If you’re on this website, or reading this blog, chances are you (or someone you love) have been referred to Dialectical Behavior Therapy (DBT). (If you’re a teen wondering how to bring up therapy with your parents, our guide “How to Talk to Your Parents About Therapy” offers step-by-step advice for starting that conversation.) First off, welcome! I’m so glad you’re taking the time to read up on this type of therapy. While I could sing from the rooftops how effective and beneficial DBT is as a therapy, it is quite intensive. I’ve found that my clients have the best success in treatment when they’re well-informed, well-oriented, and start the treatment fully understanding what they’re signing up for and why. With that in mind, let’s dive right in!
What is DBT and how can it help me?
DBT is an evidence-based form of psychotherapy that has been shown to help with a variety of mental health concerns including life-threatening behaviors (self-harm, suicide behaviors, etc.), mood disorders, addiction, trauma, eating disorders, etc. DBT tends to be a good fit for those who are experiencing intense emotion dysregulation, difficulties in relationships, impulsive or mood-dependent behavior, substance use difficulties, etc. Adherent DBT programs typically ask clients to commit to 6 or 12 months of treatment. This will allow the client to move through the skills training program once (for the 6-month commitment) or twice (for the 12-month commitment).
As the “D” in “DBT” stands for dialectics, you can imagine that dialectics plays a huge role in the therapy. Dialectics is a worldview that helps us stay away from extremes and walk the middle path in our thinking and behavior, which helps us regulate our emotions! Dialectics also help us resolve disagreements and search for the truth. Learning how to be dialectical is a huge component of therapy and helps clients make sense of really complicated issues, develop deeper and more meaningful relationships, and broaden their understanding of their experience and the world around them.
As mentioned above, DBT is great for people experiencing intense emotion dysregulation. For those who would categorize themselves in this way, they’d also probably say their life feels really chaotic at times. One of the reasons DBT tends to be more effective than other types of psychotherapy for these individuals is because it’s structured. The individual sessions are guided by a target hierarchy which the clinician and client build together at the start of treatment. It lists the problem behaviors the client wants to address in treatment so that the clinician and client can stay on track. The client comes into their individual sessions with their diary card (outlining their emotional experience day-to-day along with other behaviors they’re tracking) completed. The clinician and client set the agenda based on what was reported in the diary card, using the target hierarchy to make sure they stay on track to discuss the things getting in the way of the client reaching their goals. While this is very effective, it can be disarming for clients when they come in and want to discuss other things that are not listed on the target hierarchy. Don’t get me wrong, there is a time and place for this and those topics can be added to the agenda, AND, the structured nature of DBT would have the clinician prioritize those topics in the target hierarchy over the COW (Crisis of the Week). Again, while this can be frustrating for clients in the moment, this focused approach does help people be more effective in achieving their goals long-term, which tends to decrease their COWs over time.
In individual sessions, clients and clinicians assess these problem behaviors thoroughly to gain a better understanding of what contributes to the problem behavior, the function/purpose it serves, if anything is reinforcing it to continue, etc. The client and clinician then work to incorporate skills learned in skills training group into their circumstances and work together to address these problems in the most effective way. Clients can expect to receive homework each week to incorporate skills in various ways or implement whatever problem-solving plan was discussed in session and report back the next week. The cycle continues in this way- constantly reassessing the problem and how it’s changing over time, gain an understanding of how it happens, when, why, and figure out what works for the client to get them closer to their life worth living.
What should I expect in my first DBT therapy session?
Okay, maybe this is nitpicky of me, but typically the first session for someone is an intake. Intake sessions will vary from practice to practice but you can typically expect to go over logistics like what confidentiality is, the reschedule policy, introductory stuff like that. You can also expect to be asked a bunch of questions so that the clinician can get to know you better and gain a better understanding of what your goals for treatment are. (If getting to that first appointment feels hard, you might find it helpful to read “How to Talk to Your Parents About Therapy”, which can help ease the process of asking for support.) The clinician will hopefully provide an overview of what DBT will look like and give you an idea of what to expect from the program. This way, you can make an informed decision on whether or not you want to move forward with this treatment.
For the first session after the intake, you can expect to move into pretreatment. Pretreatment typically (not always) takes about 4 sessions. While this can also be frustrating for clients, research shows that the better oriented someone is to treatment, the more effective treatment is. Pretreatment helps lay the foundation for the rest of the DBT program. In pretreatment, you and your clinician will identify the problem behaviors you want to work on, do a behavioral chain analysis together, learn how to effectively request phone coaching, and generally get an idea of whether or not you want to engage in this program more thoroughly. This offers time to address any barriers or concerns you have for treatment and ensure that you feel confident moving forward with this commitment.
What are the four components of DBT and how can they help me?
The four components of DBT include:
- Individual therapy
- Skills training
- Phone coaching
- Consultation team
Individual therapy sessions were discussed above. Essentially, plan on meeting once a week, for about one hour, with your individual therapist. This is your time to report back to them the things you’ve worked on from the previous week in addressing your concerns, any barriers you ran into, things you’ve learned, etc. You can learn more about individual therapy sessions in this blog.
Skills training is another essential component of DBT. This is typically done as part of a group, though it can be done on an individual level as well. The group is a 2-hour group that meets once a week. There’s a mindfulness activity at the start of the group, then homework review, a break, and then you learn the new skill. Homework will be assigned to practice the skill learned that week.
