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  • Kiki Fehling Ph.D.

Not All DBT Is Created Equal

What is “adherent DBT?” And why does it matter?

Not All DBT Is Created Equal

  • DBT is an evidence-based treatment for a variety of mental health diagnoses and struggles.

  • Understanding the difference between "adherent, comprehensive DBT" and "DBT-informed therapy" is important.

  • Most research on DBT's effectiveness for BPD (and some other disorders) is based on adherent DBT.


Dialectical Behavior Therapy (DBT) is an evidence-based treatment for borderline personality disorder (BPD), post-traumatic stress disorder, substance abuse disorders, difficulties in ADHD, some eating disorders, and other mental health struggles defined by intense emotions and/or impulsive behaviors. [1-6] Because of this broad usefulness for helping many clients, more and more therapists have sought training in DBT.


Sadly, many clients who believe they’re receiving DBT are only receiving “DBT-informed” therapy or learning DBT skills as a part of another therapy. Most studies on DBT’s effectiveness for treating BPD (and some other diagnoses) are based on adherent, comprehensive DBT—not just DBT skills. Furthermore, some research suggests that the more adherent to DBT a therapy session is, the more likely the client will benefit from the therapy.


Not All DBT Is Created Equal Therapy Appointment

Adherence matters. When DBT is adherent, clinicians, clients, and client loved ones can be more confident that the therapy will be helpful and provide the powerful results demonstrated in DBT’s research.


What is Adherent DBT?

DBT experts say that a client's treatment is "adherent" when they are receiving comprehensive DBT as described in the original treatment manual by Marsha Linehan.


Comprehensive DBT always includes four main parts: weekly individual DBT therapy, weekly DBT skills group (or some form of dedicated skills learning), as-needed phone coaching between sessions, and a weekly consultation team (for the therapist). These four parts each have specific guidelines that must be followed to be considered adherent. Below, I'll review some specific features that are most prominent and easiest for clients to know about their own treatment.


Individual DBT therapy. In adherent DBT, the client meets every week for a one-on-one therapy session with a DBT therapist. While DBT explores emotions, thoughts, daily life experiences, and trauma histories, there is an emphasis on behavior. The "B" in DBT stands for behavior, after all! At the start of DBT, the therapist and client work together to collaboratively and explicitly identify the client’s goals for therapy. These goals are made into behavioral “targets” (e.g., behaviors to increase or decrease), which the client tracks using a “diary card.”


The DBT diary card is a physical or digital spreadsheet that the client fills out daily between sessions, tracking their therapy targets, emotions, and other factors important to the client. DBT therapists and clients use the diary card every session to set the agenda for what to discuss. If an individual therapy session doesn't have diary cards, agendas, or behavioral targets—it’s not adherent DBT.


Not All DBT Is Created Equal Therapy Appointment

Not All DBT Is Created Equal Virtual Therapy Appointment

DBT Skills Group. In comprehensive DBT, the client usually attends a weekly skills group with other DBT clients. These groups function more like a class than a typical group therapy session, as the focus is on learning skills in four main modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Typically, a weekly DBT skills group takes about six months to cover all of the skills. Based on special circumstances or learning needs, some clients in DBT will learn skills in individual sessions, rather than a group. In adherent DBT, clients will learn and practice skills every week.


DBT Phone Coaching. Clients in adherent DBT have the option to contact a DBT therapist between sessions. This coaching has three primary purposes: (1) helping the client navigate emotional crises, (2) helping the client apply the DBT skills to their daily life in real-time, and (3) solving problems or repairing conflicts between the client and the therapist. Some DBT therapists have institutional rules or personal limits that impact their availability for phone coaching, but adherent DBT always has some form of between-session phone coaching.


DBT Consultation Team. Therapists offering adherent DBT attend a weekly meeting with other DBT clinicians where they specifically and exclusively talk about DBT cases. This “consultation team" is designed to help the therapists provide adherent DBT. While therapists may talk about their clients during team meetings, discussion is focused on the therapists (rather than the client) and what they need to do to be the best DBT therapists they can be.


Not All DBT Is Created Equal Virtual Therapy Appointment

Is Adherent DBT Really Necessary?

Adherent DBT requires a pretty hefty commitment in time, energy, and (sometimes) money. While some clients will see the most benefit from adherent DBT, many people don't need the comprehensive treatment. There are many books, videos, and self-learning resources available for learning DBT skills in ways that are cheaper and easier to access than comprehensive DBT.


Research shows that just learning DBT skills can improve mental health for a lot of people, though it’s still unclear who exactly benefits most from comprehensive DBT versus DBT skills alone. People with BPD, those who self-harm, use substances heavily, experience frequent dissociation, or have other impulsive behaviors that cause harm, are likely to benefit more from comprehensive DBT than “DBT-informed” therapy. Of course, anyone can choose to participate in comprehensive DBT if they believe that increased structure, accountability, or one-on-one guidance will help them. An individual therapist could help you decide what treatment is best for your specific needs.


The Psychology Today Therapy Directory is one of the most comprehensive places to find a therapist online. There are specific questions you can ask a potential therapist to determine if they provide adherent DBT. I will write a future blog post about these questions!


Kiki Fehling, Ph.D., - Website -


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.


Fleming, A. P., McMahon, R. J., Moran, L. R., Peterson, A. P., & Dreessen, A. (2015). Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students. Journal of attention disorders, 19(3), 260-271.


Ben-Porath, D., Duthu, F., Luo, T., Gonidakis, F., Compte, E. J., & Wisniewski, L. (2020). Dialectical behavioral therapy: an update and review of the existing treatment models adapted for adults with eating disorders. Eating Disorders, 28(2), 101-121.


Harned, M. S., Schmidt, S. C., Korslund, K. E., & Gaglia, A. (2023). Therapist adherence to Dialectical Behavior Therapy in routine practice: Common challenges and recommendations for improvement. Journal of Contemporary Psychotherapy.


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.


Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.


Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2015). The use of dialectical behavior therapy skills training as stand‐alone treatment: A systematic review of the treatment outcome literature. Journal of clinical psychology, 71(1), 1-20.


© 2023 Dr. Kiki Fehling. The information in this post is for psychoeducational purposes, and it is not a substitute for the professional advice provided by your licensed mental health provider.


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