Just to clarify right off the cuff- not actual cows, like ‘mooooo,’ cows. By COWs, I mean “Crisis of the Week,” or the stuff going on in your immediate, right now, day-to-day life. A lot of modes of therapy allow for clients to come in and talk with their therapist about whatever they want, which typically ends up being whatever the crisis is that week. Don’t get me wrong, I think there can be a lot of benefit to that style. Plus, DBT is a lot more structured, which can make it difficult to find space for COWs in treatment. People who come to DBT and especially those who do the comprehensive program (individual, group, diary cards, phone coaching, the whole 9 yards) often have complex issues they’re working on, that may have to be prioritized over COWs. A dialectical mindset is definitely going to be needed here as there are pros and cons to discussing and processing COWs and staying focused on addressing the targets in the target hierarchy. Let’s dive in!
Just a brief refresher really quick: in DBT, we make what’s called a ‘target hierarchy’ at the start of treatment and modify it as treatment goes on. The targe hierarchy provides a roadmap of sorts for treatment. Collaboratively, the therapist and the client work together to outline various life-threatening behaviors (or LTBs, such as suicide and/or self-harm behaviors), identify therapy-interfering behaviors (or TIBs, like being late to session or not completing homework) as they arise, and come up with the various quality-of-life interfering behaviors (or QoL, such as decreasing symptoms of diagnoses that are most severely impacting functioning or other things causing major problems in your life, like homelessness, substance use, etc.). Then, each session, the client comes in with their diary card (hopefully completed prior to the session) and the therapist, using the target hierarchy, structures what the session will look like, prioritizing any LTBs that may have come up over the past week, then any TIBs, and then finally, any QoLs. If there are no LTBs and no TIBs, then they move straight to the QoL targets.
Okay, that should help give some framework to the dialectic we started out on and address the COWs. Sometimes the COWs are related to the behaviors on the hierarchy. If that’s the case, then cool beans! You’ll probably have time to discuss it, especially if it’s an LTB! Now, if your COW is a QoL and an LTB occurred during the week, expect your therapist to prioritize the LTB, even if you realllllyyyy want to discuss the COW. This is where dialectical thinking will come into play. On one side, if clients came in and focused on their COWs each and every week, they may find that they are not making progress on their more pressing concerns. On the flip side, if therapists are inflexible on this structure, clients may feel discouraged, frustrated, or even invalidated and the therapist may miss the opportunity to learn more about what the client may be currently going through that may be contributing to behaviors on the hierarchy. Sometimes, a middle path solution can be found in which the targets can be addressed and, if there’s enough time, the COW can be discussed. Sometimes the targets are so important, the COWs have to be pushed aside until the major targets are addressed. It will really depend on the situation.
I feel like an example could help make this make sense. Let’s say you are someone who self-harms and you’re in a relationship with someone you care deeply for and the two of you are going through a rough patch. If you come to session and you have marked that you self-harmed on your diary card and, on a completely separate day, you and your s/o got into a huge argument that you really want to talk about. In this situation, you can almost guarantee that the therapist is going to prioritize the self-harm incident over the argument you had with your significant other. Even if it was a really small self-harm episode, and you don’t really care about it, and you swear it didn’t even mean anything! It still has to be explored. Because research shows that self-harm can be life-threatening, if we don’t get those behaviors under control, you could literally die. And if you died, you couldn’t work on your relationship with your significant other, or achieve any of the other goals in your target hierarchy, or move towards making your life worth living! Sometimes knowing this ahead of time can make it easier in session because you know what to expect and it won’t take you by surprise. That being said, it might still not feel great.
Let me offer a dialectical perspective on this. DBT prioritizes LTB over TIBs, and prioritizes LTBs and TIBs over QoL and all those things over stuff that’s not even on the hierarchy. We do this for a reason- so that you can actually achieve your goals and feel like you’ve accomplished something in therapy. And, as I said earlier, making no room at all for COWs kind of stinks for the client. So, here’s what I suggest you do: TELL YOUR THERAPIST HOW YOU FEEL! I’d venture to guess that most therapists will help move towards a middle path solution. For instance, in the example above, if you tell your therapist at the beginning that you really want to talk about this argument with your s/o, your therapist may say, “Okay, I get that, it’s important to you! And addressing the self-harm incident is important to me and the goals we agreed upon. Let’s spend the first part of our session doing a chain and a solution analysis. If we get through that with enough time, we can spend the remainder of the time discussing your relationship with your significant other. Does that sound okay?” If you engage in a self-harm behavior in the same week you have a fight with your s/o and you know your therapist is going to make you do a chain in session, do the chain before the session! Then review it with your therapist in session and you two might move through it much faster, making more time to address the fight with your s/o! Plan ahead!
All in all, target hierarchies exist for a good reason- it’s to keep you and your clinician on track so that you can address the concerns you’re having in your life that you haven’t been able to figure out yet. Doing this will help you feel better overall and help you move towards your life worth living. And, COWs come up all the time, and those can be really important to dive into as well! Talk to your therapist about how you feel about the structure, participate in making the agenda at the start of the session, and work together to figure out how to address the COWs as they show up in treatment. Best of luck! Moooo!!!
About the Author
Maria Mangione (she/her), M.A., LPCC-S is a licensed clinical counselor who specializes in dialectical behavior therapy. She works to help people develop the tools they need to develop trust in themselves and build their life worth living. Maria believes in having meaningful connections with her clients and believes that therapy and healing can be fun. Click Here to learn more about Maria’s experience and therapeutic style.