Top Five Questions to Ask Therapists Before Starting DBT

1.  When does your consultation group meet?

Treatment adherent dialectical behavior therapy groups have specific criteria that a clinic or program must follow.  DBT clinics must have a consultation group for their therapists.  These meetings are designed to support the treatment team.


2.  How are you using coaching?


The integration of technology in counseling has added a new dimension for supporting skill generalization and connection with the treatment team.  Even though confidentiality can be compromised, clients and therapists who use text messages, phone coaching, and emails can guide the client to practice mindfulness skills to regulate, check the facts, reframe the situation, and see the dialectic. 


3.  How are you using assessment to track change over time?


Diary Cards are essential for tracking the change over time for emotions, target behaviors, and DBT skills.  For more information about customized diary cards for clients with specific diagnoses and target behaviors, please contact Sarah C. Turner (me) at scturner@uh.edu. 


I have developed the DBT Diary Card--Texas Edition that includes the emotions, areas for target behaviors, and updated skills from the DBT(R) Skills Training Manual, Second Edition (Marsha Linehan, 2014).


Be sure to ask about developing the life-worth-living-goal, diary cards, chain analyses for working through the problem and target behaviors, and the transition the conversation into solution analyses.


4.  What types of training in dialectical behavior therapy and professional development did you and the staff receive to become DBT therapists?


Different training programs have different approaches for training mental health professions, clinicians, researchers, and staff.  Some are more intensive than others.


5.  Do all clients who come for treatment for a broad range of symptoms and diagnoses receive DBT?


Treatment choice is complicated.  Individuals who are seeking DBT usually carry comorbidities, such as depression and borderline personality disorder.  When looking at evidence-based practice, dialectical behavior therapy is not as effective for certain disorders as other evidence-based treatments. 

Marsha Linehan's Long Awaited 2nd Edition DBT Skills Training Manual Comes to Amazon on October 20, 2014!

Marsha Linehan's groundbreaking Skills Training Manual is now in

the Second Edition and will be available on October 20, 2014!

Guilford Press and Amazon.com have pre-order options for Marsha Linehan's Second Edition of the Skills Training Manual.  




Click here to visit Marsha Linehan's page on Guilford Press.  You'll find more details about her other publications.  In a quick view of Guilford's website, you'll find many options to meet your interests and learning about evidence-based practice. 


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"[Guilford's] website has been designed to make it simple to find exactly what you're looking for. You can view complete information on all in-print titles (and share it with your social networking contacts), including tables of contents, reviews, full-chapter excerpts for selected titles, and samples of reproducible handouts and forms. The site also includes electronic mailing lists for early notice on releases in specific fields, desk and exam copy information for instructors, information on publishing with Guilford, and job listings.

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Click here to visit Marsha Linehan's page on Amazon.com. 

New to This Edition of the DBT Skills Training Manual (Amazon.com)

*Handouts and worksheets (available online and in the companion volume) have been completely revised and more skills and examples added, yielding over 225 in all.

*Each module has been expanded with additional skills.

*Multiple alternative worksheets to tailor treatment to each client.

*More extensive teaching notes, with numerous clinical examples.

*Curricula for running skills training groups of different durations and with specific populations (such as adolescents and clients with substance use problems).

Preliminary Reviews

"DBT is a proven evidence-based treatment that combines the best of our science with the knowledge and compassion of Marsha Linehan--an exceptional researcher and clinician whose innovative work has advanced the field and shifted many individuals from lives of suffering to lives of hope. These outstanding second editions offer guidance on how to implement DBT skills training, while providing the tools needed to deliver this state-of-the-art treatment. They will stand as the authoritative guides for teaching DBT skills, partnering with clients to build lives worth living, and helping us to address our national and international priorities of saving millions of lives lost to suicide worldwide. These 'must-have' books belong on the shelves of every clinician and will be valuable course texts." 

—Joan Rosenbaum Asarnow, PhD, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles

“DBT skills are useful not only for individuals who suffer from persistent emotion regulation difficulties, but also for individuals in extreme circumstances and people who have ordinary problems. This updated manual provides the ‘flexibility within fidelity’ in teaching these skills that practitioners and treatment adopters need. New, improved, expanded, and much clearer skills—they’re all here! Skills trainers and their clients will benefit from Linehan and her colleagues’ decades of systematic research and time spent developing, testing, and refining these skills, empowering practitioners to confidently offer multiple ways of understanding and practicing new behavior. Experienced skills trainers will notice the evolved richness and depth, while the explanations and teaching points will provide new trainers and students with an excellent foundation for skills training with both adults and adolescents. Providing a solid evidence-based foundation for core clinical training curricula, this manual and the accompanying volume of handouts and worksheets will be essential across the mental health disciplines.”

