Commitment Strategies and Engagement in DBT
This presentation is an excerpt from the online course “DBT Secrets No More: Animated Role Plays“.
So in these next few minutes, I step in and start to ask more direct questions. I start to ask for commitments. We transition from kind of some back and forth, not extremely direct dialogue, into “Can you promise me that you wouldn’t just quit therapy?”
So, I use a foot in the door technique. I get my foot in the door by asking for something smaller. The patient is hesitant.
I continue with the validation. I want to make sure I’m listening really well, that I’m reflecting back what she’s saying, that I’m maintaining a dialectical stance. The dialectical stance involves phrases like “and” instead of “but.” A therapist is supposed to listen. A therapist is supposed to understand. A therapist is supposed to be able to look at both sides of a situation.
The most important thing, in my opinion, is to be able to be a real-life human and not a strange, weird therapist type. At one point, I attempted to reinforce and also teach a little bit about validation. Observing my own thoughts and my own reactions is extremely important for me to be able to validate, and to observe my limits, and to intervene.
That’s a DBT skill: observe. Those are 3 DBT skills: observe, describe, participate.
So that dialectical stance is in everything that we do.
Dr. Vaughn: Can you promise me that you wouldn’t just quit therapy?
Emily: I don’t know. It’s really hard.
Dr. Vaughn: Yeah, yeah. I ask a lot harder things too sometimes.
Emily: Like what?
Dr. Vaughn: Like not to kill yourself or not to cut yourself. Sometimes, I’ll just ask that outright like do not do that. Can you commit to me that you will not do that? And then when we’re looking at DBT, one of the commitments which is kind of a strange commitment if you think about it but it’s to take suicide off the table as an option for the time that we’re in therapy which we’re talking about committing to a year.
Emily: I mean, obviously, I don’t want to kill myself but when things get really – Like I don’t know. Like you said, none of us know like what’s coming. I don’t know. I hope I can promise that but I don’t really know.
Dr. Vaughn: Yeah. So part of your hesitation and agreeing to it is that you don’t know necessarily what the circumstances are going to be and something could change.
Emily: Yeah. What if something really bad happens and I can’t handle it?
Dr. Vaughn: Yeah. Well, that’s what I’m hoping that I can help you with. I mean, the other thing we’ve got to talk about is phone coaching which in a moment like that, when you have that thought, “I’m not going to be able to deal with it,” it would be great if you had someone, something to pull from to try other than thinking about suicide. But going back to that commitment, I think that goes for any commitment. I mean, every commitment that we make whether it’s like marriage or we’re going to be roommates or you’re going to take a class and finish it, I mean, it’s sort of like a handshake anyway. I mean, even if you’re signing papers, we can always sign other papers or we can change our mind. So I get that commitments are – Things change. And at the same time, I’m asking, can you commit today to taking it off the table as an option, not to not try and kill yourself or not to not self-harm. I’m not asking about the behavior. I’m asking about what goes on inside your mind like between your two ears. If it’s not an option…that’s one step away, one step further away from following through.
Emily: Yeah. I mean, I guess I can try.
Dr. Vaughn: Okay. Tell me what you’re thinking just now because you look like a whole lot was going on in your head.
Emily: I just feel like just things can change on an instant. And like I said, I don’t want to commit suicide, I don’t want to hurt myself but that’s just the only, like that’s the only thing that has worked in the past, you know, cutting myself. So I just feel like if I take that away that’s the way I know how to cope.
Dr. Vaughn: Right. And then it’s like what am I going to do if I don’t use that? Yeah, yeah. You know what I like about this conversation is that I know at the point where you make that decision or you say, I’m committed, I’m going to take it off the table that you really mean it because you’re so hesitant to say that, that I know when you do that’s going to really mean something.
Emily: Yeah. I mean, this whole process means a lot to me. I mean, this is everything I have. This is my last chance. Like no other therapist really wanted to take me in and this is it. And I’m really hesitant. You’re right because I don’t know if this is going to work for me. I don’t know.
