Dialectical Behavior Therapy at Harborview
About DBT
Dialectical Behavior Therapy (DBT) is a skills-based treatment program that was designed to help with distress tolerance and to teach new ways of coping with problems, without self-harm, suicidal thinking, or other problematic coping strategies. DBT strategically blends cognitive behavior therapy (change-based approaches) with validation (acceptance-based approaches). DBT is an evidence-based treatment that has been shown to help people with the following problems:
DBT was developed by Dr. Marsha Linehan and is considered a best practice approach in treating patients with these behaviors. Harborview DBT was the first site to implement DBT outside of Dr. Marsha Linehan’s research clinic at the University of Washington, and has been has been offering DBT to the Seattle community since 1988.
Harborview DBT is an intensive program that utilizes individual therapy, group skills acquisition, coaching and a consultation team. Patients attend at least two visits per week for six months to two years, depending on the presenting problems.
Before requesting a screening appointment, please click on links below and review this information on your own or with people whose opinion about your treatment you respect. Your DBT screening clinician will confirm that you understand and agree with these important aspects of treatment before accepting you into the DBT program. Please ask any questions you have.
- Borderline Personality Disorder
- Self-harm and suicidal behaviors
- Substance abuse
- Impulsive behaviors (i.e., reckless driving, high risk sex, etc.)
- Intense emotions
- Difficulty building and maintaining healthy relationships
- Chronic feelings of emptiness
- Depression
DBT was developed by Dr. Marsha Linehan and is considered a best practice approach in treating patients with these behaviors. Harborview DBT was the first site to implement DBT outside of Dr. Marsha Linehan’s research clinic at the University of Washington, and has been has been offering DBT to the Seattle community since 1988.
Harborview DBT is an intensive program that utilizes individual therapy, group skills acquisition, coaching and a consultation team. Patients attend at least two visits per week for six months to two years, depending on the presenting problems.
Before requesting a screening appointment, please click on links below and review this information on your own or with people whose opinion about your treatment you respect. Your DBT screening clinician will confirm that you understand and agree with these important aspects of treatment before accepting you into the DBT program. Please ask any questions you have.
The Harborview DBT Team
Our clinicians all have extensive training and expertise in DBT, with most having completed the intensive training course and practicing DBT for years.
Britt Alvy, LICSW
Penni Brinkerhoff, LMHC
Adam Carmel, PhD
Kate Comtois, PhD, MPH
Gail Efroymson, LICSW
Lynn Elwood, LMHC
Carson Robinson, LICSW
Penni Brinkerhoff, LMHC
Adam Carmel, PhD
Kate Comtois, PhD, MPH
Gail Efroymson, LICSW
Lynn Elwood, LMHC
Carson Robinson, LICSW
Getting Started
- To inquire about getting connected to Harborview’s Psychotherapy Clinic for DBT services, call the Patient Access Center at (206) 744-8845, ask to be registered with the Psychotherapy Clinic, and inform them that you’re interested in the Harborview Mental Health & Addiction Services (HMHAS) DBT program.
- You will be scheduled to speak with a Harborview Representative via telephone in order to verify your insurance and explain any associated costs that you may be responsible for.
- Once someone at Harborview verifies coverage, they will schedule you for a telephone screening with a clinician. If you meet the criteria, you will be scheduled for an in-person screening appointment to discuss the program in more detail. If you are accepted and decide to do the program, you will be put on our wait list*.
*Note: Harborview's DBT program often has a long wait list. Please click here for a list of other local DBT providers.
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CONTACT US AT:
(206) 744-8845 |
OUR PROGRAM IS LOCATED AT:
Harborview Mental Health & Addiction Services 401 Broadway, 1st floor Seattle, WA 98104 |
Description of the Harborview DBT Program
What is Standard DBT?
DBT is a cognitive behavioral and mindfulness treatment developed by Dr. Marsha Linehan at the University of Washington for the treatment of intense emotional dysregulation, Borderline Personality Disorder, and/or chronic life-threatening or other dysfunctional behaviors that reduce quality of life. DBT helps clients engage with their ultimate goals and learn change and acceptance skills to achieve them. Research has shown DBT to be effective in decreasing suicidal behavior, treatment dropout, psychiatric hospitalization, anger, and interpersonal problems as well as increasing social functioning. Harborview’s Standard DBT program is one year of treatment.
What is DBT-ACES?
DBT-ACES (Accepting the Challenges of Employment and Self-Sufficiency) is an optional second year of the program which has a special focus on the ability to pursue a career of your choice, work at a living wage, and be financially independent. This is our focus for many reasons, chief among them are:
Program Structure
DBT is a demanding and difficult program that will require commitment and hard work from you. We want to be sure that you will be successful and are willing to put the effort in to the program to make it work for you. Please consider the time and effort that will be required from you to help you to decide if this is the right program for you.
