Pros and Cons the Fancy DBT (Four-Square!) Way

This skill is a practical, versatile favorite.

When clients are struggling with a decision -- anything from whether to leave a job to end a relationship to drink alcohol -- I can hardly wait to screen-share my virtual whiteboard and create a four-square grid for us to fill in. The benefit of this format is that it's comprehensive -- you see gaps and add details that you may not consider if simply freestyling out loud. It is also incredibly validating, because we see in black and white how complex many decisions are, how there are significant consequences in every direction rather than one clear, "right" answer (no wonder we're struggling). Despite the complexity, having things spelled out has a tendency to nudge us forward. We glimpse that ultimately, we're going to pick a square and live with the consequences, because even "not" choosing is a choice -- it's choosing inaction/"no"... which has consequences. 

​The example above is a relic from pre-pandemic in-office days that explores a client's habit of isolating when depressed ("TB" means target behavior in DBT-speak). As you would expect, enumerating the pros of ‘not isolating’ can be motivating. Less intuitive is that listing out the cons of not isolating can be validating rather than shaming — we see and appreciate how hard it can be to make that choice when in the thick of things (i.e., depression). Identifying specific cons further allows us to brainstorm what can help reduce their feared consequences, such as emotion regulation and distress tolerance skills. We note which elements are short-term (S here) and which are long-term (L) to get a better sense of how to weight the decision and make a plan to cope. Lastly, clients can screen-shot the finished pros and cons matrix for continued reflection, and motivation, outside of session.

Which dilemma in your life could use the fancy pros and cons treatment?