Most people don't know that Dialectical Behavior Therapy (DBT) has 4 (technically 5) stages. Stage 1 is the most common so that's generally what people think of when they're discussing or referring to DBT, but the truth is that there are multiple layers to this evidence-based treatment.
Brief Overview: Stages of Dialectical Behavior Therapy (DBT)
“DBT requires voluntary rather than coerced consent” - Kelly Koerner, PhD
Pretreatment
Primary Goal(s):
Eligibility assessment
Orientation to DBT:
o Rationale
o Modes of treatment
- Individual therapy (weekly)
- Group skills training (weekly)
- Phone coaching
- Consultation team
o Stages
o Biosocial Theory and connection to lived experience
Obtainment of client agreement to treatment:
o Treatment modes
o Treatment length (standard 6-12 months for adults)
o Close the door to suicide and work on life-threatening behaviors
o 4 miss rule
o 24 hour rule
Stage 1
Primary Goal(s):
Stabilize maladaptive behaviors:
o Extinguish life-threatening behavior
o Decrease/extinguish therapy-interfering behavior
o Decrease/extinguish quality of life interfering behavior
Increase skill knowledge and use
Stage 2
Primary Goal(s):
Move from quiet desperation (hopelessness/despair/misery) into emotional experiencing by decreasing:
o Intrusive/PTSD symptoms (trauma processing if needed/wanted)
o Avoidance of emotions
o Avoidance of situations and experiences
o Emotional dysregulation (both heightened and inhibited emotional experiencing, specifically related to anxiety/fear, anger, sadness, or shame/guilt)
o Self-Invalidation
Stage 3
Primary Goal(s):
Integrate what was learned in stages 1 and 2 (generalize)
Work toward resolving problems in daily living (e.g., conflict, stress at work, managing chronic pain)
Increase sense of self-respect (e.g., self-compassion)
Increase sense of steadfast connection (e.g., common humanity)
Stage 4
Primary Goal(s):
“Becoming free of the need for reality to be different from what it is at the at the moment” (Kelly Koerner, PhD) through:
o Addressing a lingering sense of incompleteness (i.e., lack of purpose or meaning)
o Giving up “ego”
o Participating fully/authentically in life
“Although stages of therapy are presented linearly, progress is often not linear and the stages overlap. When problems arise it is not uncommon to return to discussions like those of pretreatment to regain commitment to the treatment goals or methods.” -Kelly Koerner, PhD
Resources:
DBT Skills Training Handouts and Worksheets: Second Edition by Marsha M. Linehan, PhD
Doing Dialectical Behavior Therapy – A Practical Guide by Kelly Koerner, PhD
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