There are 4 skills modules covered in group: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Mindfulness helps you become more aware of your emotions, thoughts, body, urges, etc. It can help increase focus and attention, decrease judgmentalness, and be more effective and intentional in your day-to-day life. Emotion regulation helps you learn more about emotions- what they are, why they show up, how they influence thoughts, how they influence behaviors, and even how they influence the way your body feels. Emotion regulation will help provide you strategies to change your emotional responses and increase emotional resilience. Distress tolerance helps you learn how to navigate intense emotional situations and helps you not make a bad situation worse by decreasing your emotional elevation to more manageable levels. Finally, interpersonal effectiveness teaches you skills in building and maintaining relationships, getting what you want and/or saying ‘no’ effectively, and increasing your self-respect effectiveness. You can learn more about the skills training group here.
Phone coaching is a very unique (and super cool) part of the DBT program. Phone coaching allows clients to reach their therapist 24/7 for help integrating skills into their daily life. Phone coaching calls are not meant to be therapy over the phone. Rather, they are 10–15-minute phone calls in which you call your therapist according to the protocol discussed. You would give a brief account of what you need, your therapist gives you skills to try or other things to do, and the call ends. You go and do the things and, hopefully, notice that it helped. Otherwise, you could always call back. While 3 hours (2 in group, 1 in individual) of therapy is pretty intensive, that’s only 3 hours out of your whole week that you have a professional in front of you. Phone coaching is designed to help you bridge the gap between what you’re learning in group and in your individual sessions to your actual day-to-day life. It helps people make more effective, meaningful changes in their lives and see more significant progress in treatment. You can learn more about phone coaching here.
Finally, consultation team is a once-a-week meeting among the professionals on our team. It’s a chance for us as your clinicians to receive consultation, feedback, and support to better assist our clients. It’s a community of clinicians serving a community of clients. You don’t just have one therapist at your disposal, you have an entire team. This helps ensure that you are receiving the most effective treatment possible because your therapist, if they’re ever stuck or unsure, if they’re experiencing burnout, and/or if they have questions, they have a group of people they can ask for help. It benefits the clinicians and the clients a like.
How can I get the most out of my DBT group sessions?
Oh, I love this question. There are so many things you can do to get the most out of your DBT group sessions. This will definitely depend on the person, so you might not resonate with all of these points, but here are some ideas to get the ball rolling.
- Come prepared- plan ahead of time to be at every group, on time, with your book, ready to learn. Troubleshoot and/or problem-solve any potential barriers so that you can be on time for group, whether it’s online or virtual. Have your book, a pen, and maybe a snack and some water all ready to go so you feel prepared.
- DO YOUR HOMEWORK- If I could just download the skills into your brain and ensure that you’d be good at them right off the bat, I would do that. I’m good, don’t get me wrong, but I’m not that good. I know it can be so easy to forget. You get caught up in your daily life and the million things you have to do AND, if you want to see real results in treatment, you have to do the stuff. So, practice the skills you’re learning in group as many times as you can, with as many people, in as many situations, with as many different emotions as you can. For example, get good at checking the facts when you’re angry, and also when you’re anxious, and also when you’re feeling a lot of guilt. Practice DEARMAN with your best friend, mom, boss, and neighbor. DO THE STUFF. If you’re finding that you’re not doing the stuff, DON’T THROW IN THE TOWEL. Go to your individual therapist, let them know what you’re noticing and problem-solve whatever the barriers are.
- Know what your specific struggles/difficulties/limitations are and plan ahead for those- For instance, if I were to do group as a client, 5:30-7:30pm or 6-8pm would be ROUGH for me. It would be after a full day of work and my brain would be mushy. I would also struggle to be willing to go, if I’m being honest. So, I know this about me. I could plan around that. I would bring snacks and fidget toys to group so I can stay alert and focus better. I’d plan to bring my colorful pens so I can take color-coded notes (because my brain is mushy and it’ll be hard for me to remember what was discussed, plus the colors make it more fun). I might ask a trusted individual to hold me accountable- if you verbally commit to someone to do something, you’re way more likely to do it, especially if you know they’re going to check in with you about it. I might set up a lil’ reward each week for going. Like I might make Tuesday my Chipotle night and after group, I go to Chipotle and pick up dinner for myself to help with the willingness. Whatever it is that you think might get in the way or might make it hard for you to participate or engage in group, give it some thought or even notice it while it’s happening and then plan ahead for that! You can do this in individual therapy too!
- Keep practicing the skills, even after the week it’s assigned for homework- Don’t just learn the skill, do the homework, and then forget about it. Make a plan to keep revisiting the skills. I had a client one time put the skills on popsicle sticks and she would pull a different popsicle stick out each week. She’d then spend the week focusing on that skill. This helped her ingrain the skills into her mind more until she was doing the skills naturally and she didn’t need to rely on her popsicle sticks anymore. You don’t have to do that necessarily, but maybe think about ways you could keep the skills fresh so you keep using them until they’re second nature to you.
- TALK TO YOUR INDIVIDUAL THERAPIST- If there is something in group that is hard, makes you not want to go, or something you struggle with, DON’T KEEP THAT A SECRET! Either tell the group leaders or tell your individual therapist. I swear I’ve heard just about everything. I’ve heard my clients tell me their difficulties focusing in group, not wanting to go because it feels like school, being annoyed by another group member, feeling shame for forgetting to do homework so they just don’t want to go, and so much more. Trust me, you are probably not alone in what you’re thinking and feeling and you probably won’t offend your therapist if you talk to them about it. We want group to work for you! So, tell us what you’re struggling with and we can work on that together so that you can get the most out of your experience.
Okay, I feel like this is simultaneously a very long blog but also a very short blog. “What is DBT and how can it help me?”, talk about a loaded question! DBT is so vast and has so many principles and strategies. I can truly talk about it all day. We have so many resources on this site to help teach you more about DBT, please peruse the website, read more, learn more, and let us know if you have more questions! (If you’re a parent hoping to support your teen in getting started, check out our related post “How to Talk to Your Kid About Seeing a Therapist”.) We’d love to have you and show you exactly what DBT is and how it can help!