DBT’S 4 THERAPY STAGES
DBT is a comprehensive treatment. The original outpatient model for borderline personality disorder (Table 3) has been adapted to different settings and applied to other populations.
Outpatients meet weekly in individual psychotherapy and a skills training group.3 Therapists also meet weekly in a consultation team viewed as “therapy for the therapist.”
Between sessions, therapists consult with patients by telephone to:
- decrease suicide crisis behaviors
- increase generalization of behavioral skills
- decrease patients’ feelings of conflict, alienation, or distance with the therapist.
Four stages. DBT follows four stages. For persons with borderline personality disorder, researchers have evaluated the efficacy of stage-1 therapy. Studies on stage-3 DBT have been conducted with nonborderline-personality individuals with eating disorders. The goals at each stage are:
Stage 1. Move from severe behavioral dyscontrol to behavioral control. Decrease suicidal and other life-threatening behaviors and those that interfere with therapy and quality of life. Increase mindfulness, tolerance for distress, interpersonal effectiveness, and emotion regulation.
Stage 2. Move from quiet desperation to emotional experiencing.
Stage 3. Address problems in living, and move toward ordinary happiness/unhappiness.
Stage 4. Move from incompleteness to capacity for joy and freedom.
Seven randomized controlled trials have shown that DBT can be useful in treating borderline personality disorder.4-10 The initial trial by Linehan et al4 included 47 women ages 18 to 45 who met criteria for borderline personality disorder and had at least two parasuicide incidents in the previous 5 years, with one in the previous 8 weeks. Treatment lasted 1 year, and subjects agreed to stop other individual psychotherapy if assigned to DBT.
Subjects were then randomly assigned to either DBT or “treatment as usual” in the community. In the various DBT studies, treatment-as-usual has included community therapists, Department of Veterans Affairs outpatient treatment, client-centered therapy, and treatment by persons identified by their peers as experts in their communities.
Subjects were assessed every 4 months while in treatment and for 1 year thereafter. DBT was more effective than usual treatment in:
- reducing suicide attempts and self-injury
- decreasing premature dropout from therapy
- reducing emergency room admissions and length of psychiatric hospitalization
- reducing drug abuse, depression, hopelessness, and anger.
Table 3
Modes of therapy in outpatient dialectical behavioral therapy
| Therapeutic goals | Mode |
|---|---|
| Improve motivational factors | Individual psychotherapy |
| Enhance capabilities | Skills training |
| Ensure generalization to natural environment | Between-session consultation |
| Enhance therapist capabilities and motivation to treat effectively | Therapist consultation team |
| Structure the environment | Consultation to the patient |
RECOMMENDATIONS
Some psychiatrists may find “borderline patients” frustrating and unpleasant to treat. DBT therapists, however, make two assumptions that can help anyone working with individuals with borderline personality disorder. To avoid falling into the trap of polarization with these patients, assume that:
- they are doing the best they can
- their efforts are insufficient to meet their needs.
They therefore need to do better, and the therapist’s job is to help them do so. Also assume that if you try to help a patient with borderline personality disorder, you will need help, too. We require DBT therapists to participate in consultation teams.
Training. DBT is a comprehensive program that requires familiarity with the manuals mentioned in this article (see Related resources). Some teams have learned DBT through self-study and consultation with other teams.
If you plan to offer DBT to patients with borderline personality disorder, we recommend that you be:
- trained in behavior therapy and CBT
- familiar with research on emotions and processes involved in emotion regulation.
If you have not had CBT training, find a behavior therapist to join your team or get consultation from a behavior therapist.
An intensive training course in DBT—with 2 weeks of instruction and case consultation and several months of consultation with someone well-versed in DBT—is an efficient way to become familiar with the most critical principles of the treatment. If you cannot train toward adherent delivery of individual therapy, we recommend referring patients to someone trained in DBT.
- Lieb K, Zanarini MC, Schmahl C, et al. Borderline personality disorder. Lancet 2004;364(9432):453-61.
- University of Washington, Behavioral Research and Therapy Clinics. www.brtc.psych.washington.edu/frameResearch.htm;
www.brtc.psych.washington.edu/framePublications.htm - Behavioral Tech, LLC. Consultation and training in dialectical behavioral therapy. www.behavioraltech.org.
Disclosures
Dr. DuBose is president and CEO/co-owner of DBT Center of Seattle, PLLC, and a speaker for Behavioral Tech, LLC.
Dr. Linehan is a shareholder in Behavioral Tech Research, Inc., which develops computerized training for DBT, a DBT trainer for Behavioral Tech, LLC, and the author of two books on DBT. She also receives research grants from the National Institute of Mental Health and National Institute on Drug Abuse.