Dialectical Behaviour Therapy (DBT) is a structured and evidence-based approach designed to help individuals manage emotional distress, build interpersonal effectiveness, and create a fulfilling life.
However, behaviours that can derail therapy can arise throughout treatment. In DBT, these are called therapy interfering behaviours (TIBs) & can include any actions or patterns that hinder therapeutic progress. Addressing these behaviours effectively is crucial to helping clients achieve meaningful change.
Understanding TIBs
TIB's in DBT can manifest in various ways. Some example are:
Repeatedly missing sessions
Refusing to participate to the best of one's ability
Engaging in aggressive behaviour
Repeatedly showing up to sessions affected by substances
Not paying fees
Refusing to adhere to reasonable policies/ procedures requested by the therapy team
Engaging in any behaviour that makes it very difficult or impossible for therapy to continue.
TIBs are considered a very high clinical priority in DBT. In fact they are second on the hierarchy of treatment, second only to life threatening behaviours in seriousness & urgency for addressing.
DBT holds a core assumption that clients are unlikely to get better without therapy. Most clients with borderline personality disorder, complex trauma or other chronic emotion regulation difficulties have a long history of treatment attempts before they get to DBT. This demonstrates the need for consistent & long-term therapeutic support for positive outcomes.
For some clients, getting & staying in treatment is the difference between life & death, so it can't be understated how important it is for therapists to know about, look out for & quickly address TIBs if working with these presentations.
Underlying Causes
TIBs are often a result of fear, avoidance, or emotion regulation difficulties. Therapy can be a difficult & confronting process at times, & urges to drop out are common. Conditions such as BPD & complex PTSD are characterised by frequent times of emotional crisis, & avoidance behaviours designed to give short-term relief but make problems worse in the long-term.
Participating in groups, individual therapy sessions & phone coaching can feel difficult for clients, particularly in the beginning of their DBT program or therapy.
Social stressors are often present for clients outside of sessions, & these can create episodes of emotional crisis resulting in TIBs.
It's important to understand clients are not intentionally trying to derail their treatment when engaging in TIBs (although it may look like that at times). The client is often simply repeating behaviour patterns that have provided short-term relief from distress in the past.
Validation & compassion are required to identify & respond to TIBs, & get therapy back on track towards the client's goals.
TIBs in Therapists
Therapists can also engage in TIBs, which may unintentionally derail therapy.
Examples of TIBs in therapists include:
Frequently missing or rebooking appointments
Frequently running late or shortening sessions
Not adhering to DBT framework & assumptions
Repeated blaming, shaming or invalidation towards clients
Discharging clients without sound clinical grounds & adequate follow up
Therapists working in DBT should be actively involved in a DBT clinicians group that meet regularly to review client progress. It is the role of the group to compassionately identify any therapist TIBs if they arise, & provide support for the therapist to address them.
Responding to TIBs
Discuss & Plan for TIBs Ahead of Time- The concept of TIBs should be introduced to clients in the initial assessment, & past TIBs should be documented for reference. Clients benefit from being asked how their therapy team can best support them if they notice TIBs, & be willing to do so. Clients should be encouraged to raise TIBs done by therapists if observed.
Promote Radical Acceptance – Help clients recognise TIBs without shame or judgment. Creating a validating environment fosters self-compassion, which is essential for change.
Teach Behavioural Strategies – Apply DBT principles such as opposite action. For instance, if a client avoids groups due to high anxiety, teach distress tolerance skills to help them attend.
Encourage Transparent Communication – Clients may feel ashamed about discussing their struggles with engagement. Normalise these challenges and encourage open conversations about barriers to progress in treatment.
Utilise a Therapist Group – Therapists should be meeting regularly with other therapists to help identify & address TIBs in clients, as well as therapists. There need to be clear group agreements around how these issues will be discussed.
Implement Policies, Procedures & Written Agreements That Promote Commitment – Develop clear team processes to respond to TIBs, including requests to drop out of treatment. Ensure admin staff have clear procedures to escalate issues to the clinical team, such as missed payments or frequent cancellations. Consider program structures that encourage program completion, such as upfront payments or fixed- term contracts.
TIBs are common in treatment, particularly with complex mental health conditions characterised by emotion regulation difficulties. Awareness of TIBs & frameworks to address them can significantly increase positive client outcomes & reduce occurrences of failed treatment attempts.
If you are a mental health professional wanting more training in TIBs or DBT generally, check out our range of training options here :)
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