What is DBT?

What is DBT?

By Kerrie Toole, LICSW, Executive Director 

“I tried DBT before and it didn’t help.”

If I had a nickel for every time I’ve heard this statement from a client during an initial meeting… 

Typically after hearing this from a prospective client, my next line of questioning includes asking what they did in their DBT sessions: What Target Behaviors were on their Diary Cards? What patterns were identified through Chain Analyses? How often did they utilize Phone Coaching with their therapist? How long did they participate in Skills Groups?

Most of the time, I’m met with blank stares and confusion.

There is a sizable amount of misinformation in the therapy world about what Dialectical Behavior Therapy (DBT) is, and many therapists are even attending trainings where they are led to believe that they are doing DBT treatment when they actually are not. This is why the developer of DBT, Marsha M. Linehan, Ph.D., ABPP created the Dialectical Behavior Therapy - Linehan Board of Certification credentialing process to demonstrate to the public those therapists who are providing DBT with full fidelity to the treatment as it was designed. In this post, I will review the core components of DBT so you can ensure that you are receiving the best form of treatment for your needs. 

DBT was initially developed by psychologist Dr. Marsha M. Linehan to address self-harming behaviors and emotion dysregulation commonly associated with borderline personality disorder (BPD). However, DBT has since proven to be beneficial for individuals dealing with a range of mental health concerns, including depression, anxiety, bipolar disorder, and eating disorders. 

Dialectical Behavior Therapy (DBT) consists of four core modalities that work together to provide a comprehensive and integrated approach to therapy. These four modalities are:

• Weekly DBT Individual Therapy sessions. Individual therapy forms the foundation of DBT. In this one-on-one setting, the client and therapist work collaboratively to address specific goals and target behaviors, which are tracked on an individualized Diary Card and reviewed at the start of each session. The therapist utilizes comprehensive interventions to provide guidance, support, and skills training to help the client develop effective coping strategies, manage emotions, and work towards positive change. Within the individual therapy process, there are different Stages of Treatment that a client works though.
  • Stage 1 is when clients are engaging in self-destructive behaviors to cope with their emotions, and the intention in this stage is to assist the client to learn and implement skills to replace maladaptive behaviors and learn to tolerate their painful emotions. 
  • Stage 2 is when other therapeutic approaches are woven into the treatment process to address symptoms of PTSD, trauma, OCD, Depression, and other challenges, with the goal of building up the client’s tolerance for emotional experiencing.
  • Stage 3 is when the work begins to address quality of life issues impacting the client, such as challenges in relationships, occupational difficulties, stress management, etc. Stage 4 is focused on assisting clients develop a capacity for sustained joy, or “A Life Worth Living.” Within the individual therapy process, the therapist is utilizing specific and concrete intervention strategies and behavior analyses that enhance flexible thinking, emotional experiencing, and tolerance to address all-or-nothing thinking and avoidance behaviors.
• Weekly DBT Skills Groups. DBT incorporates a structured skills training component that typically takes place in a group setting. These groups meet weekly and are designed to teach individuals the necessary skills to navigate life's challenges. The skills training modules are divided into four key areas:
  • Mindfulness: Participants learn to cultivate present-moment awareness, non-judgmental observation, and acceptance of their experiences.
  • Distress Tolerance: Individuals acquire skills to tolerate distressing situations, manage crisis situations, and prevent impulsive reactions.
  • Emotion Regulation: Participants learn strategies to identify, understand, and regulate their emotions effectively.
  • Interpersonal Effectiveness: Skills in effective communication, setting boundaries, and maintaining healthy relationships are taught.

Adolescent groups also include a module of Walking the Middle Path skills. In these groups, we practice a Mindfulness skill, review the skill from the previous week and how clients were able to implement the skill, and then a new skill is taught. Groups are run very much like classes, and there is no “emotional processing” done in this setting - that is for individual sessions. It typically takes us about a year to complete the full curriculum. Group skills training provides a supportive environment for clients to practice the skills they learn and receive feedback from both the therapist and peers. It promotes peer support, validation, and the opportunity to learn from shared experiences.

• DBT Phone Coaching. This modality is unique to DBT, in that when clients are in a moment of crisis or discomfort and need support in implementing DBT skills, they have access to their DBT Individual Therapist for skills coaching in-the-moment for support, guidance, and assistance in applying skills. Phone coaching helps clients navigate real-time challenges, manage crises, and reinforce the use of DBT skills in their daily lives. It provides a safety net and promotes continuous learning and growth.These calls are not therapy, they are not addressing past issues, or even an opportunity to vent. They are moments when the client is seeking assistance and feedback about skills implementation. As this is not a therapeutic intervention, this modality is not covered by insurance.

 

• Weekly DBT Consultation Meetings for the therapist. Clients do not directly participate in this required component of DBT; this is a weekly meeting for the DBT therapists to provide support and consultation to each other to ensure fidelity to the DBT model. The consultation team helps therapists manage any challenges they encounter during therapy, provides guidance on treatment strategies, and ensures the therapist's adherence to the principles and techniques of DBT. The team helps maintain the therapist's motivation, growth, and accountability.

Adolescent DBT: Modifications in the treatment protocol for adolescent clients and their families include an additional Module in DBT Skills Groups called Walking the Middle Path, which focuses on building the balance between validation and change within families and within oneself. Family therapy is also a signature component of Adolescent DBT, and Castlebrook also requires that parents or caregivers attend a 12-Session DBT for Parents group to educate parents about ways to recognize patterns in their teens, regulate themselves, and offer support in constructive and compassionate ways.

If you read this far, you can see that DBT is a highly structured, intensive treatment protocol. What is described above just scratches the surface of what DBT treatment looks like.

Now one might ask, does following the full DBT Protocol to a “T” mean that this is the ONLY way that DBT can be effective? The research says no, not necessarily. Recent studies on DBT have been focusing on the dosage of treatment, and how to match up a person’s individual symptoms with the most effective component of DBT. This may mean that someone could benefit from participating in the DBT Skills Groups as an adjunct to traditional therapy. Conversely, it may mean that the full protocol is the recommended dosage, and to provide less than that would be doing a disservice to the client. The dosage of DBT is often assessed by the therapist and the client during the initial assessment process.