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 at Ebright and can move forward into the next stage.

Click the buttons below to learn more about DBT and Pre-Treatment

1 Page Summary of Pre-treatment

2 Page Article called "DBT in a Nutshell"

DBT for Adults One Sheet

DBT for Adolescents One Sheet

*Please note that anyone in pre-treatment is not considered a client just yet. You are encouraged, therefore, to remain in whatever current treatment you are in until pre-treatment is complete.  At that time, we ask that you terminate any conflicting treatments 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. To this end, DBT provides a robust set of healthy coping skills to replace destructive behaviors and tame out-of-control emotions. The ultimate goal in DBT is to use these skills to help identify and run towards life worth living.
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​*For more information, click HERE to go to our DBT page.

Functions and Modes of DBT

DBT 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 6 months (up to a year).
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STANDARD DBT MODE	FUNCTION
Skills Training Group	Enhance Client Capabilities - To teach clients Emotion Regulation, Interpersonal Effectiveness, Distress Tolerance, and Mindfulness skills
Individual Therapy	Enhance Client Motivation - To motivate clients to use skills, stay with the treatment, and structure their environment to work for them
Phone Coaching	Assure Skills Generalization - To assist clients in using skills in their everyday life ​
Case Management	Structure the Environment - To ensure the client's world supports progress in treatment
Consultation Team	Strengthen clinician commitment - For clinicians to support each other, increase skillfulness, and maintain motivation to provide high quality therapy

*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!*

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 might think a loved one is perfect exactly as they are.  Yet that person might think, “I am so messed up.”  Dialectical reasoning seeks to integrate both views.  When thinking dialectically, you might synthesize your thoughts with your loved one’s by stating, “Humans are perfectly lovable AND in need of serious work at the same time.”  A dialectical worldview seeks to openly integrate differing ideas in search of a greater truth and a more effective way of seeing things. Dialectical strategies are used to protect against holding extreme points of view, rigid thoughts and emotions, and prevent the therapist and client from becoming stuck in polarizing opinions and mired in arguments. The viewpoint of acceptance and change is a core dialectic in DBT. Click HERE to download more on dialectics. 

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. The theory that helps explain this emotional development, and consequent emotional vulnerability, is called the Biosocial Theory of Emotional Development.

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 emotional baseline. On the environmental side, this theory states that individuals with emotion regulation issues usually live in a pervasively invalidating environment where scenarios such as 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. This dysregulation can have a variety of serious consequences that include behavioral problems, out of control emotions, relationships issues, identity confusion, etc. Individuals who benefit most from DBT will relate to the Biosocial Theory. 
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Click HERE for a short video that helps explain the Biosocial Theory of Emotion.
Click HERE and HERE for handouts on the Biosocial Theory of Emotion.

Stages of Treatment

Pre-treatment Stage
There are four stages of treatment in DBT. Before these four stages, however, a pre-treatment stage is required. (This web page covers much of what takes place during the pre-treatment stage).  The purpose of pre-treatment is for you and your therapist to learn about each other, better understand DBT, and determine if the program is a good fit.
 
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 specific behaviors that get in the way building the life you want. The behaviors we look at are prioritized in a particular way which will be discussed below under the section "Treatment Hierarchy."
 
Stage 2
Stage 2 of treatment targets emotional experiencing. 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
The goals of stage 3 are to increase self-respect (being able to say no to unwanted requests and sticking to this no, learning how to be assertive, 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
In Stage 4, you work to increase your capacity for joy, involving the ongoing pursuit of a life worth living.
 
Not all stages will occur while in treatment. 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.  
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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." The pictures below are an example of what a diary card looks like. All versions of a diary card tend to track emotions, problem behaviors, and skills being practiced. This diary card is filled out every week and begins every DBT individual session.