DBT Skills Group Classes
DBT requires attendance at weekly skills training groups (aka classes). Here are the times these are currently offered:
There is a DBT skills training class option for people who have struggles taking in information. This group goes at a slower pace, lasting 18 months rather than 12 months, every Wednesday at 10-11am. If you think this group would be a better fit, please let your screener know.
The DBT-ACES skills training group (an optional program for graduates of DBT interested in returning to work) meets Thursdays 3:00-5:00pm.
DBT is a cognitive behavioral and mindfulness treatment developed by Dr. Marsha Linehan at the University of Washington for the treatment of intense emotional dysregulation, Borderline Personality Disorder, and/or chronic life-threatening or other dysfunctional behaviors that reduce quality of life. DBT helps clients engage with their ultimate goals and learn change and acceptance skills to achieve them. Research has shown DBT to be effective in decreasing suicidal behavior, treatment dropout, psychiatric hospitalization, anger, and interpersonal problems as well as increasing social functioning. Harborview’s Standard DBT program is one year of treatment.
What is DBT-ACES?
DBT-ACES (Accepting the Challenges of Employment and Self-Sufficiency) is an optional second year of the program which has a special focus on the ability to pursue a career of your choice, work at a living wage, and be financially independent. This is our focus for many reasons, chief among them are:
- financial independence and freedom from poverty
- the ability to make choices in your life free from the opinions and rules of disability payers, social services, family or friends
- reducing anxiety and depression by spending ongoing structured time in a supportive environment where you are an “insider” not an “outsider” (also known as work, college, or training program)
- concrete way to follow your vision and values
- assuming a role which gives you status in your social community
- to promote further hopes, dreams, and plans for the future
Program Structure
- Screening and Pre-Treatment: Potential clients are referred to a DBT screener who evaluates their appropriateness for the program and works with them to increase their commitment to the demands of DBT. Only clients who demonstrate commitment are admitted to the program. Others are asked to re-apply when they can make treatment a top priority.
- Standard DBT (12 months): one hour per week individual DBT therapy, one, two-hour skills training group each week, phone/email/text coaching to use skills between sessions, and therapists meet weekly for consultation.
- Normative/Productive Activities: A schedule has been developed to increase the amount of normative and productive activity outside your home. You will work on this goal with your therapist and the maximum time is 20 hours/week.
- DBT-ACES (optional 2nd year): Successful graduates of DBT who want to pursue living wage employment and social and financial independence can apply for the DBT-ACES program. This entails one hour per week individual DBT, one skills training group each week, phone/email/text coaching to use skills between sessions, and therapists meet weekly for consultation.
DBT is a demanding and difficult program that will require commitment and hard work from you. We want to be sure that you will be successful and are willing to put the effort in to the program to make it work for you. Please consider the time and effort that will be required from you to help you to decide if this is the right program for you.
DBT Skills Group Classes
DBT requires attendance at weekly skills training groups (aka classes). Here are the times these are currently offered:
- Tuesdays 2:00-4:00pm
- Thursdays 2:00-4:00pm
- Wednesdays 1:00-3:00pm
There is a DBT skills training class option for people who have struggles taking in information. This group goes at a slower pace, lasting 18 months rather than 12 months, every Wednesday at 10-11am. If you think this group would be a better fit, please let your screener know.
The DBT-ACES skills training group (an optional program for graduates of DBT interested in returning to work) meets Thursdays 3:00-5:00pm.
Ways DBT is Different from Other Therapies
Most people coming to the Harborview DBT program have been to therapy before. DBT can be quite different from other therapy experiences you have had. IT IS VERY IMPORTANT THAT YOU READ THIS INFORMATION AND DISCUSS IT WITH US PRIOR TO COMMITTING TO DBT. It will help you know what to expect from the DBT program and what will be expected of you. This will help you decide if you want to participate. It also helps you anticipate how your therapist will respond to various problems that arise in the process of DBT.
Topics:
Attendance Expectations
Expectation: Come on time to every appointment, group, individual therapy and medication management session.
Remember, feeling depressed, anxious, relapsing, or not feeling well are not reasons to miss appointments or group – they are reasons to come and let us help you feel better! If these factors are interfering, we strongly encourage you to call to get coaching from your therapist (or backup if therapist is not available) to help you attend your scheduled appointment.
Remember, clients who don’t get therapy generally don’t get better! Attendance is emphasized in this program because in our experience when clients have difficulty attending, they really have not received the treatment and therefore don’t get better. Your therapist will work closely with you to try to prevent this from happening.
