As a counsellor, I sometimes feel overwhelmed when a client begins their session by listing the various crises that happened during their week. It’s difficult to know where to start when someone starts with, “I told my boss off,” “I fought with my boyfriend and downed a handful of pills,” and “If he leaves, I’ll kill myself,” What can I do in one hour to help when so many crises are happening at once?
When clients have complex mental health concerns and engage in high-risk behaviours, I feel like each session is putting out the current fire without getting to the issues that would make a deeper impact. Of course, without addressing a crisis, things could deteriorate. Yet continually jumping from crisis to crisis doesn’t always allow the time needed to address the core issues, solve some problems, and accumulate skills to enhance coping and achieve better long-term outcomes.
Dialectical behaviour therapy suggests a three-step treatment hierarchy that helps structure counselling sessions in such a way that will help counsellors remain committed to their clients when the work is complicated, contains risk, and feels stormy:
Priority One: Life-Threatening Behaviours
Keep in mind, these are not relevant to every client, nor are they prevalent in every session. Life-threatening behaviours include:
- Suicide ideation
- Suicide attempts or preparatory behaviour
- Self-injury urges and actions
- Other impulsive behaviours that put personal safety at immanent risk (e.g., drinking and driving, getting into physical fights, etc.)
- Risk of harm to others
When people initially present with life-threatening behaviours, assess the risk and develop a safety plan right away. Understanding what prompted the life-threatening behaviour, what contributed to it, and what happened afterwards is key to developing a treatment plan. This is essential for helping people move away from suicidal ideation/attempts as a means of coping or solving problems and keeps the treatment focused on skill development, support, and working towards a client-defined life worth living.
The patterns that are problematic in a client’s life often show up in their relationship with the therapist – there is great opportunity to address them in this safe environment if both parties are willing.
Sometimes clients really want to talk about the fight they had with their partner, not the handful of pills they swallowed afterwards. However, to help create safer outcomes, we need to ensure there is time to understand why a life-threatening behaviour occurred, reduce the risk of it reoccurring, and increase skills and capacity for coping. Fights with partners will happen again, but when each one is followed by a suicide attempt, we need to intervene with understanding and concern that working on both risk and relationship are synonymous. Simply put, to work on the relationship, the client needs to be alive to do the work.
Priority Two: Therapy-Interfering Behaviours
If someone stops attending therapy or something is preventing the therapy from working, this needs to be discussed and acknowledged. Therapy-interfering behaviours can be caused by the therapist or the client. Examples include:
- Not attending a session or consistently showing up late
- Only showing up or seeking help in a crisis
- The therapist or client being unprepared for the session
- Dissociation or shutting down in session
- Something in the relationship is causing a blockage, lack of trust, invalidation, etc.
- Boundaries are crossed that demotivate either party
I like to be direct about how important these factors are because if the client or counsellor feels unmotivated or unconnected, there is a risk of nothing working. If something was said that was considered invalidating or insensitive, it needs to be addressed so the connection remains strong. Clients in private practice are often aware of their power to move on if there are therapy-interfering behaviours on the part of the therapist. However, in government or non-profit work, there may not be a choice.
Continually jumping from crisis to crisis doesn’t always allow the time needed to address the core issues.
Counsellors and clients need to be mutually committed to working on therapy-interfering behaviours by being direct and honest. They ensure they are both rowing the proverbial therapy boat in the same direction, at the same time. The patterns that are problematic in a client’s life often show up in their relationship with the therapist – there is great opportunity to address them in this safe environment if both parties are willing.
Priority Three: Issues That Impact Quality of Life
These are the problematic issues that people usually want to talk about in therapy, as well as those they might prefer to keep quiet but contribute to their current problems. Examples include:
- Situational stresses with work, family, friends, and relationships
- Problematic substance use
- Mental health issues (e.g., depression, anxiety, disordered eating, ADHD, etc.)
- Problematic behaviours that make things worse such as avoidance or impulsive actions that are emotionally driven (e.g., ending friendships)
Even though this is the third piece on the treatment hierarchy, it contains serious and significant issues that are not always easy to address. These issues often need sorting into manageable chunks, some of which can be addressed immediately, and others that get delegated to the “parking lot” – especially if there are other life-threatening or therapy-interfering things to address first. Questions to consider when addressing these issues are:
- What does the client consider most important?
- What could make things harder for the client if they are not addressed today?
- Where is the easiest place to start?
- What is the client most willing to work on?
In terms of timing, the hierarchies are not always addressed in this order. For example, quality of life issues often prompt a life-threatening behaviour. However, it is still possible to hear and validate the pain the person is expressing while continuing to work on understanding and mitigating risk both by increasing safety and working on the core issues that put them at greater risk to begin with. Although it’s not always possible to address these priorities in order, this is a good starting point for having more effective counselling sessions with high-risk clients.
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