Hierarchy of therapeutic objectives

The top priority: Life security

DBT operates under a strict hierarchy of goals that guides each session, preventing therapy from straying into trivial issues when emergencies exist. The top of this hierarchy is occupied by life-threatening behaviors.

This includes any suicide attempts, active suicidal ideation, planning, or non-suicidal self-injurious behaviors (such as cutting or burning). Serious physical assaults on others are also included.

The logic is irrefutable: therapy cannot be provided to a deceased individual.

Therefore, if a consultant comes to session reporting a conflict with a roommate but also admits to having accumulated medication with lethal intent, the entire focus of the session is immediately redirected to safety and suicidal crisis management, temporarily ignoring the domestic conflict.

Protection of the clinical process

The second level of priority is therapy-interfering behaviors (TIBs).

These are actions that prevent the consultant from receiving effective help or that threaten to burn out the therapist.

Examples include missing sessions, being consistently late, remaining in hostile silence during clinic time, or calling the therapist at ungodly hours in an abusive manner. If these behaviors are not addressed, therapy is doomed to fail.

For example, if an individual physically attends but refuses to talk or work on skills, analysis of this blocking behavior is prioritized over any other quality of life issues, since "being in therapy" is a prerequisite for improvement.

Quality of life and skills acquisition

Once the life and integrity of therapy is assured, the third level focuses on behaviors that interfere with quality of life.

Here we treat serious disorders such as major depression, anxiety disorders, severe financial problems, or criminal behaviors that, while not immediately killing the individual, make life miserable. Finally, the fourth component is the enhancement of behavioral skills.

This involves replacing the maladaptive behaviors eliminated in the previous levels with new functional responses learned in the skills group.

The goal is for the individual to not only stop acting destructively, but to actively learn how to regulate their emotions and relate effectively to build the life they want.

Summary

The strict hierarchy places the patient's life safety at the top. Any suicidal or self-injurious behavior is addressed immediately, as it is impossible to provide effective therapy to a deceased individual.

The second level addresses behaviors that interfere with therapy, such as misconduct or hostility. If the patient is uncooperative or blocks the clinical process, therapy is doomed to failure.

Finally, behaviors that destroy the quality of life, such as severe disorders, are treated. The aim is to replace maladaptive patterns through the active acquisition of new functional and healthy behavioral skills.