—André Ivanoff, PhD, Columbia University School of Social Work

 

Monitoring Change over time in DBT: DBT Diary Cards

In DBT, behavior patterns are monitored by self-report in diary cards.  These diary cards look like a table with a list of behaviors on the left and seven boxes that have ratings of 0 to 5 of the intensity of the urge for each day of the week; asterisks are placed adjacent to the rating if the adolescent acted on the urge. 

For example, an adolescent, whose target is cutting, experiences the urge to cut as a 4, which would be noted as 4* if she did decide to cut; see the left corner, so look at Monday and the urge column. 

Diary cards are filled out by the adolescent each day, often around bedtime.  The backside of the diary card tracks skill use with a similar chart system, as the adolescent places a check mark beside the skills she used each day.  This side is also important for the skills trainers to see that the adolescent is practicing the skills presented in the DBT skills group. 

There is a section of the diary card that asks for the number of times the adolescent filled out the card, as it can be difficult to remember or desire to find and fill out the diary card consistently.  See the upper right corner.

Sammy Banawan developed the DBT Diary Card app that is available in the App Store for $4.99.  The app keeps track of entries that can be downloaded and printed by the adolescent for use in individual therapy.  

Factors to Consider in Finding a DBT Treatment Center

A parent may ask, “In doing research online, I’ve seen and heard about cognitive behavioral therapy. What is the difference?”  Dialectical behavior therapy began as a cognitive behavioral therapy that soon added dialectics and validation.  CBT principles are used to target suicidal and other problem behaviors.  However, the unique foci of DBT are on dialectics, validation, and the dialectic of acceptance-oriented and change-oriented skills and strategies (Manning & TIC, 2013). 

In looking at selecting a treatment center for the individual, be sure to ask the center if their clinicians are members of a DBT consultation team who have attended the Core Clinical Training© in DBT, use diary cards in sessions to monitor behavioral changes over time, and follow the processes in Linehan’s treatment manuals (1993a; 1993b).  

There are inpatient and outpatient options in Houston, Texas.  The Menninger Clinic uses a combination of clinical approaches, including mentalization-based treatment (MBT) and DBT.  The Dialectical Behavior Therapy Center offers outpatient treatment with an intensive outpatient program (IOP) with skills groups and individual therapy with a DBT therapist, skills groups that meet each week, individual therapy, and medication management with board certified psychiatrists.  There are treatment sites in other locations across the U.S. and Canada.  There are often waiting lists to join a DBT program. 

In DBT, individual therapists focus on targeting specific behaviors that the client has agreed to work on changing, as arranged in the following hierarchy: life-threatening behaviors, therapy-interfering behaviors, and quality of life behaviors.  “You only get what you target. . . and what changes is what you work on” (Manning & TIC, 2013).  In adolescents with borderline personality disorder, common behavioral targets include: cutting, intentional overdosing, suicidal ideation, driving over the speed limit, purging, and restricting.  Consider the individual's concerns and behaviors when looking for the treatment plan that is a good fit for her.

The relationship between the individual and her therapist is essential in pushing for change while simultaneously accepting the adolescent in the moment and helping her radically accept herself; acceptance is not approval or agreement with the behavior or thought.  “Those who practice DBT are compassionate and dedicated to understanding the experience of BPD but at the same time believe, unwaveringly, that the most compassionate thing we can do is help people with BPD to change” (Manning, 2011). 

Dialectical Behavior Therapy versus Mentalization-Based Treatment for Borderline Personality Disorder

Two evidence-based treatment options for adolescents with borderline personality disorder are dialectical behavior therapy (DBT) and mentalization-based treatment (MBT).  

Dialectical behavior therapy emerged from a cognitive behavioral framework and added dialectics and validation to catalyze behavior change and acceptance.  The overall goal of DBT is a life worth living (Linehan, 1993; Manning & TIC, 2013). 

Mentalization emerged from investigating theory of mind and is defined as the “process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes” (Bateman & Fonagy, 2010, p. 11).  “Mentalization-based treatment is a model of psychodynamic therapy rooted in attachment theory that aims to enhance the individual’s capacity to represent thoughts, feelings, wishes, beliefs and desires in themselves and in others in the context of attachment relationships” (University College London Psychoanalysis Centre, 2013). 

The primary difference between the two approaches is that DBT is rooted in behaviorism, so there are specific targets and goal behaviors, and is more concrete than mentalization’s focus on thoughts and their frameworks, called schemata; essentially, the targets and goals are based on different perspectives and objectives.  Both have evidentiary support from randomized controlled trials, though DBT has a more substantial base of evidence with nine randomized controlled trials.

To learn more about mentalization-based treatment, visit the University College London's Psychoanalysis Centre at http://www.ucl.ac.uk/psychoanalysis/research/mbt.htm.