Last Updated Nov 30, 2022

The Structure of Standard DBT: The 4 Skill Modules

This presentation is an excerpt from the online course “DBT in Practice: Mastering the Essentials”.

Highlights

The structure of standard DBT involves a pre-treatment period of time.
- Therapist and client agree to work together.
- A typical DBT agreement is one year for adults.
Weekly individual and group sessions.
- Diary cards, behavioral chain analysis, prioritizing targets and formal assessments are included in individual DBT.
There are four modes in DBT: individual therapy, group skills training, peer consultation team meetings and intersession contact between therapist and patient.

The structure of standard DBT involves a pre-treatment period of time.
This is when the patient and the therapist determine whether they can work with one another and whether the patient is willingly entering into a DBT plan.
The first two to three sessions, the therapist and the client are discussing the terms of DBT, how it’s different from standard therapy or CBT and they’re discussing the DBT’s patient and therapist agreements.
The most significant parts of those agreements involve the one-year term gentlemen’s agreement to stay in therapy. One year is the minimum requirement for engaging DBT with adults.
Another significant agreement involves the client taking self-harm and suicide off the table for a period of time. Taking it off the table does not imply that a client will be terminated if they do engage in self-harm or have a suicide attempt. More clarification on the therapist and patient agreements will come later.

Once pre-treatment has passed and the agreements are signed, then the patient would enter into stage one.
Stage one is the most well-known phase of DBT. It’s the one that’s most talked about and it involves getting the patient’s behaviors under control.
There are four modes of therapy or there are four modes in DBT. One involves individual therapy.

So individual therapy is just a part. It involves weekly sessions, is structured. It requires the most training for the therapist. To be a group leader does not require as much training but for an individual therapist, they need to be well versed in a variety of different parts of the DBT and CBT.
In an individual session that’s structured, there is homework every week and the diary card, the DBT diary card being one of those.
The individual therapist will be engaged with the client in conducting behavioral chain analysis repeatedly during each session in stage one. The individual therapist will be prioritizing targets. What’s most important to address and whether or not we’re able to discuss with the client who brings in as much detail as they would like to talk about it is determined by a hierarchy of targets that we’ll discuss later.
In addition, we want to, in individual therapy, be conducting formal assessments and doing data tracking. For example, in an individual session with a client who might have increased their suicidal thinking, we would do a formal assessment called the Linehan Risk Assessment Protocol. So that would be an example of a formal assessment that DBT requires.

The next component after individual therapy is group skills training. This is absolutely required. In fact, more research has come out suggesting that group skills training is helpful in and of itself independent of individual DBT. Group skills training is a weekly one-and-a-half hour to two-and-a-half hour psychoeducational group.
You would have in a DBT group between three and 10 individuals and that would determine how long your group was. If it was between an hour and a half to two and a half hours is somewhat determined by the amount of patients that you have in that group. There are four modules in group and mindfulness is the most popular and most well known of those. But there are also three other ones that we can discuss in more detail later on down the line.

Another component, we have individual, group, another component is intersession contact. Now, intersession contact can exist in different forms. That could be telephone coaching. It could be if the patient had an individual therapist and they were on a residential unit, then they would have access to someone in between their sessions at any point in time. This is a 24-hour intersession contact possibility. If you were doing individual therapy, that client would have your personal cell phone number. They might call. They might text. They might email. Being able to manage and set limits around that is a key feature in DBT. Any violation or problems that arise around that would be treated as what’s called a therapy interfering behavior. Therapy interfering behaviors are another concept that we can go into more detail at another point. So observing limits for the therapist is extremely important when it comes to intersession contact and that is partially why an individual therapist needs to be well versed in all of the DBT principles in theory and practices.

The final component in DBT is what’s referred to as peer consultation team meetings. And these are weekly meetings that last between an hour and two hours between all members of a team which are treating the patient. And within the DBT perspective, the treatment of a patient in DBT requires a team. And so your team might be the individual therapist, the group leader, the group co-leader, the medication provider and/or possibly a nutritionist or anybody who is willing and able to join in the group that is treating the patient. And the purpose of this is partially to support the providers who are treating the client. And oftentimes, providers who are conducting DBT need extra support. So it’s partially a support for the therapists. It’s also a forum for being able to discuss cases and to apply DBT principles to the case. And it’s also a way to learn more about DBT and reinforce some of the practices from group that each and every provider needs to actually practice for themselves.

The key points for this talk are: All patients begin in pre-treatment. Pre-treatment involves the therapist and the client agreeing to work with one another. There are no involuntary patients. There are weekly individual therapy and weekly group. Diary cards, behavioral training analysis, prioritizing targets and formal assessments are included in individual DBT. There are four modes in DBT – individual therapy, group skills training, peer consultation team meetings and intersession contact between therapist and patient. A typical DBT agreement is one year for adults and the structure is different for adolescents.

DBT in Practice: Mastering The Essentials

The Structure of Standard DBT: The 4 Skill Modules

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