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DBT, For Therapists, Substance Use

What Topics to Prioritize In Therapy?!

How DBT therapists prioritize therapy conversations

Does it sometimes feel like you don’t know how to prioritize everything going on in your life? Especially when you are in your therapy session, it might feel like there is so much to talk about.  It can be frustrating if your therapist focuses on a different aspect than what your emotions are wanting to focus on.  

When using DBT, there is a hierarchy of targets that help guide a single therapy session. This same hierarchy also guides the overall process of therapy.  The reason behind this hierarchy is to create progress in therapy that focuses on the highest acuity issues. We must stabilize these “targets” prior to dealing with any other issues brought to therapy.  

Here are the 3 Phases that we Prioritize in DBT Therapy

hierarchy of treatment targets or priorities
  1. Life threatening behaviors
  2. Therapy interfering behaviors
  3. Quality of life interfering behaviors

Phases 1 and 2 must be addressed first and behaviors stabilized in order to begin making progress in Phase 3. This is because if you aren’t alive, or aren’t in therapy (or using therapy effectively), therapy can’t help with anything else.

Priority One: Life Threatening Behaviors

The first area is addressing the most imminent and serious behaviors that risk the safety of the client.  This includes both suicidal ideation (SI) as well as self-harming behaviors. We call this non-suicidal self injury (NSSI). NSSI can lead to imminent medical harm quickly. Therefore, it is included in phase 1. Target 1 includes both past or future actions, urges, and thoughts.  While targeting the life-threatening behaviors, we track emotions and behaviors in order to identify patterns and correlations which give us more information for areas 2 & 3.

Other target 1 behaviors may include life threatening risk-taking and or medical negligence that pose imminent risk. Sometimes, this level also includes substance use. Substance use poses a life threatening risk when there is high probability of overdose. It also can pose a life threatening risk indirectly, when someone’s suicidal ideation and impulsivity increases when under the influence. In these situations, substance use may be a part of target one. In all other substance use scenarios, it is usually addressed in level 3.

Priority Two: Treatment Interfering Behaviors (TIB)

The next area to work on is addressing behaviors that create issues within the therapeutic environment.  Examples of this include frequent absences, coming late or leaving early from sessions, not completing diary cards, not speaking in sessions, and unwillingness to address target 1 issues.

It also includes behaviors that impact the therapeutic relationship. This could be constant arguing with the therapist, or interpersonal issues in therapy relationships. When working with teens, parents’ interference in therapy may also be treatment interfering if it weakens the therapeutic relationship. See this article for more about this. Therapeutic relationship is essential to success in therapy. Therefore, these issues must be addressed prior to phase 3 in order for everything else to work. TIBs will decrease the effectiveness and consistency of therapy.  We can’t proceed with therapy if therapy isn’t happening.

Quality of Life Behaviors

The largest collection of issues often fall into phase 3: the Quality of Life phase.  This includes ALLLLLL the other behaviors that create a life worth living. This can range from anything like medication compliance, relationship problems, financial issues, failures to complete activities of daily living, high risk sexual behaviors, binge eating, non-risky drug use, school issues, job issues, and housing crisis, etc.

It is in this phase that we tend to work on traditional symptoms of depression and anxiety. This includes isolation, panic attacks, and avoidance. Defiant behaviors are also addressed in level 3. This may include lying, stealing, lashing out, or other difficult behaviors that impact relationships. So are parent-child concerns and friendship or intimate relationship concerns.

We also wait to address trauma until Phase 3. This is because we want to make new stabilize the most acute safety related risk before engaging in even more emotionally challenging work. We don’t want the disruption in homeostasis, no matter how unhealthy, to lead to any life threatening or therapy threatening crises.

The process of working through these priorities takes time and commitment. 

Consistency in therapy supports the progress and effectiveness of the treatment. It is important to remember that the more stable the behaviors are in phases 1 and 2, the more progress will be made in phase 3. And since phase 3 is what is most noticeable externally, most people, both clients and parents, are eager to see progress here as soon as possible.

A Note about Priorities in Therapy For Parents

Man standing on a mountain with the caption "remember... it's a marathon not a sprint!"

Please don’t expect to see outward changes at home right away. Because of the order of these priorities in treatment, the first signs of progress or success of your child’s therapy will be invisible to you. It is not until phase 3 that you will begin to notice observable differences, and even then it may take a significant amount of time before you start to experience relief in the relationship tension.

If you have a child or teen going through DBT, it is important to help guide them by showing your own commitment to therapy. Especially when addressing TIBs, parents can make a large impact in helping their child’s progress by addressing their own behaviors. To help support your child in their work, we recommend that parents increase their knowledge and practice of the same DBT skills that their child is learning. This can be done through a DBT parenting class to help learn the DBT language that your child is learning. This can also be done via self study. Check out our recommended readings that include “Parenting a Child Who Has Intense Emotions” by Pat Harvey and Jeanne A. Penzo. Parent coaching and/or individual therapy are other supports that parents can use to help progress their child’s treatment.

About The Authors

Annie Bertran, LCSW-C and Laura Goldstein, LCMFT co-authored this blog.

Annie Bertran (left) and Laura Goldstein (right)

Annie is a licensed certified social worker-clinical & therapist in Olney, MD. She obtained her Bachelor’s degree in Social Work with a minor in Psychology and went on to earn her Master’s degree in Social Work from the University of Maryland, Baltimore. She has extensive training in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Dialectical Behavioral Therapy (DBT). Annie sees telehealth clients in both Maryland and Virginia and both our Rockville and Olney offices. She also provides clinical supervision for Maryland LMSWs and LGPCs.

Laura is a Licensed Clinical Marriage and Family Therapist Founder of Montgomery County Counseling Center, LLC. Laura obtained her Bachelor’s degree in Neuroscience and then went on to earn her Master’s degree in Family Therapy. She became intensively trained in Dialectical Behavioral Therapy (DBT) through Behavioral Tech Linehan Institute in 2015. Laura sees clients in both the Rockville and Olney offices and provides consultation for other therapists.


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