The Roles of the DBT Individual Therapist

By Stephanie Vaughn, PsyD

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

Highlights

  • A primary goal for DBT individual therapists is to help motivate clients
  • In addition to individual therapy sessions, DBT individual therapists provide intersession contact and attend peer consultation team weekly
  • The relationship between therapists and clients in DBT is considered to be a “real relationship between equals,” involves mutual self-disclosure, and is collaborative

 

 


The roles and activities of a DBT therapist are many. DBT individual therapists must be well grounded in the theory and practices of DBT as a whole. They have a variety of roles including being a navigator to the process of DBT. DBT can be experienced as something foreign even to those who have been in therapy for many years and there are many facets of DBT that are new. To be a navigator in the beginning and throughout the process so that the patient doesn’t feel like they’re thrown into the deep waters of the unknown can make the difference between a patient staying in therapy and dropping out.

 


The DBT individual therapist must also be a motivating cheerleader. So motivating the client for change is important. Part of our role as individual therapists in DBT is to cheerlead and to remind the patient that they have access to skills and resources and that basically they can do it. Of course, we want to balance that with validating that the patient’s situation is in fact a terrible situation or that it is unbearable as it is currently being experienced. So an important role of the DBT therapist is to stay dialectic. So we do both and we want to be both centered and flexible. We want to be both nurturing and demanding. And we want to focus on accepting the patient as they are, the acceptance piece, while at the same time being oriented to change and motivating them to change.

 


So we’re a collaborator with the patient in the process of change. The DBT therapist believes deeply in the autonomy of the client, that the client is their own individual separate entity with their own wise mind and they have an innate right to make their own decisions in the world. As a collaborator, the DBT theory is that the relationship between the therapist and the patient is a real relationship between equals, not some sort of false alternative universe sort of relationship. It is a real relationship. Both parties find out information about one another. They see each other in a real setting, in a couch, in a couple of chairs that they develop a real relationship and DBT acknowledges that is the case. The therapist does self-disclose more in DBT perhaps than in other therapies. And part of the orientation for clients who have been in other types of therapy involves making sure that they are aware that the DBT therapist self-discloses as part of that real relationship and partly as a contingency management strategy at times.

 


The DBT individual therapist is also a teacher. So they must be well grounded in the skills that they teach and are continuously practicing them on their own. They need to be well versed in behavioral principles and can use behavioral language. We want to try to teach the patient to be ultimately their own therapist and to use the very skills that we learned in school and in continuing education on themselves and change their environment as is possible and radically accept when it’s not possible. So cognitive theory is also extremely important in DBT and we want to teach all those cognitive principles to our patients. So the DBT therapist also needs to be grounded in cognitive theory and any other methods of change because ultimately as we’ve referenced before DBT is a model of change and that change is what is going to be the most helpful for patients to create their life worth living. We’re teaching the practice of mindfulness. So the DBT therapist needs to practice their own mindfulness strategies and to be well versed in the principles of mindfulness and how to apply it in any given moment so having a repertoire of mindfulness activities to fall back on.

 


The individual therapist is really the juggler also of all of the problems their patient brings in to session. They need to be able to use the target hierarchy that we’ll be discussing in another module. And they need to be able to prioritize the time in session to utilize the diary card to determine which topics to cover first, for how long and at what intensity and all within a 45-minute or a 60-minute session getting in all of the important and essential discussions particularly those involving life-threatening behavior even when the patient is insistent that other topics take priority. So the DBT therapist is the juggler of all of the problems within a session.

 


They are also the validator. They need to be able to fall back to validation when the change strategies become too aversive. The individual DBT therapist needs to be able to move very quickly from change strategies to acceptance-validation strategies sometimes within a minute. They may move from change to acceptance from session to session but need to be able to have that flexibility in responding. So understanding the six levels of validation is important and to keep that label in mind, “which level am I validating at right now?” and recognizing whether validation is going to be helpful for the long-term from one moment to the next. More on validation strategies in another recording.

 


The DBT therapist needs to keep the overarching DBT theories in mind and let that flavor their interventions. In any given session, in any given moment, there may be a variety of and often multiple paths to take in decision making of how to respond to a patient. But all of those need to go back to some sort of DBT principle or idea. And so we are looking in DBT following the spirit of the law rather than the letter of the law at all times. And the dialectic there being of course we want to follow the letter of the law in DBT and at the same time, not but, and at the same time when those letters of the law don’t fit, we need to be able to go back to the spirit of the law and make our critical decisions based on theory and just what makes sense and wise mind.

 


A primary goal for DBT individual therapists is to help motivate clients. The relationship between therapist and client in DBT is considered to be a real relationship between equals, involves mutual self-disclosure and is collaborative.

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