3 Misconceptions about Dialectical Behavior Therapy DBT
Updated: Apr 8, 2022
When I was first trained in Dialectical Behavior Therapy (DBT) in 2005, it formed me as a clinician. I knew: “This was what I wanted to use with all my clients!” The Cognitive Behavioral Therapy techniques were good, but this was even better. I found the amazing dance of acceptance & change for the first time and the power to sit Mindfully in a session with another human being. Because I was learning with other new clinicians, it felt like everyone knew DBT. I was surrounded with 25-30 other clinicians and supervisors who were all regularly practicing DBT with clients from all types of situations. I received weekly individual supervision, weekly group supervision and attended a weekly DBT Consultation team meeting.
As I began networking with other therapists and telling them how excited I was to be trained in DBT, I learned that not everyone understood DBT as I did. They would be excited to tell me that they were leading a DBT Skills Group too. I would get excited with them—“Yes, the skills are great!” But, when I would ask them what they did in their individual sessions, they would look at me with puzzled expressions. When I would ask them about doing a BCA (behavior chain analysis) with their client, which treatment levels and targets they were working on with their client, or what they liked most about the biosocial theory, the frown and the puzzled look would deepen on their faces. We discovered that we weren’t talking about the same DBT-- Dialectical Behavior Therapy.
First misconception about Dialectical Behavior Therapy – DBT is skills ONLY
Don’t get me wrong! The DBT skills are amazing and helpful to all who practice them—and practice them and keep practicing (not just “learn” the skills). However, for those with Borderline Personality Disorder, the power of the modality tends to be in the relationship with the individual therapist. As the therapist & client work in individual sessions to change behaviors over time that relationship is the attachment and encouragement the client needs to support their changes and setbacks.
The diary card is the crucial piece of work in individual therapy sessions (as well as tracking skills learned in group). It’s used to track clients’ behaviors to decrease or increase. If the client uses the diary card daily to track their behaviors and the client brings that to his/her individual session, it is very advantageous to both parties. The diary card lends good structure to the session and clients can see that they are meeting their goals. Better yet is when the client begins to use the skills and not even realize how often they are using them. Being able to notice together that the client is no longer using their previous ineffective behaviors, we can really mark these significant changes.
The client’s nervous system is most likely calming down and able to learn, practice and apply new skills in multiple different arenas in their life. They get skillful at work, in their homes, at school, and with friends. This work is through the generalization of skills with their individual therapist over time.
Second misconception about Dialectical Behavior Therapy – DBT is a step-by-step method of treatment
This is not just a series of protocol steps that a therapist can follow and apply with all clients in 12 or 24 weeks. There are principles and assumptions that are key in being able to hold space for a person with Borderline Personality Disorder and all their changing emotions. There are many different dialectics to understand and be able to move between. There are dialectics in being able to be irreverent with clients and then switch back to having reciprocal/warm/kind communication. There are techniques to being unwaveringly centered while being compassionately flexible. Dr. Linehan refers to being able to “play jazz” with the client. A really good DBT clinician can be spontaneous and create intricate themes and variations in each session with the client to keep them just a little off balance so there is novelty to the work. And, a really good DBT clinician is able to let the client know that they are deeply cared about to create the space for them to make mistakes and try again.
There are relapses in behaviors that are completely normal. None of us can simply stop a long standing behavior/coping method and never do it again. The goal is over time to reduce the occurrences and shrink the length of time spent on these behaviors (e,g, cutting, burning, substance use, disordered eating), any impulsive behavior used to manage emotions).
Third misconception about Dialectical Behavior Therapy – DBT can be used by therapists WITHOUT support
I would not be where I am today in my ability to use and apply DBT without the amazing DBT Consultation Team I was on for 14 years. They supported me. They were my biggest cheerleaders. They challenged me to do difficult things. They gave me a safe place to examine my own emotions, beliefs, and habits. They gave me a place to practice new things before I went back to my clients.
As Dr. Linehan (1992) states in her book, “I have come to believe that it is extraordinarily difficult to deliver effective treatment to most borderline patients without consultation or supervision. I have been amazed at how many very good therapists end up conducting ineffective therapy or making major mistakes with this patient population. In clinical settings, such as inpatient units and agencies, therapists at times seem to act almost as borderline as their patients. They are often extreme in their positions; invalidate one another and their patients; blame the patients as much as the patients blame themselves; are vulnerable to criticism or feedback from others about their manner of treatment; have chaotic relationships with one another, often marked by “staff splitting”; and vacillate among feeling alone, discouraged, hopeless, and depressed, feeling angry and hostile at the patients or other staff members, and feeling energetic, confident, encouraged and hopeful.”
A fabulous DBT Consultation Team meeting is one that everyone on the team commits to attending consistently. They take a dialectical stance with each case, making sure all sides of a case are being considered. They do not expect one another to all behave the same with all clients. Each therapist is allowed to have their own style, limits and expectations with clients. The therapist helps the client deal with the differences, just like client will have to deal with differences “in the real world.” Therapists on a DBT Consultation team look for non-judgmental stances regarding clients’ behavior. They look for empathetic interpretations of clients’ behavior.
Therapists on a DBT Consultation Team accept that all therapists are fallible—even themselves. This might be the most important agreement we make when we join the team. This was difficult at first, and over time it made more sense why we need to accept this about others—and most importantly—ourselves!
Being aware of these 3 misconceptions will help both clinicians and clients to know when they are working with someone who has been fully trained in Dialectical Behavior Therapy. If clinicians require diary cards, attend a weekly DBT Consultation Team and have a dialectical stance & flow in their individual session, you are working with someone who has more training than simply picking up a DBT Skills book and starting a group.
If you want to work with someone with extensive training in Dialectical Behavior Therapy, please email or call today to schedule a 15-minute phone consultation. I look forward to helping and bringing hope back to your life—even just a little bit.