close friends were we able to identify his intellectual one-upmanship as therapy interfering. This was especially tricky because he was a law student and this behavior was continuing to be reinforced in class and in specific social situations. However, it remained therapy interfering in the rest of his life and in session (he wanted to debate theory and learn more about psychology rather than look at his own behaviors and emotions).

KNOW YOURSELF: OBSERVING LIMITS WITHOUT JUDGMENT OF SELF OR CLIENT TIB is likely the part of the standard DBT hierarchy where it is most important for therapists to be clear on their own personal limits. Sometimes the answers may be obvious, and other times we may need to lean on our team to discover them. Here are some questions to ask ourselves before we address TIB: • Why is the TIB upsetting to me, specifically? • Am I making assumptions about this TIB or the motives behind it?

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• Do I actually need to directly address it . . . or maybe not? • Is it important that I make a change here, rather than my client? While it can be tempting to have a big discussion with our clients and address a TIB “head on,” often a more dialectical (and thus transactional) solution can be more effective. One of my clients met criteria for both histrionic disorder and BPD. Often, when she told stories in session, she did so in a dramatic and over-the-top way: flailing her arms, using voices, and emphasizing the emotions as if she was on a regional theater stage. I’ll be honest: I hated it. When in this “mode,” my client reminded me of peers from my previous life as a drama major in college. I became so irritated when she told stories this way that I disengaged completely (I even had fantasies of walking out of the session). Lucky for me, my team stopped me from addressing this directly with “a talk.” They were concerned this would only shame the client without helping her develop an alternative way of interacting with me when she got animated. Rather, they wisely suggested that I start doing extra reinforcing (leaning in, acting interested, posing follow-up questions) when my client was not speaking this way and lean away and act mildly disinterested or incredulous when she communicated “dramatically.” By putting her “big” storytelling behaviors on extinction and reinforcing her more genuine, accurate communication, I was able to address this TIB effectively. I changed first, and then she followed.

STRIKE WHILE YOU’RE LIKABLE: HOW TO ORIENT YOUR CLIENTS TO THERAPY-INTERFERING BEHAVIOR The most common mistake you can make in addressing TIB is not telling your client early enough that TIB is a high-priority target and you will be addressing it directly and often. Later in this chapter, we go through how exactly to tell your clients about the concept of TIB to make sure both of you are ready to address it whenever it needs to be addressed. Here is what to keep in mind while you orient your client to the concept of TIB:



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1. Address TIB early and often! Don’t wait! In much of the DBT supervision I do, this question comes up over and over again— therapists worry that discussing TIB too early in treatment (or during a particularly “good” session) will “ruin the vibe.” Many trainees have told me they don’t want to upset a client, so they wait to address TIB until later in treatment. Their clients seem very excited about DBT and like them a lot, so they don’t want to bring up something negative at this point. This will always come back to haunt you! Because TIB is a natural and expected part of the treatment, it will happen. When it happens and you have not let your client know in advance that you expect it, you are stuck in the situation of building the plane while flying it—not impossible, but a lot harder than getting into an already constructed jet and taking it for a spin. The solution is to address TIB as soon as possible: during orientation and commitment. I know, we have so many things to go over in our pretreatment stage of DBT, but you’re already orienting to the DBT treatment hierarchy. You can do this: Spend more time on TIB. 2. Be matter-of-fact. I endeavor to bring up and describe TIB descriptively and nonjudgmentally. As therapists, we don’t want to blame our clients (remember, everyone interferes with therapy from time to time, even you), and we don’t want to accidentally punish skills that may need a little more shaping. One of my clients had spent his whole childhood going along with what others wanted—really never standing up for himself. As a teenager, he would sometimes come to session very angry at me for having “missed something important” in our previous session. On the one hand, I wanted him to share his experience. At the same time, yelling at me was not going to be great for our relationship in the long run. I needed to be very dialectical and descriptive in noting this as a TIB because his clumsy assertiveness skills were also a move in the right direction. 3. Forecast TIB before it happens. Everyone does it. Normalize this and let the client know you expect it, not just in your relationship but in all relationships. Nobody’s in trouble. TIB is just a normal thing that occurs that we need to address.

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Below is an example of a first conversation about TIB with a new client. After you read through the example, I will discuss some of the principles demonstrated. Therapist: So, the second part of our agenda is to address something called “therapy-interfering behavior.” Have you ever heard of that? Client: Not exactly. Therapist: OK, let me tell you a little about it. It’s not meant to be like, a “scold-y” term. It’s not “you did something wrong.” It’s really a concept that’s meant to capture anything you or I do that can get in the way of our work together. Client: OK . . . Therapist: Sometimes therapy-interfering behaviors, or TIBs, happen on purpose, but very often they are either outside of our awareness or sometimes even outside of our control. For instance, let’s say your boyfriend was going to give you a ride to our session, but he got caught up at work and didn’t pick you up on time, so you were late. Would that be your fault or my fault? Client: I mean, it sounds like I shouldn’t rely on him . . . Therapist: Well, let’s say for the sake of argument he has always been reliable before, and that this one time there was a true emergency at his job. Would that be either of our faults? Client: I suppose not. Therapist: Right. And if you were still 20 minutes late to session, that would get in the way of us doing all the work we needed to do that day, so that would be TIB. Does that make sense? Client: I guess, but you would be mad at me even though it wasn’t my fault? Therapist: I’m so glad you asked that question. No, I would not be mad at you. And I would hope that we could both work together to make sure it doesn’t happen again, because I think it’s so important that we have all of our



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time together. The idea behind labeling TIB is that it frees us from spending a bunch of time on “whose fault” a particular TIB is. Instead, we can put the TIB on the table here between us and work together to find a way to solve it. Make sense? Client: Yes . . . but some things will be my fault. For example, I forgot my diary card already and it was the very first one. Therapist: Right! Great example. The truth is, we do need your diary card to have as effective a session as possible. So not bringing your diary card was indeed therapy interfering. That said, do you know the percentage of clients who forget their first diary card? Client: No. Ten? Therapist: I wish! Probably 90%. Developing a new habit is hard. So, while we want to address it together, to troubleshoot and problem solve to help you bring your diary card next week, that doesn’t mean you are bad or in trouble because a TIB is “your fault” (uses air quotes). We all do things from time to time that get in the way of our goals. Having a way for us to address TIB helps us with that. Client: Got it. I will probably do other stuff too, though. Like sometimes I am not honest about how I’m feeling. Therapist: Wow! I am so impressed and so glad you brought that up this early. That’s actually a problem for a lot of people in DBT. What happens if you’re, say, really scared about something but you act really mad instead? Client: Well . . . not much good, I guess. Therapist: That’s a judgment, yeah? I think you mean things don’t go how you’d hoped? One of our big focuses in our work together is going to be accurate expression of emotions. When you don’t tell me what’s really going on, I’m definitely going to invalidate you. I won’t be able to magically know how you are feeling, and then I can’t validate or reinforce important behaviors and emotions. Has that happened before?

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Client: Yeah, at my residential program they kept focusing on my anger problems and we never got to work on my trauma. Therapist: Exactly. So, you working to tell me how you’re actually feeling may help us be a lot more effective. Even if it’s scary. Client: That sounds hard, but important. OK . . . You said you can also be therapy interfering? Therapist: Boy, howdy, can I! Listen, part of the commitment I am making as your DBT therapist is that I am going to work my butt off to help you reach your goals. We’re going to figure out together what your life worth living looks like, and I’m going to help you as much as possible to get there, right? We are both going to work hard. Client: Yeah, that’s what we agreed to before. Therapist: Indeed. And I give you my word on that. And . . . it turns out I’m human. Sometimes, even though I am trying really hard, I will mess up. I might misunderstand you, and I might not be as validating or as helpful as I could. One TIB that I am often guilty of, is that you may need more validation than I give and I might start to push change too fast. I’m doing it because I want to help you very much but you might not experience it as helpful. Has that ever happened to you before? Client: Yeah, my uncle is always giving me advice and it’s super overwhelming. He does it without listening to what I have to say. Therapist: Exactly! Perfect example. I’m going to work really hard not to fall in the same trap as your uncle . . . but I still might. If I do, I want you to tell me honestly so I can work to correct that with you. Client: You want me to say, “You’re acting too much like my uncle?” Therapist: Sure. Then I would want you to be descriptive about



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the ways it didn’t feel like I was being helpful. Does that make sense? Client: Yeah, OK. Therapist: And, of course, I can accidentally engage in TIB, too. For example, do you like egg salad? Client: Ew, no, it’s gross. Therapist: Yeah, a lot of people feel that way. I like it, though. I could have an egg salad sandwich for lunch here in my office, and I could throw the paper away in my wastebasket, and then several hours later it could be time for your session. I don’t even smell it anymore because it’s been there forever and you come in and it smells so gross you can’t focus. That’s my TIB. Client: But you weren’t like, “I’ll make my client suffer with this gross egg salad wrapper!” Therapist: Exactly. I don’t think that most TIB is on purpose to hurt the other person. It just happens, for a whole lot of reasons, and then we have to work together to fix it regardless of what’s causing it. If it interferes with our work, we need to address it. Client: Gotcha. Therapist: Another thing that could happen is that I could accidentally invalidate your experiences because of my own blind spots. I work really hard not to do this but the fact is that you and I are from different backgrounds. I’m committing to you that I will work hard to trust your experiences of racism and ableism, since those are things I haven’t experienced. You have experiences of oppression that I don’t have and vice versa. If I say something insensitive or just ignorant, I want you to call me out on it. Client: I might not be able to in the moment. Therapist: Oh, that’s a great point. I didn’t mean to give you more emotional work to do in that specific moment. Whenever you can, even if it’s after the fact. I will also work to

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notice my own behavior. And I want you to know that I am open to feedback about anything about my behavior that might be getting in the way of our work, even if it seems like an especially sensitive area. Because even if we had the exact same background on paper, we still have different life experiences, so things will affect each of us in different ways, right? Client: Right. Therapist: How are you feeling about me addressing TIBs in you? Client: I mean, fine. It makes sense. We need to make the therapy as effective as possible. I don’t want to waste time. Therapist: Totally. What about you addressing them in me? Client: Honestly, it sounds a little scary. I’m not sure I can call you out like that. Therapist: It might be hard the first time. All I can say is that I will be very proud and excited when you do it, and I will attempt to reinforce you for it. Addressing TIB directly is a new behavior for most people—I know a lot of people get frustrated with their therapist and just keep it to themselves. Client: Yeah, that’s what I have always done. Therapist: Sooooo . . . this is another new behavior you and I will get to practice together in DBT. It’s an opportunity. And I really do want you to tell me . . . one of the reasons I like being a DBT therapist so much is because the feedback from my clients helps me become a better therapist, which is really important to me. If you like me so far, the best way to reinforce me is actually to tell me when I mess up. Whether it’s an egg salad mess up or a pushing change mess up or a racist mess up. I’m open to all of it. Client: OK, I’ll try. Therapist: Fantastic. One last thing: I’m going to put it on the agenda every week, just to make sure we always check in



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on it, even if there’s nothing that week. It will help keep us honest. Sound good? Client: Yes, OK. Therapist: Wonderful! Hopefully you noticed a number of different techniques in that vignette. Here are some of the main strategies I see this therapist using (you may notice others, too): • The therapist emphasized the role of accurate expression in the client. We can’t validate or reinforce what we don’t understand. We want to prep our clients early that they need to practice showing their emotions as accurately as possible and also acknowledge that this will be a new behavior. • The therapist gave lots of real-life and hypothetical examples of their own and other clients’ TIB. Examples and stories help the client understand how central and important TIB is to our treatment goals. • The therapist acknowledged that naming and addressing TIB is a new behavior. Most clients are not in the habit of addressing their own TIBs and even less in the habit of calling out their therapist. Making it an explicit goal to practice helps normalize this shift for clients. • The therapist specifically identified the special role of systems of oppression in creating TIB. Some of our biggest TIBs have to do with lack of cultural humility and not being aware of the ways in which our own internalized biases (e.g., racism, transphobia, xenophobia, ableism, heteronormativity, sexism, the list goes on and on) can affect our reactions to our clients’ experiences. Naming these potential areas for misunderstanding, invalidation, or worse, serious harm, before any of them come up is essential. When we highlight our differences early on, we are signaling to the client that we are open to discussing these issues. It also models fallibility and acknowledges an essential part of all therapeutic relationships—the therapist is human and not perfect. We have a much better chance of being able to resolve and repair cultural missteps and harm if both

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the therapist and the client are looking out for their occurrence from the beginning. TIB Tip Systems of oppression create gaps between our experiences as therapists and the experiences of a client from a different background from us. Always acknowledge this and work to increase your cultural humility.

• The therapist made a plan to put TIB on the agenda every single week. Don’t make it an unusual thing. If it has to be a big production to bring it up, your client won’t. A quick check-in about it every week makes it much less likely that you will miss something. And remember, this is a required part of the DBT hierarchy anyway.

FINAL THOUGHTS ON THERAPIST TOOLS There are a few other things you can do to make the consistent addressing of TIB a smooth and reliable part of your DBT agenda. By utilizing radical genuineness and clear orienting, you can delegate your main “jobs” in this DBT enterprise. As the therapist above referenced, it is the therapist’s job to work incredibly hard to help their client build her life worth living. The client’s job is to make the therapist want to be her therapist. Essentially, while discussing TIB, we also want to demystify the playbook for our clients of how they can engage in therapy-promoting behavior. Our therapist above notes that they are reinforced by the client pointing out their TIB. What else is reinforcing to you? Can you tell your client early and often? I like thank-yous, well-structured coaching calls, and genuine laughter at my jokes. For you it might be different. Help your client out and tell them how to reinforce you (see Figure 3.1 for some other ideas). Don’t forget to role-play addressing TIB (both yours and the client’s) when nothing is wrong. The more you practice, the more likely it is that you will be able to have a real discussion of important TIB when the time is right. Just like using distress tolerance skills in skills class when no one is dysregulated helps our clients use them



Skills and Principles to Address Therapy-Interfering Behavior 43 How can your clients reinforce you? 1. Client says “thank-you.” 2. Client completes the diary card before session. 3. Client does the therapy homework. 4. Client answers questions thoroughly and honestly. 5. Client participates in group 6. Therapist and client engage in small talk at beginning and end of session. 7. Client laughs at therapist’s jokes. 8. Client jokes about the skills. 9. Client shares pop culture knowledge with the therapist. 10. Client treats other personnel in the clinic kindly. 11. Client arrives on time to session, attends consistently. 12. Client remembers something the therapist said awhile ago and brings it up. 13. Client shares things and acts engaged throughout session. 14. Seeing the client use a new skill. 15. Client almost does something ineffective and then chooses an effective behavior instead. 16. Client gives the therapist specific interpersonal feedback that makes the therapy better. 17. Client shares good news. 18. Client uses their PLEASE skills consistently (attends to their biological vulnerabilities). 19. Client catches judgments and uses dialectics. 20. Parents of a young client tell you about seeing their child use their skills. FIGURE 3.1.  Potential reinforcers for therapists.

when they are trying to avoid self-harm, pretending to address TIB increases the likelihood that we can address it in real time. TIB Tip Stay mindful with the client in front of you. Just because they displayed egregious behaviors with a previous clinician doesn’t mean you will see those same behaviors.

Last, it is very important that therapists are not overly influenced by reports of previous client behavior. It is easy to hear from either our clients or their previous providers how challenging they

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are or how much TIB they engaged in that was eventually therapy destroying. Try to remember that our time with our client will be different from their time with another provider—our transactions are not the same. In addition, DBT is different from other types of psychotherapy. Sometimes expected behaviors show up, and sometimes they don’t. Work with your client to try to avoid a repeat of some of their “greatest hits” of TIB but don’t assume they will definitely show up. Treat the behaviors in front of you and approach your client by giving them the benefit of the doubt. By orienting to DBT early and often, you are building your team—the two of you can handle these behaviors as they come.

CHAPTER 4

Assessing TherapyInterfering Behavior

E

very effective therapist knows that assessment is essential to create a useful and targeted treatment plan. The same is, of course, true when creating a plan to target TIB in our clients. Without thorough assessment and functional analysis, we can create the wrong plans and then have no impact on the TIB we are trying to reduce, or worse, we can accidentally increase them! This chapter is designed to help you understand the form and function of your clients’ TIBs and to better position you to build a plan together to target them.

THERAPIST ASSUMPTIONS ABOUT THERAPYINTERFERING BEHAVIOR Before we jump to assessment, I want to acknowledge that TIBs can stir up a great deal of emotion in therapists. Because clients with BPD are exquisitely sensitive, therapists can be especially prone to assumptions about a given client’s behavior. I know I have the thought “She is so sensitive and understands so much, she must know how frustrating this is for me.” These assumptions increase the intensity of our emotions, so we need to pay attention to the content of the assumptions. A general theme throughout this chapter is 45

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“We don’t know what we don’t know.” Getting our own emotions in check is essential to effectively addressing TIB. Let’s start with a list of common ineffective assumptions therapists are prone to make about TIB: 1. A given TIB is on purpose. This is the most tempting assumption about TIB. I hear it frequently from non-DBT therapists referring their clients to our program. It is also an assumption I make all the time (see the “Lean on Your Team” section at the end of this chapter for more on helpful strategies). When we make this assumption, we often assume a deliberate action regarding a TIB, and that the client intentionally acted the way that they did for a specific reason. Common presumed goals of clients are that they want to hurt us, avoid a topic or therapeutic task, they intend to be “provocative,” or they want to get attention. Do some clients engage in TIB for these reasons? Of course. And it’s not all the time and it doesn’t make me a more effective therapist to assume so. 2. The client knows they are doing a TIB. When a client expresses a lot of direct anger or other “big” interpersonal displays (e.g., loud crying, slamming doors, shocked and/or exaggerated facial expressions), it can be hard to believe that some of these actions could be outside of their awareness. And yet they can be. We don’t know what our clients don’t know. Also, because many people in their environment (family members and often, past therapists) have been walking on eggshells around them (or simply leaving), we may be the first to give them direct feedback about a specific interpersonal behavior. 3. The client doesn’t know they are doing a TIB. The same assumption can be detrimental in reverse. With clients who are quieter, more compliant, or more internalizing, we can slip into “caretaking therapist” mode and assume that all TIBs from a given client are unintentional and outside of their awareness. I have been surprised (and a little impressed!) more than once when one of my “quieter” clients confessed they had been changing the subject and/or avoiding a particular topic on purpose for quite some time.

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Rather than rely on the above assumptions, I’d like to make very explicit some DBT assumptions that therapists should be making about TIB (summarized in Table 4.1): 1. Every client and every therapist will engage in TIB. You know this one already. TIB is a part of treatment. It’s not you or your client being “bad.” Accept it, embrace it. 2. TIB is TIB. Nothing more, nothing less. We have to address it and we have the tools to do so. We don’t need to look for deeper meaning in a given TIB. 3. We don’t know what parts of TIB matter (intent, impact, goals) until we assess them. TIB will matter in different ways with different clients. Assessment is our best friend. Keeping these assumptions in mind, you’re ready to dive in and work to assess your client’s TIB.

FUNCTIONAL ANALYSIS: KNOW YOUR CLIENT Our main tool when trying to understand a given instance of a TIB is to rely on behavior chain analysis, just as we do for all of the behavior we are targeting for change in DBT. We use this tool again and again across the course of treatment to gain a deeper understanding of the times TIB does what it does best: interferes with therapy. At the outset of our treatment, however, we have a great opportunity to learn about TIB and potential TIB before it interferes with our work. Thus, I have divided this chapter into an initial interview/discussion of TIB section, and then give several examples of behavior chains and mini-assessments to demonstrate TABLE 4.1.  TIB Assumptions for Therapists 1. Every client and every therapist will engage in TIB. 2. TIB is TIB. 3. We don’t know what parts of TIB matter (intent, impact, goals) until we assess them.

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how we learn more about TIB and its functions across the course of treatment.

Initial Interview Start with a broader conversation about the client’s understanding of their potential TIB. Members of my team ask some or all of the questions in Worksheet 4.1 (located at the end of this chapter) when trying to gain an understanding of a new client’s behaviors that could get in the way of DBT. The advantages of having this conversation early, when you are orienting to the overall concept of TIB, cannot be overstated. Strike while you’re likable! Follow Worksheet 4.1 to ask about many areas that are rife with potential for TIB. This information will aid you in getting your client’s commitment to work on the specific challenges you and your client are likely to have throughout their time in DBT. The discussion can then lead to a skills plan for monitoring and managing TIB that you and your client can collaborate on together. As you can see from the worksheet, this is not a semistructured diagnostic interview. These questions are designed to be a springboard to discussion. Some of them will prompt contemplation of interpersonal dynamics that your client likely hasn’t pondered before. Others will be validating to the client, in that you are likely asking about concerns or worries they have about this new therapeutic relationship, but may be too nervous to bring up. Either way, you will gain a lot of information that will make your job easier in the future. Let’s take an example of a cisgender teenage boy starting DBT. We demonstrate a potential conversation from the “Goals” section of the assessment worksheet. Therapist: So, it sounds like you have a lot of goals, both around your friendships and your schoolwork. That’s great. What do you think will get in the way of our therapy? Client: Hmm. Well, I like therapy. I’m usually up for talking about things. But it’s hard for me to be motivated. Therapist: That makes a lot of sense, depression definitely saps

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motivation from us. Tell me a little more about what you mean. Client: I don’t know—Ben, my old therapist, said I would participate a lot in session, but then I had a hard time doing any of the things we talked about. Therapist: Oh yeah, he mentioned that to me, too. Do you think that’s true? Client: Yeah, probably. Therapist: OK, so we are definitely going to have to make sure we really plan for homework you need to do outside of session. There can be lots of reasons that it’s hard to follow through. Are you a person who likes to do things on your own? Is it hard for you to follow rules and/or take advice? Client: Actually, yeah. I mean, obviously, I want your help, that’s why I’m here—and Ben thought it would be helpful, too. But in general, like, if someone tells me to do something, I kinda want to do it less. I like feeling like I can solve my own problems. Therapist: OK, that’s super helpful to know. I think there’s sort of a stereotype about that being true of teens in general, but a lot of people have a certain amount of that—it’s actually a personality trait called “reactance.” It basically means once you’ve been told to do something, you’re less likely to do it. Client: Yeah, that’s totally me. Therapist: OK, so we will keep an eye on that, too. I need to know you’re not bullshitting me, you know? If we make a plan together in session, we will have to discuss if you’re likely to follow it or not. So, in general, how willing are you to do what I say—assuming my advice is considered and informed—in pursuit of your goals? Client: It’s not that I’m not willing, but it is something that’s hard for me. Therapist: I’m so glad we talked about this; that’s really helpful for me to know.

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How I use this information varies with the client and their goals. Asking about it early with this client gives me the chance to offer a nonpejorative, normalizing take on his behavior (“some people are high on reactance”) and then he and I can address it as we go, rather than me becoming another adult who is disappointed that he’s not following through. If we anticipate that TIB, we can work on it together more effectively. It’s also less of a disappointment to both of us when TIB occurs: “Oh no, something must be wrong with the treatment or our therapeutic relationship if this is happening.” Rather than being surprised or upset, we have the DBT framework and treatment hierarchy offering us scaffolding, as if to say, “We knew this was coming. This is what we prepared for, what can we try next?”

Further Assessment: Behavior Chains Once you have the general picture of your client’s self-reported past TIBs (as well as therapy-promoting behaviors), you’ll often need to get a little more information about what is behaviorally maintaining these TIBs. You will use all of your DBT assessment tools in the process: questions and the interview, of course, building a case conceptualization and understanding the transactional model of how your client’s behaviors affect their environment and vice versa. Just as you will use chain after chain to help understand LTBs, you will do the same for TIB. This often includes chains on what was maintaining those behaviors in previous therapeutic relationships and what still may be maintaining them in their personal relationships. I am aware that many therapists skip doing chains on TIB. It’s generally not life-threatening, and we often either run out of time or minimize the importance of chains to our care until our client is on the precipice of dropping out. Let this paragraph be your reminder to do lots of TIB chains. For more on chains, see Shireen Rizvi’s (2019) excellent book in this series, Chain Analysis in Dialectical Behavior Therapy. Below is an example chain on a very common TIB: not calling for skills coaching at a time when it would have been effective to do so. Let’s also assume that our client, Michele, has only been in fullprogram DBT for about a month.

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Therapist: [Transitioning from chain on SI] Michele, I’m so glad you were able to get through Tuesday evening without acting on your suicidal thoughts. That’s huge. And it sounds like it was a really hard night, yeah? Client: Yeah. I was sort of barely hanging on. Therapist: Yeah, I picture you literally hanging off a branch, like one of the kitten posters. Holding on supertight, like “white-knuckling” it, is that accurate? Client: (laughs) Totally. That’s exactly what it was like. Therapist: OK, then I want to spend a few minutes on that, because I hope across the course of DBT we can give you a few tools so it doesn’t feel so precarious to get through days and nights like that. Even though, as I said, I think it was very impressive that you did. Client: I mean, I know I should have used some skills, but I really didn’t know which ones to use . . . Therapist: Yeah, I wouldn’t really expect you, 1 month into DBT, to know all the skills. There’s a reason this program lasts a year! Client: OK, well I’m not sure what else I could do. Therapist: Right, so I have an idea (pantomimes holding a phone). Client: Oh, right. Phone coaching. Therapist: Ding ding ding! Correct. And my guess is you had some good reasons for not calling. So, even though we just finished our chain on your ideation, I’d like to do a quick behavior chain on why you didn’t call. Sometimes we also call that a “missing links analysis.” Client: I just forgot about it. It’s not that deep. Therapist: OK. Well, I’d still like to spend a little time learning more about why. Let’s say 5 minutes, tops? Client: OK, but it better be only 5 minutes. I didn’t even want to talk about the suicidal thoughts and now we have to talk about this, too, and I have other stuff I need to talk about. I’ll just call you next time.

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Therapist: Five minutes, I promise. First, have you ever thought about calling for coaching, since the first time you did it 3 weeks ago? Like, does the thought enter your mind occasionally? Client: Yeah, it does. I even thought about it earlier that day, I’m pretty sure. Just not when things were really bad. Therapist: Great! So, it’s not an issue of getting it into your short-term memory. When did you think about calling me earlier that day? Client: Just when Andy wasn’t calling me back. I was feeling super anxious and I thought maybe I should check in or think of some skills to calm my body down a little bit. But then I got lunch and I got distracted and I felt a little better. Therapist: Well, that’s huge. I love that. It’s early in the chain that led you to SI—as we discovered earlier—and seems like a great time to call. Did anything else keep you from calling then, other than the fact that you needed it a little less after lunch? Client: I mean, I guess it seemed sort of silly. Like people don’t call people all the time. I didn’t want to bother you for something small. Therapist: Ah, so I hear a little self-invalidation there—“it’s silly”—as well as a worry about my time. Is that accurate? Client: Yeah. I mean, it’s easy to say I don’t want to bother you, but it’s mostly the first one, it feels dumb. Therapist: OK, I hear another judgment there. What’s the emotion when you think, “it’s dumb.” Client: It’s like “you can’t even handle not being texted?” Therapist: So you have some thoughts judging yourself. Sounds like maybe some embarrassment, or shame? Client: Yeah, like, I’m 25, I should have this figured out. Therapist: Oof, more judgments! Client: Yeah . . . Therapist: OK, so for us to get you to use coaching, we are going to have to work on some of those.

