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Managing Therapy Interfering Behaviors (TIBs)

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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


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