Psychotherapy Parking Lot Questions
Questions that we don’t get to during the ECHO sessions will be discussed by the Hub Team and answered here on a weekly basis.
What is the most appropriate/effective clinical response when a patient is too fearful to change?
I think I might then pivot to self-compassion, validation around “stickiness”, and a reminder that she can always seek treatment should her desire to work on these issues change. Likely there is some goal the client may be willing to work on. If a client is completely unwilling to work on changing, I would try to explore what they want out of therapy. If it’s supportive listening with no change focus, perhaps that’s something you can help connect the client with someone who does this.
How do you mitigate relapse if clients are unable to commit 100% to their goal?
The idea is that the commitment is to a goal. A relapse is not failure, it is the reason why the goal is there. The issue then to understand what led to the relapse and what can be done to prevent it in future. Having the goal does not mean that they need to not relapse.
Commitment is about setting an intention about your goals. Commitment doesn’t necessarily equal behaviour. In other words, I can be committed to exercising regularly however I may not necessarily follow through on my commitment. This may not mean that I don’t have a commitment to exercise regularly. Other factors may have gotten in the way. The task of therapy is to help me figure out what got in the way of my achieving my goals
As a therapist would you be responsible to report a client who admits to driving under the influence?
This depends on the professional obligations of the therapist. For example, physicians have specific reporting obligations around unsafe driving. Psychologists do not. This does not mean you would not want to address the behaviour. I would consider drinking and driving to be a life threatening behaviour and therefore would consider it a high priority target behaviour, and would try to work with the client to enhance safety for themselves and others.
Is DBT applicable to only Borderline Personality Disorder (BPD) or other emotional situations too?
DBT was developed initially for chronically suicidal individuals with BPD. It has since been applied to a range of disorders and clinical populations (and likely others). It has been studied with eating disorders, substance use disorders, depression, and PTSD.
How do you respond to a client saying that they didn't do their homework?
When a client doesn’t do their homework, you can respond in a number of ways. In DBT, this behaviour is typically analyzed (using a behavioural analysis or chain analysis). Here, you would try to understand what got in the way. Once you’ve assessed the barriers, you then try to problem solve those barriers. Often what gets in the way is emotions (aversive emotions arise that the individual then tries to avoid/escape), skills deficit (they’re not sure how to do the homework), cognitions (maladaptive thoughts like, “I can’t do this”, “I’m stupid”), behaviours (not writing exercise down then forgetting), or environment (e.g., reinforced for not doing homework). It may be a combination of these things. The key is to respond with curiousity, assess the problem behaviour, problem solve, then get a commitment.
We could not find the Emotional Sensitivity Dimension. Could you please clarify what this is?
I believe Bob was talking about the transaction between emotional sensitivity and the invalidating environment. When we talk about emotion sensitivity, we can consider this as occurring on a dimension. On the one end, are extremely sensitive people (high reactivity, sensitivity, and slow return to baseline). On the other end of the spectrum are people who are extremely insensitive to emotion (not highly reactive or sensitive). Everyone falls somewhere on this spectrum. Consider yourself or the people in your life. Likely you can identify individuals close to you with varying levels of emotional sensitivity. It can be helpful to consider that clients, too, fall somewhere on this spectrum. Clients with BPD in particular tend to be on the more extreme end of this spectrum.
When identifying what the client will do as an exposure exercise, how much of this is a collaborative process between the client and therapist?
Or is it up to the therapist to be more directive in assigning the homework given the information that was determined from the exposure hierarchy?
Goal setting in general, and planning exposure exercises specifically, should be a highly collaborative process. There will be greater buy-in from the client if they play an active role in planning the exposure exercises. It can be helpful to use open ended questions to help hone in on some specific exposure ideas.
- Ex. “Looking at the exposure hierarchy, what are some exposure exercises you would be willing to try out this week that would push you a little bit outside of your comfort zone?” or “Given the exposure exercises we focused on in session today, what do you think would be some next steps that you could work on during the week to get more practice?”
- Ex. If the client doesn’t have any ideas or repeatedly suggests “safe” exposures that are not sufficiently challenging, it’s okay for the therapist to also make suggestions. Ideally those suggestions should be made in a collaborative manner (“Is it okay if I make a suggestion for another exposure you could try based on what we talked about today?”).
Understanding the rationale for CBT’s emphasis on collaboration and transparency is important: we want to empower our client to have agency and also prevent resistance. That being said, when working with avoidant clients, giving them too much open ended decision making may overwhelm them. For this reason we look for flexibility within the structure. A classic example is giving a child the choice between three sets of clothes as opposed to opening the whole closet before them and asking them to choose their outfit.