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In this example, you can see that the chain started off in a pretty basic place (“Did you remember to call me or not?”) and then went to a much more emotional place, likely related to other parts of the client’s goals (self-judgment and shame). The client did not want to do this chain (“It better be only 5 minutes”), but the therapist kept it on the agenda as required nonetheless. This might have been valuable blocking of an avoidance behavior (not wanting to discuss shame), or simply a case of the client prioritizing another goal. We don’t know that yet but the therapist did get Michele to provide some valuable information that may increase the likelihood that she will call in the future.

Other Factors to Address In the following section, I discuss other factors about the client and their history that may have an impact on their TIBs. Sometimes we assess these directly through questions and other times this information is revealed through chains. When and how you address the topics below is dependent on your treatment hierarchy, your case conceptualization, and how interfering a given behavior is at a given time in treatment. These factors include cultural context, the client’s personal learning history, and how to assess new TIB as it appears.

Cultural Context Most broadly, you want to take your client’s overall context into account. You assessed this somewhat in your initial interview but you need to keep attending to it throughout treatment. What is your client’s personal history? If they are an individual who is minoritized in one or more ways by the dominant culture where you both reside, how can the two of you work to help them feel less minoritized in the context of your relationship and DBT? Given that systems of oppression (e.g., racism, transphobia, and ableism, just to name a few) form a backdrop of potential invalidation, how can you work to undo that to the best of your abilities in this relationship? In what ways can these factors lead to TIB in you, the client, or both?

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For example, clients in North America who are Black, Indigenous, or other people of color often have cultural mistrust, or “healthy cultural paranoia” (Whaley, 2004). This is a distrust of white society, given the threats and experiences of discrimination and racism. Cultural mistrust often leads clients of color to have a harder time being open and honest with a white therapist. This is totally reasonable given the client’s and/or their family’s previous experiences. Unfortunately, this can also be a TIB—lack of trust, though warranted (and not the fault of the minoritized client!), can impede a client’s progress. If only a white therapist is available, it is incumbent upon that white therapist to work extra hard to find what therapy-promoting behaviors they can do to increase their client’s level of trust and comfort with them over time. The white therapist who does not engage in this work would also be therapy interfering. TIB Tip It is always the job of the therapist to work to increase a client’s comfort with you and gain their trust over time. The therapist has to figure out what is therapy promoting for the client in front of them.

Personal Learning History What does your client find reinforcing? What do they want to avoid more than anything? You will find some of this out by asking, but mostly it’s revealed through behavior chains. Over time, you will assess and discover: • What are the current contingencies in your client’s life that maintain TIBs? • What are the risks of giving up the TIB? • How can you reinforce the client in the moment for not giving into TIB urges? For example, let’s say you have a client who struggles with perfectionism. For most DBT cases, this would be under qualityof-life–interfering behaviors on our hierarchy. However, sometimes

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perfectionism can lead to TIB—if the client brings in their homework or diary card only when it’s “perfect” (whatever that means)— which can result in occasionally (or frequently) having no diary cards and no homework at session, an all-or-none (and very undialectical) outcome. You would need to then go through the questions above to see what specific factors are interfering with bringing in “imperfect” homework. If you jump straight to exposure as an intervention, you may be missing other reinforcers that are maintaining this behavior. It is crucial that you assess the behavior thoroughly to get the homework to the session.

How to Assess New TIB as It Appears We will not know all of our client’s TIBs at the outset of treatment. New ones show up for all kinds of reasons as we progress in treatment. We have to do targeted behavioral analysis of new TIBs as they occur, or we risk leaning back on those ineffective assumptions from the beginning of this chapter. We need to know whether the behavior is automatic (a conditioned response [CR], or an unconditioned response [UCR]). Is it an overlearned operant behavior with a strong history of having been reinforced? We can ask ourselves the questions in Table 4.2 about a given behavior and do chains and behavioral experiments to answer these questions. First, is it a skill deficit? Does the client even know how to perform the desired behavior? If they do, we can examine other things that may be maintaining the TIB. If the TIB was previously reinforced, what might the original function have been? Is that function still valid for the client? Or has it become problematic, relative to their current goals? TABLE 4.2.  Questions a Therapist Might Ask about a TIB • Is it a skill deficit? • What was its original function? • Is the function of the TIB still valid? • How is the client affected by the TIB? • How is the therapist affected by the TIB?

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If it is not problematic for the client in other contexts, how does the client’s behavior affect you, the therapist? What can you do to react differently, tolerate it, or find the valid piece and validate it? Sometimes the best thing to do with a TIB that affects only the therapist is learn to let it go (more on this in Chapter 5). Let’s take the behavior of not saying hello or greeting the therapist in the waiting room as an example. Depending on the client, this could serve many different functions. For one client, it may indeed be a skills deficit, and very important to their goals that they learn to make an initial connection with another person—we may need to target it early, and our relationship can serve as practice. For another, looking down and not addressing elders may be part of their cultural practices. For another still, they may have been punished for being friendly and may be fearful of doing so. A fourth client may have learned the skill, but anxiety is getting in the way of using it, and not just with the therapist—it is blocking them from making friendships, a top life-worth-living goal for them. Because of this, the therapist would want to address this as soon as possible—not because it is upsetting to the therapist but because it is relevant to the client’s goals. A final client might just be a teenager who doesn’t want to be there—greeting the therapist may not be important to them. Only by doing this analysis are we able to decide what mode of intervention (if any) to use for a given TIB.

QUICK AND ONGOING THERAPY-INTERFERING BEHAVIOR ASSESSMENTS In this section I provide two short examples of discussing TIBs with clients. Addressing TIB compassionately and in a nonblaming, nonthreatening way helps to make sure you are targeting TIB adequately without letting it take over your whole appointment. In a given session, you are, of course, addressing higher-order targets like self-harm and suicidal thinking first. In order to keep your client engaged, you also want to make sure to budget enough time to address quality-of-life goals that are time sensitive and/or very important to them. I hope the following tiny examples give you

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ideas for how quickly you can assess/label a TIB and still get to everything else you need to do in your session.

Therapy-Interfering Behavior and Goals Of course, questions about potential TIB are tied up with questions about goals and reasons for being interested in DBT in the first place. The use of commitment strategies can be very helpful in linking TIB back to the reasons the client is coming to you in the first place. Let’s take a client whose main life-worth-living goals are centered on developing deeper friendships and eventually finding a romantic partner: Therapist: Thanks so much for telling me that you tend to get angry and defensive when you are feeling ashamed. That’s really important for me to understand. My guess is we will have to talk about some things that make you feel embarrassed or ashamed in order to help you feel ready to date again. Do you think that’s true? Client: I don’t like it . . . at all . . . and yes, that’s probably true. Therapist: Well, luckily, I’m not expecting you to like it. Shame is an emotion that’s really hard for many people to tolerate. I’m actually optimistic that DBT has many tools that can help you manage it. Unfortunately, I can’t teach them to you all at once, so there will be some instances where I need you to tolerate shame during our sessions. What can we do to work together if you start to get angry and defensive, though? I want to make sure you and I stay on the same team, working toward getting you those close relationships you want to have. Client: Well, sometimes I don’t realize I’m doing it. Like, I’m so used to slipping into the anger I don’t notice it at first. Therapist: Oh, that’s super helpful. How do you think you would respond if I pointed out some early anger signs, like you are clenching your fists, for example? Client: I mean, it might make me mad. Therapist: OK, what do you think I could do instead?

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Client: Sometimes, just telling me to slow down works. Like, “Annie, slow down for a second.” Therapist: Oh, I like that. I can definitely do that. Then you think after a minute or two I can ask some other questions about emotions? Client: Totally. In this way, the therapist both reminds the client of her goals (close relationships) and reminds her of the overall treatment contract (client and therapist are on the same team and working together toward the client’s goals). The therapist then invites the client to help problem solve regarding her TIB—this is something she and the therapist will work on together, not something the client needs to just “stop.”

DBT Compared to Previous Therapy Some of our clients’ previous experiences in therapy have been warm, kind, and loving—but have not helped them reach their goals. This is usually the result of a therapist TIB of being too focused on acceptance and not enough on change (for this particular client): Client: Well, my best previous therapist was Cheryl. She was so sweet and so validating—she really got me. She understood what I was saying and she let me know it. I also really liked that she let me talk about whatever I wanted to talk about that day. Therapist: That sounds really comforting. I’m glad you had that positive relationship with Cheryl, as that shows me you can form a close bond with a therapist. I’m also glad that you are telling me about this now, because I think there are some ways that I can be like Cheryl and some where I can’t. Client: (suspicious tone) What do you mean? Therapist: I’m going to work really hard to be as validating as possible and to really let you know I hear where you’re coming from.

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Client: Good . . . Therapist: And, at the same time, I’m afraid I can’t only do that. You’ve said you’re coming to me because you really want to go back to school and the cutting and your hospitalizations are getting in the way, right? Client: Yes, that’s true. Therapist: So, I just want you to be prepared that I’m going to make us set an agenda and stick to it, so we can work toward your goals in every session. Also, there will probably be times when I’m not validating enough for you, because I’m trying to encourage some change. You can always give me feedback if I’m pushing too much change and we can work on it together. Deal? Even “good” things about previous treatment can give us the opportunity to discuss how DBT may be different for our clients. Those differences may be jarring and can be a perfect breeding ground for TIB if we don’t discuss it in advance. We model dialectics by not making false promises (“I’ll be just as validating as Cheryl”) while also explaining our reasoning (“You are here to change and I will help you”).

LEAN ON YOUR TEAM TIB targeting is slippery and often emotional. The focus can move off of TIBs quickly: Sometimes we are working to resolve a TIB that seems to be the most important thing on our hierarchy, and then a new LTB or even a different TIB can knock it several spots down our priority list. We can collaborate with a client to address a specific TIB and it can come back in a different form or in a different context. For example, I had a client who often called her best friend when she wanted to self-harm instead of calling me. The friend was accidentally reinforcing self-harm, which wasn’t helping the client reach her goals, and it was directly stopping her from getting skills in the moment. Over several sessions, my client oriented this friend to help her call me instead and was able to go several weeks during

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which she used coaching appropriately and did not call her friend during a crisis. About a month later, when I had just gotten comfortable that she was using coaching as intended and not building her relationships to reinforce her LTB, she started to call a new romantic interest when she wanted to self-harm. This makes sense given her history: This type of “bonding” with new people had been heavily reinforced in the past. I am also human, however, and I had all kinds of unhelpful thoughts like “I thought we were done with this!” that would not have led me to address this behavior very effectively. This is when I need my team—for these moments of confusion and frustration in my work against TIB in myself and my client. Our teams are essential support systems that help us refocus and understand our client’s TIB. In just the last 2 weeks, my team has helped me address TIB by: • Helping me develop more empathy for my client or their family. • Checking my assumptions. • Pointing out what I’m leaving out. • Leading me to additional assessment questions or behavioral experiments. TIB Tip Having a challenging time with a troubling TIB? Don’t go it alone! Your team is there to help you understand your limits and make a plan.

As with everything in DBT, you don’t have to go it alone. Our consultation teams are our most important resource for keeping ourselves regulated while we address TIB in all its forms. Your team members can point out the other side, help you reregulate, and come up with new and innovative ways to address a TIB that is hanging on too long (either on your part or on the client’s part). They can also help us understand where our personal limits are and why a particular TIB might be especially vexing to us (when it is not to someone else).

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Assessing TIBs in DBT is an ongoing process. While we can gather a lot of information at the start of treatment, new TIBs, both our own and our client’s, will pop up along the way, and some of them will still surprise us. Our evolving case conceptualization and ongoing behavior chains will give us the information we need to target them and keep our clients moving forward toward their life worth living. Now let’s travel onward to Chapter 5, where we can discuss when and how to label TIBs effectively (and when not to).

Worksheet 4.1.  TIB Worksheet Use the following questions as a guide to learn about your client’s potential TIBs and your common behaviors that may become TIBs for the client.

Questions about DBT What have you heard about DBT? What rumors have you heard about it, if any? Do you want to do DBT? Why? Do you have any concerns about the treatment? Do you have worries about your ability to do it?

Questions about Goals Do you want to feel better? Why? What would you be doing with your life now if you didn’t have the symptoms you have? Are there times when you don’t want to feel differently or better? What do you think will get in the way of your therapy? Are you a person who likes to do things on your own? Is it hard for you to follow rules and/or take advice? How willing are you to do what I say (assuming my advice is considered and informed) in pursuit of these goals?

Questions about Past Therapy Have you been in therapy previously? If yes, what type of therapy was it? What has gone well during previous treatment? What hasn’t gone well during previous treatment? What did you like or dislike about your previous treatment and therapists? Are there particular things that have gotten in the way of the effectiveness of your past treatment (either your behavior or the therapist’s behavior)? From Therapy-Interfering Behaviors in DBT by Esme A. L. Shaller. Copyright © 2025 The Guilford Press. Permission to photocopy this material, or to download and print enlarged versions (www.guilford.com/shaller-forms), is granted to purchasers of this book for personal use or use with clients; see copyright page for details.

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Worksheet 4.1.  (continued) What invalidating things have previous therapists said and/or done? Who was your favorite previous therapist and why? What did they do that was most helpful to you? If no previous therapy, who was a valuable/influential coach, teacher, counselor, religious leader, or other mentor figure for you? What did they do that was most helpful to you?

Questions about Interpersonal Relationships What do you think contributes to the ups and downs in your relationships? What might be some clues for me that you’re not doing well in our relationship? Do you tend to be up front about those things or do you tend to hide them? Have people in other relationships given you feedback about your behavior?

Questions about Societal Context What is your cultural, ethnic, and racial background? What systems of oppression (e.g., racism, patriarchy, heteronormativity, ableism, or fatphobia, to name a few) affect you on a day-to-day basis? How have these systems of oppression affected your experiences of therapy in the past? What factors help you learn to trust people who are members of a group that has oppressed you? Has that trust been earned and then broken in the past?

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CHAPTER 5

How to Address Therapy-Interfering Behavior in Your Client

N

ow that you have read about how to assess your clients’ TIBs, we begin addressing ways to deal with them effectively. This chapter provides a general overview about how to choose which behaviors to address and in what order. This step is vital as our clients often engage in multiple TIBs simultaneously and we can’t target all behaviors at once. Next, I talk about the important roles of ignoring and extinction before moving on to using behavior chains to understand TIBs and making problem-solving plans to address them. Let’s jump in.

PRIORITIZING: ADDRESS THERAPY-INTERFERING BEHAVIOR IN ORDER There are many different ways a specific behavior may interfere with your work with a given client. As discussed in Chapter 1, the overall goal in addressing TIB is to make sure we are increasing the likelihood that a client stays in DBT to benefit from the potentially lifesaving care we provide. As such, we need to prioritize the behaviors that are linked to our highest targets, as well as the targets most likely to keep someone in our care. Therefore, I recommend you 64

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address TIB in the following order (expanded upon slightly from Linehan, 1993; see Table 5.1): TIB Tip Remember, we always address LTBs before TIB. That’s why TIB related to LTBs doesn’t come first.

1. When a behavior threatens continuation of therapy. There are only a few truly arbitrary rules in DBT, chief among them the “fourmiss” rule. If a client’s lack of attendance is putting them dangerously close to “absenting out” of DBT, this simply must be addressed, or they will no longer be in DBT to address any of the other behaviors that brought them to treatment. Similarly, if a client’s milieu or waiting room behavior is so egregious that your larger institution is threatening to force you to remove them from your program, this must be the top priority. I work in an outpatient comprehensive DBT program for young people. At times, a school has not believed that my client could remain safe in an outpatient level of care (even though my team thought it possible). If we didn’t address my client’s in-school behavior that was causing their teachers to worry, the client would be forced out of DBT because they would need to access a higher level of care by mandate from their school district. In these examples, the TIB threatens the client’s continued DBT treatment. 2. When a behavior interferes with the immediate process of therapy. If we can’t do therapy . . . well, we can’t do therapy. Clients who are on telehealth calls and refuse to turn on their camera may fall in this category. Certainly, clients who remain silent or, conversely, spend the session yelling or enumerating reasons they want to quit TABLE 5.1.  Priority Order for Addressing TIB 1. When a behavior threatens continuation of therapy 2. When a behavior interferes with the immediate process of therapy 3. When a behavior is functionally related to suicide or self-harm 4. When a behavior mirrors problems outside of session 5. When lack of progress might be a potential TIB 6. When a behavior burns out the therapist

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DBT fall into this category as well. Not doing a diary card, especially when coupled with a very poor recall of the week’s emotions and behaviors, can also be similarly interfering. Each of these TIBs needs to be addressed so that we can be effective in actually helping the client get closer to their life worth living (which is, of course, the best antidote to TIB). 3. When a behavior is functionally related to suicide or self-harm. Of course, attending to LTB always remains our top priority target. Remember that as we focus on TIB throughout this book, we are assuming that we have continued to address LTB first. These categories are clearly not mutually exclusive, however. The next most important TIBs to address are those that contribute to suicide behaviors (including threats, communication, and preparation) and/or nonsuicidal self-injury. This can be as simple as not calling for skills coaching when a client is having urges to self-harm. However, TIB can be functionally related to LTB in many other ways. A client who ignores their biological needs and thus ignores their PLEASE (treat PhysicaL illness, balance Eating, Avoid mood-altering substances, maintain good Sleep, get Exercise) skills when they know that this is a big vulnerability on their chain leading to suicide communication may also be engaging in TIB. 4. When a behavior mirrors problems outside of session. The next priority is when a given TIB is the same as (or very similar to) a behavior that is getting the client in trouble in a different context. I had a teenage client who was very invested in getting along with others, so he would not address “small” behaviors that others did that hurt his feelings or invalidated him. Some of these were truly small (e.g., someone accurately validating his emotions, but maybe not understanding the true extent to which he was upset) while other behaviors were more important (e.g., racial microaggressions from friends and from his white mother; the client was not white). Rather than address these as they came, using his DEAR MAN (Describe, Express, Assert, Reinforce, (stay) Mindful, Appear confident, (be willing to) Negotiate) or FAST (be Fair, no Apologies, Stick to values, be Truthful) skills, my client would let them pass and then invariably explode at the person later. With me, this resulted in him

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getting very angry that I wasn’t “paying enough attention to his phobia,” and screaming in my face and storming out of session. I was very confused, as we had discussed his phobia as a quality-oflife target at the outset of treatment and were tracking his experiences with it on his diary card. It turned out that he had wanted to bring it up many times but had demurred, thinking that it was better not to “rock the boat.” Only through addressing several of these “blowups” in our work together was he able to begin to use his interpersonal effectiveness skills in both our relationship and in other relationships to make his needs clear. This reduced his need to “make a serious point” with his close others by “exploding” (his wording in quotation marks). I had another client whose main way of interacting with others was through correcting them. She was praised a lot as a child for being the “smartest in the class” and felt most comfortable connecting with others through facts and knowledge. I actually had a high tolerance for this as a therapist and did not feel the need to address it for myself—it was not leading to burnout. While this 15-year-old was very intelligent, I was quite comfortable that I knew more about DBT (and many other subjects) than she did (I am also a bit of a know-it-all, it turns out). Sadly, it soon became clear that this behavior was pushing her peers away, and that we could not make progress on her goals of building friendships and being less lonely if we did not address her “know-it-all” behavior (her term). This became a focus we targeted under both TIB and quality-of-life. She practiced engaging with me in a different way in order to use these new strategies with her peers. 5. Lack of progress as a potential TIB. We DBT therapists have taken on a challenging task: to support the building of a life worth living for someone who has experienced such misery that dying by suicide seemed like the best option. Inherent in this undertaking is an important piece of acceptance—progress is usually slow. DBT therapists need to be comfortable attending to the “just noticeable difference” for which most clients do not give themselves credit. Did she consider calling you before she bought that alcohol, even if she didn’t call? Did he cut himself six times instead of 10? These are

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the small wins and moves in the right direction we are accustomed to celebrating in order to shape our clients toward their long-term goals. And yet . . . how slow is too slow? On some occasions, slow progress can be a form of TIB. Most of the time it isn’t. Most of the time, we rely on our team to tolerate the slowness, and find new behaviors to shape. And there are times when our team can help us see ways in which the lack of progress itself might be therapy interfering. If so, it goes on the agenda and we address it as such. I had a client who had done very well in standard DBT, and we were moving toward beginning DBT with prolonged exposure (DBT-PE; Harned, 2022) to address her posttraumatic stress disorder (PTSD). As is often the case, we were approaching this slowly, at the client’s request. Very slowly. Finally, a wise teammate asked me if I was really sure that this client still wanted to work on PTSD. Standard DBT had reduced her avoidance behavior a great deal, and she was not experiencing much impairment in her day-to-day life from her remaining PTSD symptoms. It turned out that my client actually did not want to prioritize DBT-PE at this time, as she was doing quite well in general. While her TIB appeared to be the slow progress itself, it was instead the fact that she had declined to tell me that she was actually ready to stop therapy. My TIB, in turn, was assuming our original goals were still relevant and not reassessing the problems her PTSD symptoms were still causing. Both of these were masquerading as “slow progress.” TIB Tip Keep hold of your dialectics when working with TIB. It’s always helpful to ask, “What am I leaving out?” This is especially true when it appears that slow progress is the TIB. It may be something else.

6. When a behavior burns out the therapist. I find this to be the most satisfying area of TIB to address, mostly because it makes my job better. When a client and I work together to reduce their namecalling, racist language, or saying “I don’t know” over and over (all

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TIBs that cross my personal limits), it does more than make my life a little easier. When I’m not dreading an upcoming session with a specific client, it turns out I am a much better therapist! I’m more mindful, I’m focused on their goals, and I’m much better able to do my job. Addressing TIB that burns out the therapist is not selfish—it is vital to accomplishing what we have set out to accomplish with a given client. TIB Tip Addressing TIBs that burn out the therapist can be almost addictive. Take care to address them only when it is vital to do so, not for your own reinforcement.

That said, once you get the reinforcement from addressing TIB that impacts the therapist, it can become tempting to charge in and address these all the time. Remember, the laws of behaviorism affect therapists as well as clients. These conversations, when they result in change, can be very reinforcing. We need to watch ourselves carefully to make sure we are not addressing these TIBs for our own needs (e.g., satisfaction, making our job easier). Instead, we should address TIB that impacts the therapist in cases where we would be ineffective if the behaviors were to go unaddressed. It turns out, that as a DBT therapist, I have a lot of skills I can use to handle the behaviors my clients display that I dislike. When I have pressing TIBs to address in Categories 1–5, I use my own mindfulness, distress tolerance, and emotion regulation skills to manage my reactions to my clients’ behaviors before resorting to a heart-to-heart and a behavior chain to address things that fall under Category 6. Would you ever address TIB in a different order? As with everything in DBT, the answer is “it depends.” There are certainly circumstances that may make a “lower-category” TIB rise to a higher place on your hierarchy. You’ll also notice a fair amount of overlap among the categories. Behaviors that threaten continuation of therapy are also likely to burn out the therapist; behaviors that lead to suicide or self-harm usually are related to other behaviors that

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mirror problems outside of session. Generally speaking, however, this guideline of prioritization is a helpful place to start. Your case conceptualization of your specific client will guide you further (see Manning, 2019).

IGNORING: WHEN TO JUST LET IT GO Ignoring is one of the most powerful tools a DBT therapist has in their quiver. Sometimes ignoring is part of a strategic extinction schedule. Sometimes it’s just moving on quickly and giving the therapist an opportunity to reinforce a more skillful alternative behavior. TIB Tip Don’t ignore ignoring. Extinction is often one of the first tools we try for a TIB.

As a general rule of thumb, if you can ignore a TIB successfully, do it. What do I mean by successfully? 1. Ignore as part of a specific mini-treatment plan. If I am currently working on an important goal, I may choose to ignore a specific TIB until we have made progress in this other area. For example, if I have a client with a serious substance use history who has relapsed, I may choose to ignore an instance where they were late to session for a week or two while we are working on regaining their sobriety. If they’re staying sober and engaging in other skills practice, I may “round up” and not worry about their lateness or other TIBs until their sobriety is a little more stable. 2. Ignore at the service of a more important TIB. The know-it-all client I referenced above was working with me for all the typical DBT reasons as well: self-harm, suicide, risky sex. While she acted like a know-it-all from the beginning, she was also engaging in many other TIBs: not doing her diary card, not calling for coaching, and the like. I needed to let her interpersonal style go for quite some

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time in order to follow the hierarchy and address the most important things first. 3. Ignore because it’s just very low on the hierarchy. My clients, because they are humans, do a lot of small annoying things (just like I do). Some are messy and leave wrappers or little bits of paper they have been ripping up in my office. I ignore this. It’s just not worth the time it would take in session. Sometimes, they bring weed with them in their bag to session and my office reeks afterward. With some clients, I address it, as I don’t like the smell, it makes it hard for me to concentrate, and could be triggering to my next client if they’re working on drug use. With others, I simply don’t have time to discuss whether they make my office smell like weed, because we have too many other important things to address. My “do what works” approach is to leave my door open and use another space for an hour or two.

STEPS TO ADDRESS A THERAPY-INTERFERING BEHAVIOR Now that you have prioritized TIB and assessed that you need to address it rather than ignore it, it’s time to actually dive in and address it directly. We will go through the six steps (see Table 5.2) to address a TIB in detail, with clinical examples. 1. Define the TIB. You want to be as behaviorally specific as possible and simultaneously make clear that this behavior is very important and you need to address it, while at the same time not TABLE 5.2.  Steps to Address TIB 1. Define the TIB. 2. Convey what it is about this specific TIB that gets in the way of your work. 3. Explain clearly why your client should care about this. 4. Do a behavior chain analysis. 5. Make a problem-solving plan. 6. Obtain commitment and engage in troubleshooting.

