DBT is an evidence-based modality that can help individuals who suffer from depression, bipolar disorder, ADHD, trauma/PTSD, substance misuse, disordered eating, self-harm/suicidality, and borderline personality disorder, as well as broader issues with emotional regulation and interpersonal functioning. DBT was founded by psychologist, Dr. Marsha Linehan, and developed from the early part of her career’s focus on suicide research.
At the heart of DBT is the dialectic of balancing acceptance and change. This means that we work with clients to balance accepting themselves exactly as they are in the current moment, while working to change the parts of their behavior that aren’t serving them well. The overall goal in DBT is to help people “create a life worth living.”
The last few years have witnessed a significant increase in DBT providers and skills training groups. While we are happy to see this modality being more widely offered, it’s important to know that DBT is a complex treatment consisting of multiple parts. Offering just one component of DBT without the other components or supports in place may fail to provide the consistent benefit of the treatment demonstrated in the research. The same is true for offering a watered-down version of one of the components. For instance, skills training groups have been researched using a standard curriculum, with groups run by co-leaders, and with co-leaders having access to a consultation team. If a skills training group lacks these elements, or rushes through its curriculum, it’s difficult to say if it might have the same positive outcomes as those observed in the literature.
At Gatewell, we offer comprehensive DBT. This means that our program offers multiple components of treatment, originally developed by Dr. Linehan and researched significantly over the years. A comprehensive DBT program consists of four components:
1. Individual therapy: Here, a client meets with a therapist one-on-one to focus on individual struggles and problem solving. Like in any other therapy, DBT relies on a solid therapeutic relationship typified by empathy, validation, and compassion. In DBT, two tools are used for assessment and intervention purposes: chain analyses and diary cards. Together, they help us gather information about symptoms and skills use that can aid in a client’s recovery.
Individual DBT occurs across four stages. Stage 1 consists of addressing high-risk target behaviors and teaching coping skills. The goal here is behavioral control of life-threatening, life-interfering, or otherwise problematic behaviors through skills acquisition. In Stage 2, now that the client has access to an arsenal of coping skills, we can start to access more difficult emotions. While a client’s behavior might be more controlled now that they are out of Stage 1, they are often still “silently suffering” due to trauma, grief, etc. Stage 2 targets these experiences, emphasizing the processing of trauma and other emotionally “lodged” experiences. Stages 3 and 4, which haven’t been covered as extensively in the literature, focus on improving clients’ overall quality of life, helping them create a life worth living. Stage 3 involves a focus on problem-solving, accomplishing goals, and cultivating self-trust and self-respect, while Stage 4 is when the client might obtain deeper meaning through spiritual exploration. Clients explore interconnectedness, wholeness/completeness and, in the process, might experience increased capacity for freedom and joy.
2. Skills training: Skills training is another component of comprehensive DBT. Typically occurring in a group setting, skills training covers the four modules of DBT skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Skills are presented during the group meetings, and members practice what they’ve learned through weekly homework assignments, which they share in group.
As mentioned above, there are a few conditions that must be met in order for skills training groups to be adherent to the original model. Groups must follow one of the evidence-based curricula. In most cases, this means offering the standard 24 weeks of skills training, which many programs recommend (or require) that clients repeat, for a total of 48 weeks of skills training. Skills training groups are also c0-led (meaning there’s more than one leader) in order to be adherent to standard DBT protocols. The leaders have different roles in the group and come together to support group members.
3. Phone coaching: Phone (or skills) coaching is another component of comprehensive DBT. Here, clients are offered access to their therapists between sessions for help with DBT skills. Since DBT clients are only with their therapists for a couple of hours a week, there are plenty of hours in between when crises can occur and clients need help with skills. In comprehensive DBT, therapists agree to be available to clients in between sessions to offer support and guidance when difficult situations and emotions arise. In DBT language, this helps clients generalize skills to their natural environments.
Each DBT practice has different parameters around skills coaching, but the important thing is that clients are able to speak to their therapists in between sessions. Gatewell offers phone coaching during business hours and then refers to crisis hotlines outside of these times. Some practices offer 24-7 phone coaching. It’s important to know when your DBT providers are available to you and how to handle crisis situations if you are not able to make contact with one of them during a crisis.
4. Consultation team: Providers at comprehensive DBT practices are part of a consultation team, a weekly meeting where therapists come together to support each other and put their heads together to solve problems and offer clients the most comprehensive care. Sometimes referred to as “therapy for the therapist,” the goal of the consultation team is to increase therapist motivation and capability.
The consultation team is a critical component of comprehensive DBT and unfortunately one that is often omitted by providers who offer skills training. Even if just teaching skills, a provider must be part of a consultation team; if they aren’t, then they aren’t offering DBT. Gatewell has a weekly, 90-minute consultation team meeting, where our DBT providers practice mindfulness together, support one another, and consult on cases, so that each client in our practice can benefit from the collective wisdom and expertise of the entire team.
These four components work together to offer clients the most comprehensive, wraparound care. If you are looking for a DBT program, or even a DBT skills group, ask about these four components. Ask if your provider or team has been intensively trained in DBT (the gold standard for training is Behavioral Tech, founded by DBT creator, Dr. Linehan). Other trainings, even if they advertise DBT certification, fail to compare in terms of depth and breadth offered by Behavioral Tech. In asking these questions and searching for programs that are adherent to how DBT was intended to be offered, you can increase the chances that you will receive the most thorough, evidence-based care.