Dialectical behavior therapy (DBT), developed by Marsha Linehan, is one of the few evidence-based treatments for borderline personality disorder. However, since its origination 20 years ago, DBT has been implemented with populations in various settings with positive results. DBT is intensive and involves many techniques, including cognitive behavioral skills training, mindfulness meditation and behavioral interventions.
Counselors who wish to introduce DBT in their own practice often struggle with where to begin regarding implementation and training. The implementation of full, “standard” DBT can be costly and time intensive. However, it also has the most evidence base and increases the likelihood and strength of positive outcomes.
On the other hand, counselors may be interested in implementing only some modes of DBT (for example, the skills training group) or making adaptations to the current skills curriculum and handouts. This has been termed as “DBT-informed” treatment, and it can be beneficial as well, depending on the setting and population with which the counselor is working. This article discusses basic considerations for counselors who are thinking about implementing either standard or DBT-informed practices.
The four modes of DBT
There are several treatment modes in DBT to consider, and each covers one or more specific functions of the standard model. Although Linehan states that other ancillary modes may be included in DBT treatment (for example, pharmacotherapy and case management), these are the four standard modes.
1) Skills training: The DBT skills group is one of the most frequently implemented modes of DBT because it often requires the least amount of resources and features tangible handouts and instructions for group leaders. A strong research base also exists for the effectiveness of exclusively using skills training to address a variety of treatment goals and mental health symptoms. The skills training experience is structured and psychoeducational. During this mode of DBT, clients focus solely on obtaining new skills, enhancing their capabilities and generalizing skills to other aspects of their lives. There are four skills modules: mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness.
Skills training can be completed during individual sessions. However, as Linehan notes in the DBT Skills Training Manual, it can be difficult for the counselor to be directive and structure time for skills training within the therapy session. Therefore, group sessions tend to be the preferred method. In the group setting, sessions are traditionally offered weekly for two to two and a half hours. The first hour is devoted to review of homework from the previous session, whereas the second hour focuses on the acquisition of new skills.
The modules typically span five to seven weeks. However, the time frame and format can be altered based on the needs of the site and the clients. For example, a shorter time frame can be used, or group sessions can be offered more than once per week. Linehan also notes that although groups can be open or closed, open groups seem to be the most beneficial for skills training purposes. In my practice, I (Michelle) closed the group after the commencement of a new module and then opened the group to new members when the next module began. This allowed for group members to work and learn together during each module.
2) Phone coaching: Intersession phone coaching is often considered the most demanding mode of standard DBT. This is understandable because counselors expend significant energy being present for their clients during regularly scheduled sessions and may want to focus solely on personal time and their families outside of work. Counselors also may have concerns about clients — especially clients with a history of acute needs — abusing the ability to call them anytime after hours.
However, Linehan has emphasized the importance of intersession coaching to help clients generalize the skills they have learned in training to everyday life. The duration of a skills coaching call is often short, typically between 10 and 20 minutes. Though the frequency of calls will vary by client, Linehan and her colleagues note that the frequency should decrease with the amount of time spent in the program.
Several guidelines are outlined regarding the use of phone calls between sessions for skills coaching. This structure reinforces the client for using skills instead of engaging in life-threatening behaviors (for example, nonsuicidal self-injury) or seeking unnecessary hospitalizations. Linehan states that if DBT is implemented in an inpatient or residential setting, skills coaching interactions with nurses, mental health technicians and other staff members can take the place of traditional phone coaching.
3) Therapist consultation team: Linehan and her colleagues emphasize the importance of support for therapists. The consultation team is composed of therapists providing DBT who meet weekly for case consultation and support and to maintain the fidelity of the treatment. Counselors considering implementing DBT at their current sites can start a new consultation team or approach another DBT consultation team in the community.
Finding a DBT team to join can be difficult, especially in rural areas. However, Linehan notes that team members may use online tools to coordinate weekly meetings if necessary. For those starting a new team on-site, Linehan and her colleagues recommend assigning a team leader. A competent leader helps keep the team focused and invigorated and provides guidance throughout the treatment process. This person will also be helpful in determining who will fill various roles on the team based on interests, experience and strengths. The consultation team addresses the function of enhancing therapists’ skills and motivation in standard DBT.
4) Individual treatment: Individual treatment in standard DBT is conducted weekly and mainly covers the function of improving the client’s motivation. The skills trainer is usually different from the individual counselor. Individual therapy also offers the client a dedicated place in which to process nonsuicidal self-injury and suicidal thoughts because the group sessions are more psychoeducational in nature. Per Linehan’s original text on treating borderline personality disorder, in standard DBT, the individual therapist adopts dialectical and validation treatment strategies, in addition to a behavioral approach to quality-of-life, life-threatening and therapy-interfering behaviors.