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conveying so much anger or irritation that shame prevents the client from addressing it successfully with you. “Kalila, I’ve noticed that you aren’t filling out the skills area of your diary card consistently. I’d like us to work together to help you do it more consistently. Can we add that to the agenda today?” 2. Convey what it is about this specific TIB that gets in the way of your work. Validate the client in advance to let them know you understand the TIB is not their attempt to torture. Convey the benign nature of the TIB while also conveying how it is blocking your goals. “I know you have some concerns, maybe even some complaints, about some of the skills, and I want to take those seriously and see if we can troubleshoot to make them work better for you. Without an accurate record of the skills you are trying, I worry we won’t be addressing the most important challenges you’re having.” 3. Explain clearly why your client should care about this. No matter how you approach the beginning of a TIB conversation, you want to get a clear, behaviorally specific definition, convey clearly (or elicit from the client) how it’s getting in the way, and then link it back to the client’s life-worth-living goals. Why does this TIB matter? “You have been very adamant that you want to go back to school, but that some of the skills we have been trying to help you stay regulated and reduce emotion–mind decision making haven’t helped you get to your enrollment meeting or meet with your counselor. I worry that if we don’t pay attention to the specific skills you’re trying, we won’t be able to make a plan that fits your needs.” This is, of course, just one example. With many clients, you may invite them to help label the TIB by starting with a question:

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“Alright, I think I have been engaging in a TIB and you have, too. What do you think is getting in the way of progress here?” You’ll come up with your own style, which will likely vary from client to client. TIB Tip We are never targeting TIB “because DBT says so.” Addressing TIB serves to help both of you stay on track and get where the client wants to go—your client should be aware of this as well, and they may need to be reminded.

4. Do a behavior chain analysis. After you’ve defined a given TIB, guess what? It’s time to do a chain. For more on behavior chains, refer to Shireen Rizvi’s (2019) excellent book in this series, Chain Analysis in Dialectical Behavior Therapy, especially Chapter 7, “Chains on Thoughts, Urges, and Missing Behaviors.” Many DBT therapists think of formal behavior chains as reserved for target behaviors, or as less necessary for “smaller” targets or TIBs. I am not suggesting that each and every TIB, however small, requires a large written diagram on your office dryerase board or in your client’s skills binder. However, chains are crucial to effectively addressing TIB. They may be short and simple, but we cannot make an effective plan to handle TIBs without chaining why a specific client or therapist is doing one. Here’s a quick example: TIB Tip Don’t forget to do chains on TIB, just like on other targets.

Therapist: So, what do you think is getting in the way of doing that part of the diary card? Client: Honestly, sometimes I just forget to flip it over. Therapist: OK, so there’s a memory piece. Remind me when you usually do your diary card. Client: Right before I go to sleep. I’m usually pretty tired.

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Therapist: OK, did you notice any other thoughts or emotions when you did it, say, yesterday? Client: I guess I think, “Here we go again . . . ” Therapist: (laughs, to convey that she is not offended) That makes total sense. Doing your diary card is a lot of work. Yesterday when you were doing it, did you remember that we had agreed you would try to track the skills? Client: Honestly, yesterday, I did. And then I thought, “What’s the point, those skills don’t work anyway.” Therapist: Ah, there it is! I’m so glad you told me that. That’s definitely different from just a memory challenge, right? We need to address that hopeless thought if we have a chance of you really trying to track skills. As you can see from the conversation above, if the client and therapist tried to solve this problem without doing the full chain, they likely would have resorted to setting alarms, or putting a sticky note on the diary card to alert the client to the skills section. However, as long as Kalila doesn’t see the usefulness of the skills at all, those kinds of strategies are unlikely to produce change for her. Once we do a chain (or, more often, more than one chain on the same or similar behaviors), we can move on to the next step— namely, problem solving. 5. Make a problem-solving plan. Once you understand the links in the chain leading to this TIB, it’s time to make a plan to address it. As with all of our plans in DBT, this one is an experiment, and will result in iterative plans down the line. Let’s say that in further fleshing out the chain above, our therapist and Kalila determine that sometimes the skill section of the diary card is blank because of a memory gap, and sometimes it’s because of hopelessness. They need to work together to solve both issues. Therapist: OK, well, for the times when it is actually memory— what do you think might work to cue you that the skills section is important?

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Client: Hmm . . . this may sound silly, but I could flip the card over—like, how I store it on my desk? I could keep it with the skills side up and plan to do that side first? I actually sort of like filling out the rest of my diary card, so maybe if I do the skills first, it’s kind of like eating my vegetables? Therapist: I love that idea [though of course I’m hoping we can at least turn the skills into vegetables that you enjoy]. Anything else we can do to really highlight that section? Client: If you give me like, a sticker, or a tape flag or something else bright to put on my diary card there, that could remind me. Therapist: Yes, awesome. How’s this? (pulls out a bunch of stickers from drawer) Client: Yeah, that will help I think. Therapist: Beautiful. OK, on to the hopelessness, that thought of “What’s the point, they don’t help anyway?” First, I need to check some facts: Is it that you haven’t had success with any of the skills, or is it just that some of them have been disappointing? Client: No, that’s not very dialectical (winks). I admit some of them have been helpful. I’m probably doing the other ones wrong . . . Therapist: Well, I don’t know if you are or not, because you can’t remember by the time you get to session. That’s why we are talking about this, right? So, let’s try to get out of that hole. Probably you are tripping up in places where a lot of people do, but we are discussing it so we can get to the bottom of it. Here, look at the skill list—can you tell me some that have worked or been helpful for you? Client: Hmm . . . I mean wise mind has been very helpful. And STOP (Stop, Take a step back, Observe, Proceed mindfully). I’m just finding interpersonal effectiveness (IE) so hard. Therapist: OK, let’s make sure we work on the IE skills some today. I think wise mind and STOP are perfect for this situation, though.

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Client: Really? How? Therapist: Well, after this discussion, do you agree in your wise mind that it would be helpful to track your skills use more closely? Client: Yes, I do. That’s fair. Therapist: So maybe we can cue you to check in with wise mind before you start your diary card? Client: Oh, yeah, I could do that. And use STOP if I still think “What’s the point?” Therapist: You got it. It’s almost as if you’re really good at learning and applying DBT skills (smiles). Seriously, I think this is a good plan, and can really get us some information about what is challenging you with the IE skills. Client: OK, I’ll try it. 6. Obtain commitment and engage in troubleshooting. Finally, you will work with your client to see what might get in the way of effectively addressing a given TIB. Like any other problem-solving or skills planning we do in DBT, you want to anticipate that things may not go the way you hope—such is life! When you get commitment and troubleshoot, you are doing two things at once. You are highlighting how important resolving this TIB is (“Look, I’m going to spend even more time talking about this!”) while at the same time doing the work to make it more likely that your attempts to resolve it will succeed. This step is invaluable and not one to skip. Some clinicians have told me that they worry troubleshooting in advance may convey that they don’t have faith in their clients. If this is a worry you have, think about how you can use self-disclosure, metaphors, and examples to highlight the fact that challenges with new behaviors are simply a part of being human. TIB Tip Normalize troubleshooting by highlighting how all humans have a hard time with behavior change. Share your own examples or examples from loved ones.

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Therapist: Beautiful. We have a plan you’re willing to try—leave your diary card skill-side up, and use STOP and wise mind before you start it (in case you have some of those “What’s the point?” thoughts). What’s your level of commitment to following through on this? Client: Honestly, pretty high. This conversation has helped clarify why it matters. Therapist: Wonderful. Is there anything you think might get in the way of executing it? Client: What, you don’t think I can do it? Therapist: On the contrary, I am excited that we made a plan together. Just remember I also know that following through on change is very hard. I think I have mentioned before that I know I need to exercise more, right? Client: Yeah . . . Therapist: Well, I know it’s important and I care about it a lot, because I like to do active things with my kids, like hiking and kayaking and biking. And the pandemic and some other family obligations in the last year have made it really hard. I am totally on board with wanting to exercise. Do you think I got out of bed for my yoga class this morning? Client: Yes? Therapist: No, no I did not. And truth be told, I do far less often than I should. I am still working on what my TIB is about exercise. I say this just to note that no matter what the behavior is, it’s hard to do things differently, right? Client: Yeah, I suppose so. Therapist: Great, so how do you think we can monitor whether you are staying on track with this? Client: Usually for me starting something is harder than maintaining it . . . maybe I can text you the first few days I do the diary card so you can reinforce me? Therapist: Oh, love it. I can send a whole bunch of awesome gifs your way. Would that help?

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Client: Yeah. Therapist: Great! And what if you don’t feel like it, and it’s hard to implement STOP or wise mind? Client: Could I call you for coaching and tell you I don’t feel like it? Therapist: Meaning just to complain? Or meaning so I can remind you why we both agreed this is important? Client: Oh, the second one! (laughs) Therapist: Then absolutely. (smiles) One final caveat about addressing TIB: Don’t talk about it too much. Our goal here is clear now, I hope. We want to get enough information to make an action plan, and once we have that, we make a collaborative plan and then check back on it. If you find yourself talking too much (have I mentioned this is my biggest TIB?), please jump to Chapter 8, “When and How to Address Therapy-Interfering Behavior in Yourself.” You now have a basic recipe for addressing TIB. The trouble is, we interact with clients in a wide variety of ways in DBT, not just in individual sessions. While I stand by the formula above, we have to make some adjustments to it (for family and couple work) or even throw parts of it out the window (for skills class). In the next chapter, I address how to manage TIB in all those other circumstances.

CHAPTER 6

Addressing Therapy-Interfering Behavior in Skills Class, Coaching Calls, and Family Sessions

T

hus far, you’ve read about examples of TIB from individual therapy sessions. Addressing TIB in skills class, on coaching calls, and in family sessions is a little different, both more and less complicated. We take a look at all three here.

ADDRESSING THERAPY-INTERFERING BEHAVIOR IN SKILLS CLASS Remember that while our individual therapy treatment hierarchy dictates that TIB is second only to LTB, this is not the case in other modes of DBT. In DBT skills training, decreasing TIB is literally at the bottom of the list of priorities, coming after stopping potentially therapy-destroying behaviors and, of course, the main point of skills class: skills acquisition, strengthening, and generalization (see Figure 6.1; Linehan, 1993, p. 186).

Therapy-Destroying Behavior Let’s talk first about behaviors with the potential to destroy therapy. These are truly egregious behaviors and, thankfully, rare, though 79

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TherapyDestroying Behavior Skills Acquisition, Strengthening, and Generalization TherapyInterfering Behavior

FIGURE 6.1. Treatment hierarchy for skills class.

certainly contagion effects can make them happen more frequently in a given skills class. Examples of potentially therapy-destroying behavior can be obvious: A group member engaging in a violent act, like throwing a chair or physically posturing against someone, is likely to be therapy destroying in any group. Others may be more context dependent. Depending on the members that comprise the group, a specific verbal comment (or repeated comments) could also be potentially therapy destroying. The order of the skills class hierarchy is intentional and the message is clear: Only truly serious things are worth dropping our teaching agenda to address. Therapy-destroying behavior is sometimes addressed by asking the person who engaged in it to leave the skills group (and sometimes exit from the whole program). If a person is harassing others or being violent, it is our responsibility as group leaders to keep the group as a whole safe. This may mean that the person who engaged in the behavior is offered individual skills training rather than the group format, or it may mean that they simply cannot continue in an outpatient level of care. The final decision of how to address a given therapydestroying behavior should always be made in consultation with the DBT treatment team.

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Of course, when addressing a therapy-destroying behavior, you use many of the same tools you do in addressing TIB: being behaviorally specific and doing a chain to better understand it. Generally speaking, though, you are not doing this during group. Our goal when a therapy-destroying behavior is happening is to stop the therapy-destroying behavior and protect the group. Later you will figure out how to best address it, and always in consultation with your DBT treatment team.

Therapy-Interfering Behavior Skills class is ripe for TIBs. Some common in-group TIBs include: • Being late • Not doing the homework • Attempting to have “process group-like” conversations, even when redirected/reoriented. Skills class is a place to learn new skills, not to process emotions or have focused conversations about what is going on in an individual client’s life. • Sleeping • Interrupting others • Saying things that upset, distract, or dysregulate other group members, including initiating discussions of target behaviors Most of the time in skills class you will not be directly addressing therapy-destroying behavior (thank goodness) or even just TIB. Our job is to teach, teach, teach! The goal of skills group is to get the skills in, so we can pull them out in individual therapy, family therapy, and skills coaching. Of course, because our clients are humans, they will still engage in TIBs. However, we lean even more on extinction and differential reinforcement than we do in individual therapy. Several examples will help clarify. When I’m leading a skills class, I like to channel both of my parents, who spent their careers as teachers in public middle and high schools. Their main goal, of course, was to teach their students about social studies and English. In order to do that, they had to be excellent classroom managers. This is true even if you are teaching

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adults. You manage your classroom in order to maximize learning for the largest number of people. In DBT skills class, the leader is teaching, and continues to teach, through almost all behaviors (the one exception being those that could destroy treatment, as discussed above). This doesn’t mean the leader is not addressing TIB. A good skills group leader is using shaping all the time, while combining it with extinction. TIB Tip Extinction, in the form of planned ignoring, is usually our most used tool to address TIB in group.

If I’m teaching my skills group the DEAR MAN skill, and there is a teen or parent with their head down, I continue teaching. I engage the group members who are paying attention, and I make sure I’m being entertaining and making lots of good points. I am simultaneously lying in wait. I am doing some sneaky schoolteacher things to try to elicit a different behavior from my head-down friend. I may walk around the room and stand near them while I teach. I may ask someone next to them to elaborate further on a question or comment. As soon as I get a slightly different behavior, I work to reinforce it. TIB Tip Channel your inner schoolteacher in skills group. Move around the room and use your physical location strategically. Relentlessly reinforce desired behavior, especially if that behavior is incompatible with problem behaviors.

How I reinforce a given skills group participant away from their specific TIB will, of course, vary based on what is and isn’t reinforcing to them. A pretty common occurrence in my multifamily groups is teenagers not doing their skills practice homework. New habits are hard to build and shaping high school students to do even more homework is a big ask. Some participants are very eager and like to participate in groups—they are reinforced by talking and sharing.

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If one of these chatty teenagers doesn’t do their homework, I don’t let them share. I want to reinforce homework completion with the attention of the group and the ability to talk more in the discussion. On the other side of the dialectic, some participants don’t do the homework because they don’t want to share. They are hoping that if they haven’t prepared, I won’t make them contribute. In this case, I use negative reinforcement instead. When they actually do the homework, I will let them share very little about it and move on quickly. When they don’t do it, I keep “the heat” on longer, attempting to draw out examples from their week and help them find times when they did indeed use the skills. With luck this will motivate them to do the homework the following week so they can have a shorter turn in the hot seat during group. I also lean hard on differential reinforcement of other behavior (DRO) and differential reinforcement of incompatible behavior (DRI) in skills group. I tell my student co-leaders: We will ignore 90% of our clients’ off-task behavior in skills group. That may be a bit of an exaggeration, and we do want to use our resources to reinforce their on-task behavior and hope for extinction on the rest. If the client has their binder open to the right page, it can’t also be closed and under the table (this is DRI, as the binder cannot be both open and closed). If they are usually chatty and distracting to others during group but this week they are doodling instead, great! I will reinforce that (this is DRO, doodling instead of chatting; they could do both, potentially, but I’m hoping that reinforcing the doodling will help reduce the chatting). Remember, when the skills group leader is teaching the show must go on. The content is paramount, and unless therapy-destroying behavior is happening, the leader is not addressing it directly; they are working on skills. The co-leader’s job is to take the emotional temperature of the room and attend to what will best reinforce learning. This may be accomplished simply by wandering near someone while the leader is teaching so they are more likely to pay attention to the leader. A good guideline addressing TIB in skills group: We want to avoid heart-to-hearts. We are almost never going to have a big ol’

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talk in skills group about a client’s TIB. If we can’t address a given TIB using extinction and differential reinforcement, we will find a time outside of skills group to address it (this can be done by the group leader or, more often, the individual therapist). When we must do that, we use the same approach we use with our individual clients. Let’s walk through an example. Let’s say my colleague Sam has my individual client in her skills group. My client Angie has already been in the skills group for four modules, and continues to remain quiet during most skills groups—they don’t really participate unless pressed, and often have their head down. Sam has been shaping Angie’s behavior for months, but if Angie wants to graduate from skills group (which they do), they need to participate a bit more actively and demonstrate their skills knowledge in group. Given that Angie is not a distraction to other group members, the first step is for me to have a conversation with Angie during the “TIB” part of our regular session. I’ll discuss with them what might be getting in the way of more active group participation (following the template from Chapter 4). Let’s say anxiety is getting in the way—this is a great opportunity for Angie to practice opposite action, which they also need in other areas of their life. They are afraid, however, that Sam will overreinforce them for participating— that Sam will be so happy that Angie will feel shame and embarrassment rather than pride, since Sam is so used to Angie being quiet. Using this knowledge, Angie and I practice a DEAR MAN for Sam, so that Angie can ask Sam to reinforce them quietly after group, rather than in front of their peers and caregivers. Most readers will recognize this as a “consultation-to-the-client” strategy—I’m not intervening with Sam on Angie’s behalf but coaching Angie to work on it directly with Sam. Now, we can make this beautiful plan and the next week, Angie still might show up to group, but not do their DEAR MAN and again, not participate. In this situation, after assessing what got in the way, we may make a different plan. It might only have been a memory challenge that prevented Angie from doing their DEAR MAN, in which case a discreet reminder at the beginning and end

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of group from Sam might help. We will work together to find the next piece of our potential solution that may address their original TIB: lack of skills class participation.

ADDRESSING THERAPY-INTERFERING BEHAVIOR DURING COACHING CALLS Just as in skills class, there is a separate hierarchy for coaching calls (see Figure 6.2): to decrease suicide crisis behaviors, to increase generalization of new behavioral skills, and to decrease distance from/ increase connection to the therapist (Linehan, 1993, p. 188). At least with skills class TIB is on the hierarchy but it isn’t even mentioned here. Perhaps this is because neither client nor therapist engaged in TIB on coaching calls. Ha! I’m sure most of you reading this have experienced or heard that coaching calls are fertile grounds for TIB, from both clients and therapists alike. We both do TIBs—we just don’t discuss them on the call. For more on this, refer to Chapter 8 of Alexander Chapman’s (2018) book in this series, Phone Coaching in Dialectical Behavior Therapy.

Decrease Suicide Crisis Behaviors Increase Generalization of New Behavioral Skills Decrease Distance from and Increase Connection to Therapist

FIGURE 6.2. Treatment hierarchy for coaching calls.

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Our basic principle for addressing TIB on coaching calls is to bring it back to session. Coaching calls are short. Coaching calls are designed to keep people in their lives, and to be finished quickly. They are not times to attempt to address TIB, especially without the advantage of our nonverbal social cues to supplement our voice tone (many clients find telephone calls especially stressful because it is harder for them to discern how the other party is feeling). Make a mental note of the TIB and bring it back to the following session for resolution. TIB Tip Need to address a coaching TIB? Bring it back to session.

Some common TIBs that occur on coaching calls: • Client hanging up • Clinician calling back at a time when they are not able to be fully present • Client “yes-butting” and refusing all skills advice • Clinician not returning call in a timely manner (or at all) • Clinician allowing the focus of the call to drift (thus increasing likelihood of the client engaging in their own TIB of misusing coaching) • Client not using skills while they wait for a callback For all of these, you may note them in the moment, or you may not. If the TIB is mine, sometimes I find it helpful to label it in order to get the callback on track: Therapist: Whoops, I’m getting off track with you here. I know you called for help managing your anger at your boyfriend and refocusing on your homework. Let’s get back to that. If it’s the client’s TIB, I will name it if it feels like it might help get things back on track: Therapist: Hang on, I’ve given you a few choices, but you’re telling me that you’re sure none of them will work? It feels

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like you might be having some hopelessness that’s resulting in some “yes-butting” for you, is that possible? If the client agrees and is open to this possibility, we can practice some willingness together. Whether I name a TIB directly like this during a coaching call is usually dependent on two things: 1. Have we addressed the TIB before in session? 2. How emotionally dysregulated is the client in this moment?

Situation 1: The Client Already Agrees the Behavior Is a TIB Having named a TIB in session and worked to problem solve it makes it much more likely that referencing it on a call will work. This is the commitment strategy of connecting prior commitments to current commitments. The client and I have a shorthand that means I have the potential to redirect them. Once I engage them with some quick mindfulness to make sure they can be receptive, I may try to connect these previous discussions to what is happening now. Client: No one is listening to me at all! My boss is out to get me, and so is my roommate, and you obviously don’t care because you took 40 minutes to even call me back! Therapist: (ignores accusation about how long it took her to call back) OK, I can hear you’re feeling really sad and maybe a little scared? Client: Shit yeah, I’m scared! Therapist: OK, can we slow down a little bit? Client: I guess . . . Therapist: OK, can we do 5–4–3–2–1 really quick? Tell me five things on the walls of your room. Client: I have five Fillmore posters. Therapist: Oh, cool! How about four soft things? Client: Um, two pillows, my squishmallow, and um . . . my cat.

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Therapist: Hi Meowski. How about three red things? Client: My binder, my socks, and a bottle of Gatorade. Therapist: Two squares? Client: My window and a record cover. Therapist: One long thing? Client: A string of lights. Therapist: OK, do you feel a little bit calmer than when the call started? Client: Yes. Therapist: Perfect. So, I actually think this feeling of everyone being against you is related to what we talked about in session a couple weeks ago. Client: It is? Therapist: Yeah, that when you feel really low, often sad and scared, you start listing to yourself the ways that people have wronged you. Do you remember what we called that? Client: Oh yeah (chuckles). Therapist: What did we call it? Client: My shit list. Because it makes me feel like shit. Therapist: Yes. I’m wondering if this first step in this call is to increase your dialectical thinking about some of these people who you were listing when you first called. Because while I’m sure emotion mind is convinced that me and all the other people on that list are really out to get you, I’m not sure that’s what your wise mind thinks. Can we practice those dialectics for a second? Because I think that will bring your emotions down even more. Client: Yeah, OK. Now, if I had noticed this client’s tendency to do this but we had not yet addressed it in session, I would not address it on this call. It would take too long and would likely further anger them. Instead, I’ll file it away as another piece of data and come back to it with

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curiosity in our next session (when we debrief this coaching call). I would keep the call focused on getting them out of emotion mind and avoiding target behaviors.

Situation 2: The Client Is Extremely Dysregulated Remember, addressing TIB is not even on our coaching calls hierarchy. If the client is very dysregulated, they need to be working on getting reregulated in order to head off a suicide crisis or other ineffective behavior. I don’t know about you, but when I am dysregulated, I am certainly in no headspace to receive feedback about my interpersonal behavior. With high levels of dysregulation, I’m always going to stick to my DBT basics and return to distress tolerance and mindfulness to wait out the current episode. This is not the time to discuss TIB. Remember when I said “don’t talk about it too much” in the previous chapter? That goes double for coaching calls. Your client will often not even remember the details from a coaching call during which they were highly dysregulated. It’s not the time to try to solve larger challenges in the therapy. Kick it back to session and discuss it there, in wise mind. We want to do this with almost all coaching call TIBs. Client: I can’t handle this! Therapist: I’m glad you called, it sounds like you’re really hurting right now. Client: Yes! I! Am! Hurting! I can’t do this, I can’t do this . . . Therapist: OK, can we slow it down a little bit? Client: No, I can’t, I can’t . . . (hyperventilating) Therapist: OK, I’m going to start breathing slowly and counting along with it and I hope you’ll do it with me. [Therapist does box breathing and then gets client to the freezer to do an ice dive: paced breathing and then the temperature skill from TIPP (temperature, intense exercise, paced breathing, progressive muscle relaxation).] Client: (pace of talking slowed) OK, I’m a tiny bit calmer.

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Therapist: Great. Can you tell me what skills you used before I called you back? Client: I didn’t use any skills. I just called you and then I was lying on my bed, freaking out, daydreaming about cutting. Therapist: (ignores TIB of not using skills before coaching or while waiting for callback—makes mental note to address in next session) OK, what’s the emotion right now, then? Tending to the top of the hierarchy and managing in-themoment dysregulation are all this therapist–client pair have time for right now. Discussing the client’s TIB would be distracting at best and potentially iatrogenic at worst. TIB Tip When a client is dysregulated on a coaching call, discussing the client’s TIB would be distracting at best and iatrogenic at worst. Attend to the top of the hierarchy and manage the dysregulation in the moment.

Situation 3: Relationship Repairs The exception to all of this “bring it back to session” business is if the client calls for a relationship repair. This, by definition, is in-themoment work to resolve a TIB. Relationship repairs are calls that either the client or therapist initiates following a challenging interaction in session, a relationship rupture of some kind. By definition, if there is a rupture, one or both of you has interfered in the therapy in some way. The purpose of the coaching call itself is to address the TIB, though the therapist may not even be aware of their TIB when a client inititates a relationship repair call (and vice versa). Ideally, the client makes the purpose of the relationship repair call clear at the beginning of the call. If they do not, this is another TIB that you can shape, both on calls and in session. TIB Tip Therapist, be honest with thyself. A client is going way out on a limb when they initiate a relationship repair. Though you likely

Addressing Therapy-Interfering Behavior in Your Client 91 didn’t mean to hurt them, remain open and be willing to hear about the damage you caused.

Addressing a relationship challenge on a coaching call is most commonly a combination of owning your own TIB (e.g., perhaps the client was hurt because I was late to session or I seemed tired or disinterested) while also clarifying or helping the client check the facts (this part need not supersede the apology or acknowledgment of your TIB). Sometimes clients are hurt by something we do in session because we did not do a good enough job orienting them (a common therapist TIB) or we were pushing change without enough validation (also a common therapist TIB). Therapist, be honest with thyself. Most of the time, we did what we did for a good reason . . . and our clients may still be hurt, and so then it wasn’t effective. Our beautiful, complex, intentional clinical reasoning doesn’t matter if it hurts our client and they can’t take it in. Letting them know we understand and are committing to a new way of being can be very helpful for our ongoing work. Therapist: Hey Elliot, I’m glad you reached out. Your text said you wanted to discuss a relationship issue? Client: Yeah . . . I’m kind of nervous. Therapist: OK, well, you haven’t made one of these calls before, so that makes sense. And, if it helps, I’m already really proud of you for calling. This is exactly what coaching calls are for. Whatever you want to address, I can take it. [Therapist is attempting to reinforce client in advance for being brave and for calling as directed.] Client: (takes a deep breath) OK. Thanks for saying that. Well, I just left session yesterday feeling like a failure. Therapist: Oh no! That’s a big self-judgment. I’m guessing from what you said at the beginning of the call that I had something to do with that? Client: Yeah . . . I just . . . you had so many suggestions for things I should be doing differently, and I felt really stupid

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that I cut last week. Like I should have used my skills and that you were disappointed in me that I didn’t. Therapist: Wow, that’s a lot. That sounds awful. It’s OK if you can’t, but do you remember any specific things I said that really made you feel that way? Client: I mean, you looked really bummed out when you saw my diary card, and then when we were . . . what was that thing with all the steps? Therapist: The behavior chain analysis? Client: Yeah, that. When we were doing the behavior chain, you pointed out all of these places where we could put a skill instead of what I actually did, and I felt like an idiot. Therapist: Oh man, Elliot. I am so sorry. Client: What? No, I mean, I think I am kind of an idiot about these things. Therapist: OK, first of all, ding (therapist mimics mindfulness bell)! That’s a judgment. And I definitely don’t think you’re an idiot, for the record. Can I say a little more about my apology and explain what I think happened? Client: Yeah, sure. Therapist: OK, so first, I truly do apologize. I never mean to hurt you during session, and I truly didn’t mean to imply that you were stupid or even that you “should have” done things. I think I committed a couple of major TIBs in session, and if it’s OK with you, I’d like to name them really quick so hopefully we can prevent them in the future. Would that be OK? Client: Yeah, OK. I’m still not sure it’s about you, though, it might be my problem. Therapist: Oh, I definitely think it’s me. So first, I clearly didn’t provide enough validation at the beginning of and throughout our session. I know last week was a really hard week, yeah? Client: Yeah.