If there is an unavoidable reason to miss a session (for example, serious illness, work conflict that is unavoidable, medical appointment you cannot reschedule, etc.), we expect the following:
Attendance Requirements
Attendance is emphasized in DBT! DBT treatment requires patients to agree to attend both individual therapy and skills training each week as discussed above. Individual therapists will work assertively with clients to solve any attendance problems.
4-Miss Rule:
In DBT, if you miss 4 consecutive sessions of any one type of treatment you are out of the DBT program. That means you would be discharged from the program if you miss 4 individual sessions in a row, 4 once-a-week skills groups in a row, or 4 scheduled medication management sessions in a row, etc.
Initial grace period:
The first 2 months of therapy (i.e. since the first group therapy session) is a grace period. The therapist and client will work together to understand and address any attendance problems
After grace period:
Why so strict?
Patients exited from DBT due to low attendance are eligible to re-enter the Harborview DBT program after six months if the problem causing their low attendance has been resolved.
Suicide Behaviors
24-hour rule:
The 24-hour rule applies if you make a suicide attempt or non-suicidal self-injury during DBT. If you harm yourself, DBT therapists will not provide you with coaching or other between-session calls for the 24 hours after you’ve harmed yourself.
Why does DBT have this rule? Because we want to strongly encourage you to call your therapist (or backup person, if your therapist is not available) BEFORE you harm yourself so that we can help you practice skills that will prevent you from self-harming. After you’ve harmed yourself, you have made a decision to solve a problem by using dangerous behaviors, and it’s too late for your therapist to influence that decision. We WANT you to call to get coaching BEFORE you harm yourself.
If you have already harmed yourself and need medical help, please seek it right away. If you call your therapist, he or she will direct you to medical services and will then end the call.
If self-harm is a risk for you, your individual therapist will work with you in session to increase skills to use if you self-harm so you don’t do it again within the 24 hours.
Regardless of whether you have harmed yourself, you will still attend previously scheduled appointments such as individual therapy, groups, etc.
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Hospitalization
Many clients who come to DBT experience chronic suicidal ideation and/or have had multiple psychiatric hospitalizations. In DBT, we believe that hospitalizations can often cause more problems than they solve. This is because when someone is hospitalized, they are taken out of their real-world environment and away from the problems they are having. While this may temporarily solve problems, it does not encourage you to learn how to apply DBT skills to solve your problems, which in the end we believe will get you to your goals.
In addition, some people may find it to be a pleasant experience to go to the psychiatric hospital. In this case, a hospital stay may inadvertently reinforce, or reward, whatever behavior occurred just before it. For example, let’s say someone was in crisis, was suicidal, or made a suicide attempt, and this was followed by a hospitalization which they experienced as a positive experience. The hospitalization could actually serve to reward suicidal behavior, making it more likely that a person will have suicidal thoughts or make a suicide attempt in the future. Generally, this happens without the client wanting it to – reinforcement just works that way!
Because we are working to help you be less suicidal, not more, therapists in the DBT program will strongly encourage you to use DBT skills to stay out of the psychiatric hospital. On the other hand, there are some times when hospitalization is appropriate for some people. We encourage you to discuss this with your therapist at the beginning of your treatment so that you know what to expect.
The majority of clients who have graduated from our program are no longer suicidal and have stopped psychiatric hospitalizations altogether. Many of these clients have found that learning skills needed to solve their own problems, and finding alternatives to the hospital when they are in crisis literally has not only saved their lives but also made their lives worth living.
Wanting to Quit
We want to let you know up front that many clients going through the program experience urges to quit the program when things get difficult.
Many people experience a ‘honeymoon period’ in which they feel hopeful about DBT helping them, feel very motivated to attend groups and individual sessions, and to do the homework.
As time goes on, however, changes may not happen as quickly as the client had hoped or he or she becomes discouraged with all the work that the program expects of them. The urge to quit often happens at this time, and may come up multiple times through the program.
Ultimately, the decision of whether or not to quit is yours. What we want you to know, is that quitting the program is one way to ensure it will not work for you. Quitting does not give you the chance to find out whether DBT will work for you.
We can’t ensure DBT will work for you, but we can assure you that many clients who wanted to quit and didn’t thanked us in the end for helping them to stay and follow through with something that they started, something they rarely did before DBT.
Ask yourself, how would my life be different if I followed through on what I started? Here’s your chance.
Behaviors That Get in Way of Therapy
In DBT, we call behaviors that get in the way of therapy “Therapy-Interfering Behaviors.” Many DBT clients have had difficulty keeping therapists or staying in therapy long enough for it to work. Therapy interfering behaviors are often the cause. You can expect your DBT therapist to talk to you about behaviors that get in the way of therapy working. Some examples include not coming to appointments or group, being late, not doing homework, doing things that ‘burn out’ your therapist (e.g., crisis calls when haven’t tried skills first, rejecting therapist suggestions, repeatedly criticizing therapist). You and your therapist will work to identify these behaviors and help you stop engaging in them.
