Please click on individual components for a description:
PHASE I
A. Assessment (1-2 sessions)
An important initial part of treatment is evaluating the "goodness of fit" between DBT and the client's problems and
treatment goals. To this end, we assess for the presence of the following problem areas: 1) Confusion about Self
(including how one feels and thinks); 2) Impulsive Behavior; 3) Emotion Dysregulation; 4) Interpersonal Effectiveness;
and 5) Conflicts Among Family Members.
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B. Pre-treatment (1-6 sessions)
We have also found that the use of special commitment strategies is very important in the pre-treatment assessment.
That is, we ask clients to commit to making certain behavioral changes even though they have not learned to master them.
This is based on ample evidence suggesting that people are more likely to behave in a particular way if they agreed to
do so beforehand. We also explain all aspects of treatment, and anticipate and problem-solve any potential treatment
barriers (e.g., not attending sessions, staying silent in sessions, feelings of hopelessness). We seek commitment not
only from adolescents, but also from the accompanying caregivers.
The use of commitment strategies is crucial for teenagers, given that many would not "choose" to be in therapy if given
the option. Since adolescents have often not yet experienced the consequences of their behavior, they may feel unconcerned
about them. As such, adolescents are often encouraged or mandated by parents, teachers, or friends to seek treatment,
and may not be "motivated" initially. It is for this reason that the individual DBT therapist spends a significant
amount of time during the early phases of treatment using commitment strategies that aim to help teens understand the
triggers of their behaviors, the consequences, both positive and negative, of their behaviors, and the implications for
behavior change.
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C. Active Treatment
a. Weekly individual psychotherapy (20 sessions)
Individual DBT therapists will help the client to 1) identify and maintain focus on the primary problems to be
addressed; 2) stay motivated to work hard in treatment and apply new behaviors in their daily lives; and 3) coordinate
and consolidate the different parts of treatment and make sure it is all tailored for the particular teenager and family.
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b. Weekly multi-family skills training class (20 sessions)
The class meets for two hours each week in the evening and
includes 3-5 teens along with their caregiver(s). Each family learns skills, and parents learn to understand and respond
to certain adolescent behaviors, to encourage use of the skills at home, and to receive support from each other within a
DBT framework. The class lasts for 20 sessions and is led by two skills trainers who combine lecture, discussion, and
practice exercises in order to teach the following skill modules:
- Core mindfulness: teaches participants how to focus the mind, direct attention, and how to nonjudgmentally observe
and describe what they are feeling and thinking in the moment. These skills can help teens develop a more stable sense
of who they are, and can help reduce reactivity to painful thoughts and emotions.
- Distress tolerance: targets impulsivity by teaching teens how to effectively distract and soothe themselves while
considering pros and cons of their actions. These skills typically replace problem behaviors such as cutting classes,
self-inflicted cutting, physical fights, and using alcohol or drugs.
- Emotion regulation: addresses extreme emotional sensitivity, rapid mood changes, and other unregulated moods such
as chronic depression, anxiety, or hostility. Examples of specific skills include learning to identify and label
emotions, learning how to increase positive moods, and learning how to make yourself less vulnerable to negative moods.
- Interpersonal Effectiveness: addresses difficulties in maintaining consistent and rewarding relationships by
teaching skills such as how to ask for what you want, how to say no in a gentle yet effective manner, and how to
maintain your sense of self-respect and independence in the face of peer pressure.
- Walking the Middle Path: targets extreme and nonbalanced thinking and behaviors among teens and family members.
These skills involve learning about common areas of conflict and polarization in the family, and reducing the conflict
by learning methods of behavior change as well as methods of validation and acceptance.
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c. Telephone coaching with the therapist.
Phone coaching is designed to promote skills use where it matters most–in the real world. When adolescents feel "stuck"
and unsure what to do, they are encouraged to contact their individual therapist for help in using DBT skills. In
addition, parents are able to contact one of the skills trainers for coaching in how to apply skills with their teens.
d. Family therapy.
Family therapy occurs on an as-needed basis to increase behavioral skill use within the family system, improve communication
between family members, and to reduce family interactions that interfere with either the adolescent's or the family's
quality of life.
e. Weekly therapist consultation team.
The two-hour consultation meeting is for DBT practitioners at CBCW. The DBT treatment team meets weekly to assist each
other in providing effective and compassionate treatment. We spend time problem-solving difficulties that interfere with
client progress in treatment and help keep each other practicing within a dialectical framework.
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PHASE II
A. Graduate Group (16 weeks)
Graduate group is strongly recommended for adolescents who have completed the 20-week multi-family skills training group
(Phase I). Research with adolescents suggests that a continuation phase of treatment is necessary following an acute phase
of treatment to help reduce the chances of relapse (back to their old behavioral patterns and symptoms). Thus, the primary
goals of our DBT Graduate Group are (1) to prevent relapse by reinforcing the progress made in Phase I of DBT; (2) to help
the adolescents strengthen and generalize their behavioral skills to various settings and relationships; and (3) to help
the adolescents increase behaviors that improve their overall quality of life while decreasing behaviors that impede their
quality of life. To achieve these goals, the group leaders encourage the adolescents to employ all of their newly learned
DBT skills, with extra attention being paid to the use of validation and problem-solving skills with each other. Each week,
the adolescents are required to identify individual homework assignments tailored to assist them in reaching their longer
term goals. The graduate group is a 90-minute group that occurs once weekly for 16 weeks, with the opportunity to re-contract
for additional time if there are clear treatment goals identified.
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