Dr. Vaughn: Yeah. And I don’t either. I don’t know that either. I wish I did but I don’t. So I think if both of us can commit to doing the best that we can do then we can at least get started. I mean, there are some specific DBT commitments. I know I sent them with you last week to look over. And then you may have read one of them and it said you agree to work on therapy-interfering behaviors. I didn’t know if you knew what those were or if you had questions about any of the commitments because it seems like as we’re talking I just keep sliding in new commitments, you know. I kind of feel like that. If I was on your end, I’d be like wait a minute, you just were talking about commitment for a year and now you’re talking about taking suicide off the table. Now, you’re –
Emily: Yeah. I mean, it is a lot. It is a lot to commit to. And it almost just kind of feels like I’m just, you know, signing my life away to all these commitments. Yeah, it is a lot to think about. And I definitely reviewed the document you sent [with] me. So yeah, it’s good to talk about it I guess to help me understand.
Dr. Vaughn: You know, you’re very good at validating. Do you know what validating is?
Dr. Vaughn: You just – Like to me, looking at you, if I put myself in your position, I would be really hesitant about the whole thing I think also. But in spite of that, you said, “yeah, I think it could be really helpful to talk about.” Like you filtered out some of the stuff and then said something which is really validating. And on my end, I felt like “oh yeah, this is really encouraging.” And you’re very easy to talk to. Are you always this way?
Emily: I mean, I don’t know. I just – This is just something I don’t want to mess up. I guess it just means a lot to me and I want to make sure that I know all the rules and that I know what the commitments are and everything because it’s all I have and I don’t want to mess it up again.
Dr. Vaughn: Yeah. When I hear that, half of my mind is like oh, I’m so glad she’s interested in doing it well. And then other part of my mind is like hmmm, I don’t know anybody including me that does things perfectly. So I just want to highlight briefly that I love that you’re willing to work and that you want to do your best. And at the same time, I think it’s super important to whatever mess up, to mess up because that’s when the most to me, from my experience, the most fruitful stuff happens.
Emily: Okay. Well like –
And then I step in and ask for something much bigger and really, actually, much more important in my mind, which is for her to not kill herself or cut herself.
So that’s the foot in the door technique. And she responds noncommittedly, but I want to reinforce that because had she have jumped in and said, “Well, sure. You know, I can agree to that.” Well then, I’m going to be really skeptical of that response. And so sometimes, what we think we want, we haven’t really even thought about yet. I can go in and ask for something. But then once I get it, if she were to say, “Yes,” the irony is I could be extremely skeptical that she means what she says. So I want to make sure that I acknowledge that, that that hesitation is actually something that is normative, lends greater weight to when she actually does commit.
One of the things that I say at one point is, “Yes, things change.”
And at the same time, I’m asking, “Can you still commit basically?” So it’s both, and it’s not, but it’s both. And, “Um, yes. I agree. Things change. And I’m asking for a commitment today to take it off the table as an option.”
So, that is one of the basic minimum requirements for engaging. A DBT year commitment is the patient has to agree to work on, and eventually eliminate, life-threatening behavior, such as suicide and self-harm, and as well as therapy-interfering behavior to work on that and quality of life interfering behavior. But the basic minimum requirement is that, you know, the patient’s got to be able to commit to working on taking it off the table as an option.
Now, I also make sure to validate by reading emotions at one point, because you may be able to hear it in her voice, that there’s some foot dragging where she says, “I guess I can try.” But rather than read into what that means, that that means that, “Oh, she doesn’t really want to,” or “She’s just saying something to get me to, you know, argue with her or go somewhere else,” something pejorative, I just ask. I just want to find out, so I’m validating that I can say that something’s going on for her and I want to know what that is.
So then when she gives it to me, she basically says things can change. And I’m just not really sure about that. Then I just want to validate by letting her know that makes sense to me. And I’m adding to reading, you know, reading her mind, so to speak. That’s a validation level 3. I’m reading into emotions and thoughts, and that helps her to continue to elaborate on her hesitation. And that’s what I really want.
