Dialectical Behavior Therapy

Doing Dialectical Behavior Therapy

 

Natural contingencies are the powerful natural consequences that occur within each therapeutoc interaction that are also similar to how things work in nontherapy relationships. Self-involving self-disclosure is one way the DBT therapist uses natural contingencies to benefit the client.

Interactions with the therapist or aspects of the therapy itself (e.g. Session frequency or length, payment) may evoke some of the same behaviors that trouble the client in other relationships. For example, the client takes an angry, demanding tone when he makes a request of the therapist that is an imposition of the therapists's time. Others in the client's life are turned off and withdraw from him when he does this to them; his angry tirades inhibit others from giving him feedback; he feels lonely and incapable of keeping good relationships. This is a key place to use self-involving self-disclosure to help the client see the contingency between his behavior and its effects. The therapist might say, “Your voice tone sounds quite angry and demanding as you ask me to do this for you. Were you aware of how your tone comes across? When you ask me in this way, it makes me feel less like doing it. If you asked in a way that showed you realize it may be an imposition, you'd get more of what you want from people.”

It is beneficial when the client engages in behaviors with the therapist that are similar to those that cause problems in other relationships because a well-known aspect of reinforcement is that the closer in time and place the behavior is to its consequences, the greater the effect of those consequences. The key is to be aware, from chain analysis and formulation in advance, of what you are trying to strengthen and what you do not want to reinforce. For example, in one case, others would not respond to an emotional pain of a person unless this person became dramatically upset and made extreme statements such as “I'm going to kill myself if she says that again!” The contingency in therapy should be different: you would want to tune in and respond to distress with plenty of help without in having to escalate.

Loneliness. Photo by Elena.

Therefore, warmth, care, and attention should be at a good baseline frequency so that low-level requests and expressions of difficulty regularly produce appropriate help. You would closely monitor the client's current vulnerability factors and antecedents so that when the chain to the pattern is triggered, you can quickly attend to emotional pain but block extreme statements. For example, when this person begins to tell you about an interpersonal conflict similar to those that have led to extreme statements and suicide threats, you might say “I'd really like to help you get things to go the way you want in this situation, so that you do not have to escalate but instead really get what you need.” You would stay responsive and warm to the client's appropriate expression, and become cooler when extreme statements are made, even actively blocking them. “When you threaten suicide, it makes us have to assess the risk. To me that takes a lot of time and distracts from what's most important, which is that you are upset by a real problem – could you tell be about it without the threats.

What happens close in time to the incident is more likely to affect the behavior's future probability. Treatment effects will be stronger, therefor, if client's problem behaviors and improvements occur during the session, where they are closest in time and place to the available reinforcement that the therapist can provide. Nowhere is this more visible than when the therapist and client negotiate solutions to problems in their therapy relationship by by explicitly discussing how each person's responses reinforce our fail to reinforce the other's motivation and engagement in therapy.

Some people have objections to contingency management, as if deliberately responding in a contingent way is harmful or deceitful. This objection ignores the fact that we are all responding contingently all the time with everyone anyway. If I am sharing something about myself, you are either responding in a way that makes me more likely to continue to share or less likely to continue to share; this happens whether either of is is aware of the effects or not. As therapists, we want to be as aware as we can be so that we harness our responses to the client's benefit rather than simply responding to alleviate our own discomfort. A good base rate of genuinely noncontingent positive regard is a prerequisite to effective use of contingency management. Unless the client experiences you as genuinely invested in his or her best interests, contingency management feels manipulative or coercive.

Doing Dialectical Behavior Therapy (A Practical Guide by Kelly Koerner)

Oblivion. Photo by Elena.