Dialectical Behavior Therapy (DBT) is a behavioral therapy that has been used since the 1990’s. Since then, it has rapidly grown in popularity as a highly effective treatment. It’s no surprise you may have heard of it. It’s bound to be mentioned either from a peer, in a therapy intake, a clinician’s bio, or as a referral. And there is a lot of info our there about DBT. You may become overwhelmed as you explore more of what DBT involves and find yourself thinking:
- Why would I need to be in a group AND individual therapy?
- What the heck is phone coaching?
- Why do some places require me to stop working with my previous therapist but others don’t?
As you see that different providers describe DBT differently, you may start to realize that there are subtle differences. At the broadest level, the most important differences lie between comprehensive DBT treatment versus therapy that’s informed by DBT principles. Since DBT can look different between adherent and informed approaches, it’s vital to understand the differences. This helps you be an informed consumer of therapy. And this leads to the BEST care, with the BEST results, with less time and money spent in the trial and error of mental health care.
Let’s dive into understanding the differences between adherent DBT and DBT-informed treatment, starting with the therapists!
DBT-Certified Clinicians vs DBT-Trained Clinicians
A DBT-certified clinician is someone who completed their training from the DBT Linehan Board of Certification program. This program is run by the creators of this treatment, where evidence- based research was conducted to prove that fidelity to the DBT model works! To be certified, you have to go through 40+ hours of trainings and meet other requirements including exams, evaluations, and a minimum of 12 months of DBT consultation. This level of DBT-certification is rare and prestigious.
On the other hand, someone who identifies as DBT-trained may have any number of hours of training under their belt: some local DBT trainings could be very brief (1-2 hours) while others could be more thorough. Many “DBT-trained” folks have gone through the 40+ hours of training from Linehan Foundation. Those therapists are likely to have a very solid knowledge base about DBT. But they may either have less experience practicing 100% fidelity and/or did less testing to prove proficiency.
DBT-trained and DBT-certified clinicians are both capable of providing quality care. But there is a significant difference in the level of proficiency between the two. You are most likely to receive adherent DBT from a DBT-certified provider.
Adherent DBT: Also referred to as Comprehensive DBT
Adherent DBT involves delivering DBT “by the book”. This means applying the treatment protocol exactly as the research dictates it to be delivered. The DBT skills manual emphasizes 4 components of treatment that are delivered over the course of between 6-12 months. These are individual therapy, skills training, phone coaching, and dbt consultation.
Individual DBT Therapy
Treatment starts with an important orientation and commitment phase. A client needs to understand how and why DBT works. And they have to commit to doing so for at least 6 months.
Ongoing individual DBT interventions use the therapeutics relationship to provide a balance with empathy and accountability both inside and outside of sessions. Tools include diary cards and behavior chain analyses to track emotions and change target behaviors. Clients fill out diary cards throughout their weeks. They review important patterns between emotions and behaviors at the beginning of a therapy session to set the agenda. Focusing on the most important behaviors that interfere with your goals, you and your clinician then use a behavior chain analysis to map out a recent event. You will gain insight and empathy for all the factors that contributed. And you also gain accountability for all the ways that you may have been able to do something different along the way. By doing this, you learn how you can do it better next time. Finally, you also complete repairs needed from a regrettable event.
Group Skills Training
See up there where it says “do something different”? Well in order to try something new, you have to learn something new! Your individual therapy can help you apply skills but you have to learn them first. And skills training is where to do that!
In comprehensive DBT, this learning takes place in a psychoeducational group, in weekly 2-hours groups. A facilitator teaches the lesson. And a co-facilitator maintains the DBT framework when emotions or target behaviors show up DURING the session. It takes 6 months to learn all the skills from all 4 modules. The research says you should learn each skill twice; once for initial understanding and once for generalization. This means in comprehensive DBT,
Phone coaching is when a client texts or calls their clinician for help preventing unwanted behaviors. These are opportunities where one might otherwise engage in unhelpful behavior but would rather try the new way. If you need help figuring out what tool to use, or how to use it, that’s exactly what phone coaching is for! The goal is not to process a situation or discuss long term prevention/solution strategies. Rather, it is to use your new toolbox to get you to the next session without doing anything that destroys your goals. Adherent DBT must include this treatment component and adhere to the specific rules and techniques about using this intervention.
DBT Consultation Team
This is a weekly meeting for DBT clinicians. They provide support for each other as well as consultation for their cases. There is a particular protocol for these team meetings that maintains the DBT framework in our work with our clients. Even though it happens behind the scenes, a provider must have a DBT consultation team for treatment to be considered comprehensive. And because of this, most comphrehensive DBT providers want the individual therapy and the skills group to be provided by the therapists on the same team. This helpsto ensure fidelity and deliver a cohesive treatment that works!
Who Should Seek Adherent DBT
Adherent DBT is most helpful for clients with highly risky behaviors. This includes self-harm suicidal ideation, life-threatening substance use, severe emotion dysregulation and personality disorders. Adherent DBT is also recommended for whom other treatments (either DBT-informed treatment OR other modalities entirely) have already proven unhelpful .
