Prioritizing Targets: The DBT Hierarchy
This presentation is an excerpt from the online course “DBT in Practice: Mastering the Essentials”.
- In DBT, there are 3 categories of targets: life-threatening behavior, therapy-interfering behavior, and quality-of-life-interfering behavior.
- Imminent and upcoming risk takes precedence for discussion over past patient behavior and urges.
Before beginning a behavioral chain analysis in individual DBT, the therapist will need to prioritize which targets to address and manage the time according to DBT’s hierarchy of targets. It’s not uncommon for multiple issues to exist in any individual session and it can become difficult for a therapist to decide where to start especially when emotions run high. The diary card is an excellent resource for determining what should be addressed first and for what amount of time, at what intensity. However, you don’t want to necessarily fall back on the diary card as your only tool for determining what you should talk about. And that’s because the diary card is a record of what has transpired up to now. There are times that the thing that’s on fire so to speak is actually happening in the present moment or is upcoming.
So one of the questions that I have figured out is an excellent one to ask at the beginning of a DBT session once you have the diary card in hand is, is there anything that’s upcoming or that’s happening now that’s likely to increase your risk for self-harm or to increase your risk for unskillful behavior as a whole? So that will hopefully guide you in terms of whether you should address life-threatening behavior that’s happened over the past week or something that’s happening right now. And there’s nothing worse than finishing up a session and you feel really great about having done an excellent behavioral chain analysis on something that happened last Tuesday and the patient starts to walk out the door and says, oh, by the way and then we know that the dreaded door knob statement as they call it is about to happen. And they say, oh, by the way, my rapist was released from prison. And you as the therapist are aware that the patient has said before that she would kill herself if he ever got out because she couldn’t live with the symptoms of PTSD that she was experiencing. So that would be an example of something that could have been prevented if we would have asked the question in the beginning. Is there anything that’s upcoming that might increase your urges or your risk for suicide or self-harm?
So if you haven’t figured it out already, life-threatening behavior definitely takes priority in a DBT session. Life-threatening behavior would be anything that increases the patient’s imminent risk for death. Also any self-harm behavior. So that is subsumed under life-threatening behavior. Determining whether a behavior is life-threatening or not can be confusing to some therapists who are new at learning DBT. We wouldn’t characterize drug use or alcohol use as a life-threatening behavior even though perhaps the patient is using to the point that it is risking their health. That’s a more long-term life-threatening behavior. We only categorize something as a life-threatening behavior once it is imminently risking a patient’s life.
So urges and actions are differentiated in DBT and actions will take precedence. They take priority over the discussion of urges. o if we’re still talking about the category of life-threatening behavior, thinking about or having urges to kill yourself over the past week, that is an important discussion to have. And on the diary card, a therapist can at a glance see at what intensity the patient experiences that. However, if at a glance the therapist also sees that the patient has had a life-threatening act, perhaps they self-harmed or they put a yes under suicidal behavior, meaning that they did some sort of suicidal act, that would take precedence. The discussion of that would be essential. We’d need to tease that apart, ask questions about it, determine exactly what happened prior to assessing any of the urges that had happened outside of that. And again, the current experience and future experiences even take precedence.
So some of these are going to be determined by wise mind. If I’m sitting in a session and I’m looking at a diary card, there is a self-harm act that’s occurred over the past week, there is a yes under suicidal behavior that it has happened in some shape, form or fashion, I’m still going to ask the question of “is there anything upcoming that’s going to put you at risk?” because yes, the person may have attempted on Tuesday but if they’re planning on attempting tomorrow or after they leave session, I’m going to need to spend the bulk of session assessing that. So sometimes, most often actually, they all tie in together. So it’s a matter of keeping those target priorities in your working memory so that you don’t let anything fall through the cracks. It is a lot like juggling.
The formal suicide assessment tool that’s recommended in DBT is Linehan’s Risk Assessment and Management Protocol that is referred to as the LRAMP. And you can find that online at the University of Washington’s website. And it’s a basic tool. It can take a little time to fill out. There’s an abbreviated version and a more extended version. But we want to use that anytime that we’re doing a formal suicide assessment. And we can discuss that in further detail in another video.