Following life-threatening behaviors, making therapy work effectively is the second highest priority in DBT. This means your therapist will work with you on understanding why therapy-interfering behaviors happen and changing them whenever they occur – even when there are other issues that may be higher priority to you. Why would we do this? Two reasons. First, these behaviors interfere with therapy working – and if therapy isn’t working well then any problem addressed in therapy won’t be resolved. Getting therapy working well will make solving all other problems easier.
Second, many problems that bring clients to DBT are interpersonal. Your therapist will work with you to improve your interpersonal skills with others but there is no better place to practice than when they occur with DBT team members. Then we have both your report and our experience to work from and a chance for you to try new skills in a low-risk setting. This may feel frustrating, and we’ve seen how much faster clients learn with this type of practice.
DBT therapists also have Therapy Interfering Behaviors – primarily not balancing accepting who you are now and what your struggles are with pushing you to learn skills and change. Also, behaviors like forgetting to check on your homework, being late, or not calling you back. You are encouraged to address these with your therapist. This is also addressed in DBT in a weekly consultation team of therapists, where videotapes of sessions could be reviewed to help clarify and address problems.
Alcohol or Substance Abuse Policy
If your alcohol or substance use is related to either life-threatening or therapy-interfering behavior, then it is a serious problem and additional treatment may be required. In our experience, DBT treatment cannot be successful if serious substance abuse is ignored or treated in only a minimal way.
In some cases, fully participating in DBT + using the DBT skills when urges to use alcohol or drugs occur is what is needed to control or stop the problem. If this is your preference and you are willing and able to throw yourself into using DBT skills in this way, your therapist may be willing to pursue this route first. If it doesn’t work in a month or two or if the alcohol or substance use problem is significant, however, other intervention may be required.
If there is evidence of alcohol or substance use problem either when you enter DBT or after you have been enrolled, you may be required to actively participate in substance abuse treatment and may be required to achieve at least 30 days of no alcohol or substance use before you begin DBT treatment. The decision as to whether additional substance abuse treatment is required will be made by your screening clinician or your therapist in consultation with the DBT treatment team.
If substance abuse treatment is required, you may continue DBT while you are getting enrolled. However, you will have a max of 4 weeks to be a full participant in substance abuse treatment before you will be suspended from DBT. Your DBT clinician can give you referral options and coach you in getting enrolled quickly. Please be aware that it often takes several weeks to be fully enrolled in substance abuse treatment so it is important to move quickly if this required of you.
If you are suspended from DBT, you will not participate in DBT individual therapy nor attend DBT skills groups. You will have coaching from your therapist solely on getting back into the program. If our clinic is prescribing medications for you, they can be continued while you are suspended for up to 4 weeks. After that, we cannot continue to hold your therapy slot and you will be discharged from the center and would have to re-apply to DBT once you are fully participating in substance abuse treatment.
We want DBT to work for you, so we want to be sure you can benefit from it. Controlling substance use is a key piece.
Steps to Getting Active and on the Path to a Job You Like
Everyone comes to DBT with the goal of creating a “life worth living.” This means different things to different people, but for many a life worth living includes a job you like – either for the enjoyment of the job itself, for the income, for the social network you gain, and/or as a way to contribute to your community. Even if you don’t work, it is critical to get and stay active in order to successfully treat depression and anxiety.
Our goal is that you graduate DBT with the ability to engage in normative, productive activity regularly 20 hours/week. This assures you have the skills you will need to alleviate depression and anxiety and work your way to a job you like.
We recognize that you may have felt invalidated throughout your life by being told that your problems were not important or that you were over-reacting or that people felt it should be easy to solve problems and reach difficult goals such as a job you like. Partially because of this, many of you may now minimize the difficulty of solving your life problems…then you do too much too fast and fail…and then you have hopeless thoughts and quit. We want you to take hard problems and big goals seriously.
Therefore… we have come up with a step-by-step plan for helping you to get active during DBT - slowly but without stopping or backing up. What is getting active? It means doing something that is normative (i.e., you act as if you don’t have emotional problems around people who act as if they don’t have emotional problems) and productive (i.e., structured, active, goal-oriented, and rewarding) outside of the mental health system. It can be a lot of different things including work, school, job-hunting, taking a class, going to the gym, attending a concert series, volunteering at a food bank, writing a novel…
The schedule is for you to work each four months of the program toward a new target:
Clients who do not meet the criteria will be suspended from DBT*.