What about those who do not have life-threatening behaviors or fit diagnostic criteria? This may all sound a bit intense for that right!? Well this is where DBT informed therapy comes into the picture! For less intensive cases, a more flexible, or “DBT-informed” approach may suffice.
“DBT-informed treatment” means the clinician uses the DBT concepts for your therapy. However, there will be flexibility around which of the 4 DBT components to include and/or how to include them. Though it strays away from the evidence-based model, it holds true to the principles of how DBT therapy creates change.
Who should seek DBT Informed Therapy?
This best suits those who struggle with non-life threatening behaviors. This includes people with moderate emotion dysregulation, ineffective communication skills, lack of self-awareness, relationship distress, rigid black and white thinking, and impulsive, but not life threatening, coping behaviors. DBT informed therapy can also be very helpful to a person who has a loved one who meets the criteria for adherent DBT treatment, regardless of whether or not their loved one has committed to engage in such treatment.
What does DBT informed treatment look like?
Since this is not based on research, DBT-informed treatment can look like a variety of different things. Any number or combinations of the following adaptations to comprehensive DBT treatment could be considered DBT-informed treatment:
You are in a psychoeducation skills group but it’s not implemented with the adherent DBT protocol:
- The curriculum does not cover every skill from each module in the order in which they are meant to be taught.
- The client is not required to complete all modules of DBT (e.g. emotion regulation, mindfulness, etc.).
- The group does not follow all guidelines for DBT group sourced from the manual.
- There is no accountability for homework and practice outside of group.
- There is no co-facilitator and/or they do not follow the protocol for what happens when real-time emotions/behaviors arise during a group.
- It’s a mix of psychoeducation and processing/support.
- Mindfulness is not included at the start of each group or relates to DBT skills being practiced in the module.
You’re doing DBT therapy but aren’t in a DBT skills training group:
- Your therapist teaches you the skills as part of your individual sessions.
- You learn skills from a book instead of a group.
- You might be asked to change (ie: “you need to use skills”) without being taught which skills, assuming that you already have/know them.
You are in a DBT skills group but don’t engage in DBT individual therapy:
- You have no individual therapy OR
- Your therapist’s therapy is not DBT-therapy
- Your therapist provides an adaptation of DBT.
Your individual therapy incorporates DBT principles but is not fidelity DBT-therapy:
- Your therapist does not use DBT commitment strategies and specific DBT tools (diary cards and behaviors chain analysis) as the main interventions.
- Your therapist does not role model the balance of empathy and accountability as the foundation evaluating your behaviors.
- You have not been offered phone coaching.
- Your therapist is not on a DBT consultation team.
- Your therapist has received some DBT training but not in the extensive way described earlier (e.g. behavior tech).
- Your therapist does not use the first four sessions to orient you to DBT.
So What Now?
Our main purpose of sharing all of this is so that you can be an informed consumer. You are now primed to understand the type of treatment to ask for based on your needs or what another provider recommended for you. And you can suss out the differences in what is being offered. You now have some better questions to ask as you are seeking treatment.
Example of questions you can ask:
- Do you provide comprehensive DBT or DBT-informed care?
- Are you part of a DBT consultation team?
- Is your DBT skills group run according to the adherent model?
- Does individual therapy include behavior chain analysis, diary cards, and phone coaching?
- Have you received extensive training in DBT?
Most practices provide EITHER comprehensive DBT OR informed-DBT. At MCCC we have the flexibility to offer both. Our DBT clinicians have gone through the 40-hours of training directly from the DBT-LBC (DBT Linehan Board of Certification). However, We have not gone through the certification process. When asked for comprehensive DBT, or if we assess that it’s needed, we will do our best to put together all of the components together based on availability. And if we cannot put together an adherent approach when it’s needs, we will make recommendations for other comprehensive programs accordingly.
For more information about MCCC’s DBT services, check out all our DBT blogs!
About the Authors
Laura Goldstein, LCMFT and Diana Gomez, LGPC co-authored this article.
Laura Goldstein, LCMFT is a Licensed Clinical Marriage and Family Therapist in Rockville Maryland. She found Montgomery County Counseling Center in 2017. Laura obtained her Bachelor’s degree in Neuroscience from Franklin and Marshall College in Lancaster, PA. She then went on to earn her Master’s degree in Family Therapy from Thomas Jefferson University in Philadelphia. Laura became intensively trained in Dialectical Behavioral Therapy (DBT) through Behavioral Tech Linehan Institute in 2015. After working in IOP programs, Laura now works in her private practice alongside her excellent associates!
Diana Gomez, LGPC is a Licensed Graduate Professional Counselor at Montgomery County Counseling Center. She obtained her Bachelor’s degree in Psychology from Mount St. Mary’s University. She went on to earn her Master’s degree in Applied Psychology from the University of Baltimore. Diana has recently completed the Comprehensive Training in Dialectical Behavior Therapy at Behavioral Tech Institute.