So if life-threatening behavior takes priority, that doesn’t mean that our other categories of behavior are ignored. Again, we need to make sure that we are able to juggle each of these and address them to some degree.
So if we also have therapy-interfering behavior going on, let’s say that the same patient also arrived extremely late to session, 30 minutes late for that matter and you’re trying to juggle all these targets and keep your hierarchy and therefore address life-threatening behavior, it’s going to be very difficult for you to address the fact that the patient arrived late to session. However, that’s an important topic to address. And so more discussion about how to address therapy-interfering behaviors is in another module as well. Therapy-interfering behaviors are a whole other category and there are multiple ways of addressing those. But some of the examples are the misuse of intersession contact. So maybe the patient is calling more frequently than the therapist is okay with, //failure to complete the diary card at all. So not only might the patient arrive to session late but then we don’t even have a diary card filled out that we can look at and then even begin to come up with our target hierarchy. Interpersonal //dynamics between the therapist and the patient in session such as a patient arguing incessantly or saying I don’t know, withdrawing emotionally, those are the types of things that can interfere with therapy. So these are things that both interfere directly with therapy as in the patient is not even there or they’re not conscious in session, maybe they’re sleeping or something and then also things that are likely to lead to premature termination either by the therapist or from the patient themselves. So that’s the second most important thing to address.
The third is quality-of-life-interfering behavior. So that’s a catch-all for most everything else and that includes things like drug use, binge eating, failure to take prescribed medication, legal problems, high risk sexual behavior, relationship problems, the loss of a job, financial issues. It’s everything else. So if it’s not imminently life threatening, then it most likely falls into this category.
Therapists can get easily distracted into focusing on quality-of-life-interfering behavior over life-threatening behavior because it tends to be the more interesting at times. I mean, to discuss relationship problems can be far more interesting than discussing a self-harm act that occurred last Tuesday. And it may seem like old news to the patient. The patient often can reinforce the therapist inadvertently to moving away from discussing life-threatening behavior. And so it’s just easier to discuss quality-of-life-interfering behavior. But as Linehan says, we can’t do therapy if the patient is dead. And so we have to make sure to fully address anything that risks their life before we’re able to move on to the quality-of-life-interfering behavior.
So sometimes, it’s hard to differentiate between these different categories. For example, a patient who might seek repeated psychiatric hospitalizations, so they are taking themselves to the psychiatric hospital, attempting to be admitted, perhaps being admitted on multiple occasions, this could be a quality-of-life-interfering behavior because, I mean, for obvious reasons it’s getting in the way of them being able to have a life worth living, to have relationships to sustain, employment. And so it could be considered a quality-of-life-interfering behavior. However, it could also be considered a therapy-interfering behavior if their hospitalization prevents them from attending therapy. So other examples of how a behavior might fall into multiple categories. High risk sexual behavior. So if a patient is engaging in high risk sexual behavior, we would qualify it as a quality-of-life-interfering behavior. However, if that happens to be a, let’s say that they have a history of sexual trauma and we know from having spent enough sessions and done enough behavioral chain analyses with them that every time that they engage in high risk sexual behavior, that leads to suicidal urges or self-harm urges and it’s so conditioned that we’re 99% sure that it’s going to lead to that, then it becomes a precipitating event for life-threatening behavior, essentially being the same as life-threatening behavior. So we would want to definitely address that as a life-threatening behavior as well.
Drug use can be one of those more precarious situations and also binging and purging can be one of those precarious situations that we’re not sure whether to categorize it as life threatening or quality of life interfering.
The important thing is don’t get caught up in semantics or the details of things. What you really want to do is fall back on wise mind and we’re really using this to determine how much time we dedicate, we devote to addressing this, at what intensity. And so this is the question, is this imminently threatening the patient’s life now? Then we absolutely need to address it and hit it hard. Otherwise, we may need to put it aside to focus on other topics like therapy-interfering behavior because if the patient is not in therapy, you’re not going to be able to address the drug use anyway. So we definitely want to use wise mind when considering where something falls on the hierarchy.
In DBT there are 3 categories of targets to which are prioritized respectively: life-threatening behavior, therapy-interfering behavior, and quality-of-life-interfering behavior. Imminent and upcoming risk takes precedence for discussion over past patient behavior and urges.
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