Pre-Treatment and Orientation to DBT

This page will help orient you to the initial stage of treatment, called “pre-treatment,” in DBT. It will cover DBT concepts in order for you to make an informed decision and commitment to this treatment.

What is Pre-treatment

The pre-treatment stage of DBT is where you and your therapist decide whether DBT will be an effective treatment for you. This is a time (usually up to 4 sessions) where you learn about the program and are able to really explore what DBT is all about. We take a commitment to our program very seriously so we want to make sure you know what you are committing to. Once you fully commit to treatment, you are considered a client The PTSD and Anxiety Center.

*Please note that anyone in pre-treatment is not considered a client yet. You are encouraged, therefore, to remain in whatever current treatment you are in until pre-treatment is complete. After commitment is made, we ask that you terminate any conflicting therapies in order to maximize the benefits of DBT.*

What is DBT

Dialectical Behavior Therapy (DBT) is a mental health treatment that aims to alleviate serious behavioral issues that come from the inability to regulate emotions. DBT provides a set of healthy coping skills to replace destructive behaviors and tame and/or shift intense emotions. The ultimate goal in DBT is to use these skills in everyday life to help build a life worth living.

Functions of delivering the treatment of DBT

DBT treatment is meant to serve five major functions that help move you towards a life worth living. Each function is supported by a mode of service delivery. When making a commitment to DBT, you would agree to participate in each mode for a minimum of a year.

Function	Mode
Enhance client capabilities	Skills group training*
Enhance client motivation	Individual therapy
Improve therapist skill & motivation	Consultation team*
Assure skills generalization	Phone coaching as needed
Structure the environment	DBT case management

*WARNING: If the above functions are not ALL fulfilled, then you are NOT doing DBT. For example, if a therapist is not on a DBT consultation team, then they aren’t doing DBT!*

Ok, so what exactly IS DBT, what does “Dialectical” mean in DBT

The “dialectical” in DBT can be defined as holding two different views or ideas side by side and allowing them to coexist. For example, you can have love for someone who may be unhealthy for you. Dialectical reasoning seeks to integrate both views. When thinking dialectically, the goal is to synthesize the opposing viewpoints. Dialectical strategies can be used to decrease or eliminate extreme points of view, rigid thoughts and emotions, and prevent the therapist and client from becoming stuck in polarizing opinions and arguments. DBT also operates from the viewpoints of the dialectical stances of acceptance and change.

The Biosocial Theory of Emotion

DBT assumes that problematic behaviors, emotions, cognitions and relationships are caused by the interaction between an individual’s biological emotional state and an invalidating social environment. This theory involves inborn emotional sensitivity with a mix of invalidating environments that increases constant emotion dysregulation.

According to the Biosocial Theory, the interaction between one’s biological factors and one’s social environment contribute to the development of our emotions.

On the biological side, some people experience higher emotional sensitivity, higher emotional reactivity, and slower than average return to their emotional baseline. On the environmental side, this theory states that individuals with emotion regulation issues can end up living in a consistent invalidating environments. Invalidating environments can look different! Some examples are- invalidation of private experiences, ignored or punished emotional displays, and oversimplification of emotions or experiences occur. This interaction over time can help explain why some people tend to struggle with significant and pervasive emotion dysregulation. AT times, this dysregulation can have a variety of consequences that include behavioral problems, out of control emotions, relationships issues, identity barriers, anger issues, substance use etc. Individuals who benefit most from DBT will relate to the Biosocial Theory.

Stages of Treatment

Pre-treatment Stage/Commitment

The purpose of pre-treatment is for you and your therapist to learn about each other, understand DBT concepts and what you are committing to, and determine if the program is a good fit for you. Pretreatment and commitment stage lasts about 3 sessions.

Agreements made before starting stage 1 and becoming a client.

Usually around session 3 or 4 agreements can be discussed and committed to. You cannot start DBT UNTIL THESE AGREEMENTS ARE MADE with your therapist! Thus, both make the following agreements:

Therapist agrees to:

Make every effort to conduct effective therapy
Obey standard ethical and professional guidelines
Be available to the client for weekly sessions, phone consultations, and provide needed therapy back-up
Respect the integrity and the rights of the client
Maintain confidentiality
Obtain consultation when needed

Client agrees to:

Stay in therapy for the contracted time period (usually 6 months or 1 year)
Attend scheduled sessions
Agree that building a life worth living is the primary goal
Work to eliminate life-threatening behaviors
Work on problems that arise that interfere with the progress of therapy
Participate in skills training and follow group guidelines
Abide by any research conditions of therapy
Pay agreed-upon fees

Stage 1

Once a commitment is obtained to take part in treatment, you will begin Stage 1 of DBT. Stage 1 treatment is strongly focused on ineffective BEHAVIOR. During Stage 1, you will target behaviors and or emotions that get in the way building your life worth living and track these weekly. The behaviors we look at are prioritize are discussed under “Treatment Hierarchy.”