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Therapist: And I bet me going on about skills you could have used felt pretty invalidating, like maybe I didn’t get how hard it was? Client: Yeah! I didn’t really realize that before, but that’s exactly the issue. Therapist: Yeah, remember our core dialectic: how we are always trying to balance acceptance and change? I think this is one of those times when I leaned too far on change. I’m so glad you called about this, and in the future, I’ll make sure to check in about it at the end of session because I don’t want to do this again. Client: I mean, I do need to change a lot of things. Therapist: Sure! And it’s much less likely that you will make those changes if you feel super invalidated! Client: That’s true, I guess. Therapist: The other thing I did, I think, is that I didn’t do enough orienting about our behavior chain. The goal of it is not to point out all the things you “should have” done. Chains are really about us learning together what some of your common stuck points and vulnerabilities are so that next time you’re in a similar situation you’ll be less likely to have the same outcome. Does that make sense? Client: Yeah . . . It seemed a little mean, honestly. Therapist: I can see that! Does this explanation help a little? Client: Yeah. I do want to do things differently, but I don’t feel very capable. Therapist: I know you want to. It’s my job to help you feel more capable, not less, so I think this is definitely on me. I’m so glad you called, and I’m so sorry, again. Do you think you can use coaching for other reasons this week, now that we’ve cleared the air a little bit? Like, could you call tomorrow for a self-harm urge? Client: Yeah, I think so. Therapist: Fantastic! Amazing relationship repair call, dude! I’ll

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also put my TIB on the agenda for next Tuesday so we can check in about it a bit more in session. Is there anything else you need now? Client: No, I don’t think so. Therapist: Great. Do you feel a little less disconnected from me, a little less judged? Client: Yeah, definitely. Therapist: Wonderful. Great job, again. I’ll talk to you soon. Client: Thanks. Bye. These general guidelines should help provide some scaffolding for addressing TIBs during coaching calls. Remember, the vast majority of the time—kick it back to session.

ADDRESSING THERAPY-INTERFERING BEHAVIOR IN FAMILY SESSIONS Whenever there are more people in the room, the potential for TIBs goes up precipitously. We have discussed the effect of this in skills class already, now it’s time to tackle it in family sessions. If you are working with teenagers (and sometimes young adults), children, or couples, you are also doing family or couple sessions (Note: since couples are families, I refer to all of these configurations as “family sessions” throughout the book). Here are some common TIBs that occur in family sessions: • Teenager leaves the room or “blows up” • Parents who don’t take risk seriously • Partner defends or speaks on behalf of the client • Parents who minimize the experiences of the teen • Parents don’t allow teen to speak • Partner views couple work as only the other partner’s work to do (and references this frequently) • Parental communication outside of session (flooding with emails and messages)

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• Secret keeping • Therapist becomes too aligned with the parents or the partner to the detriment of the alliance with the identified client.

Context of Family Work There are two different situations in which you may be working with a family or couple using a DBT frame: adjunctive family or couple work and primary family or couple work. Of course, families in either situation can engage in TIB, but our approach is a little different depending on whether an individual is our client or the family unit is our client. Let’s dive in to each of these situations separately below.

Adjunctive Family or Couple Work The first setting is adjunctive work that is in addition to our individual work with a given client. This is the most common setting for family work in the context of an adolescent who is participating in a comprehensive dialetical behavior therapy for adolescents (DBT-A) program. The adolescent has individual therapy every week, and also family therapy. In our program, most families meet with the individual therapist every other week, though some do weekly and some only do monthly sessions. An individual adult client may desire or be recommended to have some couple sessions with their partner in addition to their regular work in DBT. While the client sees the therapist consistently, the partner may join for a few sessions or a series of sessions in addition to the individual work. These are both examples of adjunctive work. This differs from more traditional family therapy (such as structural or strategic family therapy) as our client is indeed the “identified client.” The family is also the identified client, but we often have a closer relationship with the client than with their partner, parents, or adult children.

Primary Family or Couple Work This is more likely to take place outside of the context of a comprehensive DBT program, but might be a vital part of some DBT-informed

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work for a given family. In this setting, you are not seeing either partner alone, or you are not seeing the teenager or other members of the family alone. The entire couple or family is the target of the intervention. I discuss methods of addressing TIB in both of these contexts below. In general, addressing TIB in family sessions is not that different from individual sessions. In fact, we follow the same “Steps to Addressing TIB” outlined in Chapter 5, Figure 5.2.

Addressing Therapy-Interfering Behavior in Adjunctive Family Work Sometimes the person engaging in the TIB in family session is, indeed, our client. This is the simplest situation. We bring it back to an individual session and address it there. Easy peasy. Remember, our goal in addressing a family member’s TIB is the same as our goal in addressing any individual TIB: to keep the client (and family member) in therapy and help advance the work. Sometimes it’s harder to do that if the family member doesn’t understand that TIB is not an accusation and doesn’t make them “bad.” This is especially amplified because family members are worried about their partner, child, or parent. When addressing TIB in a family member, we want to make sure that our intentions are clear and that we are all on the same page in wanting what is best for the client. With family members the line between something being a TIB and a target of the treatment can also be very thin. A common challenge for parents of teens is to stop reinforcing their child’s suicide communication. We need to help most family members support their teen’s accurate expression of emotions (“I feel sad and angry”) and asking for help (“Can you sit with me for awhile?”) over suicide communication (“Get away! I want to kill myself!”). The fact that parents accidentally reinforce suicide communication by giving it more attention is not TIB—it is a very human response when your loved one is suffering. It’s simply a target of treatment. However, something that can be a human impulse (letting your kid stay out with friends later because they’ve had a hard week) can turn into TIB when it goes against plans that were made and agreed upon in

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treatment (both parents agreed to a new behavior plan for the teen to earn rewards but Mom is not following the plan so Dad looks like the bad guy). The tricky thing about addressing TIB in family members when they are not clients is that we often don’t have as close a relationship with that person. They also don’t have the benefit of as much orientation as we are able to give to our clients. We simply spend less time with them than we do with our clients and thus they don’t swim in the DBT waters with us for as many laps. Because of this, we need to resolve a few things before we address TIB in family members: 1. Carefully define the family member’s TIB and determine whether the best way to address it is to label it (as opposed to simply following a behavior plan you create). Use your team to help you hone this. 2. Assess this particular family member’s baseline openness and willingness. Based on what you know about them, strategize the best way to address the TIB with them (e.g., in session, on the phone, after session; I do not recommend email). 3. Reorient this family member to TIB (as if you have not already done it at all. Trust me on this). A common TIB for parents, especially when their child is actively self-harming and suicidal, is to frequently question whether DBT is the right treatment for their child. They may bring this up frequently in family sessions, which means time is taken up discussing the appropriateness of the treatment rather than doing DBT. It takes time away from the family learning skills and makes it harder for the client to improve. It can also sow doubts in the teen and other family members. In deciding to address it, I follow up on the points we need to address: 1. Carefully define the family member’s TIB and determine whether the best way to address it is to label it. Use your team to help you hone this. I will get my team to help me define this behavior as nonjudgmentally

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as possible. This is important, because it’s easy to be judgmental of family members when you feel your client’s progress is in jeopardy. The team can help me find empathy and understanding for Dad in asking over and over whether we should reconsider residential treatment (he’s scared, and residential programs “feel safer” to many families). They can also help me define the behavior (bringing up other programs when it is not on our family therapy agenda). 2. Assess this particular family member’s baseline openness and willingness. Based on what you know about them, strategize the best way to address the TIB with them. I think about how Dad has responded to other redirection in the past and think about what might be the best way to address it with him. Some parents are super open to discussing this in family session, with the rest of the family present. Depending on Dad’s culture, his upbringing, and his thoughts about the way he needs to present himself in front of his children, bringing it up during the session might produce so much shame that it’s ineffective. If this is the case, I may ask him to come a little early to session, check in with him at the end of a session, or schedule a phone call. 3. Reorient this family member to TIB. Once I’ve determined the setting, I discuss it with Dad and lead with validation and curiosity. This then dovetails to our “Steps to Addressing TIB”: Therapist: Thanks for taking my call, I really appreciate it. Is now still a good time? Dad: Yes, it’s fine. What’s up? Is Xochitl OK? Therapist: Oh, yes. I think she’s doing a great job in the program. I wanted you and me to have a chance to check in about her progress briefly when we aren’t in the middle of a family session. Dad: OK. I’m glad to hear you think she’s doing OK, but I’m still really worried that this DBT business isn’t enough. Therapist: Yeah, I figured that. You have been asking a lot of questions about other programs lately. What makes you worried?

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Dad: Well, you know. I don’t want her hurting herself. And the school seems to think she has to have more. I know you guys talk about all the science behind DBT but I’m just so scared of losing her. Therapist: Of course. You’re a good dad. It’s terrifying when your kid is suffering the way Xochitl is suffering. And you’re right—we have a lot of data showing that comprehensive DBT has the best shot in helping Xochitl with exactly the symptoms you mention. Dad: I mean, I know that with my brain . . . but I’m still worried. Therapist: That makes total sense. This is actually related to what I wanted to talk to you about. Dad: Yeah? Therapist: Yeah, do you remember when we started the treatment we talked about this concept called “therapy-interfering behavior”? Dad: Yeah, like if Xochitl misses sessions or doesn’t do her homework for group? Therapist: Yeah, those are examples. But everyone can do TIB, even me, and even you and Marta. It’s just sort of expected as part of our treatment. Nobody means to do it, but sometimes we each do things that can get in the way of Xochitl doing the work you all need to do. Does that make sense? It’s not like, an accusation, it’s just sometimes we have things we need to address to make the treatment more effective. Dad: OK . . . I have a feeling you’re going to tell me I’m being therapy interfering? Therapist: Well, yes, but it’s in a way that I’m sure you intend to be therapy promoting. Dad: How so? Therapist: In our last couple of family sessions, we had an agenda set to continue to work on safety planning and to give everyone more skills to use when Xochitl is feeling really down and hopeless, right?

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Dad: Yeah. Therapist: My worry is that your worry is getting us off track from that goal. Your very understandable worry and concern for your baby girl means that we are spending time discussing other programs rather than getting what you can out of DBT. Dad: Ohh . . . yeah. But I mean, I just want the best thing for her! Therapist: Of course. We can all agree on that. Like I said, I know this is coming from a good place. And we spent 25 minutes last week discussing the other programs. That’s half our time where we could have been doing more DBT. Does it make sense why I’m concerned about this and labeling it a TIB? Dad: Yeah, I get it. I’ll stop it. Therapist: I mean, maybe? But you also are probably going to continue to have questions, because of how much you care. If you do, is it OK if I remind you in the moment that that’s a TIB? So we can get back on track with our agenda? Dad: Yeah, that’s fine. I’m sorry. Therapist: Hey, it’s really fine. This is a part of treatment. Thank you for being so open to discussing it. I really want to make sure we are giving DBT the full shot it needs to see if it can help you and your family; I know we have the same goal there. You’ll notice we don’t do a ton of problem solving and troubleshooting here. Because of Dad’s level of willingness, I have some faith that just redirecting him will work. If it doesn’t, we can have another check-in.

Addressing Therapy-Interfering Behavior in Primary Family Work Addressing TIB when the unit of intervention is the family or couple is a little easier, because everyone has an equal amount of orientation at the beginning. Because all of your work is with the whole

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family unit, you will do your orientation with the whole unit and invite everyone, each week, to address any TIB. This means that any member of the family can add a TIB about any other member (or you) to the agenda, as can you. Using the principles of “strike while you’re likable” and normalizing TIB will make it relatively smooth sailing once a more complex TIB comes on the scene. Then just follow the guidelines for individual therapy (just with more people in the room). Now you know the basics of addressing TIB in skills class, on coaching calls, and in family work. For the next chapter we take an even deeper dive into the use of contingency management in addressing TIBs.

CHAPTER 7

Using Contingency Management to Address Therapy-Interfering Behavior

W

e have assessed the TIB in which our clients are engaging. We have oriented them to why we need to address a specific one, and we have discussed approaches to TIB in a variety of contexts. In this chapter, I go a little deeper into how to use contingency management to shape our clients away from TIB.

FIRST: STOP BEING SUCH A THERAPIST! One of the best things about writing a book about clinical practice is that I get to write whole sections that are advice to myself. My hope is that I too will actually get better by following my own advice. Before I talk about the specifics of different behavioral strategies for addressing TIB, we need to focus on our own antecedents: How are we setting the stage to effectively influence TIB? I have now spent several chapters advising you to thoroughly orient your clients about TIB and I truly want you to do that. After you orient them thoroughly—I want you to shut up. We therapists are really, really good at talking. The danger here 102



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is that we may just keep talking about TIB and not start doing—that is, we put off enacting the behavioral plans that help us actually shape and change the behavior. So, this is an opening caution for you: Make sure your TIB (as the therapist) is not talking about TIB so much that you’re not changing it. Orient and then dive in by using some of the strategies I present in the latter sections of this chapter to make changes. I also want to highlight that we don’t even need to talk about all TIBs. There may be some that are lower on your priority list that you can make some progress on without addressing them directly. We don’t have to talk about everything. If I’m shaping a client toward looking at me more during session, I could talk about it, explaining that it could be an opposite action for shame and a useful exposure. Or I could I just work to reinforce them when they are looking at me more directly. Depending on my case conceptualization and how their nonverbal behavior is related to their goals, I may speak to them directly about “looking down” or “poor eye contact” as a TIB (or not). TIB Tip TIB is just like the other parts of DBT: Less talking, more doing.

From here on out, I will assume you are better than I am about just shutting up and doing the work with your client (talking too much is my most frequent clinician TIB). Let’s see what strategies we have before us to choose from.

DIALECTICAL AND STYLISTIC STRATEGIES AS CUES FOR NEW BEHAVIORS One of the unique things about DBT compared to other types of behavior therapy is that it has several strategies built directly into the treatment that will increase the likelihood of getting a different behavior from our clients. In this section, I discuss the ways that both the dialectical strategies and the stylistic strategies can serve as cues for new behaviors.

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Dialectical Strategies I provide a brief review of the dialectical strategies in Table 7.1 but refer to their original descriptions in Linehan (1993, Chapter 7) for more thorough discussion. All of the dialectical strategies are designed to promote dialectical thinking and expand both client and therapist awareness of the many dialectical tensions in therapy (and in life). For the purposes of this chapter, I focus on their ability to surprise our clients and promote some very effective discomfort in them. Highlighting dialectical tensions can serve to signal to a client: “The behavior I’m doing now is hard to reconcile with       .” That fill-in line can be their values, their long-held beliefs, or simply new information they get from thinking dialectically or considering things from a different angle. In this way, entering the paradox can click with or even shock our client into responding differently (and thus changing a TIB). Let’s go through another example. I was working with a client who was in recovery from addiction. They had been sober for some time, but harbored much guilt TABLE 7.1.  Dialectical Strategies Strategy

Explanation

Entering the paradox

Acknowledging an unresolved dialectic and sitting with it

Use of metaphor

Highlighting content with a metaphor instead of head-on

Devil’s advocate

Taking the ineffective side of a client’s internal debate in order to help them find wise mind

Extending

Taking a client more seriously than they are taking themselves

Activating wise mind

Asking, “Is this really in line with your wise mind?”

Making lemonade out of lemons

Finding the slimmest of silver linings around a black cloud in the client’s life

Allowing natural change

Not shielding the client from normal life changes

Dialectical assessment

Asking, “What is being left out?”



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and shame about what they had put their family through while they were in active addiction. We were attempting to work on some behavioral activation, but their well-laid plans from session were not translating to work outside the therapy room. Though we agreed on goals, they couldn’t seem to follow through with plans between sessions. Chains on the TIB of not doing their behavioral homework revealed self-hatred as a crucial link. When they attempted to make a social plan or take care of themselves in some other way, their immediate thought was “I don’t deserve to feel happy” because of all they had done to friends and family while high. This same client would worsen the situation by listing to themselves all of the other people whose lives they had negatively influenced. We checked the facts multiple times on these beliefs to no avail; they truly believed they caused the addictions of others, despite much evidence to the contrary. I finally entered the paradox with them and said, “Boy, you sure have a strong belief in your godlike influence on other people for someone who hates themselves so much!” The client immediately started laughing and it was as if a lightbulb went off above their head. Suddenly it became clear that these beliefs contradicted one another and were just engineered to keep the client both stagnant and reinforce their self-punishment. This one moment of clarity did not solve all of the client’s TIB around between-session practice, of course. It did, however, point out a consistent pattern and serve as a cue that they had to try some different behaviors. It also gave us a shorthand (“You’re acting like a god again!”) that we could use to highlight that a TIB was affecting our session.

Stylistic Strategies Similarly, the stylistic strategies can serve as cues to elicit new behaviors from our clients. Our mandate in DBT is to work by using the stylistic strategies at both poles (reciprocal and irreverent) to promote the therapeutic relationship and bring our clients closer to their goals. In this way, both styles can help serve as cues to decreasing TIB and increasing therapy-promoting behavior. As with the dialectical strategies, refer to Linehan (1993, Chapter 12) for a deeper discussion of all of these strategies.

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Reciprocal Strategies The reciprocal communication strategies are as follows: • Responsiveness • Self-disclosure • Warm engagement • Genuineness These strategies can each set the stage for our clients to feel equality in the relationship and to feel the warmth and positive regard we hold for them. Acceptance of this type can lead to change—through feeling validated and understood, clients can begin to reimagine how some of their behaviors may be working against them. This context may indeed prep the soil for some changes in TIB and thus promote some growth in a new direction. While the reciprocal strategies are essential to give our clients some sense of comfort and trust, the irreverent strategies can “shake up our clients” to help them see things in a new light.

Irreverent Strategies The irreverent strategies are as follows: • Reframing in an unorthodox manner • Plunging in where angels fear to tread • Using a confrontational tone • Calling the client’s bluff • Oscillating intensity with silence • Expressing omnipotence and impotence As an example, despite all my usual problem solving, orienting, and troubleshooting, a client would simply not do her diary card. Generally speaking, I can get at least some small movement on diary cards inside of a month or two of doing DBT. This client was on her fourth month and still wasting session time doing her diary card. Finally, I reframed in an unorthodox manner and said,



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“I guess you just want to be in DBT forever? You know how important getting accurate data about your emotions and behaviors is, and yet we are spending time each session doing this, and it’s likely not even accurate. So, maybe you think if you never do the diary card properly, you’ll get to stay in DBT forever?” This particular client decidedly did not want to stay in DBT forever, so this framing was quite a shake-up for her. Because she wanted to finish DBT and move on with her life, she became a little more willing to discuss the barriers to diary card completion more honestly. By opening the door to us actually being able to better assess the barriers to doing the diary card, this irreverent comment allowed us to establish which “hollow promises” were actually a bigger TIB. This also turned out to be the much more relevant therapy and quality-oflife–interfering behavior for this client. Rather than discuss important things in other relationships, this client would often give quick promises and short answers and then continue to not follow through in many arenas (e.g., at work, with friends). I do not think I would have discovered this without my irreverent approach to TIB. Irreverence is often needed for diary card completion, especially with teenagers. Another approach I often use is calling the client’s bluff combined with using a confrontational tone. If a client says they are “too busy” to do the diary card or didn’t have time, I may say something like “You’re telling me every single day this week you didn’t have 3 spare minutes in your entire waking day? It seems to me to be quite a miracle then that you are finishing any schoolwork or making it to softball practice. We really need to figure out how to help you find an ounce of free time, both to get the diary card done, but also just so you don’t burn out on everything.” If the issue really is that this client has no time at all for the diary card, that’s a serious problem we need to attend to in order to make the therapy work. Often, however, this approach will result in the client saying, “I mean, I guess I had time . . . ” and then sharing other additional reasons the diary card didn’t get done. Once we know those, we can get to the work of actually problem solving the TIB together.

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Benevolent Demanding My first DBT supervisor, Adam Payne, told me something that remains on a Post-it on my office wall 18 years later. I recently discovered he had learned it from a beloved DBT mentor, Cindy Sanderson. Cindy said that DBT therapists strive to be “slightly charming, mildly annoying, straight to the point, and empathic as can be.” This statement encompasses so many of the dialectics we strive to uphold, but it is also a useful reminder of another tool in our arsenal, that of “benevolent demanding” (Linehan, 1993, p. 108). I think of benevolent demanding as a synthesis of both the reciprocal and irreverent stylistic strategies. Benevolent demanding is actually one pole of a “therapist characteristics” dialectic. Taken together, these six characteristics describe the interpersonal ways we approach our clients (see Figure 7.1). Benevolent demanding is in dialectical tension with nurturing, and thus must come from the same warmth and genuineness we use on the reciprocal pole of the stylistic strategies, but also contain the straightforward nature of the irreverent pole. It reminds our clients that we believe the most caring thing we

Oriented to Change

Unwavering Centerdness

Benevolent Demanding

Nurturing

Compassionate Flexibility Oriented to Acceptance

FIGURE 7.1. Therapist characteristics in DBT. From Linehan (1993). Copyright © 1993 Guilford Press. Reprinted by permission.



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can do is to push them toward their long-term goals. It’s “holding their feet to the fire” so that we can squeeze a new behavior out of them to reinforce instantly, as soon as we see it. TIB Tip When you get stuck addressing a TIB, return to the therapist characteristics. Maybe it’s time to try another pole of one of these dialectics.

A common TIB with teenagers in DBT is that they work with you beautifully when their parents are not yet in the room. You can make a great plan for family session and what they are going to say (e.g., prepping a DEAR MAN to ask the parents for some more freedom). Then, mysteriously, when the parents enter the room, your bright and engaged client goes from being super skillful to being a puddle of poor eye contact, a raised hoodie, and a series of “I don’t knows.” This, of course, like many TIBs, is also a target of treatment. These behaviors with parents may also be classically conditioned (a scenario we discuss next). However, if our therapeutic goal in the moment is to get through that DEAR MAN, their avoidance behaviors definitely become a TIB. Benevolent demanding is often the first step to addressing something like this: “Katy, we had a deal, I know you can do this. Let’s start with the ‘appearing confident’ of your DEAR MAN. Take off the hoodie, put your feet on the floor, and look at your folks before you start.” If this request is met by sad, desperate looks, I’ll likely just repeat it again, with a soothing face and maybe a “I’m pushing because I know this is important to you.”

CLASSICAL CONDITIONING: DECOUPLING CUES We spend a lot of time thinking about operant learning in DBT, and will of course be going forward in greater depth about reinforcement later in this chapter. Classical conditioning often plays a role in TIB as well, especially for those for whom previous therapy has been unhelpful, punishing, or even traumatic. Sometimes, in order to address TIB we have to understand how the behavior has become

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classically conditioned to be coupled with a certain stimulus, and then work to uncouple it before we can change it.

A Review of Classical Conditioning Let’s start with a refresher on classical conditioning (see Figure 7.2). Classical conditioning always involves the pairing of a conditioned stimulus (CS) with a neutral stimulus, or unconditioned stimulus (US). The unconditioned response (UR) is something we do naturally, or biologically—the salivation, in the case of Ivan Pavlov’s dogs. The conditioned response (CR) is when the dog starts salivating when it hears that bell (the CS), as opposed to salivating when it gets served its delicious dog chow (the US). This likely sounds familiar from your intro psych class in college or old The Far Side comics. Of course, as DBT therapists we very rarely work with salivation. The most common UR we see in psychotherapy is the activation of a client’s sympathetic nervous system: the fight/flight/ freeze response. Often this starts as a UR and becomes a CR over time. In the case of PTSD, panic in response to a physical attack is the UR, and panic in response to Christmas decorations that were present where the attack happened is the CR. In the case of a phobia, the UR can be symptoms of fear even at a perceived real threat (e.g., an actually harmless spider is believed to be venomous), and the CR can be panic even at a picture of a cartoon spider. Dissociation can also be a version of this sympathetic activation: a “freeze” response in every sense. Thus, when you think of classical conditioning used in psychotherapy, the first examples that US (physical attack) → UR (activation of the sympathetic nervous system) US (Christmas decorations) → no response NS (Christmas decorations) + US (physical attack) → UR (activation of the sympathetic nervous system) CS (Christmas decorations) → UR (activation of the sympathetic nervous system) FIGURE 7.2.  Classical conditioning.



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come to mind are often those dealing with targets for change. Phobias, obsessive–compulsive disorder (OCD), and PTSD likely come to mind. Clients with these disorders have automatic, physiological reactions to stimuli that trigger their anxiety alarm system—their fight/flight/freeze response. No one with a true spider phobia spends time analyzing whether a picture of a spider is of a venomous one—it’s just a picture! Their body responds as if they are under threat regardless. Remember that our clients in DBT are exquisitely sensitive. According to the biosocial theory, their whole emotion regulation system is primed to have a bigger reaction than other people’s systems do—often to what appear to be smaller provocations. Over time, this can create many CRs that are targets of our therapy. We use exposure and response prevention (ERP) with OCD or use prolonged exposure (PE or DBT-PE) for PTSD. Often, CRs are also therapy interfering.