We first construct the exposure hierarchy collaboratively (i.e., brainstorm avoidances, in which the client comes up with most, but if stuck the therapist can definitely make suggestions, especially when it comes to the details of the exposure, then SUDS rating before constructing the actual exposure ladder). Next, explain the rationale of starting with exposures that are rated at about 40-50 SUDS. We start there. Exposures are most efficient if practiced every day, but give some flexibility in case this isn’t feasible. If there are multiple exposures at the same SUDS level, we usually discuss and the client decides which is the best exposure to practice that week, and this is repeated every week.
When determining what the exposure exercise is, is it important to be as specific as possible? (Ex. Identify a specific situation/object, determine how much time to engage and how much time to wait before turning to a safety behaviour.)
Yes, when starting exposure therapy, the more specific the exposure task, the better. SMART Goals can be helpful for setting exposure exercises too.
Think: What, When, Where; In the case of social anxiety, who would the interaction be with? This way, the client knows exactly what the expectation is going to be in the exposure, and therefore, knows whether or not they achieved what they set out to do.
As therapy progresses, if the exposures have been going fairly well, I play a less active role in planning really specific exposures and leave it more to the client to use their own judgment in setting up exposures. Given that CBT is a time-limited therapy, the goal in CBT is to teach clients to become their own therapists so they can continue making progress following treatment. For this reason, they should progressively become more involved in planning their own exposures and homework exercises over the course of treatment.
If you are asking regarding how long to wait while doing an exposure – it is usually 20 minutes or until SUDS level is reduced by half. For some exposures this is not possible (e.g., going up to a stranger and asking for directions) and then we just do the best we can. I would say NOT to return to safety behaviors – they can do it!
Regarding the specificity of the exposure, an example could be fear of taking the subway: we would then not have “taking the subway every day” as the exposure, but specify the number of stations, whether it includes a changeover etc. We could also have sub-stages, which could include safety behaviors at the first stage before we let them go, for example, travelling with a friend or family member at first and longer and longer rides.
How can we as therapists introduce imaginal exposure to clients in session? Do we kind of describe the situation/trauma and ask client to picture themselves in that moment...how descriptive should we get?
The therapist can mention that imaginal exposure is a form of exposure that can be used when it is not feasible or desirable to directly expose the client to their feared object/situation (e.g., not feasible to expose a person to an earthquake in the event of a phobia of earthquakes; not desirable to re-expose a client to an unsafe traumatic/abusive situation). In the case of imaginal exposure, a very detailed exposure script is created (the more vivid, the better). In addition to doing imaginal exposure in session, sometimes the exposure script is also audiotaped so that the client can review it over and over again between sessions so that habituation can occur.
When using exposure (either imaginal or invivo) in trauma-focused CBT, the person is exposed to reminders of the traumatic event with the goal of integrating the traumatic memory and tolerating/ coping with memories. Exposures may include to intrusive thoughts/ memories, physical sensations, sensory reminders/ triggers, etc. and also to places, people and situations that are currently avoided (usually to avoid provoking reminders of the trauma). These exposures are often done through a narrative or script of the trauma that the client co-develops with you. This narrative also often challenges trauma-distorted cognitions (e.g., “it was my fault” “I’m permanently damaged” etc). Exposure can also be invivo. Virtual reality is often used also. The important thing, however, is that this exposure is usually extremely well planned and psychoeducation + teaching affect regulation and coping skills always precedes exposure. A good resource (which you have to register and pay a small fee for) is https://tfcbt2.musc.edu.
First and foremost – trauma therapy is extremely sensitive. I would not suggest doing imaginal exposure with your client if you are not trained. The stance you take as a trauma therapist is more important than anything else – your patient has to know that you are there with them, accurately empathic, which means attuned, not fazed by anything they have to say, not pitying them, and non-judgmental. In imaginal exposure we ask the patient to describe the trauma as vividly as possible, in first person, present tense, as if they are there now, include details like what the smells, sensations and emotions were. We decide in advance what the beginning and the end of the narrative will be. When the trauma is sexual abuse it can feel extremely uncomfortable, here it’s especially important not to avoid, the client needs to know that they would be safe with you and your opinion of them will not change regardless of what they bring up.
Recently I have taken on a few clients in the health care field who would like to address burn-out prevention. One works alongside a physician, another is a police dispatcher, and another is a counsellor. What I would like from the Hub: strategies to work with burn-out and how it is addressed within the DBT Consultation team, if for instance, one counsellor feels they are starting to experience burn-out. As a case example, I will pull information from the counsellor: she’s between age 40-45; this is her second career; the last couple of months she has been seeing more clients than usual; working longer hours; and she mentions that she “hears and carries lots of trauma stories.” She also volunteers at a crisis type centre, and feels she enjoys her volunteering and would not want to give it up. Volunteering leaves her working longer days though (late into the evening- 1-2x/week). She uses CBT (reframing) when with clients and does mindfulness exercises before bed. In our next session, I’m going to do a self-care assessment and treatment with Mindfulness Self-Compassion work.