I want to hear about her hesitations. I want her to be able to articulate that. The process of articulating it, and getting it out, and feeling understood is going to make her a whole lot more apt to commit to me as a therapist. You don’t hear me ever hopefully implying that I know what’s best for this person, however.
So I can say, or I can imply, that DBT is the treatment for her. I can be excited about DBT. And at the same time, say not, but. And at the same time, I can say, “I totally get why you would not want to start DBT.” So what does that mean? That’s the paradox. That’s how we hold the paradox. We take a dialectal stance. We present both of those ideas, hold them lightly in front of us. And ultimately, the patient decides. They use their own autonomy. They use their own wise mind to be able to decide. So, in addition, as we go along, I’m bringing it back.
I’m looping it back, time and time again, to the commitments. At one point, because I’m pacing with the patient, meaning I’m putting myself in her position and hearing myself from where she’s sitting, I realized that, you know, I’m asking for these commitments and from her perspective, I’m thinking, “Man, if I was in her spot, I would be like, ‘What else are you going to ask for, lady?’” So I just said it out loud. I said, “I kind of feel like if I was on your end, I’d be like, ‘Wait a minute,’ you know?”
So, that spontaneous response or reaction helps to reinforce the patient’s idea that you get it, that you understand what’s going on. And it’s, for me, it’s radically genuine and you know, I’m a human again.
So at one point, I noticed that Emily was really validating. So, she’s saying on the one hand, “Yeah, it’s a lot to commit to.” And then she says, “Well, yeah. I mean it’s a lot and it’s also good to talk about. Um, it helps me to understand.” So, rather than being just argumentative, she’s pointing out both sides of the story.
And so notice that I thought, “Wow, that feels good to not be accused of, you know, wanting all these commitments and being unreasonable.” So I say, “You know, you’re really good at validating.” So I’m taking that moment to provide some reinforcement and to teach briefly at the same time. And then I’m curious too.
So I just ask, “You’re really easy to talk to. Are you always this way?” rather than trying to ask questions in a roundabout way because that was genuinely what I was wondering. In DBT, we talk about apparent competence. It’s that patient seemed so competent, seemed to be able to have a back-and-forth dialogue that was somewhat anxiety provoking, and to demonstrate some humility. She didn’t blame the other therapists. She considered that it could be her responsibility or she could have a large part in why she was kicked out of therapy. And so it seemed extremely healthy from the perspective that I got. And so instead of trying to ask all these questions and tap around to try to find where’s the problem spot, I just ask, “Are you always this way?” And her response doesn’t tell me that she’s not always this way. She doesn’t outright say, “No, I’m not always this way.”
But her response of, “I just don’t want to mess up and I want to know all the rules,” it gives me definitely some good information.
Once again, I’m going internally. I’m observing my thoughts.
That’s a DBT skill, observe. I’m observing my thoughts. I’m observing my body sensations. I’m observing my emotions. And I can feel myself when she talks about not messing up. I can feel myself wanting to just like, “No, no, no, no, no. That’s not going to work. You can’t want to follow all the rules.” And so I have to observe that reaction in myself and then to be able to challenge that simultaneously.
You know, the dialectical challenge usually is well, why not? And I’m doing this in my head. It’s happening really fast but it’s like, well, I mean, why not? What’s the problem? And is it not okay to want to know all the rules? Is it not okay to want to do a good job? Let’s find the validity in that.
So I want to find the validity in her perspective. At the same time, I know there’s some validity to my immediate response of, “Oh no, no, no, no, no. That’s just not going to work.” So my response is I just communicate that very transparently. So I say, “When I hear that, half of my mind says this, ‘That’s great. She wants to do well.’ And the other half says, ‘Uh-oh, that’s not going to work because you can’t do everything perfectly. This is not going to work.’”
So I’m starting to, I’m doing the self-disclosure, which is really important in DBT, but I’m modeling these skills of observe and describe while I’m participating, throwing myself in. So those are 3 DBT skills: observe, describe, participate. And taking that dialectical stance, the underlying question is well, which is it? Is it bad to want to do everything right or is it good to want to do everything right? Well, it’s both: and. And that’s not explicitly said, but it’s implied.