*If you are suspended from therapy, you will be given a specific plan of what activity targets you will have to meet to return. Be aware that Harborview Mental Health and Addiction Services has limitations on how long you can be enrolled with us while on suspension so you may have to transfer your care elsewhere and transfer it back when you meet your activity target. We will try to re-enroll you immediately, but we cannot control HMHAS rules so you may have an unavoidable delay in returning.
Topics:
- Attendance expectations
- Attendance requirements and 4-miss rule
- 24-hour rule
- What about hospitalizations
- Wanting to quit DBT?
- Behaviors that get in the way of therapy
- Substance abuse treatment policy
- Steps to getting active and on the path to a job you like
Attendance Expectations
Expectation: Come on time to every appointment, group, individual therapy and medication management session.
Remember, feeling depressed, anxious, relapsing, or not feeling well are not reasons to miss appointments or group – they are reasons to come and let us help you feel better! If these factors are interfering, we strongly encourage you to call to get coaching from your therapist (or backup if therapist is not available) to help you attend your scheduled appointment.
Remember, clients who don’t get therapy generally don’t get better! Attendance is emphasized in this program because in our experience when clients have difficulty attending, they really have not received the treatment and therefore don’t get better. Your therapist will work closely with you to try to prevent this from happening.
If there is an unavoidable reason to miss a session (for example, serious illness, work conflict that is unavoidable, medical appointment you cannot reschedule, etc.), we expect the following:
- Call the appropriate group leader or therapist with 24 hours notice and explain the reason. Be open to coaching from therapist on ways might be able to attend.
- Attempt to reschedule individual therapy appointments that you need to miss.
- If you missed group, call 1-2 days afterward to find out what homework was given for the following week. You will be expected to have completed your homework regardless of whether you attended the last group.
Attendance Requirements
Attendance is emphasized in DBT! DBT treatment requires patients to agree to attend both individual therapy and skills training each week as discussed above. Individual therapists will work assertively with clients to solve any attendance problems.
4-Miss Rule:
In DBT, if you miss 4 consecutive sessions of any one type of treatment you are out of the DBT program. That means you would be discharged from the program if you miss 4 individual sessions in a row, 4 once-a-week skills groups in a row, or 4 scheduled medication management sessions in a row, etc.
Initial grace period:
The first 2 months of therapy (i.e. since the first group therapy session) is a grace period. The therapist and client will work together to understand and address any attendance problems
After grace period:
- Expectation for attendance is 80% or (preferably) better.
- Established clients (i.e., who have been in treatment more than 2 months) whose attendance for individual therapy or group skills class is 50% or below for a month will be placed on probation* temporarily.
- If clients already on probation have a 2nd month in a row attending 50% or less of their individual therapy or group skills class sessions, they will have their continued participation in DBT reviewed by HMHAS administration.
- If allowed to continue after meeting with HMHAS administration, if there are any months during the remainder of Standard DBT with attendance 50% or less of individual therapy or group skills class, the client will be discharged from the program.
- PLEASE NOTE: There are no absences excused from these rules including being hospitalized, out of town, or physically ill. If such issues are persistent, then it is important to address and resolve them before participating in DBT or develop a plan so they will not interfere with DBT participation.
Why so strict?
- DBT includes a combination of “talk therapy” and psychoeducation classes, which means that clients who don’t attend are missing the key ingredients of the treatment.
- There are many more clients who want DBT at HMHAS than we can serve, and slots taken by those who don’t attend regularly aren’t available to other clients who need them.
Patients exited from DBT due to low attendance are eligible to re-enter the Harborview DBT program after six months if the problem causing their low attendance has been resolved.
Suicide Behaviors
24-hour rule:
The 24-hour rule applies if you make a suicide attempt or non-suicidal self-injury during DBT. If you harm yourself, DBT therapists will not provide you with coaching or other between-session calls for the 24 hours after you’ve harmed yourself.
Why does DBT have this rule? Because we want to strongly encourage you to call your therapist (or backup person, if your therapist is not available) BEFORE you harm yourself so that we can help you practice skills that will prevent you from self-harming. After you’ve harmed yourself, you have made a decision to solve a problem by using dangerous behaviors, and it’s too late for your therapist to influence that decision. We WANT you to call to get coaching BEFORE you harm yourself.
If you have already harmed yourself and need medical help, please seek it right away. If you call your therapist, he or she will direct you to medical services and will then end the call.
If self-harm is a risk for you, your individual therapist will work with you in session to increase skills to use if you self-harm so you don’t do it again within the 24 hours.
Regardless of whether you have harmed yourself, you will still attend previously scheduled appointments such as individual therapy, groups, etc.