Addressing Classically Conditioned Therapy-Interfering Behaviors Unfortunately, by the time people with BPD enter DBT, they have often had many other treatments that have not been particularly effective for them. Because of that, our clients have often developed CRs to what may be benign therapeutic interventions that can result in TIB for us. I have had many clients who freeze and get quiet when asked about details of their self-harm. This is a direct response to times in the past where providing such details have led to unhelpful hospitalizations. If clients are worried about their actual physical safety (many clients have physically traumatic experiences in the emergency room and in inpatient units), it makes sense that their sympathetic nervous system would be activated. Of course, in DBT, hospitalization is almost never our goal. We need to help the client be able to discuss nonsuicidal self-harm and suicide behaviors freely with us so we can learn from them and stop LTB as soon as possible. The following strategies can help us address TIB when it has been classically conditioned: hypothesis testing about automatic responses; using mindfulness, especially nonjudgmental stance;

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psychoeducation about classical conditioning; and teaching strategies to activate the parasympathetic nervous system. Our overall goal in using these strategies is to help us decouple cues from the past in order to better address what is needed in the moment. 1. Hypothesis testing about automatic responses. Of course, we do not know if a given automatic response is truly classically conditioned when we encounter it. We often try reinforcement strategies first to see if an incompatible behavior is easily reinforced. Often, when we have tried operant strategies and they have not worked, this is a signal to see if that client’s response may be classically conditioned. 2. Using mindfulness, especially nonjudgmental stance. Our clients are often unaware of their responses because they happen so quickly. Clients may also see their responses as unchangeable, or simply blame themselves for being “broken” or “crazy” for having them. Slowing down and using descriptive, nonjudgmental language for a particular TIB that appears to be an automatic response is the first step to understanding and changing it. 3. Psychoeducation about classical conditioning. Our clients can get angry at their bodies and feel embarrassed about classically conditioned responses. Often, they don’t realize this is a common learning experience that makes sense given their background. Learning a bit about classical conditioning and the reason their specific automatic response has generalized can reduce self-judgment and increase their willingness to address it as a TIB. This can sometimes even increase their self-efficacy about embarking on changing it. 4. Teaching strategies to activate the parasympathetic nervous system. Finally, if we have determined through chains and observation that a client’s TIB does seem to be a result of classical conditioning, one tool we have is to help them activate their parasympathetic nervous system (our “rest and digest” processes) in the presence of that cue instead. The TIPP skills are all designed to do just that. Even



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simpler interventions, like having a cool drink of water or a small snack, can help to push back against the work of the sympathetic nervous system (fight-or-flight response). TIB Tip As in DBT in general, hypothesis testing and mindfulness are powerful tools to get to the bottom of what is reinforcing a given TIB.

These four steps can be very helpful when a client’s fight or flight blocks what you both hope to accomplish in a given session. Over time, you and the client can work together to create a new response to those moments in session that bring out the client’s CR—just as you do in exposure-based therapies. We know these strategies work, we just need to apply them to our in-session interactions as well.

OPERANT CONDITIONING: DIFFERENTIAL REINFORCEMENT FOR MORE DESIRABLE BEHAVIORS In previous chapters, I covered ways to find new behaviors to reinforce when we are working to extinguish a given TIB. Here we discuss when to use both positive and negative reinforcement, as well as ways to assess their effectiveness in changing client TIBs.

Positive Reinforcement Let’s start with a quick review of operant conditioning principles. B. F. Skinner didn’t train all those pigeons for us to get lost in the weeds here. In operant conditioning “positive” means adding something and “reinforcement” means a behavior increases. We add something (presumably something the client enjoys) in the hopes of getting more of a specific behavior later on (see Figure 7.3). Broadly speaking, we want to reinforce therapy-promoting behaviors in the hopes that the reinforcement of these behaviors is more powerful than the reinforcers that are maintaining the TIB. There are three

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Doing the diary card + therapeutic warmth → ↑ completing the diary card before session Practicing a new skill + a cool sticker → ↑ skills use Sharing new information + calm response from therapist → ↑ being open in session FIGURE 7.3.  Examples of positive reinforcement in therapy.

broad categories of positive reinforcement in DBT, however, so let’s take a look at each one: therapist as reinforcer, reinforcers from the environment, and arbitrary reinforcers.

Therapist as Reinforcer In 1993, Marsha Linehan wrote: For most borderline patients, the most powerful reinforcers usually have to do with the quality of the therapeutic relationship. With some patients, little else is powerful enough to counteract the reinforcing effects already in place for destructive and maladaptive behavior. (p. 296)

In preparing to write this section, I looked back over years of notes of listening to Marsha speak at various events, conferences, and the International Society for the Improvement and Teaching of DBT (ISITDBT). I found four different versions of this quotation written in my notes: “The most powerful reinforcer in DBT is the therapist.” “The main avenue for reinforcement is our therapeutic relationship.” “The majority of the reinforcement we use in DBT comes from the therapist.” “The chief vehicle of reinforcement is the therapist.” You get the idea. Marsha was clear from the beginning. Because most people with BPD are quite affiliative by nature, it is of the utmost importance that we build a therapeutic relationship that



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is as strong as possible and then try to use it to shape our clients toward more effective behavior. TIB Tip “For most borderline patients, the most powerful reinforcers usually have to do with the quality of the therapeutic relationship. With some patients, little else is powerful enough to counteract the reinforcing effects already in place for destructive and maladaptive behavior.”                      —Marsha Linehan, 1993

Of course, using our natural interpersonal reinforcement (warmth, praise, genuine caring, interest, clear investment, approval, and the like) is a big topic loaded with nuance, and we won’t cover all of it here. My main point is that I don’t want you to forget that this is a tool we are wielding on purpose in DBT at the service of the client’s long-term goals. In the simplest case, this is letting our clients know we are genuinely excited and impressed when they bring their diary card, and being a little cold when they don’t—not because it’s a “rule” or makes our jobs harder but because the data on the diary card is vital to really helping them reach their longterm goals. It is a common therapist tendency to undersell how important our opinions and care are to our clients. Make sure to remember that the relationship is a tool you have and to be intentional in the ways you use it to shape away from TIB and toward therapy-promoting behaviors.

Reinforcers from the Environment While the reinforcement provided by the therapist is crucial, many other people in our clients’ environments provide reinforcement for them. Sometimes we are lucky and this reinforcement is already promoting therapy—a partner that is in favor of DBT and gives our client rides to session so they don’t have to wait for an unreliable bus, a friend who gives a compliment when our client uses their FAST skill—these people are priceless allies in our treatment. Unfortunately, it is also common that friends and family reinforce TIBs

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(whether they intend to or not), and it’s our job to understand those contingencies and help our client change them. Consider the following examples of ways the environment has reinforced my own and my colleagues’ clients for ineffective behaviors: • A client impulsively posts a picture glorifying self-harm on Instagram. She gets dozens of concerned direct messages telling her how loved she is, with most of those people offering validation and support. • A client’s wife tells him that he’s too smart for the skills group and doesn’t need to attend as regularly as other group members to understand the material. • A teen’s friends convince her she has “plenty of time” to get to session, so she is late. Again. • Every time a client self-harms, his boyfriend rushes over with treats and attention. He doesn’t practice his interpersonal effectiveness skills to communicate directly with his partner because this works so well. • A client and their close friends bond over their “treatment years” (time spent in residential and inpatient facilities)—the client feels close to their friends based on these conversations and is reluctant to try to build relationships based on other factors. This results in reticence to discuss issues related to identity development and goals in session. As you can see from these examples, it is very common that the environmental reinforcement itself is what is therapy interfering. No matter how reinforcing we are as therapists, if we are up against a more powerful interpersonal reinforcer in the client’s everyday life, we will not get too far. Our goal in this situation is to coach our clients to reconfigure the reinforcement schedule with their close others. How can they change it so that the people close to them reinforce the things we want them to reinforce? And in this case, “we” refers to your therapist–client team: You established goals together at the beginning, and you both want to reinforce behavior that puts you closer to those goals (even if the client may forget this at times).



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This is not an easy task—first you must do your clear assessment (as outlined in Chapter 4) to truly understand how these potential reinforcers are operating. Assuming our hypotheses bear fruit, you will engage in problem solving and commitment building with your clients to clarify how these “environmental TIBs” are getting in the way of the client’s goals. Therapist: Gina, I know it felt really good to get that support from your friends and coworkers when you made that post. Client: Yeah, I was really lonely, and it was a good reminder that I do have people who care, even if I don’t see them that often. Therapist: That’s great, that’s something I want you to have. Were there any downsides to the post? Client: (looks down) I mean, yeah. It’s embarrassing. I don’t want to be “mental illness girl” anymore, it feels super “high school.” I deleted it, but I still feel weird about what others will say. Plus . . . I dunno. Therapist: Plus, what? Client: I’m not sure . . . I mean, I’m not sure why, but it feels like it wasn’t very “DBT.” Therapist: That’s fair. Do you have a guess as to why? Or do you want me to help you figure it out? Client: It’s just . . . well, my reason is judgmental. It’s super “BPD” is all. Therapist: (laughs) I mean, that’s fair. I think you’re saying it’s not how you want to portray yourself? Or get attention? Client: Yeah, exactly. Therapist: Well, I’m really glad, because I want to talk about it for another reason, too. Client: You do? Therapist: Yeah, I actually think you and your friends were both being a bit therapy interfering. Client: How were my friends being therapy interfering? They were just trying to be nice!

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Therapist: Oh, for sure. Remember, TIB is not intentional. It just gets in the way, whether we mean it to or not. I think by reinforcing this . . . can I call it the “mental illness girl” post, like you did? Client: Yeah, totally . . . Therapist: OK, by reinforcing the mental illness girl post with love and attention, they made it less likely that you’ll try something more skillful next time. I want them to reinforce you for using skills, and for being direct when you ask for help, not for “MIG” behavior. Client: Ohh. Yeah, that makes sense. But I can’t control what they do! Therapist: Oh, I fully agree. And . . . you are clearly able to influence their behavior, right? Client: What do you mean? Therapist: Well, you got a lot of attention for the post. What I’m thinking is we need to have you talk to them about what behaviors you want them to reinforce and what behaviors you want them to ignore. Client: Say more. Therapist: No, you say more—can you think of a way to do that? Client: Well, I could tell them to ignore a future MIG post. I hope I won’t do any more of them, but if I do, they shouldn’t reach out to me. Maybe if they’re truly worried, they can call my mom or my roommate instead? Therapist: Would that be reinforcing? Client: Oh, hell no. That would suck. Therapist: Great, and what do you want them to reinforce instead? Client: Ugh, this is where I have to tell people I’m lonely and I need attention, yeah? Therapist: Yes! Exactly! But, effectively. Do you want some help with that? Client: Yes, . . . yes I do.



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Hopefully this example clarifies a way you can work with a client to reduce TIB from others in their environment. Let’s now think back to the earlier examples I gave of clients and environmental reinforcers of their TIB. Here are some possible solutions (I am certain there are others.) for those clients: • Too-smart guy. He tells his wife he also thinks he’s too smart sometimes but he actually really needs the practice and reinforcement of the skills. He plans a fun thing for them to do together after group. • “Plenty-of-time” girl. She tells her friend how important therapy is or doesn’t hang with that friend before session. • Sweet boyfriend dude. He orients his boyfriend and explains that while he is trying to be sweet, he is inadvertently rewarding self-harm. He teaches him how to reward skills practice instead. • “Treatment years” person. They work on identity development in session. They can steer the conversation with those friends to a different topic—DEAR MAN them to stop those conversations, or stop hanging out with them (at least temporarily). By using some of these strategies we can help our clients understand the ways their environment is reinforcing TIB and help them stop it. Teaching our clients to tackle these environmental reinforcers also improves their self-efficacy in influencing their environment directly and effectively.

Arbitrary Reinforcers The last category of positive reinforcement that can be used to influence TIB is arbitrary reinforcement. As humans, we generally like praise (though I offer some cautions on this below) and enjoy being recognized for what we do right. And, it turns out, we also love stickers. The biggest surprise of my professional career is how much middle-age dads love stickers. I know I am trucking in gender stereotypes here but it’s a genuine shock to the sticker collector forged in my 1980s girlhood. I have been using stickers as reinforcement in

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my group for years now and they seriously help shape homework completion for all, dads included. In my skills class, if you do your homework, you get a sticker. Now, here’s the twist: if everyone does their homework, everyone gets a puffy sticker. These are higher-quality stickers, usually made in Japan, and highly coveted in my skills group. I have the pull of a “regular” sticker to reinforce skills practice, and I have the additional social pressure from group members on one another to get the classier (yes, it’s a judgment, but it’s true) puffy sticker. We can use arbitrary reinforcers to great effect in session, especially for TIBs that have been stubbornly resistant to our praise and problem solving. Sometimes I’ll say, “What do I have to do to get you to try phone coaching?” and it turns out the answer is just “Save the last few minutes of session so I can show you a Lana Del Rey video that I love on YouTube.” Candy works great (for teenagers and adults alike), as does a bigger reward like a boba tea or a fancy coffee for overcoming a longer-standing TIB. TIB Tip Arbitrary reinforcers can work wonders to overcome a stubborn TIB.

We can also get parents, partners, or other family members involved in using arbitrary reinforcers to reduce TIBs. Is your client able to work to earn something to get them to start practicing their skills between sessions? Maybe a parent is willing to buy their teenager a new pair of Chuck Taylors after a month of completed diary cards? Work with your client’s support system to implement arbitrary reinforcers that are in line with your client’s therapeutic goals. These also don’t have to cost money. I have had teenagers work toward all kinds of cost-neutral privileges: getting to have the cat sleep in their room, choosing the film on movie nights at home (and the parents have to agree no matter what), or simply more free time with friends. You can get creative and find arbitrary reinforcers for all kinds of situations and clients.



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Some Cautions on Using Positive Reinforcement Positive reinforcement is our most powerful tool in DBT, but some cautions should also be observed. Positive reinforcement can be invalidating, especially for clients who truly hate themselves and/or do not believe they have accomplished anything. Working to titrate your reinforcement so that it is not merely an exposure but so the client can really hear it and take it in, takes time, practice, and lots of balance with validation. TIB Tip Make sure to assess how your client feels about positive reinforcement. If they find it invalidating, you may actually punish them when you intend to reinforce them.

Relatedly, positive reinforcement in the form of praise or sometimes even small gifts can make a client want to retreat. If your client gets easily overwhelmed, work with them to find smaller, more digestible ways to accept praise. Look, as a person, I am . . . a lot. I try to discuss with all of my clients how they like to be praised and reinforced and tell them in advance that a TIB of mine might be expressing too much excitement. With one particularly soft-spoken client, we used a “mini thumbs-up,” where I smiled really big (but silently) and put a tiny thumb’s-up sign next to my face. For her, this had the same effect as me yelling, “YOU’RE A F**KING CHAMPION!” to another client.

Negative Reinforcement Thinking back to the principles of operant conditioning, a reminder that the “negative” in negative reinforcement just means “taking away,” not acting in a negative way. The removal of an aversive stimulus causes an increase in a behavior: that’s negative reinforcement. Our key word when thinking about negative reinforcement is “relief.” Often in DBT we are up against a strong negative reinforcement pattern. Target behaviors are generally reinforced in this way:

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they remove an aversive emotion, thus increasing the likelihood of future target behaviors. TIBs also often provide relief. Not doing a diary card can help a client escape from thinking about behaviors and emotions that they would rather forget. Yelling at a therapist is an effective way to block them from talking about the topic that they are ashamed to talk about. Remember, we are not necessarily assuming intent here. The powers of reinforcement work on therapists and clients whether we intend them to or not. When a TIB provides our client some relief, we want to find them another way to get that relief, or make clear the ways in which getting that relief is hindering their progress toward their goals in other ways. If my client truly wants to stop self-harming but refuses to track their urges and behaviors—well, I’m not sure I can help them (and it will definitely be much more difficult, at best). We can also use negative reinforcement to kick-start or unleash a new behavior. I am not above chanting, “Look at me, look at me, look at me, look at me, look at me . . . ” over and over if I’m trying to get a client to practice opposite action for shame for the first time in a session. Once they look at me, I stop the (presumably annoying) chanting. We also use this principle to reinforce diary card completion (see Figure 7.4). The mild aversive is using your session time to fill out your diary card if you haven’t done it before session. This aversive (using session time to do your diary card) gets taken away if you bring in a completed diary card. The removal of wasted session time negatively reinforces completing the diary card outside of session (assuming your client finds time in session working on goals reinforcing, which not all do!). We really only want to use negative reinforcement to get back Does diary card before session—wasted time in session → ↑ doing diary card in advance Client looks at therapist—therapist singing annoying little song → ↑ client looking at therapist Client who doesn’t like attention volunteers to share homework in skills class – therapist attention to why homework isn’t done or shared → ↑ client sharing homework FIGURE 7.4.  Examples of negative reinforcement to address TIB.



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to positive reinforcement. I am not going to nag my client to truly do opposite action all the way in their day-to-day life. Think of negative reinforcement as a kick-start: It’s a short-term solution, and as soon as you see that behavior, get back to using positive reinforcement to shape it further.

THE BEHAVIORAL USES OF VALIDATION Does this heading strike you as a contradiction? Or maybe a dialectic? Of course, validation is on the acceptance pole of our treatment, and behaviorism is on the change pole. Yet DBT is a dance, and these work in concert to help change TIBs. In this section I discuss the ways validation can be utilized behaviorally: as an antecedent and as a response/reinforcer. I also review a few cautions about using validation to create change. We always try to create an environment where we validate the valid in DBT. A strong backdrop of validation is necessary in order to promote the large amount of change we want our clients to be making. That said, do not make the common error that a history of validation is necessary before working to make any change in your relationship/sessions. Some newer DBT therapists worry that we must validate 50 times before pushing for change once. Working toward change is also a way of validating. It shows we are taking our clients seriously and that we understand that their current way of living is not working—that is why we are both working so hard to change it. In short: Don’t wait a month before using irreverence. Irreverence also builds the relationship. Back to validation. Validation is an important piece of the puzzle throughout our quest to address TIB, but validation alone will often not “move” a TIB to a place where it stops interfering with our therapeutic work. Here are some ways to think about using validation strategically to change TIBs.

Validation as an Antecedent Often before we can effectively address a TIB we need to validate the reasons a given client might be engaging in it to begin with. If

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a client is late to session because their boss asked them to stay at work longer and they really need the overtime pay, I certainly need to validate the reasons that choice made sense before we can move on to seeing if there are other ways they can get that overtime (or if I have a better time slot to offer them). If I dive into problem solving right away, the client is likely to get frustrated or even defensive, and certainly may not be on board with solving the TIB. When we validate the valid in this way, we are much more likely to reach our goal of successfully resolving a TIB.

Validation as a Reinforcer We can also use validation as a reinforcer for behaviors we want to see more of. Validation and praise are distinct, yet overlapping categories. Often, we use them in concert to reinforce a behavior we want to see more of. When a client who has been having trouble completing an exposure-based homework assignment comes to session having done it, I cheer and clap for them: “Wow! You did it! This is so awesome!” I also offer some targeted validation: “I know you were really scared to do this, and you did it anyway. You got through it and showed yourself it was possible.” Validation of this kind can help connect our clients to us more closely (using the relationship as reinforcer) and help them feel understood (effective emotional communication as reinforcer).

A Word of Caution about Using Validation as a Reinforcer Just as we considered cautions for positive reinforcement, validation can also be an aversive experience for our clients, or it can feel like an exposure. With clients for whom self-hatred is a central problem, validation can feel indistinct from praise and may cause them to retreat or minimize the work they have done. This does not mean we don’t validate our clients. It just means we need to think carefully about the functional role of validation in a given moment. If the client in front of you is likely to view the validation as invalidating or aversive, you need to choose another way to reinforce their progress away from a given TIB.



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BLOCKING AND COACHING Blocking is a vital tool in the DBT therapist’s toolbox to address ineffective action tendencies associated with emotions. These are most often primary targets and not TIBs. One example of using blocking for a primary target is working with a client to get them to look at the therapist to use opposite action for shame rather than looking down or away when their shame doesn’t fit the facts. We can also use blocking (and accompanying coaching) in order to address TIBs. Sometimes, we don’t do a ton to address a particular TIB other than attempting to block it from happening. This can be as simple as rearranging your office furniture so that you are sitting in front of the door so that a client who tends to bolt during session is less likely to do so (of course, do not attempt this particular form of blocking with any client who has a history of violence). We can use this same principle of blocking in many other scenarios to prevent a TIB and then invite a client to engage in a new behavior. Not starting a session until we have a completed diary card is a form of blocking (provided the client is eager to engage with us). No diary card, no engagement. Of course, you can also use positive reinforcement once you get that diary card (look, I am so engaged!). You would offer a clear path for how your client can get that reinforcement (coaching) and block them from getting it another way (turning away from them, writing notes/doing other computer work) until the diary card is done. This is sometimes easier said than done. Clients in DBT are often experts in avoidance behavior, and very talented at getting the therapist off track and engaging in conversations that are not relevant to their top priority goals (or to resolving a TIB, such as not doing their diary card). This is where therapist awareness and mindfulness of the blocking plan is of the utmost importance. Blocking often involves putting a behavior on an extinction schedule. For example, a client may talk about something else instead of doing the diary card. You can remove the reinforcer of your attention to their interesting story and wait to give attention to the diary card instead.

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Often many other people are giving our clients lots of good attention for things that are actually TIB in therapy (making good jokes, distracting from hard topics, doing homework) so that we are swimming upstream with our blocking. This is why we don’t usually do a pure extinction protocol (e.g., only withdraw reinforcement)—we invite our clients to engage in the wanted behavior and coach them on how to do it.

PUNISHMENT Finally, let’s talk about punishment. Punishment, of course, is the addition of an aversive stimulus in order to reduce the likelihood of a future behavior. As DBT therapists we want to use punishment as little as possible. This is true for TIBs because we don’t want to give the impression we feel vengeful about them, especially given that most TIBs are not intentional. And, as with negative reinforcement, we swing back to positive reinforcement at the first sign of a desirable new behavior when we use punishment. Punishment should “fit the crime” (not be too big so as to be cruel or too small to work) and should always be coupled with a way for the client to return to reinforcement as soon as possible (avoid or stop the punishment).

Withdrawal of Warmth The most common mode of short-term punishment we use in DBT is the withdrawal of warmth when a client is being ineffective. This is always combined with the opportunity to earn back our warmth, and often with big positive reinforcers once the desired behavior shows up or returns. If I go to the waiting room and a client immediately calls me a name, I don’t forge ahead and say, “Hey! Good to see you.” I usually remain quiet and then walk them back to my office, giving them the opportunity to start again or apologize. If they do so on their own, I am immediately back in business and my usual warm self. If they don’t, they may need some coaching to get back on track, but I’m ready to switch out my “cold” demeanor as soon as the TIB of name-calling stops.



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Cheerful Aversives You can also use “cheerful” aversive behaviors or response costs (taking away something desired) when you have already attempted reinforcement and it isn’t working. I had a client who desperately needed to role play interpersonal effectiveness skills in session (she was not succeeding with them in between and we weren’t sure what was going wrong). She agreed this was the top goal and simply could not get started because of anxiety and embarrassment. I figured doing something more embarrassing might work, so I sang off-key 1990s R&B songs to her as a punishment. Suddenly, she was willing to do a DEAR MAN to make it stop. These are provided with orientation and a “wink.” My client knew I was being annoying on purpose to help her, not just trying to torture her. As soon as we got to practicing, I switched back to positive reinforcement. I have many different “fidgets” in my office for clients to play with while we work. I had one client working on overapologizing— he would apologize 15 or more times in a session. He also loved the fidgets. I finally took them away when he apologized. Once he rephrased what he meant without the apology, he got his favorite fidgets back. TIB Tip Only use punishment when serious attempts at reinforcement have failed and you are in wise mind.

We never use punishment when we are not in wise mind, and we use it only when reinforcement has failed. Remember that punishment does not teach new behavior, so it is a short-term strategy at best.

Correction–Overcorrection The use of correction–overcorrection (Cannon, 1983) in DBT is also outlined in Linehan (1993, chapter 10). We conduct a mini correction–overcorrection with a client whenever we “process” a client for not doing their homework or for coming late to skills class. If a client engages in an egregious behavior (say, breaking a lamp in the

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therapist’s office), they would need to not only replace the lamp and apologize but then overcorrect by perhaps adding a plant or some other décor to the office. Correction–overcorrection applies both to punishment and reinforcement to give the client a path back to the relationship and consistent reinforcement after a TIB.

Therapeutic Vacation Therapeutic vacation as outlined by Marsha Linehan is a serious punishment, and one to use only as a very last resort. As Linehan (1993) states, “we only use vacation when (1) all other contingencies have failed and (2) the behavior or lack of behavior is so serious that it crosses the therapist’s therapeutic or personal limits” (p. 310). One circumstance to consider a vacation may be if the client is willing to change self-harm but refusing to change another highly dangerous behavior (e.g., opioid use, or a serious eating disorder), such that the therapist cannot tolerate watching the client suffer. Another may be if the client is highly abusive toward the therapist. Again, vacation is always a last resort (as is the even more extreme step of unilateral termination) and should only be done in close consultation with the treatment team. Thus concludes our tour of contingency management in addressing TIBs. This chapter can serve as a problem-solving guide for when you are not sure how to attack a given TIB (once it has been properly assessed, of course). In the next chapter, we discuss when and how to address TIB in you, the therapist.

CHAPTER 8

When and How to Address Therapy-Interfering Behavior in Yourself

I

haven’t gotten this far into discussing TIB without addressing clinician TIB. I have included little examples along the way, and acknowledged the way our TIBs interact with . . . and sometimes even create our clients’ TIBs. This chapter is just for you, the clinician. We clinicians, are, of course, humans (even though our clients and maybe even our loved ones may want more from us). As human clinicians, we are subject to the same laws of behaviorism as our clients (Linehan, 1993), and we can be shaped into ineffective behaviors just as easily as anyone else. In addition, our relationships with our clients and our consultation team members are real—real relationships between equals (Linehan, 1993). This means we mess up like equals, frustrate one another, and engage in behaviors that do not always benefit us, our teams, and especially our clients. In this chapter, you learn more about your own TIB and cultivate the skills needed to minimize it when possible and address it when it’s inevitable. Much like our clients, remember: The goal is not perfection. All relationships contain some TIB, and all therapists engage in TIB. It may surprise you that it is more helpful for our clients if we engage in TIB and work to address it than it would be if we never engaged in TIB at all.

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Therapy-Interfering Behavior in DBT TIB Tip We are often more helpful to our clients if we engage in TIB and work to address it than we would be if we never engaged in TIB at all.

