We’d need to tease that apart, ask questions about it, determine exactly what happened prior to assessing any of the urges that had happened outside of that. The discussion of that would be essential. However, if at a glance the therapist also sees that the patient has had a life-threatening act, perhaps they self-harmed or they put a yes under suicidal behavior, meaning that they did some sort of suicidal act, that would take precedence. And on the diary card, a therapist can at a glance see at what intensity the patient experiences that. o if we’re still talking about the category of life-threatening behavior, thinking about or having urges to kill yourself over the past week, that is an important discussion to have. They take priority over the discussion of urges. So urges and actions are differentiated in DBT and actions will take precedence. We only categorize something as a life-threatening behavior once it is imminently risking a patient’s life. That’s a more long-term life-threatening behavior. We wouldn’t characterize drug use or alcohol use as a life-threatening behavior even though perhaps the patient is using to the point that it is risking their health. Determining whether a behavior is life-threatening or not can be confusing to some therapists who are new at learning DBT. So that is subsumed under life-threatening behavior. Life-threatening behavior would be anything that increases the patient’s imminent risk for death. So if you haven’t figured it out already, life-threatening behavior definitely takes priority in a DBT session. Is there anything that’s upcoming that might increase your urges or your risk for suicide or self-harm? So that would be an example of something that could have been prevented if we would have asked the question in the beginning. And you as the therapist are aware that the patient has said before that she would kill herself if he ever got out because she couldn’t live with the symptoms of PTSD that she was experiencing. And they say, oh, by the way, my rapist was released from prison. And there’s nothing worse than finishing up a session and you feel really great about having done an excellent behavioral chain analysis on something that happened last Tuesday and the patient starts to walk out the door and says, oh, by the way and then we know that the dreaded door knob statement as they call it is about to happen. So one of the questions that I have figured out is an excellent one to ask at the beginning of a DBT session once you have the diary card in hand is, is there anything that’s upcoming or that’s happening now that’s likely to increase your risk for self-harm or to increase your risk for unskillful behavior as a whole? So that will hopefully guide you in terms of whether you should address life-threatening behavior that’s happened over the past week or something that’s happening right now. There are times that the thing that’s on fire so to speak is actually happening in the present moment or is upcoming. And that’s because the diary card is a record of what has transpired up to now. However, you don’t want to necessarily fall back on the diary card as your only tool for determining what you should talk about. The diary card is an excellent resource for determining what should be addressed first and for what amount of time, at what intensity. It’s not uncommon for multiple issues to exist in any individual session and it can become difficult for a therapist to decide where to start especially when emotions run high. Before beginning a behavioral chain analysis in individual DBT, the therapist will need to prioritize which targets to address and manage the time according to DBT’s hierarchy of targets.
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