-
Hospitalization
Many clients who come to DBT experience chronic suicidal ideation and/or have had multiple psychiatric hospitalizations. In DBT, we believe that hospitalizations can often cause more problems than they solve. This is because when someone is hospitalized, they are taken out of their real-world environment and away from the problems they are having. While this may temporarily solve problems, it does not encourage you to learn how to apply DBT skills to solve your problems, which in the end we believe will get you to your goals.
In addition, some people may find it to be a pleasant experience to go to the psychiatric hospital. In this case, a hospital stay may inadvertently reinforce, or reward, whatever behavior occurred just before it. For example, let’s say someone was in crisis, was suicidal, or made a suicide attempt, and this was followed by a hospitalization which they experienced as a positive experience. The hospitalization could actually serve to reward suicidal behavior, making it more likely that a person will have suicidal thoughts or make a suicide attempt in the future. Generally, this happens without the client wanting it to – reinforcement just works that way!
Because we are working to help you be less suicidal, not more, therapists in the DBT program will strongly encourage you to use DBT skills to stay out of the psychiatric hospital. On the other hand, there are some times when hospitalization is appropriate for some people. We encourage you to discuss this with your therapist at the beginning of your treatment so that you know what to expect.
The majority of clients who have graduated from our program are no longer suicidal and have stopped psychiatric hospitalizations altogether. Many of these clients have found that learning skills needed to solve their own problems, and finding alternatives to the hospital when they are in crisis literally has not only saved their lives but also made their lives worth living.
Wanting to Quit
We want to let you know up front that many clients going through the program experience urges to quit the program when things get difficult.
Many people experience a ‘honeymoon period’ in which they feel hopeful about DBT helping them, feel very motivated to attend groups and individual sessions, and to do the homework.
As time goes on, however, changes may not happen as quickly as the client had hoped or he or she becomes discouraged with all the work that the program expects of them. The urge to quit often happens at this time, and may come up multiple times through the program.
Ultimately, the decision of whether or not to quit is yours. What we want you to know, is that quitting the program is one way to ensure it will not work for you. Quitting does not give you the chance to find out whether DBT will work for you.
We can’t ensure DBT will work for you, but we can assure you that many clients who wanted to quit and didn’t thanked us in the end for helping them to stay and follow through with something that they started, something they rarely did before DBT.
Ask yourself, how would my life be different if I followed through on what I started? Here’s your chance.
Behaviors That Get in Way of Therapy
In DBT, we call behaviors that get in the way of therapy “Therapy-Interfering Behaviors.” Many DBT clients have had difficulty keeping therapists or staying in therapy long enough for it to work. Therapy interfering behaviors are often the cause. You can expect your DBT therapist to talk to you about behaviors that get in the way of therapy working. Some examples include not coming to appointments or group, being late, not doing homework, doing things that ‘burn out’ your therapist (e.g., crisis calls when haven’t tried skills first, rejecting therapist suggestions, repeatedly criticizing therapist). You and your therapist will work to identify these behaviors and help you stop engaging in them.
Following life-threatening behaviors, making therapy work effectively is the second highest priority in DBT. This means your therapist will work with you on understanding why therapy-interfering behaviors happen and changing them whenever they occur – even when there are other issues that may be higher priority to you. Why would we do this? Two reasons. First, these behaviors interfere with therapy working – and if therapy isn’t working well then any problem addressed in therapy won’t be resolved. Getting therapy working well will make solving all other problems easier.
Second, many problems that bring clients to DBT are interpersonal. Your therapist will work with you to improve your interpersonal skills with others but there is no better place to practice than when they occur with DBT team members. Then we have both your report and our experience to work from and a chance for you to try new skills in a low-risk setting. This may feel frustrating, and we’ve seen how much faster clients learn with this type of practice.
DBT therapists also have Therapy Interfering Behaviors – primarily not balancing accepting who you are now and what your struggles are with pushing you to learn skills and change. Also, behaviors like forgetting to check on your homework, being late, or not calling you back. You are encouraged to address these with your therapist. This is also addressed in DBT in a weekly consultation team of therapists, where videotapes of sessions could be reviewed to help clarify and address problems.
Alcohol or Substance Abuse Policy
If your alcohol or substance use is related to either life-threatening or therapy-interfering behavior, then it is a serious problem and additional treatment may be required. In our experience, DBT treatment cannot be successful if serious substance abuse is ignored or treated in only a minimal way.
In some cases, fully participating in DBT + using the DBT skills when urges to use alcohol or drugs occur is what is needed to control or stop the problem. If this is your preference and you are willing and able to throw yourself into using DBT skills in this way, your therapist may be willing to pursue this route first. If it doesn’t work in a month or two or if the alcohol or substance use problem is significant, however, other intervention may be required.
