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  • Writer's pictureKiki Fehling

As Good as Gold: Adherent DBT

Updated: Feb 24

A version of this article was published on Psychology Today.

As a therapist, it's very rewarding to help a client who has previously been disappointed by their therapy experiences. As a DBT therapist, I've been lucky to have this experience numerous times. Probably because DBT is designed to help with problems that many therapists consider to be "difficult" to treat. Borderline personality disorder (BPD), for example, was historically considered to be "untreatable." Sadly, many mental health professionals still incorrectly view BPD that way, and it remains a misunderstood and stigmatized diagnosis. Similarly, many mental health professionals are under-trained in their ability to help people struggling with trauma/PTSD or addiction.

Luckily, DBT is an evidence-based treatment for BPD, (c)PTSD, substance abuse disorders, and a variety of other mental health struggles defined by intense emotions and/or impulsive behaviors.* Most of the research that shows DBT works, however, is based on adherent, comprehensive DBT—not just DBT skills. If you struggle with any of the above-mentioned diagnoses and you're interested in engaging in DBT, it's important that you understand what adherent DBT actually is so that you can be sure you're getting it with any future therapist.

What is Adherent DBT?

Adherent DBT is pretty complex. DBT therapists say that a client's treatment is "adherent" when they are receiving comprehensive DBT and all of its required parts as described in the original treatment manual by Dr. Marsha Linehan. Initial research suggests that the more adherent a therapist/DBT session is, the more likely the client will benefit from the therapy.**

Adherent, comprehensive DBT always includes four main parts: weekly individual DBT therapy, weekly DBT skills group (or some other form of dedicated skills learning), as-needed phone coaching between sessions, and weekly consultation team (for the therapist). There are a ton of different guidelines, principles, and structures that make each of these individual components "real" DBT. Below, I'll review the specific features that are most prominent.

Individual DBT therapy.

In comprehensive DBT, the client meets every week for a 1-on-1 therapy session with a DBT therapist. There are a ton of techniques that DBT therapists use in DBT sessions. While a lot of the guidelines are going to be in the therapist's head during session, there are two important features that any client in DBT knows as well...

First, DBT is a behavior-based therapy. (The "B" stands or Behavior, after all!). At the start of DBT, you and your therapist always will identify specific, behavioral "targets" for your therapy together. You'll identify behavior goals for therapy—what do you want to increase doing and decrease doing in your life—and track your progress using these goals for the entire time you're in DBT.

How do you track your progress? A weekly diary card. The DBT diary card is a physical or digital spreadsheet that you fill out daily between sessions, tracking your behavioral targets. The diary card also will likely track your emotions and other factors important to you and your treatment. You and your therapist use the diary card every week to decide what to talk about and to set the agenda for each session. If your individual therapy doesn't have diary cards, agendas, or behavioral goals—you're not in DBT.

DBT Skills Group.

In comprehensive DBT, the client attends a weekly group with other clients in DBT. This group usually feels more like a class than a typical group therapy session, as the focus is on teaching/learning the DBT skills. Group is usually led by 1-2 skills group leaders who are also DBT therapists, and may or may not be a client's individual therapist. Every week, clients have homework to practice new skills. In DBT group, clients always learn skills in four main areas: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Most DBT skills groups need 6 months to cover all of the skills. Therefore, there's usually a minimum requirement for clients to engage in comprehensive DBT for 6 months, though many stay for 12 months in order to learn all of the skills twice. Note: some clients in DBT will learn skills in individual sessions with their therapists, based on special circumstances; but to be adherent DBT, there would still need to be weekly skills teaching and homework.

Phone coaching.

Clients in adherent DBT (usually) have 24/7 access to call a DBT therapist for help. This help is limited to (1) navigating emotional crisis events, (2) applying the DBT skills you're learning in group to your real life in real-time, and (3) repairing any potential problems in your relationship with your therapist. Some DBT therapists have personal limits or institutional rules that may apply to their phone coaching. For example, their hospital may forbid them to take calls outside of business hours, they may not be available on days they observe religious holidays, and any given DBT therapist may or may not be OK with texting as a part of phone coaching. Whatever the specifics, adherent DBT always has phone coaching in some form, and a DBT therapist will make the guidelines and limits of their coaching clear to their clients.

Consultation team.

Therapists offering adherent DBT will always attend a weekly meeting with other DBT clinicians where they specifically and exclusively talk about DBT cases. This "DBT consultation team" is designed to help all of its therapists provide the most adherent DBT they can. While therapists may talk about their clients during team, discussion is more about them and what they are doing to be the best DBT therapists they can be. There's no required length of team meetings or required size of consultation teams. But, if your therapist is not on a DBT team, then you're not receiving adherent DBT.

How do I find DBT?

While DBT takes a lot of time, energy, and (possibly) money, comprehensive DBT is pure gold for the people who really need it. If you're willing to commit, DBT could change your life. For help finding a DBT therapist, check out my resources page.


Do learn more about DBT adherence (e.g., as a clinician): https://www.dbtadherence.com/


References

*Panos, P. T., Jackson, J. W., Hasan, O., & Panos, A. (2014). Meta-analysis and systematic review assessing the efficacy of dialectical behavior therapy (DBT). Research on Social Work Practice, 24(2), 213-223.

Haktanir, A., & Callender, K. A. (2020). Meta-analysis of dialectical behavior therapy (DBT) for treating substance use. Research on Education and Psychology, 4(Special Issue), 74-87.

Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour research and therapy, 55, 7-17.


**Harned, M. S., Gallop, R. J., Schmidt, S. C., & Korslund, K. E. (2022). The temporal relationships between therapist adherence and patient outcomes in dialectical behavior therapy. Journal of Consulting and Clinical Psychology, 90(3), 272.

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