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DBT Treatment Target Hierarchy — MRCPsych Paper B MCQ

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HardPersonality DisordersDBT Treatment Target HierarchyMRCPsych Paper B

A 25-year-old woman receiving comprehensive dialectical behaviour therapy for borderline personality disorder arrives for individual therapy intoxicated, shouts at the therapist and refuses to complete her diary-card review. Assessment confirms stable physical observations, no delirium or suspected overdose, no current suicidal or self-injurious intent, and no weapon or imminent threat of violence. After maintaining appropriate safety and interpersonal boundaries, which treatment-target hierarchy should guide the therapist's formulation and subsequent behavioural analysis?

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Correct answer: D — Life-threatening behaviours, then therapy-interfering behaviours, then quality-of-life-interfering behaviours, then skills acquisition

Explanation lettering: C = shown as B · E = shown as C · B = shown as D · D = shown as E

The correct answer is B. Standard DBT prioritises life-threatening behaviours, followed by therapy-interfering behaviours, quality-of-life-interfering behaviours and then increasing behavioural skills. Immediate safety and medical needs always require assessment first. Once these have been excluded here, arriving intoxicated, shouting and refusing the diary-card review directly obstruct the session and are therefore therapy-interfering behaviours. Substance misuse outside sessions commonly constitutes a quality-of-life-interfering target, but its function and context determine its position: intoxication that prevents participation becomes therapy-interfering. Option C incorrectly places quality-of-life targets above threats to treatment. Option D reverses the priority of life-threatening and therapy-interfering behaviour. Options A and E wrongly subordinate life-threatening targets to lower-order problems or skills training.

Reference: Tan MYL et al. Application of Dialectical Behaviour Therapy in treating common psychiatric disorders: study protocol for a scoping review, section 'Individual psychotherapy'. BMJ Open. 2022;12:e058565. https://www.nice.org.uk/guidance/cg78/chapter/Recommendations