Dialectical Behavior Therapy in Practice
There are four primary modes of treatment in DBT:
- Individual therapy
- Group skills training
- Telephone contact
- Therapist consultation
Whilst keeping within the overall model, group therapy and other modes of treatment may be added at the discretion of the therapist, providing the targets for that mode are clear and prioritized.
1. Individual Therapy
The individual therapist is the primary therapist. The main work of therapy is carried out in the individual therapy sessions. The structure of individual therapy and some of the strategies used will be described shortly. The characteristics of the therapeutic alliance have already been described.
2. Telephone Contact
Between sessions the patient should be offered telephone contact with the therapist, including out of hours telephone contact. This tends to be an aspect of DBT balked at by many prospective therapists. However, each therapist has the right to set clear limits on such contact and the purpose of telephone contact is also quite clearly defined. In particular, telephone contact is not for the purpose of psychotherapy. Rather it is to give the patient help and support in applying the skills that she is learning to her real life situation between sessions and to help her find ways of avoiding self-injury.
Calls are also accepted for the purpose of relationship repair where the patient feels that she has damaged her relationship with her therapist and wants to put this right before the next session. Calls after the patient has injured herself are not acceptable and, after ensuring her immediate safety, no further calls are allowed for the next twenty four hours. This is to avoid reinforcing self-injury.
3. Skills Training
Skills training is usually carried out in a group context, ideally by someone other that the individual therapist. In the skills training groups patients are taught skills considered relevant to the particular problems experienced by people with borderline personality disorder. There are four modules focusing in turn on four groups of skills:
- Core mindfulness skills.
- Interpersonal effectiveness skills.
- Emotion modulation skills.
- Distress tolerance skills.
The core mindfulness skills are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment.
The interpersonal effectiveness skills which are taught focus on effective ways of achieving one’s objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people.
Emotion modulation skills are ways of changing distressing emotional states and distress tolerance skills include techniques for putting up with these emotional states if they can not be changed for the time being.
The skills are too many and varied to be described here in detail. They are fully described in a teaching format in the DBT skills training manual (Linehan, 1993b).
4. Therapist Consultation Groups
The therapists receive DBT from each other at the regular therapist consultation groups and, as already mentioned, this is regarded as an essential aspect of therapy. The members of the group are required to keep each other in the DBT mode and (among other things) are required to give a formal undertaking to remain dialectical in their interaction with each other, to avoid any pejorative descriptions of patient or therapist behavior, to respect therapists’ individual limits and generally are expected to treat each other at least as well as they treat their patients. Part of the session may be used for ongoing training purposes.