When Therapy Goes Off the Rails?  Here is How you Get It Back on Track.

I was fortunate to receive training directly from the creator of Dialectical Behavior Therapy, Dr. Marsha Linehan, back in the early 2000s. Among the many invaluable lessons Dr. Linehan imparted was how to identify Therapy Interfering Behaviors, or TIBs. Over my career practicing DBT, I’ve found TIBs can present in subtle or obvious ways, but they invariably pose a threat to the therapeutic alliance if left unaddressed. I wanted to dedicate this blog as a reminder for fellow DBT therapists of the importance of managing TIBs, and an introduction for those still learning the transformative power of this treatment.

Dialectical Behavior Therapy (DBT) is an evidence-based psychotherapy that has shown to be effective in treating borderline personality disorder and other mental health conditions involving emotion dysregulation. A key component of DBT is identifying and addressing behaviors that interfere with the therapy process. Managing TIBs is essential for ensuring a productive therapeutic relationship between the patient and therapist.

What are Therapy Interfering Behaviors?

TIBs are actions or ways of relating that disrupt the course of therapy. They can originate from both the patient and the therapist. For the patient, common TIBs include frequently arriving late or missing appointments, refusing to engage in therapy activities, making threats towards the therapist, and exhibiting dramatic emotional outbursts during sessions. On the therapist’s end, TIBs can include frequently rescheduling sessions, failing to return patient calls/messages, making critical judgments of the patient, and disclosing too much personal information.

No matter who exhibits them, TIBs share the effect of damaging the therapeutic alliance, preventing the patient from benefitting fully from treatment, and reducing the therapist’s effectiveness. Left unaddressed, TIBs can lead patients to drop out of therapy and therapists to experience burnout.

Why Do TIBs Occur?

Patients often engage in TIBs unconsciously as a way to avoid the difficulties of therapy and therapeutic change. For example, frequently missing appointments may stem from finding aspects of DBT too challenging or overwhelming. Therapists’ TIBs can arise for various reasons as well, including countertransference, poor boundaries, and becoming overly invested in “fixing” the patient.

The Importance of Addressing TIBs

In DBT, it is essential to identify TIBs rapidly and take action to get therapy back on track. DBT emphasizes acceptance while also pushing for positive change, so the therapist must find a balanced approach to addressing TIBs. For mild patient TIBs, the therapist may ignore minor issues at first to maintain rapport. For more serious or persistent TIBs, the therapist sets clear limits and directly yet compassionately confronts the behavior. This models effective communication for the patient.

Likewise, therapists must monitor their own actions for potential TIBs. Seeking support through consultation groups can help therapists stay self-aware and prevent burnout. It is key for therapists to avoid responding defensively when patients provide feedback about therapist TIBs. Maintaining an open, nonjudgmental stance is vital.

Therapist TIBs

Just as patients engage in therapy interfering behaviors, therapists can also exhibit problematic patterns that disrupt treatment. Common therapist TIBs include:

– Arriving late or canceling appointments frequently

– Failing to return patient phone calls in a timely manner

– Making critical or judgmental statements towards the patient

– Disclosing too much personal information

– Seeming distracted, inattentive, or bored during sessions

– Responding defensively when patients give feedback about the therapy

These behaviors damage the therapist-client relationship and hinder the patient’s progress. It is critical that therapists monitor their own actions for potential TIBs through regular self-reflection and consultation with colleagues. Therapists should also encourage patient feedback and listen openly without becoming defensive. Addressing therapist TIBs promptly is key for successful DBT treatment.

Strategies for Managing TIBs

There are various strategies therapists can use to get therapy back on track after TIBs emerge:

– Raise the issue collaboratively and ask for the patient’s perspective

– Communicate clearly and directly how the behavior interferes with therapy goals

– Explore the function the behavior may be serving

– Problem-solve barriers contributing to the behavior

– Set limits on the behavior through a behavioral contract

– Reinforce progress and efforts to reduce TIBs

With skill and patience, therapists can effectively manage therapy interfering behaviors, strengthen the therapeutic relationship, and help patients fully benefit from DBT. Consistently addressing TIBs is hard work but vital for successful outcomes.

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