Overall factors to consider
In addition to the modes of DBT, there are several other factors for counselors to consider before implementation. An initial needs assessment will help identify where DBT can be implemented successfully into current systems. This includes assessment of the target population and available resources (human and otherwise) for treatment. Major factors to consider are:
Population: Although DBT was initially developed for adults diagnosed with borderline personality disorder, research has shown support for its use with adults and adolescents struggling with eating disorders, mood disorders, anxiety disorders and substance use disorders. Narrowing the focus on the target population will ground program creation and implementation. Admission criteria are also an important consideration, along with any possible client exclusions or exceptions. Client admission may not necessarily be narrow or broad. However, it should be consistent. Counselors should also consider how the chosen population fits the gaps in current services in the community (e.g., availability of chemical dependency treatment facilities, eating disorder clinics and existing community support groups). Furthermore, any potential adaptations to the skills worksheets and handouts should be considered. Many publications by Linehan and other professionals are available that address adaptations to fit the needs of specific diagnoses and age groups.
Training: A multitude of training options are available for counselors interested in DBT. Behavioral Tech (behavioraltech.org), the organization Linehan founded to train others and facilitate research in DBT, offers what many consider to be the gold standard in DBT training. The initial 10-day intensive course is open only to treatment teams, but it allows for counselors to use the skills in their practices as they learn them. Counselors who wish to join an existing DBT team may attend an abridged version of this course that runs for five days. In addition to online resources and additional training resources for individuals, Behavioral Tech offers an advanced intensive training for providers who have been practicing DBT for a year or more. Recently, Linehan and her colleagues began offering an official certification in DBT. Certification requires a minimum of 40 training hours related to DBT, successful completion of a certification exam and submission of a client case conceptualization with three taped sessions (for more information, visit dbt-lbc.org).
Other organizations offer numerous local and regional DBT trainings for individuals throughout the country. Multiple online and text resources are available as well. Finances and the intended level of DBT implementation are both important considerations in choosing the best training venue. Regardless of the level or type of training chosen, a cohesive and sound foundation in DBT will be necessary for all counselors and other staff involved before moving forward.
Setting and facility: The setting will have a significant impact on decisions made regarding the adaptation and implementation of DBT. Those working in inpatient or intensive outpatient settings may need to make significant adaptations to provide DBT in shorter time frames. Facilities that only treat certain populations may have very specific needs regarding adaptations of skills and modes of treatment.
Space and other on-site resources are also important considerations. Needs may vary depending on the number of clients expected and, if applicable, the number and frequency of groups being implemented. Optimally, there will be enough space for all involved counselors and other staff to work comfortably. It is also important to consider whether certain on-site resources, such as a lending library, space for other professionals and paraprofessionals, and a personal respite space for clinicians, will be provided. Analyzing the costs and benefits associated with each of these aspects is important.
Finances and billing: Full implementation of standard DBT can be costly, especially when considering training, resources and time. However, Linehan and her colleagues have found that DBT is often more cost-effective to the community than “treatment as usual” with chronically suicidal individuals because outcomes lead to a reduction of emergency hospitalizations. However, reimbursement for all modes of DBT may be difficult to obtain, especially for those in private practice. DBT researchers have suggested that community mental health centers may be the best fit for implementing full DBT because these centers often bill Medicaid and Medicare, which may be more flexible with regard to reimbursement for treatment and session limits. Conducting a cost-benefit analysis is important when deciding which modes of DBT to implement and for how long.
Assessment and program evaluation: Linehan and her colleagues have consistently emphasized that one of the most important aspects of any DBT program is assessment. Regardless of the level of DBT implementation or adaptation, it is important for all stakeholders to possess knowledge of client outcomes. Early in the implementation process, the symptoms or behaviors the program will address should be clearly identified, and the methods of assessment via psychometric tests and other means should be determined. Linehan provides a list of several options for assessment instruments in the DBT Skills Training Manual.
Administrative and structural support: DBT researchers have found that one of the major limitations to implementation of DBT is the investment of administrators. Administrators may not understand the comprehensive nature of the treatment or be aware of the evidence base for implementing all modes of DBT. Counselors will need to engage administrators with this information initially and emphasize the treatment’s benefits based on current published research.
Agency structure and support for counselors engaged in DBT is also an important consideration. Counselors need to determine if their entire caseload will be DBT focused or if they will work with other type of cases. With standard DBT, a full-time caseload may vary but will generally include 14-18 clients. This allows time for individual sessions, skills groups, phone consultation (15-30 minutes per client per week) and paperwork.
Length and adaptation of treatment: Standard DBT requires both time and commitment from the client and counselor. Because most clients with borderline personality disorder have historically received long-term mental health services, successful treatment can be expected to be intensive. Pretreatment commitment to therapy is crucial and is often a collaborative agreement between the counselor and client. Typically, this initial commitment is six months to one year (optimally, clients will complete two six-month cycles of skills training). This timeline can be extended, but the parameters of this extension — for example, duration and expectations — should be clear to help prevent a dependency on treatment or malingering. Uniform protocol for what constitutes successful graduation and how to celebrate that occasion is also helpful.