If there is evidence of alcohol or substance use problem either when you enter DBT or after you have been enrolled, you may be required to actively participate in substance abuse treatment and may be required to achieve at least 30 days of no alcohol or substance use before you begin DBT treatment. The decision as to whether additional substance abuse treatment is required will be made by your screening clinician or your therapist in consultation with the DBT treatment team.
If substance abuse treatment is required, you may continue DBT while you are getting enrolled. However, you will have a max of 4 weeks to be a full participant in substance abuse treatment before you will be suspended from DBT. Your DBT clinician can give you referral options and coach you in getting enrolled quickly. Please be aware that it often takes several weeks to be fully enrolled in substance abuse treatment so it is important to move quickly if this required of you.
If you are suspended from DBT, you will not participate in DBT individual therapy nor attend DBT skills groups. You will have coaching from your therapist solely on getting back into the program. If our clinic is prescribing medications for you, they can be continued while you are suspended for up to 4 weeks. After that, we cannot continue to hold your therapy slot and you will be discharged from the center and would have to re-apply to DBT once you are fully participating in substance abuse treatment.
We want DBT to work for you, so we want to be sure you can benefit from it. Controlling substance use is a key piece.
Steps to Getting Active and on the Path to a Job You Like
Everyone comes to DBT with the goal of creating a “life worth living.” This means different things to different people, but for many a life worth living includes a job you like – either for the enjoyment of the job itself, for the income, for the social network you gain, and/or as a way to contribute to your community. Even if you don’t work, it is critical to get and stay active in order to successfully treat depression and anxiety.
Our goal is that you graduate DBT with the ability to engage in normative, productive activity regularly 20 hours/week. This assures you have the skills you will need to alleviate depression and anxiety and work your way to a job you like.
We recognize that you may have felt invalidated throughout your life by being told that your problems were not important or that you were over-reacting or that people felt it should be easy to solve problems and reach difficult goals such as a job you like. Partially because of this, many of you may now minimize the difficulty of solving your life problems…then you do too much too fast and fail…and then you have hopeless thoughts and quit. We want you to take hard problems and big goals seriously.
Therefore… we have come up with a step-by-step plan for helping you to get active during DBT - slowly but without stopping or backing up. What is getting active? It means doing something that is normative (i.e., you act as if you don’t have emotional problems around people who act as if they don’t have emotional problems) and productive (i.e., structured, active, goal-oriented, and rewarding) outside of the mental health system. It can be a lot of different things including work, school, job-hunting, taking a class, going to the gym, attending a concert series, volunteering at a food bank, writing a novel…
The schedule is for you to work each four months of the program toward a new target:
- Start to 4 months, start getting active and taking some chances, with the support of your therapist.
- 4-8 months, be active at least 10 hrs/wk and move towards 20 hrs/wk.
- 8-12 months, be active 20 hrs/wk.
Clients who do not meet the criteria will be suspended from DBT*.
*If you are suspended from therapy, you will be given a specific plan of what activity targets you will have to meet to return. Be aware that Harborview Mental Health and Addiction Services has limitations on how long you can be enrolled with us while on suspension so you may have to transfer your care elsewhere and transfer it back when you meet your activity target. We will try to re-enroll you immediately, but we cannot control HMHAS rules so you may have an unavoidable delay in returning.
Quality Improvement Program
In order for us to offer you the best treatment possible, we have instituted two components as quality improvement; that is, to evaluate the effectiveness of DBT:
Quality Improvement Interviews
Quality Improvement (QI) is how a clinic evaluates client outcomes (positive and negative) to understand where services should be improved. The interview questions are related to the problems that brought you to DBT, your strengths, and the treatment services you have received. If you decide to drop out of the program, we will still attempt to contact you and ask you if you would be willing to complete the assessments because we learn as much from those who drop out as from those who graduate.
Your participation in the QI project is kept more confidential than your medical record as it will not be released if/when you release your Harborview records to others. If you want anyone outside of Harborview to see this information, you will need to make special arrangements with us and we can generally only provide a summary. We may ask your permission to use this information anonymously as part of summaries about DBT in presentations or articles outside of Harborview (e.g., “The average emotional dysregulation of clients in DBT was xxx”).
Videotaping
One of the best ways to maintain high-quality therapy is to monitor sessions using videotaping. We’ve found this to be very beneficial for our clients. Therefore, as part of the program, we require that you agree to have some or all of your sessions videotaped. The purpose of the videotaping is for Harborview DBT to be able to help your therapist provide top quality therapy. These tapes will primarily be used as a tool for your therapist when s/he is receiving supervision or during team consultation. The tapes are confidential and will not be viewed by anyone outside your treatment team without your explicit permission.
Quality Improvement Interviews
Quality Improvement (QI) is how a clinic evaluates client outcomes (positive and negative) to understand where services should be improved. The interview questions are related to the problems that brought you to DBT, your strengths, and the treatment services you have received. If you decide to drop out of the program, we will still attempt to contact you and ask you if you would be willing to complete the assessments because we learn as much from those who drop out as from those who graduate.