Why might this be the case? Why would I say I prefer that therapists engage in TIB and repair it than to not engage in it at all? First, I want to acknowledge that I am pushing hard against a cultural narrative about therapists. Think about the archetypal therapists you see depicted in books, TV, and movies (except for the ones that are supposed to be horrible). Think about what your perception of a therapist was before you became one. In all likelihood (once you get past a literal old Viennese man with a white beard), you picture a very caring person. You picture someone who speaks in a soothing voice and who always understands you and what you’re trying to say. This person doesn’t have their own life, problems, or emotions, and you can rely on them to always understand what you’re saying and never disappoint you. They “get” you, and they frequently let you know they understand things about you that you didn’t know until this perfect therapist pointed them out. They are also always on time and never forget the name of that one coworker you hate. Sounds nice, right? It also sounds totally unattainable, so it’s good for all of us therapists that that’s not what DBT recommends. Remember that we are not doing our clients any favors if we help them learn to interact with some kind of “stereotypical therapist character” instead of with a real person. Even if I could be “perfect” for my clients (luckily, in my case this is deeply not a risk), I would then be failing to set them up for their actual relationships outside the therapy room. No parent, boss, partner, child, relative, or friend is reliable or thoughtful 100% of the time. That person simply doesn’t exist. By being our actual human selves, we help our clients learn to tolerate the messiness of both real relationships and real life. By addressing our TIB and working to repair it, we model the respect we hope they will get from others when they also “mess up” in some way. It’s a win-win! It’s time to let go of striving for perfection and find those therapist TIBs! We first start with common therapist TIBs and the different settings in which they occur.

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We then switch gears to discuss the different skills you need as a therapist to appropriately address TIB, and then make a plan for personal practice. TIB Tip By being our actual human selves, we help our clients learn to tolerate the messiness of both real relationships and real life.

WHEN, WHERE, AND WHY DO THERAPISTS INTERFERE WITH THERAPY? It sounds counterintuitive at first—after all, we are called therapists! Why would we want to interfere with our work (therapy!) and make it harder? Of course, we generally don’t want to interfere, it just comes naturally to us (see above: We are human beings)! I briefly review the broad categories of therapist TIB here, and then give examples of how these show up in our various modes of treatment. As discussed in Chapter 2, disrespectful behavior and imbalances are considered categories of TIB (Linehan, 1993).

Disrespectful or Unprofessional Behavior Another way to think of “disrespectful” therapist behaviors might be “lack of professionalism.” Clients can view behaviors as disrespectful for a host of different reasons. Sometimes it’s practical: The client may perceive that we are wasting their time or their money. Acting in a disrespectful manner can also break a client’s trust. Finally, behavior may be disrespectful when the client and therapist come from different backgrounds with different standards for interpersonal behavior. Linehan (1993) lists 26 examples of disrespectful or unprofessional behavior in her original text; here are some common examples:  1. Missing or forgetting appointments  2. Canceling appointments without rescheduling  3. Losing files/papers/notes  4. Arbitrarily changing policies (e.g., for fees, appointment times, calls)

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 5. Appearing or dressing unprofessionally  6. Maintaining a messy or unclean office  7. Allowing interruptions like knocks or phone calls  8. Appearing visibly tired or fatigued  9. Talking about other clients 10. Repeating self; forgetting what the client said in previous appointments 11. Watching the clock while client is talking Of course, many of these examples are context dependent. The definition of “dressing unprofessionally” varies widely from Atlanta to Boston to the Pacific Northwest. What a client experiences as “arbitrary” may have a good rationale behind it, but if my client thinks it’s arbitrary, that means I haven’t done a good job orienting them (a different TIB entirely). Despite these caveats and context dependencies, disrespectful or unprofessional behaviors are important to attend to and discuss with your client if they occur. I’ll do my own opposite action to shame to say that I am guilty of most of these examples myself. Not every day, not with every client, but they have happened. These are TIBs we really do work hard to avoid, as they can deeply undermine our clients’ trust in us over time. And yet, Linehan (1993) points out that the more important fact is not whether they happen, but how we address them once they have. TIB Tip “Even more crucial than avoiding disrespectful behaviors, however, is the therapist’s response when such behaviors are pointed out by the client. The task of repairing disruptions and tears in the fabric of the relationship can be one of the most therapeutic processes the client experiences. Certainly the necessity to repair relationships is typical in the client’s life; the repair in this case, however, can prove extraordinarily healing.”                      —Marsha Linehan, 1993

Addressing these unprofessional behaviors doesn’t have to take a long time or be cumbersome. It can be a relatively quick conversation, as in this example:

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Therapist: Desi, if it’s OK, I’d like to put my own TIB on the agenda today. Client: OK . . . Therapist: I was really disappointed in myself when I double booked you with another client last week and we had to reschedule. Client: It was an accident; I know you didn’t do it on purpose. Therapist: Well, I’m glad you know that and it still wasn’t OK. Your time is valuable. When I or my other clients have schedule changes I need to be really careful to make sure something like that doesn’t happen. I just want you to know that I went ahead and booked our time in advance in my calendar and the clinic scheduling system to prevent that from happening again. Client: Thanks. It’s not a big deal, but I was pretty bummed you were so late to see me. Therapist: Yes, that makes sense! You had every right to be bummed, angry, whatever emotion. I was embarrassed and felt guilty. I do think the changes in how I manage my schedule will help, though, so at least something good is coming out of it. Thanks so much for your graciousness about this. I really appreciate it. Is there anything else you need from me at this time? Client: No, I think I’m good.

Imbalances One of our primary jobs as DBT therapists is to balance our acceptance and change strategies moment to moment in session—this is also one of the hardest tasks we have. Because of this, all the imbalances we discussed in detail in Chapter 2 are more likely to occur than disrespect or lack of professionalism. Imbalances inherent to the therapeutic relationship (like imbalances in power, information, and emotion regulation) can lead to TIBs, as can trying to stay balanced between acceptance and change in all the different contexts in which they are relevant. Doing the dance of DBT is challenging

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and no one is able to create a perfect blend of acceptance and change at all times. At the risk of (unprofessionally?) repeating myself, it’s how we address these imbalances that matters. I weave examples of both imbalances and disrespect/lack of professionalism and discuss different ways to handle them throughout this chapter.

Common Settings for Therapist Therapy-Interfering Behavior: Individual and Family or Couple Therapy I engage in the vast majority of my TIB in individual sessions, and my educated guess is that this is true for you (and most therapists) as well. We spend the most time with our clients in session and we usually get to know them better than their skills group leader. This leads to plenty of opportunities to “mess up” and engage in TIB. Turn back to Chapter 2 for a review of types of therapist TIB. I often view my own TIBs that occur during individual sessions as a gift, as it is during individual therapy that I have the most time to discuss, manage, and repair a given TIB. I also set the agenda every week, and TIB is always there, nestled between life-threatening behavior and quality-of-life issues, asking me to address it. The other reason I like addressing my own TIB in individual sessions is that it improves my relationship with my client and our work together in several ways: 1. I get to model owning and addressing TIB. This serves as an important example to my client for their own TIB. I model opposite action to shame, and I show them that I can participate in our relationship even after I have made a mistake of some kind. 2. I get to demonstrate fallibility and vulnerability. These are qualities that are often very hard for our clients in close relationships. In addition, they are often qualities that were lacking in some of their previous therapeutic relationships. Showing that I am fallible helps our relationship and also normalizes TIB. 3. It helps me reinforce the structure of our sessions and the egalitarian nature of DBT. By putting myself on the agenda, I show the

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collaborative nature of agenda setting and reinforce that the “TIB section” of our hierarchy is not there just for me to call out my client (of course we do not approach client TIB as a “call out” but since our clients are very susceptible to shame many still experience it that way). 4. It makes it much easier to address client TIB when it occurs if I have already addressed my own TIB, either in that session or a previous session. A spoonful of sugar makes the medicine go down. It also serves as an invitation to the client to address their own TIB more frequently and directly. The more I address my own, the less I feel the need to label a client’s TIB for them—they become more likely to name it and put it on the agenda themselves. TIB Tip Addressing your own TIB serves as an effective model and increases the likelihood your client will address theirs.

These same advantages apply to addressing your therapist TIB in family or couple work as well. An example of addressing a therapist TIB in individual therapy follows: Therapist: For TIB today I want to circle back to last session. Client: Ugh, I don’t want to talk about it. Can we just move on? Therapist: Well, I actually want to talk about my TIB. Does that change your mind at all? Client: Well, it intrigues me at least (chuckles). Therapist: Great! That’s always my goal. Well, we had a hard session last week, yeah? Client: I mean, I didn’t love it. Therapist: Yeah, I think you were pretty upset with me! Client: Well, yeah. You were being kind of a dick. Therapist: Ding! I don’t disagree with you, entirely, but can I tell you the slightly less judgmental way of saying it, if you’ll let me?

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Client: Sure. Therapist: I think I was pushing change and you weren’t ready for it. You had just had that big fight with your boyfriend, right? Client: Yeah, right before session. Therapist: Exactly. It was so recent. And you came to session anyway! Which was really impressive. But I don’t think I reinforced that enough, nor did I validate you enough. Client: I mean, there wasn’t much to reinforce, I was a mess. Therapist: Also a judgment. You were reasonably upset. And when you’re upset, I want to make it better, so what did I do? Client: I don’t really know what it was, but I hated it. Therapist: Well, I think what I did was try to get you into problem-solving mode. Like, immediately. Client: Oh. That’s why you were talking about what I could say to Tim next time we talked? Therapist: Yeah. I was sort of talking to you from a couple sessions back, when we were doing all that problem solving about your limits. Do you remember that? Client: Yeah—that day I was up for it, but last week—not really. Therapist: Exactly, and that was my TIB. Client: How? Therapist: Well, I didn’t pause to validate enough and understand where you were, and then I didn’t even ask you before I attempted to discuss a DEAR MAN/FAST for Tim, I just jumped into it. I’m not saying I “should have known,” but I certainly would have had a better chance of knowing if I at least asked you. Client: Fair. Therapist: So, to avoid this in the future, I want to make sure I ask before I plunge ahead into some big change talk with you.

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Client: OK, but I might not know if it’s too big. I might be overwhelmed, like I was. Therapist: Oh, great point. Well, the other thing that might be helpful is if you can tell me it’s time for me to back off a little. Client: Yikes. Therapist: No, really. It’s better than calling me a dick, isn’t it? Client: Yeah, OK. But I’m not sure what you mean. Therapist: OK, remember how DBT balances acceptance and change? Client: Yeah . . . Therapist: So, last time I was all “change, change, change.” I was not balancing. Client: Yes, OK, I see that. Therapist: Not only that, but some sessions require more of either acceptance or change, and I think last week you needed more acceptance than usual, and instead I gave you more change than usual. Client: Oh, yes. That is exactly what happened. Therapist: So if that happens in either direction, about Tim, or about anything else, I want you to say, “Whoa, I need more validation.” or “Enough validation, what can I actually do differently?” Do you think you can do that? Client: Maybe. Therapist: What if, at the end of session, I check in to see if there was a good balance, just to double check? Client: Yeah, that would work. And I’ll also really try to just tell you. Therapist: Awesome. Anything else you need from me to repair from last week? Client: Nah, I’m good. As in this example, clients often want to breeze past your TIB or make it simpler than perhaps it was (“You were being kind of a

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dick”). Being descriptive and precise will lead you both to a more functional and satisfying outcome.

Common Settings for Therapist Therapy-Interfering Behavior: Skills Class Because the goal of skills class is defined and narrow (skills acquisition) compared to any other mode of DBT treatment, imbalances are slightly less likely here. Nonetheless, there are many common TIBs in skills class. The most common TIBs that occur in skills class include: 1. Failing to follow the treatment hierarchy. As a DBT teacher and trainer, I see this one frequently. We get so accustomed to addressing important TIB in individual session that we can be overzealous about doing so in skills class. Don’t forget the TIB is last on our skills class hierarchy, after both therapy-destroying behavior and skills acquisition. Also, groups can be overwhelming. Skills class leaders may feel the need to attend to TIB in order to help their own focus and/or to feel like they have control over the group room. This is why it’s so important to use our team and make sure we are attending to shaping the behaviors we want to see in our group members. It’s human to want everyone to behave, but we get much better results by sticking to the hierarchy and using positive reinforcement on our group members (and if needed, on ourselves). 2. Not following DBT structure. Something about being in a group room can bring out the “treatment-as-usual” therapist in all of us. Engaging in frequent group process, shortchanging homework review, not sticking to the skills scheduled to be taught that night, not conducting missing links analyses when people are late or have not done their homework—these are all skills trainer TIB. In addition, attempting to lead a skills group with only one skills leader is also TIB, as it means that either the content of the group or the emotion regulation of the group will suffer if a client attends and needs help using skills. 3. Not following DBT principles. We also need to use our stylistic and dialectical strategies in group, including going where angels

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fear to tread and being direct, as well as oscillating our reciprocal strategies with irreverence. Avoidance of being direct can let people keep their cameras off in a telehealth group (I use this example for people who have reliable internet), avoid participation entirely, or keep their cell phones out in a group that is normed to set them aside and practice one-mindfulness. We need to have our same arsenal of strategies available to us in skills class as in individual sessions. 4. General professionalism. We therapists are not perfect, and we can engage in a whole host of unprofessional behaviors in group, including not starting/ending on time, canceling group frequently, or not calling on group members equally across multiple sessions. So what is the best way to address skills class TIBs? This really depends on who has been affected. Has a specific client come to you about a complaint that affects them most directly (e.g., you made a pejorative assumption about why they had not done their homework and it hurt their feelings)? It likely makes the most sense to address that TIB with that particular client one-on-one and make a direct repair to them. That said, something that affected one client (e.g., an unintentional microaggression about their identity) could indeed have effects on other group members (e.g., other members may not feel safe with you, regardless of their backgrounds). For this reason, it’s best to consult with your team on how to address skills class TIB. Often, it may make sense to address it at the beginning of group in the “admin” or “business” part of your agenda (in my program, this follows our opening mindfulness practice). These same guidelines are also generally true when we are discussing a TIB that occurred in a therapeutic milieu setting, like a residential or day program. Here is an example of addressing a “public” TIB like these: Therapist: Hey everyone, before we jump in to content tonight, I want to acknowledge a TIB of mine, which is that I haven’t been sticking to our agenda very well. For the last 3 weeks we have run out of time and I have been teaching you pieces of some skills the following week. I think this is happening because I love hearing all of your comments,

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questions, and participation so much, and you also need to be learning the skills. So, this is my commitment to stick a little closer to the schedule and make sure we cover what we need to cover. Feel free to remind me if I seem to get lost in the details, and Pev, our co-leader, will help keep me on track, too. Sound good?

Common Settings for Therapist Therapy-Interfering Behavior: Skills Coaching Calls Skills coaching is an especially fertile setting for therapist TIB. Our emotions tend to be higher during coaching calls. When our clients call us in crisis, we are often afraid, and our fear can tempt us to do things that stray from the DBT frame. Most of the times that we stray from the DBT frame also make our jobs as DBT therapists harder in the long run, as they can reinforce the very behaviors in our clients that we are trying to decrease. What follows are several examples of therapist TIB that happen during skills coaching, as well as an example of how to address your TIB during a phone call and again in session: 1. Calls are too long. As with all behaviors, we need to shape our clients’ use of phone coaching. It’s not a big surprise that initially, your calls with a client who is new to coaching will likely be on the longer side. Over time, you want to shape these calls to be shorter, both through direct orienting (“Let’s see if we can make a plan in about 5 minutes so you can start practicing”) and through more subtle shaping (“OK, can you pause a minute so I can tell you what I think you’re saying?” to interrupt a long-winded description). When I am tired, I often find my coaching calls go longer, because I have less energy for active shaping. This is generally not helpful to my client (it takes longer to get to skills; it subtly reinforces the idea that coaching is therapy) and also not good for me (when calls take longer, I may start dreading calls from a specific client). 2. Not shaping client’s “asking for help” behavior. Having a specific ask makes it much more likely that my client will get what they need

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from a coaching call and actually find it helpful. It also makes sure I’m not answering the wrong question, which can cause rifts in our relationship and lead to both client and therapist frustration. Often when clients are new to DBT, they’re not sure how to ask for help or how to use coaching effectively. Giving them a simple script (e.g., What’s the emotion? What’s your goal right now? What skills have you already tried?) and practicing it both before and on coaching calls can be very helpful. Letting the client ramble can feel easier in the short term, but this all but guarantees more frustration for both of you. 3. Not shaping client toward calling earlier in the chain. Early in DBT most calls will be about crisis behaviors: You will direct your client to do a lot of TIPP and ACCEPTS (actitivies, contributing, comparisons, emotions, pushing away, thoughts, emotions). And, as they gain more facility with these skills, you want to work in session toward the client using more interpersonal effectiveness and emotion regulation earlier in the chain, so that phone coaching is not only being used in response to a crisis. If you autopilot into distress tolerance skills on every call, this can be TIB. 4. Therapist is the skill instead of skills are the skill. It’s true that the therapist is a particularly powerful reinforcer in DBT. We don’t want the therapist themselves to be the skill. It’s fine for our clients to feel somewhat soothed and validated by our voice, or by the fact that we are available to help them. However, it can become therapy interfering when coaching calls are only validation or soothing, and do not direct back to skills the client can use. We won’t be in their lives forever, so we need to make sure we are helping them use the skills successfully on their own. 5. Too much soothing, not enough problem solving. Even when we do redirect to skills, if we spend 8 minutes soothing and 1 minute listing skills, that likely does not provide enough scaffolding for our clients to use a skill after talking to us. This TIB is a close cousin of the next one. 6. Too much talking, not enough doing. DBT is a behavioral treatment and we want to encourage active, deliberate practice. Don’t just

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tell the client to distract with thoughts—do an alphabet list together (e.g., category: animals, A for alligator, B for bear, C for capybara). Get them to walk to the freezer and get out the ice for TIPP. Have them get out paper to write on to make a list of the skills they will use when you get off the phone. Just talking about potential skills can leave the client overwhelmed, checked out, or both. 7. Calling back when you really don’t have the time or the mind space to do so. We are all guilty of this. We don’t want to leave our client hanging, or we just want to cross something off our to-do list by calling quickly and getting back to what we are doing. Not using our mindfulness and making sure we are ready to field the call is TIB. 8. Not calling back/checking your phone when you said you would. This one is obvious. We need to follow our commitments. If you can’t be available, designate a backup coach. 9. Going out of range unexpectedly. Remember TIB doesn’t have to be intentional. I have gone on Girl Scout campouts that are less than 3 miles away from the headquarters of giant tech companies only to find that my phone is a useless brick. I did not do this on purpose. And it was still therapy interfering. Here’s an example of addressing a TIB during a call: Therapist: OK, hang on a second. I got so caught up in your story, I’m getting lost. Can we back up and review what our goal is for this call? That will help me stay on track. That’s it. Keep it super short and note the ways you got off track. And here’s an example of a therapist addressing their TIB on a coaching call the following week, in session: Therapist: OK, and how do you think that coaching call went? Client: Fine. Therapist: Really? You didn’t seem fine. Client: Yeah, I guess I wanted something that you weren’t giving me.

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Therapist: Do you know what that was? Client: No. I was just frustrated. Therapist: Yeah, I could tell. I think the TIB was actually on me. This was only our second coaching call, and we are still working on understanding each other in that new context. I made an assumption about what you wanted, instead of supporting you to tell me what you wanted. Client: Well, that might have pissed me off more. Therapist: Sure, but I think if we work together we can come up with a system where you are very clear about what you need and then I can give you the advice you actually want, and then neither of us will be frustrated. What do you think? Client: I mean, sure, we can try. Addressing all TIB is a series of successive approximations. It is rare that one specific conversation will feel completely satisfying— we are building our effectiveness over time to make the next conversation a little more useful than the last.

Common Settings for Therapist Therapy-Interfering Behavior: Consultation Team Yes, we commit TIB in consultation team, too. I would wager that some of our most impactful TIB happens during consultation team, because if we are doing team-interfering behaviors, this will likely have major ripple effects on our treatment. Team is also a place where we are all attempting to practice vulnerability; if you don’t feel comfortable with that on a given day or with given team members, a cycle of team-interfering behavior can start. Teams are complex. We have an observer role that helps us stay on top of some of the following behaviors, but we may need to pay special attention to these behaviors in order to really address them: 1. Being passive and/or not putting yourself on the agenda. This is really under “not utilizing team” and can include:

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• Avoiding putting yourself on the agenda when you need help. • Overemphasizing your client’s behavior instead of looking at your own behaviors. 2. Taking up too much of the team’s time. On the other end of the spectrum, you may be taking more than your share of airtime. This might be because you’re the most experienced member of the team and you think you have great wisdom to share (which you might, but it could still be TIB). This can also be because you need a lot of validation/processing, or because you are not prepping enough to have a clear ask to help the team help you. 3. Having a vague framing question (or not having one at all). When we aren’t clear on what we need, it makes it hard for the team to help you. It can also lead to other problems because the team will inevitably offer the wrong kind of help, which can make you defensive. It can also just waste time. 4. Being late or not attending. Consultation team is a required part of DBT and has to be a priority to be used effectively. If you’re not there, you’re missing out, just like your client who is late to sessions or misses them entirely. 5. Being nonmindful. Checking your phone, chatting, or answering emails are not activities we do during team. Our team makes an exception for eating lunch, but even that is technically not being mindful and needs to be agreed upon by the whole team. 6. Too much validation/team becomes a process group. Yes, team is “therapy for the therapist,” but it is not your personal therapy. Using team to vent about life when it does not directly affect your work as a DBT therapist is inappropriate. The other function of team is to help us get better at DBT. As you well know, no one can make changes based on validation alone. 7. Not sticking to the DBT frame. People come to DBT from all different therapeutic backgrounds, and sometimes it’s hard to

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remember that you are there to improve your practice of DBT, specifically. When we therapists get lost, we try to find anything that might help our clients—this makes sense. However, bringing up a nonbehavioral case conceptualization is not in line with the goals of DBT. Everyone is there to try to increase their overall adherence to DBT. Other things that fall into this category are being nondialectical and rigid, being judgmental, and otherwise not following the consultation team agreements. By the way, making a bunch of judgmental comments and ringing the bell afterward is still judgmental. To truly use the bell, you need to stop and be more descriptive, not just let the judgments fly . . . not that I have had any experience with this behavior. (Of course I have. Judgments feel good when we are upset.) 8. Being defensive and/or being willful. “I’ve done that already,” “That will never work with this client,” “I just don’t want to try any of these things,” “I don’t see how my emotions have anything to do with this,” wash, rinse, repeat. If you find yourself saying these kinds of things, you might be being willful, and that is a team-interfering behavior. Practice willingness. 9. Offering unsolicited advice to a team member without checking to see if it would be welcome. This one is tricky. Sometimes your team members ask for the wrong advice! And if we don’t want to trigger defensiveness or willfulness, we need to ask for permission to go elsewhere. “Hey, I know you asked for validation, but I’m wondering if you’re open to a little feedback on how you addressed this behavior in session, too?” There’s no point in giving the feedback if it won’t be received, so don’t storm ahead without checking. There is a great deal more on each of these behaviors in Jennifer Sayrs and Linehan’s (2019) excellent book in this series, DBT Teams: Development and Practice, including how to address these behaviors in a teammate. Our focus, however, is on noticing and addressing these behaviors in yourself. It is definitely better for everyone involved if the therapist who has been committing the TIB owns it themselves and is open to addressing it. I encourage you to use Worksheet 8.1 (located at the end of this chapter) to do

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a self-assessment and note what team-interfering behaviors you frequently engage in and practice bringing them to team. Start now. To help, here’s an example. Our friend Keiko is the therapist, and each team member will be denoted by TM1 (team member 1), TM2 (team member 2), and the like. Let’s assume that the therapist already put herself on the agenda under TIB and the leader had just called on her. Therapist: Thanks. So I want to put myself on the agenda because I didn’t feel great about my behavior in team last week—I know I was defensive and I was a little ashamed afterward. You all were trying to help me be more effective in my sessions with Aysa and I think I spent the whole time “yes-butting” you because I was feeling so hopeless. TM1: I didn’t think you were so bad. TM2: Hang on, let her finish. Therapist: Well, I just want to apologize. I don’t think it was effective, and it sure didn’t help me have a better session with Aysa. TM2: Thank you for that. I appreciate it. I could tell you were getting tense while we were making suggestions, but I wasn’t sure what was getting in the way and how we should best handle it. Therapist: Yeah, I wasn’t sure either. I guess my framing question for you all today is what are some skills I can use to be less defensive during team so that I’m more open to everyone’s feedback? TM1: Wow, great question. TM3: Yeah, I think we could all use that sometimes. Maybe we can each go around and say one thing that helps us with our own defensiveness? Would that be helpful, Keiko? Therapist: Yes, please, I could really use lots of ideas. In this example, team member 1 starts to jump in to “save” Keiko, the therapist. This is very common. We like to make one

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another feel good as team members. Team member 2 did a great job of slowing down and making sure Keiko got a chance to make her apology, but sometimes you will have to do this yourself. If you are owning a TIB, you need to stop the team member who is trying to soothe you so that you can get to the harder things. Finally, team member 3 brought it back to what was needed in the moment (and could be helpful for everyone, not just Keiko).

WHAT SKILLS DO YOU NEED TO ADDRESS YOUR THERAPY-INTERFERING BEHAVIOR? Lucky for us, as DBT therapists we already have a host of skills that we can apply to managing our own TIB. As a reminder and a framework, the following DBT strategies and areas are most essential in using our skills to help us own and manage the TIB we engage in, whether with clients or our peers (see Table 8.1): 1. Mindfulness. To really underscore the obvious: Just as our clients can’t do much in the way of skills without first tuning into the moment at hand, we can’t either. Focus your “what” and “how” skills on yourself and then on your client to understand the impact of your behavior and be attuned to a time when it would be best to address it. Note any resistance or defensiveness on your part and dive in. Fully participate in discussions to help resolve and learn from your TIB. 2. Acceptance. If you made it this far in this book, you know I don’t want to shame you for engaging in TIB—it’s normal. And, TABLE 8.1.  DBT Strategies to Address Therapist TIB 1. Mindfulness 2. Acceptance 3. Consultation 4. Distress tolerance 5. Emotion regulation 6. Ability to make repairs

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well . . . in my experience, therapists tend to be a little bit perfectionistic. Even though I use a lot of words to remind you that therapist TIB is normal, you likely have a tiny voice in the back of your mind that wants to believe that you do it less than others. The way forward is to truly practice acceptance—of our own fallibility, of the wide variety of temperaments among human beings, of the true inevitability of misunderstandings, and of the benefits of identifying and working through TIB. Borrowing from radical acceptance practice and turning our mind again and again and again is helpful, too. 3. Consultation. Use your team, use your team, use your team. They have your back and they are there to help you come to terms with and understand your TIB. Demonstrate your openness to receiving feedback on TIBs that are not obvious to you by asking your team to “be curious” when you are stuck with a client and by actively reinforcing them for telling you hard things. I used to buy my teammate Barbara a latte every time she told me I did a TIB; she still tells me hard things to this day! Help your team help you by being open, nonjudgmental, and curious. Reinforce yourself for doing opposite action for shame in team and taking risks. All of these strategies will help you better understand and address your TIB, which will, in turn, help your clients. 4. Distress tolerance. Of course, DBT therapists need to use distress tolerance skills frequently. Depending on your temperament, you may need them even more when looking at your own TIB. I personally know that I often “lean change” in sessions. Because of this, when a client gives me feedback about not being validating enough, it is very easy for me to accept this, problem solve, and repair. However, what if I get feedback about not working hard enough to change something for a client? Well, you will see me using lots of STOP and even some ACCEPTS to help myself accept the feedback and be open to it. Self-validation helps, too. 5. Emotion regulation. My ability to regulate my own emotions can definitely be challenged when I am confronted by my own TIB.

