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. 

Symptoms of Borderline Personality Disorder: DBT versus DSM-5

Marsha Linehan's early work with individuals with chronic suicidal thoughts and behaviors became the solid foundation for applications of dialectical behavior therapy for individuals with borderline personality disorder.


Dr. Linehan's biosocial model with symptoms of Borderline Personality Disorder


Dr. Linehan viewed the symptoms of borderline personality disorder as a biosocial model of pervasive dysregulation.  Her biosocial approach was atypical, as most treatments for personality disorders were grounded in psychoanalytic and psychodynamic theoretical orientations.  Biosocial combines the biological/physiological and social perspectives to describe the extreme dysregulation and an invalidating environment.  To clarify, dysregulation (prefix "dys-" not + regulation); for example, emotional dysregulation refers to intense feelings and reactions based on the feelings that can fluctuate quickly and can come without a behavioral cue or warning.

1. Emotional Dysregulation (emotional ups and downs)
2. Behavioral Dysregulation (impulsivity)
3. Interpersonal Dysregulation (managing relationships)
4. Cognitive Dysregulation (focusing attention)
5. Self Dysregulation (knowing who you are, owning your identity, what you stand for)

The Diagnostic and Statistical Manual of Mental Disorders 5^th Edition (DSM-5)


DSM-5 is a manual that sets symptoms and threshold levels for the diagnosis of a psychiatric disorder or illness (American Psychiatric Association, 2013).  For the diagnosis of borderline personality disorder, five of the nine following symptoms must be present. 


DSM-5 categorical model of symptoms of Borderline Personality Disorder

1. Frantic effort to avoid real or imagined abandonment
2. Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance with markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging: spending (money), risky sex, substance abuse, reckless driving (speeding), binge eating
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilation behavior
6. Affective instability due to a marked reactivity of mood (“mood swings,” intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely for more than a few days
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

The sticky part of the DSM-5 categories for borderline personality disorder is the presentation.  Two individuals with marked, out-of-control behavior may only share a single criterion, but receive the same diagnosis.  Some clinicians and researchers pushed for a dimensional approach to personality disorders, not a categorical approach.