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Getting a Commitment

Before treatment can begin, pretreatment issues need to be addressed. To begin intensive treatment, the client and therapist must agree on treatment goals (e.g., a commitment to change, a commitment to initial therapy goals) and on the nature of the treatment (e.g., eliminating life-threatening behavior, engaging in food exposures, attendance rules). This phase of treatment is essential and especially important for clients who have a history of multiple, unsuccessful treatment attempts because of ongoing therapy-interfering behaviors, severe emotional dysregulation, or other Axis I or II pathology. Often, and in spite of the treatment history, when clients with severe ED symptoms present to a treatment setting, the urge is to quickly admit them into the program. The urge makes sense. Sitting across from a client who is visibly emaciated and who may be medically unstable is frightening. The therapist may feel pressure from family members or other health care providers to begin treatment immediately. It is, however, important to recognize that in DBT, the commitment or pretreatment phase is active treatment. Moreover, our experience has been that rushing clients with multidiagnostic ED presentations into treatment often backfires. Without agreement on treatment goals and how therapy- interfering behaviors will be managed, the client is likely to re-create past treatment experiences, staff are likely to feel frustrated and burnt out, and the likelihood of premature termination or lack of progress is increased. In our clinic, we have observed that taking time to work on commitment and resisting the urge to rush these particular clients into treatment leads to greater therapy collaboration and less therapy-interfering behavior.

In our program, clients must be willing to commit to three nonnegotiable criteria. The first is a willingness to eliminate life-threatening behaviors, including suicidal and self-injurious acts as well as ED symptoms that are imminently life threatening. Given that treatment is based on building a life worth living, therapy cannot proceed if a client is not willing to make this commitment. Second, clients must be willing to work on reducing ED behaviors. Although this sounds obvious, many clients we have treated are more interested in reducing self-injury or mood problems and less motivated to gain weight or stop excessive exercising. It is important to help the client understand that building a life worth living and a life with less dysregulation while also engaging in disordered eating behaviors will be difficult, if not impossible. Finally, clients must be willing to participate in the program for a minimum of 6 months. We have found that making sustainable symptom change in this patient population using shorter treatment (e.g., 3 months) is difficult. We have also observed that making an explicit agreement to participate in treatment enrollment for a specified period of time helps to keep clients connected longer. During this phase, the therapist weaves in information about treatment (e.g., the biosocial theory, how weight and meal plans are managed, contingency management for therapy-interfering behaviors, the consultation-to-the-client approach). Intensive therapy does not begin unless the client and therapist can agree on initial treatment goals and the process of change.

Although great emphasis is placed on what the client needs to do to work with the therapist, highlighting that treatment is a partnership and a collaborative effort is important. The therapist also makes specific commitments to the client. For example, the therapist agrees to attend all sessions on time, to be prepared, to offer off-hours skills coaching by telephone, to seek regular consultation to ensure the provision of adherent and effective treatment, and to treat the client with respect. It is important to highlight the things to which both client and therapist will both be agreeing should they decide to work together.

Key Points in Facilitating Client Commitment

1. Have a strong working knowledge of how to use the DBT commitment strategies. Linehan (1993a) identified seven core commitment strategies designed to increase the client's motivation to engage in treatment. Although reviewing each technique in detail is beyond the scope of this chapter, the reader is directed to review Linehan's (1993a) original writing and Koerner's (2012) expertly written descriptions of the topic.

2. Meet the client where she or he is as opposed to trying to get the client to meet the therapist's wants or needs. For example, instead of pointing out to the client all the behaviors and things that are problematic and in need of change, the therapist can identify what the client is willing to acknowledge as problematic. For example, at a first session, a client may not be particularly motivated to attend treatment but may be interested in finding a way to stop her parents from insisting that she work on her recovery.

3. Emphasize that the goal is to build a life worth living, in contrast to emphasizing that the goals are strictly ED related. It is easy for clients and therapists to focus exclusively on the details of symptom interruption. Although it is true that one must reduce or eliminate self-destructive and impulsive behaviors to have a life worth living, the therapist must help clients understand that they are committing to something much bigger than symptom change. Getting a strong commitment to build a less chaotic, more independent, and possibly more satisfying life helps clients to see the bigger picture. Once the client buys into the model of engaging in treatment to build a life worth living, discussions can then focus on how to do it (e.g., increasing weight, decreasing self-injury).

4. Commitment strategies are designed for use throughout treatment. For clients with multiple problem behaviors, the desire and willingness to change will wax and wane over time. It is important to be able to use a variety of commitment strategies flexibly over time to keep clients engaged and motivated to work on their treatment and life goals.

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