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In addition, challenges with emotion regulation can lead to therapist TIB, especially when our own vulnerabilities are high. Watch your skills, especially ABC PLEASE, and be prepared to practice what you preach with opposite action. 6. Ability to make repairs. Finally, most successful resolution of TIBs ends with practice making repairs. Don’t forget that intent matters more than impact—even when a perfectly reasonable DBT intervention hurts our clients, we have hurt them. We need to pay attention to the harm we may have caused. Apologize (but don’t overapologize) and be prepared to do what you need to do to make things right with your client.

WHAT ARE THE STEPS FOR ADDRESSING CLINICIAN THERAPY-INTERFERING BEHAVIOR? The examples above should have illustrated many of these. The steps are truly the same as the steps for addressing client TIB that we addressed in Chapter 5, with the focus shifted to you (just like when we talk about validating others and then validating ourselves). This same set of steps works if you catch yourself engaging in a TIB or if a client catches you (see Table 5.2): 1. Define the TIB. 2. Convey what it is about this specific TIB that gets in the way of your work. 3. Explain clearly why you care about this (as opposed to why your client should care about it). 4. Do a behavior chain analysis. 5. Make a problem-solving plan. 6. Get commitment and troubleshoot. Finally, as with pretty much everything we do in DBT, practice will help you get immeasurably better at addressing your own TIB. Practice, practice, practice! Use your team to role play and then do deliberate practice in session of the skills required to address your

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own TIB in all contexts (especially the ones that are harder for you). In our final chapter, we attempt to synthesize all we have learned about assessing TIB in our clients and ourselves and addressing it effectively. What helps us find synthesis, in TIB and in life? Dialectics, of course.

Worksheet 8.1.  Team-Interfering Behaviors Self-Assessment Use this worksheet to conduct a self-assessment on your common consultation team TIB. Choose one to work on, or bring to your team to discuss.

Team TIB

How often do I do it?

Being passive and/or not putting yourself on the agenda

• Never • Rarely • Sometimes • Often • Very often

Taking up too much of the team’s time

• Never • Rarely • Sometimes • Often • Very often

Having a vague framing question (or not having one at all)

• Never • Rarely • Sometimes • Often • Very often

Nonjudgmentally describe what may be causing or maintaining this behavior:

Being late or not attending • Never • Rarely • Sometimes • Often • Very often Being nonmindful

• Never • Rarely • Sometimes • Often • Very often

Too much validation/ turning team into a process group

• Never • Rarely • Sometimes • Often • Very often

     (continued)

From Therapy-Interfering Behaviors in DBT by Esme A. L. Shaller. Copyright © 2025 The Guilford Press. Permission to photocopy this material, or to download and print enlarged versions (www.guilford.com/shaller-forms), is granted to purchasers of this book for personal use or use with clients; see copyright page for details.

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Worksheet 8.1.  (continued) Team TIB

How often do I do it?

Not sticking to the DBT frame

• Never • Rarely • Sometimes • Often • Very often

Being defensive and/or being willful

• Never • Rarely • Sometimes • Often • Very often

Offering unsolicited advice to a team member without checking to see if it would be welcome

• Never • Rarely • Sometimes • Often • Very often

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Nonjudgmentally describe what may be causing or maintaining this behavior:

CHAPTER 9

The Dialectics of Therapy-Interfering Behavior

I

n this concluding chapter, I discuss how to keep your dialectics in mind as you address and problem solve TIB. I discuss maintaining balance, choosing strategies, and review when to plunge in and chase down TIB like a Jack Russell terrier and when to let it go like Elsa. This chapter ends with a review of what you’ve learned, I share some general tips for troubleshooting, and cheer you on, you TIB-addressing beast! As discussed in Chapter 3, an important therapist tool for addressing TIB is dialectics. Being dialectical helps us learn the most we can about a given TIB and also makes sure that our attempts to address TIB remain focused on what’s important—getting back to the main reasons our client has come to treatment in the first place. Let’s focus on how choosing different strategies for addressing TIB can fall on both the acceptance and change side of our core dialectic.

CHOOSING A STRATEGY Generally speaking, we want to have a reasonable balance of acceptance and change in how we address TIB. This can be reflected in the times when we “let something go” versus the times when we work tenaciously to make a change with a given client. We don’t 153

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want TIB to be the focus of our work—addressing TIB gets us back to the focus of our work. We also don’t want to try to avoid TIB—I hope the last eight chapters have made that clear. We start by detailing the different choice points and how we make micro decisions from moment to moment when addressing TIB. TIB Tip As with everything in DBT, we want to balance acceptance and change as we address TIB.

In-the-Moment Choices If a TIB presents itself mid-session, do you address it or not? Sometimes I have seen a TIB come up over time and prepped for addressing it with my team. Therapists love to feel prepared, so this is a pretty easy TIB scenario. Other times the client has brought up the TIB or potential for TIB as part of our assessment or as an agenda item. This scenario is also easily dealt with because then I know the client is at least somewhat invested in discussing that TIB. What happens when a TIB just pops up? For example, you ask about the client’s relationship with their brother and they suddenly shut down. You suggest an alternative interpretation of a situation and they yell at you (the yelling being a possible TIB, not their disagreeing with the interpretation—you could be wrong, for sure). Do you label it a TIB in that moment, or do you file it away and address it later? How do we possibly make these decisions in real time? First, a caveat (and hopefully some validation): As with everything in DBT (and honestly, therapy in general), there is no one right answer to these questions. Sometimes you will choose to dive in and it will blow up in your face. Other times, you will dive in to address it and all goes well. Your relationship to TIB in general, to the specific TIB in question, and, of course, to that particular client, changes over time. Ask yourself the following questions to help find a starting point: • Will the client be receptive? Is this your second session with this client? Or have you known them for a year? Is this someone



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who really “gets” the concept of TIB, or is this someone who was skeptical when you oriented them to the idea of TIB? If the latter, they may feel defensive about something that is happening in the moment than if you attempt to discuss it with them later. We don’t treat our clients as fragile in DBT, so just because a client may have an emotional reaction is not a reason to avoid addressing a TIB. At the same time, you may be able to communicate your message more clearly and accomplish your goal of having the client understand and address the TIB so you can get to the main work of the agenda if you address it at a different time. • Are you really ready to own your TIB effectively? If you notice your own TIB suddenly in session, are you ready to own it effectively? Do you understand your own emotions? If you are going to share some vulnerability with a client, can you handle it if they dismiss you or get angry? Sometimes more personal reflection and collaboration with your team helps refine and improve your abilities to address TIB. Sometimes you may notice a familiar TIB pop up with a newer client, and you are well practiced at owning it and addressing it. Be honest with yourself. • What is the potential cost of it going poorly now? If you’re in the middle of an important chain—wait. Make a note for yourself and circle back. When we become adept at collaborating with our clients around TIB it can be tempting to go after it every time it bubbles up, but that’s certainly not effective. On the other side of the dialectic, if the TIB is preventing you from getting to the work, diving in immediately may make more sense and be more in line with the treatment hierarchy. Lean on the frame to tell you if now is the time. • What do I stand to gain if it goes well? We don’t assess cons without pros, do we? Maybe it’s risky, but the payoff could be great, just like a well-timed mind-reading validation. If it feels like catching this TIB in the moment—either for you or for the client—could have a big payoff and move the treatment from a stuck place, you may want to risk it even if there are potential “dangers.”

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Across Your Treatment Choices With any given client, you will want to address the TIB while accepting that some of it may be left on the table. Have I mentioned before that everyone engages in TIB? And that no therapists and no clients never engage in TIB? If you spend all of your time actively addressing TIB, you will lose valuable treatment time to work on both life-threatening targets as well as quality-of-life targets that are important to the client. Across your work with a given client, therefore, you need to stay mindful to which TIBs we are working to change and how, exactly, you are changing them. In addressing TIB, therapists balance validation, benevolent demanding, and blocking. • Balancing validation. Like all behaviors, TIB makes sense: It is reinforcing in some way for our clients. We need to validate the reason the TIB makes sense and highlight how it has served our clients in the past. A behavior such as dissociation may have helped the client get through challenging emotions or traumatic experiences in the past, even if it is now interfering with our work. We want to make sure to convey understanding of and validation of the TIB: It makes our clients feel less judged, which usually deepens our connection. Bonus: It’s true. These behaviors have served a purpose. • Balancing benevolent demanding. Staying with the validation example, while we can highlight ways in which dissociation has served the client, that doesn’t mean we let them spend our whole session dissociating. Getting the client to be present and experience their emotions is a central feature of any DBT treatment plan. We may need to use our change strategy of benevolent demanding to keep the client present, using reminders and shaping to refocus them on the discussion at hand and doing mini-exposures (“Hey, look at me! Let’s stay with this”) to grab their attention away from the TIB. With something like engaging in secondary anger at the therapist, this can be holding your hands up to say, “I surrender! No need to be angry at me. Let’s stay with that sadness we were discussing.” It can also be as simple as reminding a client about the task at hand: “I know the level of detail on a chain can be really



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annoying to you, but I promise it’s going to be relevant and helpful. Let me write down that other thing you want to talk about and then let’s finish this before we move on.” • Balancing blocking. Sometimes we don’t need to talk at all. No validation, no demanding, we just structure things to block the TIB. Sometimes this is literal. I have had clients who are a flight risk during family session—when I sit in front of the door, they don’t leave (do not do this with clients with a history of physical violence). I have thus physically blocked that particular TIB. With clients who dissociate frequently, having them use a balance board or hold ice can block that tendency without discussion (Melanie Harned [2022] has written extensively about strategies like these in the context of prolonged exposure [DBT-PE]). Having a predetermined distress tolerance activity lined up to engage in when shame or other emotions run very high in session is another example of blocking. By engaging with a fidget toy or a word search in order to stay regulated, the therapist and client work together to block dysregulation that had previously interfered with session. Remember, when it comes to TIB we are not here to “fix everything” about a client as we see fit—we are here to help them reach their goals. By balancing validation, benevolent demanding, and blocking we are more likely to achieve balance on the way to that goal.

Style Choices As therapists we also make choices in the very style we use to address TIB. I may stand and make a big “time-out” sign in the middle of a couple session because there may be no other way to stop one or both partners from continuing to repeat a point. On the other end of the spectrum, I may raise one eyebrow or a corner of my mouth to indicate to a client that they are reengaging in a TIB we have discussed previously. This spectrum is also apparent in therapists’ word choices and tone when addressing TIB. The ways in which we address TIB vary as needed by the occasion, and as the stylistic and dialectical strategies of DBT dictate (and as variations

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from therapist-to-therapist dictate). If you are not a mid-session stander or an eyebrow raiser, that’s OK. In addition to general style and tone variations, there will also be some variation in the extent to which we address TIB at all. Sometimes we address things head on; often we simply tolerate them. Early in treatment, we sometimes do “small” addressing and “big” tolerating. For example, I recently started with a client who is more judgmental than the average person. His judgments come so fast and so frequently, we would talk about little else if I even rang the bell each time he said one, let alone attempted to get him to be more descriptive every single time a judgment occurred. While the judgments are certainly a target of treatment (and he has agreed to this), I can’t stay on top of every one (at least not yet). Some of his comments are therapy interfering in that he can be very harsh toward others—members of his group, his family, me—and I find that distracting. What will happen if we get into a conversation about that? Likely he will shut down from shame, my shaping efforts will be for naught, and it won’t even help the judgments. Small addressing (through psychoeducation about judgments and agreement to shape them over time) and big tolerating (me tolerating distress over things he says that I judge to be “mean”) makes the most sense here. TIB Tip Work to balance how much TIB you are addressing “head-on” and how much of it you are choosing to tolerate.

As we address TIB more and more effectively, this can switch to “small” tolerating and “big” addressing. Later in treatment with this same client, I might stop the whole session when a harsh judgment comes up: “NOPE! Be more descriptive!” I might also choose to use self-disclosure to discuss the impact of a harsh judgment on me personally if it continues to burn me out, or it feels like he will be more capable of addressing it, and shaping hasn’t stopped the behavior. Of course, we will also be everywhere in between. There will be some TIBs we never address (I have accepted that teenagers are going to put their dirty shoes on my couch, and I would



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rather they be comfortable than have a clean couch) and some we will always address (few of us would accept being punched in the face without addressing it!), and, like most things in DBT, the vast majority will fall in the middle. That’s OK. Remember that addressing TIB is not like switching a light on and off. As therapists we are highly adaptable, using strategies to address TIB that make the most sense for our case conceptualization. If you begin to address a TIB and it’s not going well, or your conceptualization was off . . . that’s fine. That’s your TIB to own and to address. We are adaptable and we can shift in and out of addressing TIB as needed.

Remember to Change Ourselves Likely the most common quandary for therapists is deciding when to work on our own reactions as opposed to trying to change our client’s behavior. This depends on all the priorities I have discussed previously in Chapter 5. My general rule of thumb is that if I can change my own reaction and tolerate a behavior, I often do so in the service of higher-order targets. Our clients work on changing so many behaviors as a part of DBT. When we can give them a break, we should. Don’t get power hungry now that you know how to assess and address TIB so effectively. Make sure to look at your own reactions to TIB, too. Usually, we change our reactions by using our empathy (and our team) to keep our client’s actions in perspective, either by understanding what has led to their actions or by thinking about how something therapy interfering to us as therapists could actually represent progress in other areas of the client’s life. We use our own distress tolerance and emotion regulation skills to handle how our client’s behaviors make us feel. Sometimes, in addition to this we need to think about the potential functions a TIB might serve beyond the negative impacts it could have. As an example, my colleague Tanisha signed on early to a 7:30 a.m. telehealth session. This was a time her client had asked for, and she was especially dreading it that morning. Her kids were home from school due to a snow day and she had to complete some complex family maneuvers to make it to the session on time. Upon

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signing on, the first thing the client said to Tanisha was “I don’t know why we are even meeting at this time; you made me do this and I hate it!” She didn’t just say it, she yelled it! Tanisha wasn’t exactly thrilled to be in the session in the first place and was immediately deeply irritated by the client’s accusation (not to mention the way in which she rewrote history about the appointment). Luckily for this client, Tanisha had her overall case conceptualization handy. This client almost never communicates her needs directly to anyone. Telling Tanisha she wanted a different appointment time was actually a huge breakthrough for her. It was therefore super important for Tanisha to reinforce this communication from the client, even though it was ineffective. Tanisha used her own skills to tolerate her annoyance in order to shape a more important target (the client’s sharing of her own opinions and internal experiences with people). Over time, Tanisha was able to use shaping and reinforcement to help her client do so more effectively (as opposed to yelling). On the other side of this dialectic, therapists tend to be givers— we are generally pretty good at tolerating our own emotions and may let clients treat us poorly when we can see the ways in which a given behavior might make sense for the client. As DBT therapists, we try to keep this in balance and use our team to help us do so. We don’t tolerate everything but we do tolerate when it would be most effective to do so.

VALIDATION CHOICES Validation is, of course, a central skill in DBT and one we are constantly wielding in order to communicate acceptance and understanding to our clients. Validation helps us build our therapeutic relationship and it increases our understanding of our client’s unique experience and thus helps us build our case conceptualization. It is the vital ingredient that balances all the change we are supporting our clients in making. In addition, it’s a powerful tool in combatting TIB and working to shape it into therapy-promoting behavior over time. Validation has many functions in DBT, but three of them are



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most relevant to TIB. Next, we look at three of the functions of validation (as detailed by Fruzzetti & Ruork, 2019) and the way these functions support our work in addressing TIB. These three functions of validation are to reinforce, act as an eliciting stimulus, and purposefully invalidate the invalid.

Validation as Reinforcement We often validate our clients as a way of getting more of a behavior we want to increase. Validation is often used to aid in discrimination training for the client, especially in order to promote accurate expression. We all feel many emotions at once, but our DBT clients are more likely to focus on secondary emotions that have been reinforced by their environment. We can use intentional validation of primary emotions in order to reinforce accurate expression and also promote our clients’ understanding of their primary emotions. Most of the cisgender teen boys I work with have had the expression of anger extensively reinforced, and the expression of other emotions ignored and/or punished. When one of my clients expresses anger every time he feels scared, for example, this may be a primary treatment target for us, but it may also be functioning as a TIB. For example, if the client becomes so angry that he shuts down and I can’t complete a chain on self-harm, I won’t be able to get him closer to his goals. By providing some validation of his anger (which of course is valid and true for him), but differentially more validation if he is able to acknowledge fear, I can use reinforcement to shape him toward more accurate identification and expression of his primary emotions. This helps him reach his primary therapeutic goals while also reducing the therapy-interfering impact of secondary emotions on our other discussions.

Validation as an Eliciting Stimulus Lots of our clients’ TIBs are overlearned behaviors. Often, they respond to invalidation in a somewhat predictable way (consistent with the biosocial theory, they have experienced chronic invalidation and have learned behaviors that help them cope with that, albeit

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ineffectively). In contrast, when we validate an emotion, opinion, or thought that the client expects to be invalidated, our validation can serve as an invitation to change behavior. Validation of previously invalidated internal experiences can be soothing, but it can also be surprising, and even shocking. In this way the novel validation the client receives is an eliciting stimulus to try something new in their relationship with the therapist; something that isn’t therapy interfering but therapy promoting. TIB Tip Validation (especially when the client is expecting invalidation) can serve as an invitation to change a TIB.

Purposefully Invalidating the Invalid Finally, let’s discuss the role of the purposeful invalidation we use in DBT. As Kelly Koerner (2012) succinctly states, DBT therapists “validate the valid, and invalidate the invalid” (p. 138). Our most classic example of this is that we can validate the misery and hopelessness that may lead our clients to contemplate self-harm without validating self-harm as an effective response to those painful emotions (nor as a response that gets our client closer to their long-term goals). A similar pattern comes up frequently with TIB. The client may have a concern about their work with us that makes sense (e.g., we accidentally invalidated something valid, we insulted them, we aren’t prioritizing items on their agenda), but their behavior following those concerns may be ineffective and something we wish to invalidate (e.g., skipping session, lying on their diary card, throwing something at us). By providing big validation to emotions (and one form of this is owning our own TIBs) we can strategically invalidate our client’s ineffective TIB. For example, if my client Phuong Anh is so upset that I forgot we didn’t get to discuss her argument with her husband that she shuts down and won’t speak to me in the next session, she misses out on help that she really wants. I can instead start the next session by highlighting my mistake and validating her valid emotions, in the hopes that the new, invalid TIB (shutting down) doesn’t take over the session:



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Therapist: I’m glad there’s no life-threatening behavior this week, because I really want to make sure that there’s time to discuss my TIB from last week. Client: (shrugs) Therapist: (plunging in) I know you really wanted to talk about your fight with your husband and I didn’t manage the time well, so we didn’t get to it. You have every right to be frustrated with me and disappointed. I know it was a big argument and very important to you to address. Client: It was. I’m still pissed. Therapist: That totally makes sense. I just want you to know I see what I did wrong and I’m really committed to not doing it again this week. Client: Really? Therapist: Yeah. Can you give me another try? Client: OK. I guess. I may go on to spend more time validating her anger, while not validating her urge to retreat/disengage. This is just one example of how we use validation strategically when addressing TIB. Viewing validation not just as a general DBT strategy but also as a tool that can be used in specific ways to decrease TIB amplifies your effectiveness as a DBT therapist.

COMMON MISTAKES IN ADDRESSING THERAPYINTERFERING BEHAVIOR I don’t want to send you off without reviewing some common pitfalls in addressing TIB and ways to stay mindful of them. Addressing TIB can be tricky, so when you find yourself doing a behavior chain on what went wrong, start by seeing if one of the following pitfalls occurred: 1. Lack of orienting. Yes, we are back at “strike while you’re likable” (see Chapter 3). Bring up TIB early and often and explain it

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over and over again. When we try to bring up the very concept of TIB after one has already occurred, things get ineffective quickly. 2. Poor prioritizing. When we dive in without considering whether the TIB we are talking about is really the most important thing to be discussing in that moment in that session, there can be problems. Make sure you want to see the TIB you are talking about all the way through. 3. Expecting to resolve it in one conversation. TIBs generally make sense for our clients—they have been reinforced, just like target behaviors. Do target behaviors stop the first time they are identified? Of course not. Shaping TIBs takes time, even when the initial conversation is collaborative and satisfying. 4. Ignoring real-world reinforcers. Because TIBs make sense (see Pitfall 3), they aren’t only being reinforced by the therapist—they are often being reinforced powerfully in clients’ day-to-day lives— by partners, friends, family members, coworkers, and so on. To truly work on a TIB in session, you may need to collaborate with the client and/or their family members to decrease the reinforcement that TIB is getting out of session. 5. Ignoring a TIB because you are avoiding. I spent the first part of this chapter highlighting times when you may indeed be strategically ignoring TIB—that’s not what I’m getting at here. Sometimes we therapists avoid for the same reasons our clients do: facing something is hard. The conversation we need to have is likely to be hard; our own emotions about the TIB make us vulnerable; we have been punished for being direct in the past. Just remember that letting an important (to this client’s goals) TIB go unaddressed will usually make your job as a therapist harder later. 6. Overuse of self-involving self-disclosure. In my time consulting and supervising DBT, I have seen that some therapists get very good at explaining the impact of client TIB on the therapist’s emotions and experiences in the room. This is a hard thing to do well, and often a necessary thing to do in DBT. At the same time, it runs the risk of becoming reinforcing for the therapist. We are humans like anyone



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else, and that satisfying feeling of connection we can get after discussing the impact of a TIB and having the client validate us . . . well, it can be tempting. Before having a heart-to-heart, ask yourself if there is another method that might adequately address the TIB, or supplement previous self-disclosure you have already done. 7. Client “defensiveness.” In my experience, the fear of our client taking offense, denying the TIB, or getting angry at us for mentioning it is one of the biggest fears when it comes to clinicians worried about plunging in with TIB. Hopefully this book helps you feel less worried about client defensiveness. And, yet, sometimes your clients will have one or more of the feared reactions I just listed. When that happens, use the following questions to help you get back on track: • Can you do anything differently to address the TIB? Would another method have been more helpful? • What can you validate about your client’s previous experiences? What are you leaving out? Use your Level 4 validation powers to better understand their behavior—How does their TIB make sense given their history or biology? • Return to orienting (or reorienting, as the case may be). Tell your client again that you are not assuming intention with their TIB, that you are truly trying to make their therapy as effective as possible. When our clients get defensive or angry, we are given a wonderful opportunity amid the challenge: a chance to repair the relationship and show our clients that people who care about each other can make mistakes and work past it. This is just another way that working through TIB deepens our work with our clients.

WHEN ATTEMPTS AT ADDRESSING THERAPY-INTERFERING BEHAVIOR FAIL You’ve oriented. You’ve assessed thoroughly. You have gone where angels fear to tread and you are confident the TIB you are attempting to resolve is the highest-order target at this moment and

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then—nothing. It’s still not working. What can you do; how can you troubleshoot? Ask yourself the following questions: • How’s your shaping? Are you going too big? Can you find a smaller, just noticeable difference to reinforce? • What does your team think? Have you brought this challenge to your team? Have you brought it back for an update? Have you paid enough attention to your own emotions and behaviors? • Which dialectical strategies have you tried? Sometimes you just have to get unstuck. Will a metaphor help the client see what you mean? Have you tried extending? What lemonade can you make out of the lemons of this specific TIB? • Do you need to consider a contract? Maybe this TIB is truly the linchpin in your treatment. The client wants to work on their self-harm, but doesn’t want to stop drinking. Three months into treatment, every self-harm chain has drinking alcohol preceding it. Do you need to make a more structured behavioral intervention to test your hypothesis and get the client more on board with addressing the TIB? • Do you need to consider a therapeutic vacation? We know that putting a client on vacation from therapy is truly a last resort (Linehan, 1993, p. 310). While we work to avoid vacations at all costs, TIBs are the behaviors that are most likely to lead us there. If you have been doggedly targeting a TIB with all the tools in your toolbox and all the support of your team, it may be time to consider a vacation with a clear and achievable way for your client to earn their way back to you by making progress on the TIB. Finally, remember that in DBT (as in life) only change is constant. Sometimes a TIB that is intractable one month can shift and move the next. Take your time and be patient with both yourself and your client. You’ll crack it eventually.

SOME FINAL CHEERLEADING In this book I have discussed how to manage TIB. How to orient to the concept, how to normalize it, how to assess it, how to address it



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when we need to and ignore it when we don’t, and how to own our own TIB. It is my sincerest hope that you feel a bit more confident in your ability to address TIB and that you had a little bit of fun thinking about it. The more we effectively address TIB, the closer we get clients to their goals. TIB is the very work itself, not an impediment. Enjoy it!

References

Cannon, S. B. (1983). A clarification of the components and the procedural characteristics of overcorrection. Educational and Psychological Research, 3, 11–18. Chapman, A. L. (2018). Phone coaching in dialectical behavior therapy. New York: Guilford Press. Fruzzetti, A. E., & Ruork, A. K. (2019). Validation principles and practices in dialectical behaviour therapy. In M. A. Swales (Ed.), The Oxford handbook of dialectical behaviour therapy (pp. 325–344). Oxford, UK: Oxford University Press. Harned, M. S. (2022). Treating trauma in dialectical behavior therapy: The DBT prolonged exposure protocol. New York: Guilford Press. Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. New York: Guilford Press. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Manning, S. (2019). Case formulation in DBT: Developing a behavioural formulation. In M. A. Swales (Ed.), The Oxford handbook of dialectical behaviour therapy (pp. 237–258). Oxford, UK: Oxford University Press. Rae, J. R., Newheiser, A. K., & Olson, K. R. (2015). Exposure to racial out-groups and implicit race bias in the United States. Social Psychological and Personality Science, 6, 535–543. Rizvi, S. L. (2019). Chain analysis in dialectical behavior therapy. New York: Guilford Press. Sayrs, J. H. R., & Linehan, M. M. (2019). DBT teams: Development and practice. New York: Guilford Press.