Benefits and limitations of DBT implementation
The following section outlines the benefits and limitations to consider when deciding whether to implement standard DBT or DBT-informed treatment at your agency or practice.
Benefits of standard DBT
- Standard DBT is a highly structured and evidence-based intervention. This can actually make implementation easier because counselors, administrators, other service providers and clients will have clear expectations of what will be included and the protocol that will be followed.
- The evidence-based nature of the approach can make DBT appealing to funders when trying to secure grant money for programs. Note that this is more likely when funders are aware of what DBT entails and the associated benefits (for example, reduced overall costs of treatment, reduced hospitalizations and a decrease in suicide attempts and nonsuicidal self-injury).
- Each mode of DBT addresses the major functions of DBT treatment: improving motivation, enhancing capabilities, ensuring generalization, enhancing environment and maintaining the skills and motivation of treatment providers.
- The overwhelming amount of research on the effectiveness of DBT is based on standard DBT.
Limitations of standard DBT
- The cost of the extensive training and the necessity of a team for implementation can be prohibitive for some agencies and practitioners.
- Practitioners must be fully committed to the DBT approach for implementation to be effective. Adherence to the model includes accepting the basic principles that guide treatment, which include 1) creating a life worth living for clients, 2) believing that clients can improve by learning how to get needs met through more functional and adaptive means and 3) realizing that DBT has an inherent amount of risk because of the generally volatile emotional states and suicidal thoughts and behaviors being experienced by the client at the onset of treatment.
- Implementing all modes of DBT can be costly, and counselors may find billing for standard DBT to be difficult with insurance companies. It can also require a significant time commitment from counselors, including making themselves available after hours for the necessary phone consultations with clients.
Benefits of DBT-informed treatment
- The skills taught in the four DBT modules can be of benefit to clients with a wide range of presenting problems, including anxiety, adjustment disorders, stress and decision-making issues. For example, interpersonal effectiveness skills can be used with social skills groups because this module addresses ways to maintain relationships, make requests and say no, and maintain self-respect in relationships.
- Research supports the effectiveness of partial implementation of DBT, with most of the research showing support for implementation of the skills-group-only approach or the skills group combined with one or two other modes of treatment.
- Implementing certain aspects or adaptations of DBT may be more cost effective for clients and counselors.
- An adaptation of DBT with partial implementation of certain modes can create flexibility for clients, counselors and administrators.
Limitations of DBT-informed treatment
- Although research supports the effectiveness of partial implementation of DBT, this research remains limited. In addition, more research is needed on the specific aspects of DBT that are most curative with regard to treatment targets.
- Those who are adapting DBT will have increased difficulty structuring treatment and ensuring that all functions of the treatment are addressed without the implementation of all four standard modes.
- Fewer resources are available for those who wish to adapt the skills and handouts for specific diagnoses, and counselors may need to create their own resources to fit the needs of their clients.
In summary, full implementation and training are necessary to practice standard DBT to fidelity. However, parts of the model can be used effectively with many clients in a variety of settings and to address many presenting issues and diagnoses. If implementing DBT-informed treatment, counselors and administrators need to communicate this clearly to clients, including providing information on the strengths and limitations of the treatment approach.
Finally, throughout the material published by Linehan and her colleagues, they emphasize the importance of assessment. Regardless of whether the counselor implements standard DBT or DBT-informed treatment, some form of assessment should be used to ensure proper evaluation of the program.
For further reading on implementing DBT, the following texts may be helpful:
- Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings edited by Linda A. Dimeff and Kelly Koerner (2007). Specifically, Chapter 2 addresses the importance of maintaining the fidelity of the treatment while adapting DBT.
- Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan (1993)
- DBT Skills Training Manual and DBT Skills Training Handouts and Worksheets by Marsha M. Linehan (2014). This long-awaited second edition to the original training manual includes handouts for each module and guidelines for implementing standard DBT.
- Dialectical Behavior Therapy With Suicidal Adolescents by Alec L. Miller, Jill H. Rathus and Marsha M. Linehan (2007)
- DBT Skills Manual for Adolescents by Jill H. Rathus and Alec L. Miller (2014)
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
K. Michelle Hunnicutt Hollenbaugh, a licensed professional counselor supervisor, is an assistant professor in the Department of Counseling and Educational Psychology at Texas A&M University-Corpus Christi. Contact her at Michelle.Hollenbaugh@tamucc.edu.
Jacob M. Klein, a licensed professional clinical counselor in Ohio, is currently working in private practice with a focus on gender therapy and is a Ph.D. candidate at Ohio State University. Contact him at firstname.lastname@example.org.
Michael Lewis is a licensed professional clinical counselor and supervisor in Ohio. He is the director of counseling services at Ohio Dominican University in Columbus and is a Ph.D. candidate at Ohio State University with a focus in online gaming addiction. Contact him at email@example.com.
Letters to the editor: firstname.lastname@example.org