DBT Agreements and Commitment Strategies: Pre-treatment and Beyond

By Stephanie Vaughn, PsyD

This presentation is an excerpt from the online course “DBT in Practice: Mastering the Essentials”.

Highlights

  • There are specific Patient and Therapist Agreements that must be consented to before beginning DBT, a vital one being the patient’s agreement to work on eliminating life-threatening behavior.
  • Adults in DBT are typically asked to commit to therapy for at least 1 year.
  • If involuntary treatment is required, patients must be allowed to choose a non-DBT alternative, as involuntary treatment is not permitted.

 

Transcript

All patients begin in pre-treatment. This is when the individual therapist discusses the DBT agreements and assesses the motivation for commitment. Individuals involved in DBT must be voluntary. DBT expressly prohibits involuntary treatment. And thus, in the case that treatment is not voluntary, the patient should have the option of choosing an alternate non-DBT therapy. So in DBT, there are patient agreements and therapist agreements. These can be verbal but optimally will be written and referred back to in case that they are needed in the future.

The patient agrees to a one-year, what we refer to as a gentleman’s agreement. So this is a one-year commitment to DBT as a whole. This is a renewable agreement so that when the year is up patient and therapist can go back and examine the progress that’s been made and determine whether a new contract should be made. This is a gentleman’s agreement in that it is not legally binding and there is not necessarily a financial obligation which goes along with it but it’s similar to a handshake in that one can agree today and change their mind tomorrow but optimally that wouldn’t happen.

The patient also agrees to attend weekly sessions and weekly skills training. They agree to work on eliminating life-threatening behaviors which include suicidal behaviors and self-harm behaviors. They also agree to work on any behaviors which interfere with therapy referred to as therapy-interfering behaviors. And if payment is received by the therapist, they agree to provide the payment necessary.

The therapist agrees beyond the standard ethics and confidentiality requirements of the profession to make what is referred to as every reasonable effort to conduct therapy as competently as possible and to attend peer consultation team meetings. The individual therapist also agrees to provide reasonable intersession contact in the form of telephone coaching. And they agree to treat the patient with respect and work on their own therapy-interfering behaviors that might arise.

Until the patient and therapist both agree to the way that treatment will proceed, the methods and the goals, the patient is not involved in DBT but rather is in pre-treatment. Pre-treatment should last typically no more than three sessions, during which time a typical assessment occurs that is not unlike any other form of psychotherapy. The agreements are reviewed and the therapist begins implementing the commitment strategies in order to solidify the patient’s commitment to treatment.

Individual therapists use commitment strategies in pre-treatment but also throughout the year when behaviors such as life-threatening behavior, threats of quitting therapy or seeming resistance to implementing new change procedures arise.

Some of the strategies are the devil’s advocate technique in which the therapist will argue for the side of not committing to treatment. This helps to reinforce the patient’s sense of choice and autonomy.

Also making a smooth segue into another commitment strategy, which is assessing the pros and cons of entering into DBT. It’s important to be genuine in highlighting the differences between DBT versus other modes of therapy and that includes the cons of entering into treatment. DBT requires more of a time commitment than CBT considering the individual therapy, group skills training and intersession contact components which occur weekly. In addition, rather than focusing on the crisis of the week, the therapist is committed to managing and responding to issues according to the DBT target hierarchies. So rather than engaging in heart-to-heart or venting sessions, a therapist may repeatedly redirect a patient back to discussing life-threatening behavior from the previous week. This can be aversive to some patients and thus, it is important to highlight this as a potential downside of treatment.

Another commitment strategy is referred to as foot in the door. And very similar to foot in the door is what is referred to as door in the face. So foot in the door is when a therapist may ask for an easy first request putting the foot in the door which then widens the opportunity for compliance and increases the likelihood the patient will agree to another request. The door in the face technique would be to ask for something larger than expected, being told no by the patient and then thus making it more likely they will agree to a less intense request. So when considering homework, for example, if we were using door in the face technique, we might ask for a new skill to be practiced every day and this may be too much of a commitment for a new patient learning the skill so we could back off and ask for three times per week.

Another commitment strategy that is important particularly in pre-treatment is highlighting the freedom to choose and the absence of alternatives, so the freedom to choose to engage in DBT treatment while at the same time highlighting that there seems to be a lack of alternatives that would be beneficial.

So the commitment strategies are not something that’s simply done in the very beginning of treatment. This is something that a therapist would go back to time and time again when commitment seems to waver, when a self-harm episode occurred, when a patient’s suicidal urges have intensified and when they are potentially considering dropping out of treatment. The way that the therapist goes back to these can vary based on style. They may pull out the written commitments or may simply refer back to the verbal commitment to work on therapy-interfering behaviors or life-threatening behaviors saying something like “but you promised in the beginning that you wouldn’t drop out of treatment.” Once the therapist and the patient agree to the way that therapy will proceed and the therapist assesses that there is adequate commitment and that progression of treatment will be voluntary, then we can move into stage 1 of the DBT.

There are specific patient and therapist agreements which must be consented to before beginning DBT, a vital one being the patient’s agreement to work on eliminating life-threatening behavior.
Adults in DBT are typically asked to commit to therapy for at least one year.
If involuntary treatment is required, patients must be allowed to choose a non-DBT alternative, as involuntary treatment is not permitted.

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