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Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life. American Psychologist, 62(4), 271–286. Whaley, A. L. (2004). Ethnicity/race, paranoia, and hospitalization for mental health problems among men. American Journal of Public Health, 94(1), 78–81.

Index

Note. f or t following a page number indicates a figure or a table. ABC PLEASE skills, 149 Ability to make repairs, 147t, 149 Ableism. See Systems of oppression “Absenting out” of DBT, 65 Acceptance choosing a dialectical strategy and, 153–154 imbalances and, 18–22, 20t, 133–134 therapist TIBs and, 147–148, 147t Acceptance versus change imbalance, 18–22, 20t, 133–134. See also Imbalances ACCEPTS (activities, contributing, comparisons, emotions, pushing away, thoughts, emotions) skills, 141 Accurate expression, 41 Activating wise mind strategy, 104t. See also Dialectical strategies; Wise mind skill Addressing TIBs. See also Therapist tools benevolent demanding and, 108–109, 108f changing therapist reactions and, 159–160 classically conditioned TIBs, 111–113 during coaching calls, 85–94, 85f dialectical and stylistic strategies, 103–109, 104t, 153–160 in family sessions, 94–101 ignoring, 70–71 mistakes in, 163–165 in the moment, 154–155 overview, 166–167 priority order for, 64–70, 65t punishment and, 126–128 in skills class, 79–85, 80f steps to address a TIB, 71–78, 71t style choices and, 157–159 treatment choices and, 156–157 validation choices and, 160–163 when attempts at fail, 165–166 Adjunctive family or couple work, 95, 96–100. See also Family sessions

Adolescents. See also Family sessions arbitrary reinforcers and, 120 benevolent demanding and, 109 Advice giving, 145 Age, power imbalances and, 22 Agenda setting addressing TIBs in the moment and, 154–155 consultation team and, 143–144, 146 imbalances and, 20 primary family or couple work, 101 purposefully invalidating the invalid, 162 therapist TIBs and, 31, 134–135, 139 tools for addressing TIBs and, 42 Allowing natural changes strategy, 104t. See also Dialectical strategies Anger behaviors that aren’t TIBs and, 17 “disrespect” and, 27 mistakes in addressing TBIs and, 165 therapist assumptions about TIBs and, 46 validation as a reinforcer, 161 Antecedent, validation as, 123–124 Anxiety, 110–111 Arbitrary reinforcers, 119–120. See also Reinforcement Assessment. See also Behavior chain analysis; Functional analysis challenges with TIB targeting and, 59– 61 discussing TIBs with clients and, 56–59 factors to assess, 53–56, 55t family sessions and, 98 ongoing process of, 59–61 overview, 32–33, 45, 50 reinforcement and, 117 TIB Worksheet (Worksheet 4.1), 48–50, 62–63

171

172 Index Assumptions observing limits and, 33–34 principles of addressing TIBs, 9, 9t therapist assumptions about TIBs, 45–47, 47t tools for addressing TIBs and, 30–31 Attendance issues, 65 Attention, 12–13. See also Behaviors Avoidance behaviors benevolent demanding and, 109 blocking and, 125 mistakes in addressing TBIs and, 164 Awareness therapist assumptions about TIBs and, 46 tools for addressing TIBs and, 29

B Balance. See also Imbalances addressing TIBs and, 156–157 therapist TIBs and, 133–134 Behavior chain analysis. See also Functional analysis addressing TIBs in the moment, 155 overview, 47–48, 50–53 steps to address a TIB and, 73–74 therapist TIBs and, 149 therapy-destroying behavior and, 81 Behavioral experiments, 55 Behavioral thinking, 9, 9t Behaviorism, 29 Behaviors categories of, 12–16 differential reinforcement of, 81–85 nonverbal behavior, 103 that burn out therapists, 12, 14–16 that destroys therapy, 79–81, 83 that doesn’t interfere with therapy, 16–18 that interfere with other clients, 12, 14, 65 that interfere with therapy, 12–14, 65–66 that threaten continuation of therapy, 65, 65t, 69–70 violent behaviors, 80 waiting room behaviors, 65 Benevolent demanding, 108–109, 108f, 156–157 Biases addressing TIBs and, 7 orienting clients to the concept of TIB and, 41–42 Binge eating, 17 Biosocial theory, 111, 161–162 Blame, 35 Blocking, 125–126, 157 Borderline personality disorder (BPD) addressing TIBs and, 7–8 therapeutic relationship and, 114–115 Boundaries burnout-inducing TIBs and, 14–15 “disrespect,” 25–26 genuineness and, 31–32 observing without judgement, 33–34 priority order for addressing TIBs and, 68–70

Breathing techniques, 89 Burnout in the therapist addressing TIBs and, 5–6 behaviors that burn out therapists, 12, 14–16 priority order for addressing TIBs and, 68–70

C Calling the client’s bluff strategy, 106–107. See also Irreverent strategies Calls, coaching. See Coaching calls Case conceptualization, 50 Categories of therapy-interfering behaviors for clients, 12–16. See also Behaviors Chains, behavioral. See Behavior chain analysis Change, pushing, 91–94, 133–134, 135–138 Cheerful aversives, 127 Children. See Family sessions Classical conditioning, 109–113, 110f Clients discussing TIBs with, 56–59 getting to know, 32–33 orienting to the concept of TIB, 34–42 Clinician TIB. See Therapist TIBs Coaching calls addressing TIBs during, 85–94, 85f dysregulated clients and, 89–90 previously named and addressed TIBs, 87–89 relationship repairs and, 90–94 therapist TIBs and, 140–143 Collaboration. See also Noncollaborative behaviors addressing TIBs in the moment, 155 noncollaborative behaviors, 13 therapist TIBs and, 134–135 Commitment addressing TIBs during coaching calls and, 87–89 steps to address a TIB and, 76–78 therapist TIBs and, 149 Communication orienting clients to the concept of TIB and, 35 reciprocal and irreverent strategies of, 106–107 therapist TIBs and, 21–22 Compliance, 13. See also Behaviors Conditioned response (CR) assessment and, 55 classical conditioning and, 110–111, 110f Conditioned stimulus (CS), 110–111, 110f Conditioning, classical, 109–113, 110f Conditioning, operant. See Operant conditioning Confrontational tone, 106–107 Consultation challenges with TIB targeting and, 60 cultural biases and, 7

Index 173 therapist TIBs and, 139, 143–147, 147t, 148 when attempts at addressing TIBs fail, 166 Consultation-to-the-client strategy, 84 Contingency management behavioral uses of validation, 123–124 blocking and coaching and, 125–126 classical conditioning and, 109–113, 110f dialectical and stylistic strategies, 103–109, 104t, 108f not talking too much, 102–103 operant conditioning and, 113–123, 114f, 122f punishment and, 126–128 Continuation of therapy, behaviors that threaten, 65, 65t, 69–70 Contracts, 166 Correction–overcorrection, 127–128 Country of origin, power imbalances and, 22 Couple sessions. See Family sessions Crisis. See Coaching calls Cultural context addressing TIBs and, 7 assessment and, 53–54 cultural humility, 41–42 cultural mistrust, 54 orienting clients to the concept of TIB and, 41–42 power imbalances and, 22 Curiosity principles of addressing TIBs, 9t, 10 tools for addressing TIBs and, 30

Dialectical strategies. See also Strategies; individual strategies addressing TIBs in the moment, 154–155 changing therapist reactions and, 159– 160 choosing a strategy, 153–160 overview, 103–105, 104t style choices and, 157–159 therapist TIBs and, 138–139 treatment choices and, 156–157 validation choices and, 160–163 when attempts at addressing TIBs fail, 166 Dialectics. See also Dialectical strategies overview, 153 priority order for addressing TIBs and, 68 tools for addressing TIBs and, 29–30 Diary cards addressing TIBs and, 106–107 blocking and, 125 interpersonal imbalances and, 19–20 Differential reinforcement, 81–85. See also Operant conditioning; Reinforcement Disability, power imbalances and, 22 Disrespectful behavior, 18t, 25–27, 131–133 Distress tolerance skills balancing blocking and, 157 therapist TIBs and, 141, 147t, 148 tools for addressing TIBs and, 42–43 Dysregulation, 89–90. See also Emotion regulation skills

D

Emotion regulation skills changing therapist reactions and, 159–160 dysregulation and, 89–90 overview, 111 therapist TIBs and, 18t, 25, 133–134, 147t, 148–149 Empathy, 159–160 Entering the paradox strategy, 104t. See also Dialectical strategies Environmental reinforcers, 115–119, 164. See also Reinforcement Ethnicity, power imbalances and, 22 Examples, using in orienting, 41 Exposure, prolonged. See Prolonged exposure (PE) Exposure and response prevention (ERP), 111 Exposure for the therapist, 9t, 10–11 Expressing omnipotence and impotence strategy, 106–107. See also Irreverent strategies Expression, accurate, 41 Extending strategy, 104t. See also Dialectical strategies Extinction addressing TIBs in skills class and, 81– 85 blocking and coaching and, 125–126 ignoring TIBs and, 70–71

DEAR MAN (Describe, Express, Assert, Reinforce, (stay) Mindful, Appear confident, (be willing to) Negotiate) skills addressing TIBs in skills class and, 84–85 benevolent demanding and, 109 priority order for addressing TIBs and, 66–67 Defensiveness addressing TIBs and, 155 mistakes in addressing TIBs and, 165 therapist TIBs and, 145 Defining the TIB to be addressed, 71–72, 149. See also Addressing TIBs Demanding, benevolent, 108–109, 108f, 156–157 Devil’s advocate strategy, 104t. See also Dialectical strategies Dialectical assessment strategy, 104t. See also Dialectical strategies Dialectical behavior therapy (DBT) overview, 1, 138–139 Dialectical behavior therapy for adolescents (DBT-A), 95 Dialectical behavior therapy with prolonged exposure (DBT-PE), 68, 157. See also Prolonged exposure (PE)

E

174 Index F Fallibility, 134 Family sessions addressing TIBs in, 94–101 adjunctive family or couple work and, 95, 96–100 benevolent demanding and, 109 context of family work, 95–96 primary family or couple work, 95–96, 100–101 therapist TIBs and, 134–138 FAST (be Fair, no Apologies, Stick to values, be Truthful) skills, 66–67 Fear classical conditioning and, 110–111 mistakes in addressing TIBs and, 165 Fight/flight/freeze response, 110–111 “Four-miss” rule, 65 Functional analysis, 32–33, 45, 47–56, 55t. See also Assessment; Behavior chain analysis

G Gender, power imbalances and, 22 Genuineness benevolent demanding and, 108 genuineness strategy, 106 therapist as reinforcer and, 115 tools for addressing TIBs and, 31–32, 42 Goals for treatment addressing TIBs and, 4 discussing and assessing TIBs with clients and, 57–58 ignoring TIBs and, 70–71 priority order for addressing TIBs and, 64–65 reinforcement and, 115–117 Goals of behaviors discussing and assessing TIBs with clients and, 57–58 therapist assumptions about TIBs and, 47, 47t Group setting, 16. See also Skills class Guilt, 4

H Heart-to-heart strategy, 31. See also Strategies Hierarchy for individual therapy. See Treatment hierarchy Hopelessness, 4, 5 “How skills,” 30–32. See also Therapist tools Humility, 30–31, 41–42 Hypothesis testing about automatic responses strategy, 111, 112. See also Strategies

I Ignoring TIBs, 70–71

Imbalances acceptance versus change imbalance, 18–22, 20t, 133–134, 153–154 emotion regulation imbalances, 18t, 25 information imbalances, 18t, 24–25, 133–134 interpersonal imbalances, 18–22, 18t, 20t nurturing versus demanding change imbalance, 20–21 power imbalances, 18t, 22–24, 133–134 reciprocal versus irreverent communication, 21–22 therapist TIBs and, 133–134 Impact “disrespect” and, 26 therapist assumptions about TIBs and, 47, 47t Implicit bias, 26–27 Impotence, 106–107 Incompatible behavior, differential reinforcement of, 83. See also Behaviors; Differential reinforcement; Reinforcement Individual sessions primary family or couple work and, 96 steps to address a TIB and, 78–79 therapist TIBs and, 134–138 Information imbalances, 18t, 24–25, 133–134. See also Imbalances Intensity, 106–107 Intent “disrespect” and, 26 therapist assumptions about TIBs and, 46, 47, 47t Intent versus impact principle of “disrespect,” 26. See also Disrespectful behavior Interpersonal imbalances, 18–22, 18t, 20t. See also Imbalances Interpretation, 29 Invalidation. See also Validation assessment and, 53 positive reinforcement and, 121 purposeful, 162–163 therapist TIBs and, 91–94 validation as an eliciting stimulus, 161–162 Irreverent communication, 21–22. See also Communication Irreverent strategies, 106–107, 108–109, 108f. See also Strategies; Stylistic strategies

J Judgment, 35, 145

L Lack of progress, 67–68. See also Progress Learning history, 54–55 Life-threatening behaviors addressing TIBs and, 7–8 behavior chain analysis and, 50

Index 175 hierarchy for individual therapy and, 2, 3f priority order for addressing TIBs and, 66 Limits burnout-inducing TIBs and, 14–16 “disrespect” and, 25–26 genuineness and, 31–32 observing without judgment, 33–34 priority order for addressing TIBs and, 68–70 Listening to the TIB, 9t, 10

Nurturing, 108 Nurturing versus demanding change imbalance, 20–21. See also Imbalances

O

Making lemonade out of lemons strategy, 104t. See also Dialectical strategies “Meanness,” 27 Metaphor use strategy, 104t. See also Dialectical strategies Microaggressions, 26–27 Microaggressions and implicit bias principle of “disrespect,” 26–27. See also Disrespectful behavior Milieu setting. See also Skills class burnout-inducing TIBs and, 16 priority order for addressing TIBs and, 65 therapist TIBs and, 139 Mindfulness addressing TIBs during coaching calls and, 87–88 classically conditioned TIBs and, 112 therapist TIBs and, 144, 147, 147t tools for addressing TIBs and, 29 Modeling, 134 Motivation addressing TIBs and, 4 burnout-inducing TIBs and, 16 principles of addressing TIBs, 10 therapist’s motivation, 15–16

Observing Limits Agreement, 14 Obsessive–compulsive disorder (OCD), 110 Omnipotence, 106–107 Operant behaviors, 55 Operant conditioning. See also Differential reinforcement; Reinforcement arbitrary reinforcers and, 119–120 environmental reinforcers, 115–119 negative reinforcement and, 121–123, 122f overview, 113–123, 114f, 122f positive reinforcement, 113–121, 114f positive reinforcement and, 113–121, 114f therapist as reinforcer and, 114–115 Opposite action technique, 84 Oppression, systems of assessment and, 53–54 orienting clients to the concept of TIB and, 41–42 Organizational factors, 15, 16 Orienting clients to the concept of TIB family members and, 98–101 mistakes in addressing TBIs and, 163–164, 165 overview, 34–42, 43–44 therapist TIBs and, 91–94, 132 Oscillating intensity with silence strategy, 106–107. See also Irreverent strategies Other behavior, differential reinforcement of, 83. See also Behaviors; Differential reinforcement; Reinforcement Other clients, behaviors that interfere with, 12, 14, 65. See also Behaviors Overlearned operant behaviors, 55

N

P

Naming and addressing TIBs during coaching calls, 86–89 orienting clients to the concept of TIB and, 41 Negative reinforcement, 121–123, 122f, 126– 128. See also Differential reinforcement; Reinforcement Neutral stimulus, 110, 110f Nonattentive behaviors, 12–13. See also Behaviors Noncollaborative behaviors, 13. See also Behaviors Noncompliant behaviors, 13. See also Behaviors Nonjudgmental stance, 112 Nonverbal behavior, 103. See also Behaviors Normalization orienting clients to the concept of TIB and, 35 principles of addressing TIBs, 9t, 10

Panic, 110–111 Parasympathetic nervous system, 112–113 Perfectionism, 54–55 Personal learning history, 54–55 Phobias, 110–111 Phone coaching. See Coaching calls PLEASE (treat Physical iLlness, balance Eating, Avoid mood-altering substances, maintain good Sleep, get Exercise) skills, 66 Plunging in where angels fear to tread strategy, 106–107. See also Irreverent strategies Positive reinforcement, 113–121, 114f. See also Differential reinforcement; Reinforcement Posttraumatic stress disorder (PTSD), 110–111 Power imbalances, 18t, 22–24, 133–134. See also Imbalances

M

176 Index Practice therapist TIBs and, 149–150 tools for addressing TIBs and, 42–43 Praise therapist as reinforcer and, 115 Presenting problems behaviors that aren’t TIBs and, 17 blocking and, 125 Pretreatment stage of DBT, 35 Previous experiences in therapy, 58–59 Primary family or couple work, 95–96, 100–101. See also Family sessions Prioritizing behaviors to address, 64–70, 65t, 162, 164 Privilege orienting clients to the concept of TIB and, 41–42 power imbalances and, 22–24 Problem solving addressing TIBs and, 8, 64, 107 problem-solving plan, 71t, 74–76, 149 reinforcement and, 117–120 therapist TIBs and, 141, 149 TIB Worksheet (Worksheet 4.1), 62– 63 validating the valid strategy and, 124 Problems outside of sessions addressing TIBs and, 4 priority order for addressing TIBs and, 66–67 Process of therapy, 65–66 Professionalism, 131–133, 139 Progress behaviors that aren’t TIBs and, 17–18 priority order for addressing TIBs and, 67–68 Prolonged exposure (PE) classical conditioning and, 111 DBT-PE, 68, 157 slow progress and, 68 Psychoeducation about classical conditioning strategy, 112 Punishment, 126–128 Purposeful displays of anger, or “meanness” principle of “disrespect,” 27. See also Anger; Disrespectful behavior Purposeful invalidation, 162–163. See also Invalidation; Validation

Q Quality-of-life-interfering behaviors hierarchy for individual therapy and, 2, 3f perfectionism and, 54–55

R Race, power imbalances and, 22 Racism. See Systems of oppression Radical genuineness, 31–32, 42. See also Genuineness

Reactions to TIBs, 159–160. See also Addressing TIBs; Tolerating TIBs Real-world reinforcers. See Environmental reinforcers Reciprocal strategies, 106, 108–109, 108f. See also Stylistic strategies Reciprocal versus irreverent communication, 21–22. See also Imbalances Reflection, 32 Reframing in an unorthodox manner strategy, 106–107. See also Irreverent strategies Reinforcement. See also Operant conditioning addressing TIBs and, 6, 81–85 arbitrary reinforcers and, 119–120 assessment and, 55 correction–overcorrection and, 127–128 differential reinforcement, 81–85 environmental reinforcers, 115–119 mistakes in addressing TBIs and, 164 negative reinforcement and, 121–123, 122f, 126–128 positive reinforcement and, 113–121, 114f priority order for addressing TIBs and, 69 punishment and, 126–128 skills class and, 81–85 of suicide communication by family members, 96–97 therapist as reinforcer and, 114–115, 141 therapist TIBs and, 134–135 tools for addressing TIBs and, 42, 43f validation as a reinforcer, 124, 161 Relationship repairs, 90–94. See also Therapeutic relationship; Therapist TIBs Reports of client behavior from others, 43–44 Responsiveness strategy, 106. See also Reciprocal strategies Rewards, 119–120. See also Reinforcement Role-play therapist TIBs and, 149–150 tools for addressing TIBs and, 42–43

S Self-disclosure genuineness and, 32 mistakes in addressing TIBs and, 164–165 reciprocal strategies and, 106 therapist TIBs and, 21–22 Self-harm. See also Life-threatening behaviors addressing TIBs and, 7–8 behaviors that aren’t TIBs and, 17 priority order for addressing TIBs and, 66 Sexual behaviors, 17 Sexual orientation, power imbalances and, 22 Shame addressing TIBs and, 4, 6–7 emotion regulation imbalances and, 25 principles of addressing TIBs, 9

Index 177 Shaping addressing TIBs in skills class and, 82–83 coaching calls and, 140–141 overview, 103 therapist TIBs and, 140–141 when attempts at addressing TIBs fail, 166 Silence, 106–107 Skills class overview, 79, 80f therapist TIBs during, 138–140 therapy-destroying behavior and, 79–81 therapy-interfering behavior in, 81–85 Skills coaching. See Coaching calls Skills deficit, 55–56, 55t Slow progress. See also Progress behaviors that aren’t TIBs and, 17–18 priority order for addressing TIBs and, 67–68 Soothing, 141 Steps to address TIBs. See also Addressing TIBs family sessions and, 96–101 overview, 71–78, 71t therapist TIBs and, 149–150 Stickers as reinforcers, 119–120 Stigma addressing TIBs and, 6–7 organizational limits and, 15 Stimulus classical conditioning and, 110–111, 110f validation as an eliciting stimulus, 161–162 STOP (Stop, Take a step back, Observe, Proceed mindfully) skills, 75–76 Strategies. See also Dialectical strategies; Therapist tools; individual strategies blocking and coaching and, 125–126 choosing a dialectical strategy and, 153–160 irreverent strategies, 106–107, 108–109, 108f punishment and, 126–128 stylistic strategies, 103, 105–109, 108f therapist TIBs and, 138–139 when attempts at addressing TIBs fail, 166 Strategies to activate the parasympathetic nervous system, 112–113 Stylistic strategies, 103, 105–109, 108f. See also Irreverent strategies; Reciprocal strategies Suicidal thoughts and behavior. See also Life-threatening behaviors addressing TIBs and, 7–8 behaviors that aren’t TIBs and, 17 priority order for addressing TIBs and, 66 reinforcement of suicide communication by family members, 96–97 Sympathetic nervous system, 110–111 Systems of oppression assessment and, 53–54 orienting clients to the concept of TIB and, 41–42

T Teenagers. See also Family sessions arbitrary reinforcers and, 120 benevolent demanding and, 109 Telehealth addressing TIBs and, 5–6 priority order for addressing TIBs and, 65–66 Therapeutic relationship behavior chain analysis and, 50 family sessions and, 97 reciprocal strategies and, 106 as reinforcer, 114–115 relationship repairs and, 90–94 validation and, 160 Therapeutic vacations, 128, 166 Therapist characteristics dialectic, 108–109, 108f Therapist TIBs. See also Therapeutic relationship; Therapists addressing TIBs in the moment, 155 during coaching calls, 140–143 in consultation teams, 143–147 disrespectful or unprofessional behavior, 18t, 25–27, 131–133 emotion regulation imbalances, 18t, 25 imbalances, 133–134 in individual and family or couple therapy, 134–138 information imbalances, 18t, 24–25 interpersonal imbalances, 18–22, 18t, 20t observing limits and, 33–34 orienting clients to the concept of TIB and, 34–35, 38–40 overview, 129–131 power imbalances, 18t, 22–24 relationship repairs and, 90–94 during skills class, 138–140 skills to address, 147–149, 147t steps for addressing, 149–150 talking too much, 102–103, 141–142 Team-Interfering Behaviors SelfAssessment (Worksheet 8.1), 145–146, 151–152 Therapist tools. See also Addressing TIBs; Dialectical strategies; Strategies; Therapists addressing TIBs and, 7 benevolent demanding and, 108–109, 108f blocking and coaching, 125–126 dialectical and stylistic strategies, 103–109, 104f, 108f not talking too much, 102–103, 141–142 orienting clients to the concept of TIB and, 34–42 overview, 28, 42–44 punishment and, 126–128 tools for addressing TIBs, 28–32 Therapists. See also Therapist TIBs; Therapist tools behaviors that aren’t TIBs and, 17 changing reactions and, 159–160

178 Index Therapists (continued) mistakes in addressing TBIs and, 163–165 as reinforcer, 114–115, 141 talking too much and, 102–103, 141–142 therapist TIBs and, 18–27, 18t Therapy-destroying behavior, 79–81, 83. See also Behaviors Therapy-interfering behaviors (TIBs) overview. See also Behaviors; Therapist TIBs in family members, 97–98 hierarchy for individual therapy and, 2, 3f overview, 1–4, 3f principles of addressing TIBs, 8–11, 9t reasons to address, 4–8 TIPP (temperature, intense exercise, paced breathing, progressive muscle relaxation), 89, 112–113, 141, 142 Tolerating TIBs, 158–160. See also Addressing TIBs Tools, therapist. See Therapist tools Transactional model, 50 Transparency information imbalances and, 24–25 orienting clients to the concept of TIB and, 34–42 Transphobia. See Systems of oppression Treatment goals addressing TIBs and, 4 discussing and assessing TIBs with clients and, 57–58 ignoring TIBs and, 70–71 priority order for addressing TIBs and, 64–65 reinforcement and, 115–117 Treatment hierarchy coaching calls and, 85, 85f, 89, 90 cultural biases and, 7 ignoring TIBs and, 71 for individual treatment, 2, 3f, 79 skills class and, 79, 80, 80f therapist TIBs and, 138 Troubleshooting steps to address a TIB and, 76–78 therapist TIBs and, 149 Trust assessment and, 54 emotion regulation imbalances and, 25

U Unconditioned response (UCR) assessment and, 55 classical conditioning and, 110–111, 110f Unconditioned stimulus (US), 110–111, 110f Unprofessional behavior, 18t, 25–27, 131–133. See also Therapist TIBs Use of metaphor strategy, 104t. See also Dialectical strategies

Using a confrontational tone strategy, 106–107. See also Irreverent strategies Using mindfulness, especially nonjudgmental stance strategy, 112. See also Mindfulness; Nonjudgmental stance

V Vacation, therapeutic, 128, 166 Validation. See also Invalidation addressing TIBs in the moment, 155 as an antecedent, 123–124 balancing, 156 behavioral uses of, 123–124 as an eliciting stimulus, 161–162 genuineness and, 32 orienting clients to the concept of TIB and, 41 overview, 160–163 positive reinforcement and, 121 purposefully invalidating the invalid, 162–163 as a reinforcer, 124, 161 therapist TIBs and, 91–94, 135–138, 141, 144, 145 Verbal comments that could be therapy destroying, 80. See also Therapydestroying behavior Violent behaviors, 80. See also Behaviors Vulnerability in consultation teams, 143 therapist TIBs and, 134 tools for addressing TIBs and, 31

W Waiting room behavior, 65. See also Behaviors Warm engagement strategy, 106. See also Reciprocal strategies Warmth benevolent demanding and, 108 therapist as reinforcer and, 115 therapist TIBs and, 21–22 withdrawal of, 126 “What skills,” 28–30. See also Therapist tools Willfulness, 145 Wise mind skill overview, 104t punishment and, 127 steps to address a TIB and, 75–76 Worksheets Team-Interfering Behaviors SelfAssessment (Worksheet 8.1), 145–146, 151–152 TIB Worksheet (Worksheet 4.1), 48–50, 62–63