Stages of Dialectical Behavior Therapy
Patients with BPD present multiple problems and this can pose problems for the therapist in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organised into a number of stages and structured in terms of hierarchies of targets at each stage.
The pre-treatment stage focuses on assessment, commitment and orientation to therapy.
Stage 1 focuses on suicidal behaviors, therapy interfering behaviors and behaviors that interfere with the quality of life, together with developing the necessary skills to resolve these problems.
Stage 2 deals with post-traumatic stress related problems (PTSD)
Stage 3 focuses on self-esteem and individual treatment goals.
The targeted behaviors of each stage are brought under control before moving on to the next phase. In particular post-traumatic stress related problems such as those related to childhood sexual abuse are not dealt with directly until stage 1 has been successfully completed. To do so would risk an increase in serious self injury. Problems of this type (flashbacks for instance) emerging whilst the patient is still in stages 1 or 2 are dealt with using ‘distress tolerance’ techniques. The treatment of PTSD in stage 2 involves exposure to memories of the past trauma.
Therapy at each stage is focused on the specific targets for that stage which are arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy but it is essential for therapists working in each mode to be clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking.
The hierarchy of targets in individual therapy for example is as follows:
- Decreasing suicidal behaviors.
- Decreasing therapy interfering behaviors.
- Decreasing behaviors that interfere with the quality of life.
- Increasing behavioral skills.
- Decreasing behaviors related to post-traumatic stress.
- Improving self esteem.
- Individual targets negotiated with the patient.
In any individual session these targets must be dealt with in that order. In particular, any incident of self harm that may have occurred since the last session must be dealt with first and the therapist must not allow him or herself to be distracted from this goal.
The importance given to therapy interfering behaviors is a particular characteristic of DBT and reflects the difficulty of working with these patients. It is second only to suicidal behaviors in importance. These are any behaviors by the patient or therapist that interfere in any way with the proper conduct of therapy and risk preventing the patient from getting the help she needs. They include, for example, failure to attend sessions reliably, failure to keep to contracted agreements, or behaviors that overstep therapist limits.
Behaviors that interfere with the quality of life are such things as drug or alcohol abuse, sexual promiscuity, high risk behavior and the like. What is or is not a quality of life interfering behavior may be a matter for negotiation between patient and therapist.
The patient is required to record instances of targeted behaviors on the weekly diary cards. Failure to do so is regarded as therapy interfering behavior.