The Ultimate Goal in DBT: A Life Worth Living
The ultimate goal in DBT is for the patient to have and achieve a life worth living. The idea being that the patient who continually attempts suicide, engages in life-threatening behavior, has a life that is currently not worth living, and we have got to work on changing that.
In order to do that, we have to be able to understand what their life would be like if it were, in fact, worth living. The assessment of these goals can be difficult. In this case, it’s a little difficult getting started, but eventually, the patient gets the plan and starts to really participate. It can be dysregulating for some patients, so you don’t want to necessarily press this. I’m reading Emily’s response and trying to assess whether or not she’s getting emotionally dysregulated. She doesn’t seem to be. It seems to be able to lighten the mood nearing-because I know we’re coming up on the end of session and I don’t want to get into very heavy material or get into another conflict just prior to ending the session.
Now, I’m not avoiding conflict. I think that’s important to point out because if there’s any time that I need to be able to engage in interpersonal conflict, it’s in those first few sessions. So again, that the patient has the information they need to be able to make an educated decision. Are they going to be able to stand me in future sessions? Am I going to be able to tolerate and stretch my limits with this patient?
But the exploration of the life worth living goals is an important one because we’ve got to be able to see the end game. It’s just like saving for a rainy day or saving for a long-term occasion. There are going to be some sacrifices that this patient is going to be making. It’s going to be a painful journey. And what’s the point if we don’t see the light at the end of the tunnel, if we don’t know why we’re doing what we’re doing? So I’m going to be able to take these life worth living goals and remind her of those when times get hard. I’m going to need to track those if they change. I’m going to need to show her her progress along the way in getting closer to those and keep those in mind.
Dr. Vaughn: Yeah. That’s hard to think about which makes me wonder. What is the end goal? What’s the end game for you? What’s your life worth living? What will or what does make your life worth living?
Emily: I don’t know anymore. Like I thought it was him but I feel like before starting this treatment I just feel I’m getting more distant. And I live with my mom.
Dr. Vaughn: So is getting out of your mom’s house one of those goals, life worth living goals?
Emily: Yeah. I mean, she loves me so much and she cares for me so much but it’s so hard. Like she’s so mean to me when stuff happens. Like if I’m having a panic attack –
Dr. Vaughn: Shift gears for me. Shift gears for me for a second because I want to get a good picture of where you’re going. And I think you’re kind of going into what the problems are now. And I’ve really got to see the end picture. I mean, when you say get out of your mom’s house, are you thinking like you’re going to get your own apartment? Are you moving in with your boyfriend? Like what does that look like?
Emily: I mean, I want to end up with my boyfriend. I can’t imagine my life without him but I don’t know if he wants to be with me, like really, really wants to be with me.
Dr. Vaughn: Okay. So just imagine. I want you to imagine. Do me a favor and just humor me. So imagine. What does this place look like that you live in? Is it small? Is it big? Is it picket fence?
Emily: Honestly, we could live anywhere as long as we’re together.
Dr. Vaughn: Oh. That’s super nice. Okay. So I’m going to put you on a motor home and you’re going to drive around the whole country.
Emily: That’s fine.
Dr. Vaughn: Okay. So you like travel.
Emily: Yeah. I’d really like to travel more but, you know, everything –
Dr. Vaughn: Okay. But don’t “but.” Okay. So travel would be a thing. What about like animals? Do you have dogs? Do you have cats?
Emily: I have a dog.
Dr. Vaughn: Do you like it?
Emily: Yeah. He’s kind of lazy. I would like him to be more active. But I guess it’s kind of nice when he’s lazy because if I don’t feel like leaving the house that day it’s fine.
Dr. Vaughn: So will your dog be with you in this imaginary scenario?
Emily: Oh. No. It’s kind of my mom’s dog because I’m living with her right now but I’d probably get my own.
Dr. Vaughn: Okay. Do you have a type of dog that you would want?
Emily: I really like retired greyhounds.
Dr. Vaughn: Nice. Okay.
Emily: Because it’s like I gave them like another life. Yeah.
Dr. Vaughn: Yeah.
Emily: And they’re really cuddly.
Dr. Vaughn: They seem skinny, like super skinny.
Emily: Yes but they’re so dopey and cute and their personalities are great. I like them.
Dr. Vaughn: All right. So I’m getting somewhat of a picture. What about like job-wise or career?
Emily: I don’t really know.
Dr. Vaughn: Are you going to be a stay-at-home mom or like what is –
Emily: I don’t know. Right now, like I’m in college for History but I don’t know what I’ll do with it. I just want to finish college.
Dr. Vaughn: Okay. So life worth living is you got your college degree. And then whether you do anything with that or not is subject to the circumstances or –
Emily: Yeah. I mean, I would feel really guilty if I went to college and then did not work but I don’t know what I’ll do with that. I just picked something I was interested in and so –
During this assessment of the life worth living goals, I’m using some redirection and contingency management.
So, the first instance is when I interrupt her and say, “Shift gears for me,” because she starts to get off track. You can tell that she starts to get in her head, and I just interrupt and gently coach her back into what we were doing. I do that also by looking really, really interested in her and her life.
So I want to know what her life worth living is and I’m so interested in it that I’m willing to interrupt her and say, “Come back on track,” “Don’t leave me now,” sort of a thing. So that’s using contingency management. I don’t want to reinforce this getting off track and jumping around topics. I do it again when I say, “Okay, but don’t but.”
So I’m starting to also introduce her to the idea of getting rid of the “but” and sticking with the topic at hand to the end.
At one point, she talks about how she has a dog. And I say, “Do you like it?” I think that’s important to point out because I’m using a little irreverence, but I’m also not judging that. I’m not imagining that I know how she feels or what she expects. It’s just like when someone comes in and says, “I’m getting a divorce.”
You don’t say, “Oh, I’m so sorry.” You basically ask, “Is that a good thing or a bad thing?” I mean, you have to ask how the person expects or wants you to respond because depending on the circumstances, of course, it could be a good thing or a bad thing. She may not like the dog. And in fact, she responds in a sort of apathetic way and she talks about wanting a different breed of dog. So had I jumped in with “Oh, that’s so great. You have a dog,” and “How wonderful” and now you go on about, “…and live happily ever after,” well, that could be extremely invalidating. So I want to make sure that I don’t assume how she feels if I don’t have the data on that.
So I get her life worth living goals are to finish college. She wants to have a retired greyhound. I’m not reading into a bunch of things. There’s a point where she says, “I like retired greyhounds because it’s like I gave them another life.” And a therapist type would really read into that. “And what does that mean to you that you would give someone another life? And would you like to give yourself another life?” And let’s just be with the topic, and the topic is what’s your life worth living look like? And on a practical level, you want a greyhound. So, great. What else? So I’m not going to read into everything. I’m going to be real. I’m not going to dig into all of the barriers. She definitely says that she would feel guilty if she went to college and didn’t work. I mean, there are all these layers of things that I could explore. But I’m just trying to reinforce her generating ideas right now. And she can always change her mind and, in fact, probably will. But I’m helping her to also see a future beyond just today and the pain that she may be in.