​Click HERE to download the diary card shown below.
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 Roadmap to Targeting Behaviors in DBT

At this point in pre-treatment you probably now have a couple behaviors to target that are getting the way of your life worth living. These behaviors will then be thoroughly assessed and then several solutions will be generated to help tackle that behavior. This process, know as a Behavior Chain Analysis followed by a Solutions Analysis, is the "meat" of this treatment. To tie this treatment together, the chart below is what we will call the Roadmap to Behavioral Therapy in DBT. Your therapist can help orient you to it.
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 DBT Session Structure

A common question we get after going through several core principles of DBT during pre-treatment is "So what do session actually look like?" This is a very fair question. Many sessions in DBT will look very similar by design. The session itself will last about 1 hour and will typically have the following structure:
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Strategies

Each of the elements described above contain a series of strategies and skills.  A program can have all of the structures above in place, and still not be adherent to DBT.  These strategies are specified in Linehan (1993), and are too numerous to name.  Two examples of strategies, however, that are relevant to all DBT clients are:
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The 24 Hour Rule
​Clients cannot receive coaching for 24 hours after engaging in life-threatening behavior.

The only exception is if there is a previously scheduled individual or group session (ie. If you self-injure before session, you are still expected to go to session).
 
Though at first this may seem harsh, there is good reason for this rule.  If a client injures themselves or attempts suicide, there will be no extra client-therapist contact for 24 hours so as not to unwittingly reinforce the behavior. "Are you going to get into the ethics of DBT?" one social worker asks of Marsha Linehan hotly. "It's always ethical to do the most effective treatment," Linehan replies without flinching. "And for the moment, DBT has the most data as an effective treatment for this disorder."
Source: Katy Butler, “Revolution on the Horizon” Psychotherapy Networker May/June 2001.

The 4-Miss Rule
The only way to be out of DBT is to miss either four group sessions or four individual sessions in a row. **

​Once a client and therapist commit to treatment, there is little they can do to get out of it. We take commitments very seriously which is why we have a pre-treatment stage that occurs before you can commit to the treatment. The ONLY way, however, that a client can breach the commitment to DBT treatment is by a client missing 4 consecutive treatment modes (Individual OR Skills Training). To be clear, if a client misses 2 individual appointments and 2 Skills groups in a row, THIS DOES NOT breach the commitment; only 4 individual or 4 Skills groups in a row. This also means that even if a client says they are leaving after treatment has started, they will still be in treatment until 4 consecutive misses. This commitment helps the client and therapist navigate any issues that come up in treatment and have the security to know neither person can “give up” on each other for a reasonable amount of time.

**For teens, we have one adaptation to this rule. If a teen or parent/guardian misses 4 consecutive multi-family group sessions in a row, they will be asked to step away from group for the remainder of the module. This issue will then become a top priority in individual to help get back on track, address any barriers to treatment, and then be invited to go back to group at the beginning of the next skills module (which could be anywhere from 2-9 weeks). In a way, it brings us back to the "pre-treatment" stage to see if DBT is a good fit at this time. If a teen misses 4 individual sessions in a row, however, they would be out of treatment.

Agreements

When committing to DBT, both you and your therapist must agree to work with each other. You cannot start DBT UNTIL THESE AGREEMENTS ARE MADE TO EACHOTHER! Thus, both make the following agreements:
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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

​*For the parent/caregiver when involved in the DBT Adolescent program. The parent/caregiver agrees to:

• Attend and actively participate in multi-family skills group
• Participate in family sessions on an as-needed basis
• To facilitate session attendance of the teen, either by driving them to scheduled appointments or offering technology needed for telehealth appointments
• To observe the rules of confidentiality by not asking the primary therapist to provide specific information gleaned from individual sessions

DBT Skills Training Book

​If you decide to jump in and do DBT, think about getting the DBT skills handouts and worksheets book that is used in our skills group! You can purchase the book HERE or anywhere the book is sold. We can also provide you a .pdf version of the book free of charge should you choose not to purchase a book for yourself.

For more DBT resources, click HERE.

One of the most common complaints about DBT is that it's just so darn complicated to understand. On the one hand, that's probably true. On the other hand, it might just save your life. We strongly think it's worth it and encourage you to continue asking questions. Our entire team will be there with you every step of the way. 
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"...I hope that you will develop the skills you need and that you will also help others have the skills they need to experience life as worth living - if I can do it, you can do it, too." - Marsha Linehan, Building a Life Worth Living. 

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If ever you have any questions, feel free to reach out !