1. Managing Therapy Interfering Behaviors (TIBs)

2. What are Therapy-Interfering Behaviors (TIBs)?
Term used in DBT that refers to a broad category of things that the client/patient or therapist does that get in the way of the process or outcome of psychotherapy

3. Examples of Common TIBs
Therapy no-shows
Lateness to sessions
Anger/hostility toward the therapist
Suicidal threats
Homework non-compliance
Avoidance
Sexually inappropriate behavior
Excessive talkativeness
Unresponsiveness to questions
Behaviors on the part of the therapist that might interfere with therapeutic progress

4. Core Strategies for Responding to TIB
Orienting to TIBs
Highlighting when TIBs occur
Validation of the valid
Contingency clarification and contingency management
Assessment of TIB triggers and functions
Problem solving, solution analysis, & troubleshooting to begin changing TIBs
Skill training to change TIBs
Dialectical commitment strategies to enhance motivation to change TIBs

5. Overview of Strategy
Collaborative and non-judgmental orienting to TIBs early and often in treatment
Collaborative targeting of TIBs
Clearly linking TIBs to clinically relevant problems outside psychotherapy
Engaging client/patient to highlight how TIBs that are clinically relevant need to be addressed in order to help them live their life within their values and attain life goals

6. Overview of Principles Used
Observe TIB in real-time during the session
Collaborative and clear re-orientation and commitment to TIBs when observed
Attending to the TIB:
Often begins with validation of what is valid
Then seamlessly and gently observe the TIB
Request willingness to attend to the TIB
Assess the function of the TIB

7. Highlighting
Highlighting involves the therapist raising the topic of TIB in a behaviorally specific, descriptive, and non-judgmental manner, bringing the client’s attention to the specific TIB.
Hypotheses, assumptions, or interpretations regarding the client’s behavior can be kept off the table in favor of collaborative and unbiased exploration

8. Highlighting TIB
Example: When a client has periodically been missing therapy sessions, for example, the therapist might say:
“I’ve noticed that you have non been coming to our sessions consistently the past month.”
Example: When a client is not speaking or providing enough detail in response to the therapist’s questions, the therapist highlighting the problem might say:
“I’m not sure if you’ve noticed this, but often, when I ask you questions, you say, ‘I don’t know’ or provide fairly brief answers without much detail. Would you be willing to talk about this for a few minutes?”

9. Validation of the Valid with TIBs
Seek the kernel of truth, legitimacy, or effectiveness associated with TIB
Acknowledging is not the same as agreement or approval
Helps the client feel understood and supported even if TIB needs to be changed
Only validate the valid
Useful to validate first before trying to change TIB, but sometimes validation does not happen first

10. Levels of Validation and TIB
Paying attention to TIB, because it matters
Active listening (e.g., reflection, paraphrasing, etc.)
Therapeutic mindreading
Behavior makes sense given the past or biology
Behavior makes sense given the present
Radical genuineness

11. Contingency Clarification and Contingency Management
Clarification: Openly talking about what will happen when TIBs occur
E.g., “When you miss our sessions unexpectedly we will need to take some time to think through what happened before spending a whole lot of time talking about other things.”
Management: Responding contingently to TIB in real-time
E.g., “Oh, you didn’t try to use any of the new skills from group last week. Let’s talk about this today.
Paying attention to client TIB mindfully, expecting non-judgmentally for it to occur
E.g., “You mentioned you are feeling ashamed right now. Let’s notice together how you express yourself when feeling this way.”
Directly targeting TIB after it occurs
E.g., blocking, redirecting, ignoring, differentially reinforcing alternatives, or problem-solving

12. Assessment of TIB Triggers and Functions
Chain or functional analysis
Assessment of factors surrounding a single instance or occurrence of the behavior
Instead of assessing lateness in general, for example, the therapist and client reconstruct the event leading to lateness on a particular day, for a particular session
Antecedent, Behavior, Consequences (ABC)
Any thoughts, emotions, physical sensations, and events
The therapist approaches this task with the spirit of exploration and curiosity
Two detectives searching for answers to the question of why?

13. Collaborative Assessment of TIB
"We have a wonderful opportunity here to really understand what makes it hard for you to follow through on commitments you make, like showing up on time for therapy or, outside of here, completing jobs you take on at work. Imagine how different your life would be if we could really understand and get to the bottom of this problem. If we can understand how this happens I think we can start chipping away at it together."

14. Problem Solving, Solution Analysis, & Troubleshooting to Begin Changing TIBs
Identify multiple hypotheses about why TIB occurs
Collaboratively explore ways to solve TIB both in session and as it relates to clinically relevant problems outside therapy
When a solution is identified, analyze its pros and cons, and refine the solution or find a new one
Troubleshoot the details and how/when the newly refined solution will be helpful

15. Skill Training to Change TIBs
Mindfulness
Emotion Regulation
Distress Tolerance
Interpersonal Effectiveness

16. Dialectical Commitment Strategies to Enhance Motivation to Change TIBs
Foot-in-the-door
Door-in-the-face
Devil’s advocate
Making lemonade out of lemons
Using client values and goals to guide the way