I’m sorry we didn’t get to your question about burnout on Tuesday. It’s an important one! To clarify, it sounds like you are looking for help helping a client with burnout. Is this correct?
If we were to address this on a DBT consultation team, we would be focusing on the therapist (in this case, you) and helping the therapist address their need as it relates to the client. It sounds to me like in this case, the need you have is problem solving interventions for working with a client who is feeling burnt out.
On a separate note, if the therapist was identifying their own burnout on the consultation team, the team would help the therapist figure out ways to support them. This could be through validation, through practical problem solving (e.g., how to reduce case load, how to observe their limits, etc.)
When it comes to burnout – either our own or our clients, it’s helpful to identify the source of the burnout. Is it related to stuff going on at work, in your personal life, in the world? Proper problem assessment will help with this.
In the case you have presented, there seem to be a few problems she is identifying:
-Seeing more clients than usual
-Working longer hours
-“Hears and carries a lot of trauma stories”
-Extracurricular activities that increase her working day
For each of these problems there is a different solution.
One concept we often think about in DBT is observing limits. In DBT, observing limits is the process of noticing whether someone else’s behaviour or a situation is acceptable to you in the short or long term. It’s different than setting limits, which can sometimes be a bit arbitrary. They key with observing limits is to paying attention to how one’s behaviour / environment impact how we feel. To observe limits, we have to first notice that our limits are being pushed.
It may be the case that your client is seeing too many clients and working too many hours. She may not be observing her limits – stretching herself too far beyond what she is capable of doing. This is a recipe for burnout. I would explore with her whether there is a way for her to reduce her workload/change her schedule so that it is less taxing. There may be barriers to changing her schedule/reducing her workload. For example, her environment may be unsupportive, a therapist may fee criticized or judged for their limits (e.g., too rigid, too flexible). Alternatively, her clients may feel upset or rejected if she’s less available than usual. In either case, you will need to seek solutions to these barriers, which may include: interpersonal effectiveness skills, distress tolerance skills, and radical acceptance.
Here is a really nice blog post on Observing Limits by Dr. Alex Chapman, an expert in DBT: http://dbtvancouver.com/observing-limits-contd/
In terms of “hearing and carrying trauma stories”, I would do some further assessment as to what she is experiencing and how it’s affecting her. It sounds like you are using mindfulness with and CBT strategies with her, which I think makes sense, if the difficulties she is experiencing is related to rumination. If she is experiencing vicarious trauma, or if working with traumatized client is activating unresolved conflict from her own history, she may need to a different kind of processing/intervention.
Finally, when it comes to her extracurricular activities, it sounds like she is enjoying this work and unwilling to give it up, though it may increase her burnout given her long days. Similar to the first points I made above, this seems to be a matter of limits. Is there a way for her to continue doing her volunteer work, in a way that doesn’t exceed her limits and allows her to attend to needs around self-care.
It was mentioned [in the didactic] that binging/purging is a response to emotional dysregulation; is this eating disorders in general or is there something about binging/purging that is more specific to emotional dysregulation?
Great question! In the didactic, the point about binging/purging was used to illustrate a constellation of problematic behaviours that may appear seemingly unrelated but share a core function: to help the individual regulate distressing emotion. A person who binges/purges may or may not meet criteria for an eating disorder, but we would conceptualize it the same way within the DBT model. DBT for eating disorders centres emotion dyregulation as the core problem that leads to problematic eating behaviours. DBT for eating disorders works by helping people understand the typical patterns that them to engage in eating disorder behaviours, and to learn skills for increasing their ability to tolerate and decrease these difficult emotions without turning to these behaviours.
There have been a number of studies supporting the efficacy of DBT for eating disorders. Here are some resources for those interested in DBT for eating disorders:
Federici, A., & Wisniewski, L. (2013). Dialectical behavior therapy for clients with complex and multidiagnostic eating disorder presentations. In L. H. Choate, L. H. Choate (Eds.) , Eating disorders and obesity: A counselor’s guide to prevention and treatment (pp. 375-397). Alexandria, VA, US: American Counseling Association.
Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eating and bulimia. New York, NY, US: Guilford Press.
Wisniewski, L., & Ben-Porath, D. D. (2015). Dialectical behavior therapy and eating disorders: The use of contingency management procedures to manage dialectical dilemmas. American Journal Of Psychotherapy, 69(2), 129-140.