Practicing Dialectical Behavioral Therapy, or DBT, with fidelity, is critical to effective care, yet there are few providers who implement the modality as its developer Marsha Linehan intended. Wondering if you learned “true DBT” or if the treatment program you’re researching practices DBT with fidelity? Keep reading as we dive into the truth of how a DBT treatment program was meant to be run, and share our first-hand experience at THIRA health.
Taking bits and pieces of the DBT structure and cobbling together something to help patients can sound appealing; true DBT takes a lot of work and what could the harm be, after all? Especially when you know DBT treatment programs have regularly been shown to be so helpful for many patients? The truth is, the success of a DBT treatment program is in the structure of DBT. Serious issues could arise if DBT is not practiced with fidelity and this potential for improper treatment is worth taking seriously.
First things first, what is true DBT, and what is practicing with fidelity?
True DBT
True DBT involves four different modes of providing therapy:
- Individual therapy
- Group training for skills
- DBT consultation teams for DBT therapists
- On-call, in-the-moment phone/video counseling for crises
Practicing True DBT with Fidelity
The goals of the four modes, for a patient and a therapist using DBT, are to help a patient move toward acceptance, behavioral change, and reduction of extreme emotional symptoms. DBT is particularly helpful for people who deal with severe, possibly treatment-resistant symptoms that can include self-harm and emotional instability, so taking care to provide quality care becomes imperative, sometimes even life and death.
DBT also involves working on a set of four skills in the therapeutic process, including:
- Mindfulness
- Emotional Regulation
- Interpersonal Effectiveness
- Distress tolerance
Four DBT Stages When DBT is Practiced With Fidelity
A true DBT treatment program approaches patients with a structure to ensure that their very serious needs are met early and that the structure continues to carry them past the initial harmful behaviors and thoughts, into a state where patients are able to thrive. Typically, four stages occur as a patient works through a DBT program:
- Before starting DBT, and early in a DBT treatment program, a patient may experience very harmful behaviors and thoughts, and likely feel that their emotional state and responses are unstable and out of control.
- Once the DBT framework has been in place for a while, a patient may have fewer harmful, out-of-control emotional states, and a reduced likelihood of self-harm. But, they do not yet have a sense of emotional well-being, and have underlying issues and past experiences that should be addressed now.
- This is the building stage; helping patients build the life they want to lead, with the emotional, interpersonal, and life skills they need to live life fully and emotionally well.
- Finding a deeper meaning in life isn’t needed by all patients, but can be critical to some, to ensure that the hard work they’ve put in doesn’t end up feeling meaningless.
Hazards of a DBT Treatment Program Without Fidelity
It can become clearer to see the serious concerns about deviating from true DBT when you see the journey that DBT takes patients through in the four stages. Each successive stage solidifies the successes and lessons of the previous stage, and abandoning the proper structure of true DBT at any of these stages could reverse progress and endanger patients.
Potential Hazards of DBT Without Fidelity By Stages
1. Discouraging patients early on from sufficient structure
Without the structured support and consistent work of DBT practiced with fidelity, a patient may find themselves at a loss, discouraged by their lack of progress and worried about their persisting harmful thoughts and behaviors. A lack of on-call phone support, or missing out on group work to build skills, could make a patient feel like their treatment is not enough, and could never be enough. They may feel alone, abandoned, or let down—all very dangerous things for patients who may be in a fragile emotional space.
This can both reinforce the notion that therapy will fail a patient, or perhaps introduce the idea that the patient has failed. At the particularly sensitive time of a patient feeling out of control and emotionally unstable, this can be disastrous.
At THIRA, we know that a patient cannot fail at DBT. But a therapist can fail to practice true DBT, and DBT can fail a patient, especially when not practiced with fidelity, including all the checks and balances of group and individual support for patients, and group support for DBT therapists.
2. Assuming reduction in harmful behaviors and emotions is all that is needed.
True DBT starts with helping a patient reduce harmful behaviors and emotions, but it’s understood that in order for that progress to truly “stick,” a deeper addressing of trauma and underlying issues must happen.
Skipping structural components of a DBT treatment program after a small, surface amount of progress, can easily lead to a patient having recurring symptoms, and assuming that the therapeutic practice is failing them, or that they are failing. This could lead to the assumption that ALL therapeutic practices are failing them, and severely set patients back in their emotional progress.
3. A Therapist Attempting DBT Without Support May Fail Their Patients
Therapist support includes workshopping ideas and a space to seek out support and combined experience. It is insufficient to skip this step, as the support available to a DBT practitioner becomes support available to a DBT patient.
Therapist burnout, a lack of ideas for help for patients, and falling behind on learning new skills for work, all can result from a lack of support for DBT therapists. This can lead DBT to fail a patient, or a therapist to fail at DBT.
THIRA Health Practices True DBT
THIRA Health practices DBT with fidelity, to stick by our patients as they progress from severe symptoms to living their best lives. We prioritize proper DBT structure, and want to ensure our patients receive support in skill building and beyond. Contact us today to see if our true DBT practices will benefit you.