Stage 2

This stage targets emotional experiencing, trauma and or PTSD. This is where emotions may be addressed, such as those derived from traumatic experiences, mood disorders, or other issues. This includes helping you live your daily life to the fullest without being controlled by overwhelming emotions. One way to think about the difference between Stage 1 and Stage 2, is that in Stage 1 we work to block avoidant coping behaviors, and in Stage 2 (and beyond), we actively work to solve problems directly.

Stage 3

This stage we increase self-respect (being able to say no to unwanted requests and sticking to this no, learning assertiveness skills, healthy communication etc.), to set and work toward certain individual goals you have (such as obtaining and keeping a job) and to teach you how to solve everyday life issues (budget money, pay bills, etc.)

Stage 4

This stage you work to increase your capacity for joy, involving the ongoing pursuit of a life worth living. Sometimes clients come into treatment in different stages. The primary objective is to get you on a path toward building a life worth living, the pursuit of which is a life-long process.

Treatment Hierarchy When beginning treatment in Stage 1, DBT follows a clear hierarchy of target behaviors that are created collaboratively:
1	Life-threatening behaviors (eg, suicidality, self-injury). Put bluntly, we cannot do therapy with someone who is dead. It is of the utmost importance we make sure we have skills to keep you alive.
2	Therapy-interfering behaviors (eg, problems with therapist, not doing homework, missing sessions, etc). Simple put: We cannot do DBT if we are not doing DBT! Once we attend to anything life-threatening, we then have to make sure nothing else is getting in the way of therapy. These types of behaviors are looked at nonjudgmentally and targeted with the hope to learn skills needed to address those issues (often times those same skills will be useful with similar problems outside of therapy as well).
3	Life-interfering behaviors (eg, depression, anger issues, addiction, eating issues, etc). Once the above two targets are attended to, we then look at all the other barriers to a life worth living. There might be many behaviors that are getting in the way so we start with the most problematic ones and over time work our way through each behavior. Often times the skills we learn to address one issue tend to help address other issues as well (eg. if I figure out skills to curb impulsive drinking, those skills will also help with impulsive spending.).
4	Skills deficits (eg, distraction skills, mindfulness skills, changing emotion skills, etc.). While we address all the above targets, we might find some areas of life that may need a skill or two in the moment to help us out (eg. while hearing about your life, we might discover you struggle to assert yourself a need a skill for that).

Diary Card

These targets are then tracked on what’s usually called a “DBT diary card.” All versions of a diary card tend to track emotions, problem behaviors, and skills being practiced.
This dairy card is filled out every week and begins every DBT individual session.

Roadmap to targeting Behaviors in DBT
While you are in treatment the process of addressing targets on the diary card in sessions is known as a Behavior Chain Analysis followed by a Solutions Analysis. This is the “meat” of DBT treatment.

Determine Life Worth Living Goal(s)
Translate LWLG into specifically defined problems (increase or decrease).
Translate the problems into the primary target hierarchy.
Get commitment to target the problems.
Pick several targets for monitoring on the diary card.
Do thorough behavioral assessments of the target behaviors.
Conduct Behavior chains looking for controlling variables.
Begin Solutions.
After several chains, generate a hypothesis about a controlling variable and test it.
Repeat for possible controlling variables.
Begin treatment based on the assessments / chains that address the controlling variables. (Usually they will involve contingency management, cognitive modifications, exposure and / or behavioral skills.)
Update the diary card to reflect refinement in goals and problem behaviors.
Repeat steps again for all target behaviors until client achieves LWLGs.

What do individual DBT Sessions look like? The Structuring of a DBT Sessions

A common question is “So…. What do sessions actually look like?” Many sessions in DBT will look very similar. The session itself will last 55 mins and will typically have the following structure:

Welcome to session
Diary card review
The diary card sets the topics/agenda for sessions
Review homework from the week
Attend to agenda/”road map”
Assign homework
Wind down
Address any scheduling/billing issues (if needed)