frustrating. We review motivational strategies in greater depth in Chapter 19.
Teaching the patient new coping mechanisms
A comprehensive treatment teaches the patient new ways of coping with life’s challenges or enhances a person’s existing capabilities. In DBT, therapists hold the assumption that people who are struggling aren’t doing so out of choice but rather that they lack, or need to improve, several important life skills, including the following:
The ability to regulate emotions
The ability to pay careful and accurate attention to the experience of the present moment
The ability to tolerate difficult moments
The ability to effectively negotiate relationships
Incorporating new skills into the patient’s daily life
Comprehensive treatment generalizes the new skills and new ways of coping to a patient’s daily life. If the skills learned in therapy sessions don’t apply or transfer to patients’ daily lives, then it would be difficult to say that therapy was successful. This function is accomplished in two ways:
In the skills training group, the therapist provides and then reviews the weekly homework assignments given in the skills group.
The patient is allowed to contact the therapist between sessions so that they can get help directly from the therapist in situations where the patient doesn’t know what to do or how to apply the skills. (Find out more about phone coaching later in this chapter.)
Supporting the therapist
To be effective in the work they do, therapists delivering DBT treatment must stay motivated to work with patients, particularly those patients whose behaviors they find challenging. Many therapists find the work with patients who have BPD and related conditions to be very rewarding, while at the same time, their patients’ intense emotions and at times self-endangering behaviors can lead to therapist burnout and despair.
Therapists who provide DBT are required to sit on a consultation team, which is a group of other DBT therapists who meet on a weekly basis to help each other by using the same techniques that they use with their patients. Therapist burnout is essential to deal with and is applied by using consultation with the therapist, problem-solving, validation, and ongoing training and skill-building, as well as encouragement to persist in applying compassionate care. The typical consultation team meets once per week for one to two hours. We talk about consultation teams in more detail later in this chapter.
Structuring the patient’s environment
Structuring the environment, when necessary, in a way that maximizes the chance of success includes the use of reinforcement of adaptive behavior and not reinforcing maladaptive behavior. Structuring also includes helping patients modify their environment. For example, patients who use drugs might modify their circle of friends. People who use dating apps that have led to abusive relationships may be coached to delete the apps. Patients who struggle by staying up late at night might need to modify their nighttime routine to promote better sleep hygiene.
Patients may need help in finding ways to modify their environments. Typically, the patient is coached as to how to make the modifications, but for younger or less skilled patients, the therapist may need to take a more active role in helping structure the environment. Get the scoop on structuring the environment in Chapter 16.
Checking Out Modes of Treatment
How can the five essential functions in the preceding section be attained? There are four modes of treatment in the standard model of DBT to ensure that the treatment can be comprehensively applied. Not included in these four modes are other modes of treatment, such as medications and services like case management. These other modes can be added to DBT, and often; however, they aren’t core to the treatment.
Skills training
In this mode, patients focus on learning new skills in a classroom-like atmosphere. The skills are then enhanced through practice exercises, as well as generalized to other aspects of the patients’ personal lives by the assignment and review of homework. The specific skills that are taught are the four DBT skills modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. The modules are typically taught over six weeks, although this can vary, depending on the needs of the patients and how quickly they learn the material. The specific skills are reviewed in depth in Part 3.
In a group meeting, the typical structure is once per week, lasting somewhere between two and two and a half hours. The first hour is devoted to a review of the homework assigned in the previous session, and the second hour is dedicated to the teaching of new skills. Homework is then assigned as the last task of the group.
Note: There are certain circumstances when skills are taught in individual sessions. For instance, a person may have work limitations that don’t allow them to participate at a particular time, or they may have language limitations or learning disorders that don’t allow them to keep up with the pace of teaching in a large group.
Individual therapy
Individual treatment in standard DBT is conducted weekly or biweekly in 60-minute sessions, and it’s focused on understanding, exploring, and targeting the behaviors that a patient wants to change. It does so by keeping the patient motivated to complete the treatment and encouraging them to apply the new skills they have learned in the group. A variety of techniques, which are covered in Part 4, are used by the DBT therapist to address motivation when it has started to wane.
Phone/skills
