There are four stages and targets in DBT treatment.
The four stages and targets do not include
the pre-treatment phase which is the phase
that every potential DBT client needs to participate in.
Once passing through the pre-treatment phase
when the therapist and client determine that
they can work together, they typically entern stage 1.
Stage 1 is when the therapist and the client
work together to get behavior under control
reducing problem behaviors, life-threatening behaviors,
therapy-interfering behaviors and
increasing skills-based practice.
The patient will be learning skills in stage 1.
It’s important to understand that the stages
are not chronological.
They’re actually circular, meaning that
there are certain issues in each stage that
the therapist and the client may have to work
through repeatedly.
So it is not uncommon for a pat ient to finish
stage 1, enter stage 2 and then go back to
stage 1 again.
Stage 2 involves reducing any trauma-related
symptoms including formal diagnoses of posttraumatic
stress disorder and other traumatic emotional
experiences that may not fit the criteria
for PTSD.
In addition, invalidating emotional experiences
that clients may have experienced when they
were in childhood can be discussed here as well.
It is important to not turn up the heat in
therapy as much until you are in stage 2.
I think of stage 2 as turning up the heat
because we’re processing traumatic histories
and intensifying emotion.
It is essential not to intensify the patient’s
already difficult emotional experiences from
stage 1.
So how you determine the stage that a client
is in DBT depends upon the behaviors that
they exhibit when they come to treatment.
Most often, patients will come to therapy
with a tendency to begin in stage 1.
They may have self-harm that’s present.
They may have suicidal behavior or ideation
that’s significant.
They may also have what DBT refers to as quality
of life interfering behaviors, significant
quality of life interfering behaviors such
as substance abuse or very dysregulated romantic
relationships, anything that contributes to
the difficulties in creating their life worth
living.
So if they are exhibiting any of these problem
behaviors, then they would begin in stage
1.
It’s not really possible to have a patient
fully resolve all stage 1 behaviors prior
to moving on to stage 2.
However, the most important thing to get under
control is the suicidal behaviors and self-harm
behaviors.
The amount of time that DBT therapists will
recommend for having a patient abstain from
life-threatening behavior before moving in
to stage 2 is variable.
Patients must have a commitment to abstain
from life-threatening behavior prior to moving
on to stage 2.
And when considering therapy-interfering behavior
or quality of life interfering behavior, the
therapist will want to consider the intensity
and frequency of both of those.
By the time a client moves in to stage 2,
they should have an excellent grasp of the
skills which are taught in group skills training.
For each stage, there are targets which are
prioritized depending upon the relevance to
the patient’s daily behavior and the relevance
to the session at hand.
So this is a target-based agenda in individual therapy.
The targets differ for individual and for
group as well as for intersession contact
such as text messaging the patient, emailing
the patient or calling the patient.
There are different targets for each of these
which we can go over in a later section.
Beyond stage 2, the stages 3 and 4 are not
as developed as stages 1 and 2 in DBT theory.
In fact, not much has been written about stage
3 which involves living life, trusting the
self and reaching individual goals or stage
4 where the patient obtains deeper meaning
through spiritual existence.
Most of the work that is done in DBT that
has been studied is on stages 1 and 2.
Key points.
Standard DBT includes four stages and a pre-treatment
phase.
All patients begin in pre-treatment.
There is no timeline for moving through these
stages.
The targets differ in each stage.
Most patients begin in stage 1.
Stage 1 is the most frequently discussed and
involves behavioral stabilization.
If with life-threatening behaviors, self-harm
or significant therapy-interfering behavior
or quality of life interfering behavior,
the patient should remain in stage 1.
Childhood history and histories of trauma
are not addressed until stage 2.
And finally, very little information exists
for treatment in stages 3 and 4.