The structure of standard DBT involves a pre-treatment
period of time.
This is when the patient and the therapist
determine whether they can work with one another
and whether the patient is willingly entering
into a DBT plan.
The first two to three sessions, the therapist
and the client are discussing the terms of
DBT, how it’s different from standard therapy
or CBT and they’re discussing the DBT’s
patient and therapist agreements.
The most significant parts of those agreements
involve the one-year term gentlemen’s agreement
to stay in therapy.
One year is the minimum requirement for engaging
DBT with adults.
Another significant agreement involves the
client taking self-harm and suicide off the
table for a period of time.
Taking it off the table does not imply that
a client will be terminated if they do engage
in self-harm or have a suicide attempt.
More clarification on the therapist and patient
agreements will come later.
Once pre-treatment has passed and the agreements
are signed, then the patient would enter into
stage one.
Stage one is the most well-known phase of DBT.
It’s the one that’s most talked about
and it involves getting the patient’s behaviors
under control.
There are four modes of therapy or there are
four modes in DBT.
One involves individual therapy.
So individual therapy is just a part.
It involves weekly sessions, is structured.
It requires the most training for the therapist.
To be a group leader does not require as much
training but for an individual therapist,
they need to be well versed in a variety of
different parts of the DBT and CBT.
In an individual session that’s structured,
there is homework every week and the diary
card, the DBT diary card being one of those.
The individual therapist will be engaged with
the client in conducting behavioral chain
analysis repeatedly during each session in stage one.
The individual therapist will be prioritizing targets.
What’s most important to address and whether
or not we’re able to discuss with the client
who brings in as much detail as they would
like to talk about it is determined by a hierarchy
of targets that we’ll discuss later.
In addition, we want to, in individual therapy,
be conducting formal assessments and doing
data tracking.
For example, in an individual session with
a client who might have increased their suicidal
thinking, we would do a formal assessment
called the Linehan Risk Assessment Protocol.
So that would be an example of a formal assessment
that DBT requires.
The next component after individual therapy
is group skills training.
This is absolutely required.
In fact, more research has come out suggesting
that group skills training is helpful in and
of itself independent of individual DBT.
Group skills training is a weekly one-and-a-half hour
to two-and-a-half hour psychoeducational
group.
You would have in a DBT group between three
and 10 individuals and that would determine
how long your group was.
If it was between an hour and a half to two
and a half hours is somewhat determined by
the amount of patients that you have in that group.
There are four modules in group and mindfulness
is the most popular and most well known of
those.
But there are also three other ones that we
can discuss in more detail later on down the
line.
Another component, we have individual, group,
another component is intersession contact.
Now, intersession contact can exist in different forms.
That could be telephone coaching.
It could be if the patient had an individual
therapist and they were on a residential unit,
then they would have access to someone in
between their sessions at any point in time.
This is a 24-hour intersession contact possibility.
If you were doing individual therapy, that
client would have your personal cell phone
number.
They might call.
They might text.
They might email.
Being able to manage and set limits around
that is a key feature in DBT.
Any violation or problems that arise around
that would be treated as what’s called a
therapy interfering behavior.
Therapy interfering behaviors are another
concept that we can go into more detail at
another point.
So observing limits for the therapist is extremely
important when it comes to intersession contact
and that is partially why an individual therapist
needs to be well versed in all of the DBT
principles in theory and practices.
The final component in DBT is what’s referred
to as peer consultation team meetings.
And these are weekly meetings that last between
an hour and two hours between all members
of a team which are treating the patient.
And within the DBT perspective, the treatment
of a patient in DBT requires a team.
And so your team might be the individual therapist,
the group leader, the group co-leader, the
medication provider and/or possibly a nutritionist
or anybody who is willing and able to join
in the group that is treating the patient.
And the purpose of this is partially to support
the providers who are treating the client.
And oftentimes, providers who are conducting
DBT need extra support.
So it’s partially a support for the therapists.
It’s also a forum for being able to discuss
cases and to apply DBT principles to the case.
And it’s also a way to learn more about
DBT and reinforce some of the practices from
group that each and every provider needs to
actually practice for themselves.
The key points for this talk are:
All patients begin in pre-treatment.
Pre-treatment involves the therapist and the
client agreeing to work with one another.
There are no involuntary patients.
There are weekly individual therapy and weekly group.
Diary cards, behavioral training analysis, prioritizing targets and formal assessments
are included in individual DBT.
There are four modes in DBT – individual
therapy, group skills training, peer consultation
team meetings and intersession contact between
therapist and patient.
A typical DBT agreement is one year for adults
and the structure is different for adolescents.