Your participation in the QI project is kept more confidential than your medical record as it will not be released if/when you release your Harborview records to others. If you want anyone outside of Harborview to see this information, you will need to make special arrangements with us and we can generally only provide a summary. We may ask your permission to use this information anonymously as part of summaries about DBT in presentations or articles outside of Harborview (e.g., “The average emotional dysregulation of clients in DBT was xxx”).
Videotaping
One of the best ways to maintain high-quality therapy is to monitor sessions using videotaping. We’ve found this to be very beneficial for our clients. Therefore, as part of the program, we require that you agree to have some or all of your sessions videotaped. The purpose of the videotaping is for Harborview DBT to be able to help your therapist provide top quality therapy. These tapes will primarily be used as a tool for your therapist when s/he is receiving supervision or during team consultation. The tapes are confidential and will not be viewed by anyone outside your treatment team without your explicit permission.
Frequently Asked Questions (FAQ)
What if I have trouble learning because of cognitive difficulties or psychiatric symptoms?
There is a track for individuals with cognitive difficulties and/or psychosis which runs at a slower pace, and lasts 18 months.
Who are the clinicians in the program?
Our clinicians all have extensive training and expertise in DBT, with most having completed the intensive training course and practicing DBT for years. Upon request, you will get a list of therapist credentials and experience.
Can I continue to see another therapist when I enter the DBT program?
No. We require that you discontinue with current psychosocial treatment when you enter the program. Participating in multiple treatments at the same time is not allowed because it leads to conflicting advice and/or therapeutic principles. Also, most individuals find that adding other therapy to the intensive DBT schedule is not feasible.
What funding sources do you accept?
The program accepts certain Medicaid, Medicare, and commercial insurance plans. An insurance review is conducted prior to screening in order to clarify what is covered and what is part of your obligation to pay.
Can my family participate in treatment?
Yes, on a periodic basis. Family members may participate in some therapy sessions if there are issues that the family wants to present or at the request of client or therapist. Involving family members in a session requires permission of the individual client and therapist, as it is not a regular part of the DBT treatment program. It can be very helpful for family members to participate in programs specifically for loved ones. Your DBT therapist can provide information about this, or please click here for additional information in regards to your family's participation in your treatment.
What if I have an active substance abuse problem?
We currently do not have a substance abuse track in the DBT program. If you have active substance dependence, it is not the right time to start DBT treatment. After 1-3 months of clean time (one month if in good standing in substance treatment or three months if you are not in treatment) if you have less severe substance abuse problems, we will treat problematic substance use as part of the normal course of DBT. If your substance abuse substantially interferes with DBT, you may be asked to pursue addiction treatment in order to remain in DBT.
What if I have an eating disorder?
We also do not have a specific track for individuals with eating disorders, but will treat an eating disorder as part of the normal course of DBT. If an eating disorder is life-threatening or substantially interfering with treatment, additional treatment specific to eating disorders may be required to remain in DBT.
I have a chronic medical condition. What is the DBT policy on missing therapy due to medical problems?
DBT is a rigorous and time-consuming program that requires attendance at multiple sessions each week. The DBT program will consult with your medical provider on what DBT services and recommendations are appropriate for you given your medical condition. If you have medical problems requiring appointments or bed rest that your medical provider believes are in conflict with the demands of DBT, we recommend you postpone DBT treatment until these problems are resolved. If your medical provider supports participation in DBT, your therapist will work with you to manage your time, energy, and symptoms to participate effectively and according to your medical provider’s recommendations.
If Harborview DBT-ACES (optional second year) is about working, could I lose my disability or medical benefits?
A long-term goal of the DBT-ACES program is to help clients achieve living wage employment so that there is no need for disability benefits. The process of going off of disability benefits can be stressful and anxiety provoking. Different benefits programs have different rules about how much you can make, and for how much time, before disability and medical benefits are stopped. A consultation early in treatment can be arranged for you with a benefits expert at Harborview so you can understand how to make the best decision for you.
There is a track for individuals with cognitive difficulties and/or psychosis which runs at a slower pace, and lasts 18 months.
Who are the clinicians in the program?
Our clinicians all have extensive training and expertise in DBT, with most having completed the intensive training course and practicing DBT for years. Upon request, you will get a list of therapist credentials and experience.
Can I continue to see another therapist when I enter the DBT program?
No. We require that you discontinue with current psychosocial treatment when you enter the program. Participating in multiple treatments at the same time is not allowed because it leads to conflicting advice and/or therapeutic principles. Also, most individuals find that adding other therapy to the intensive DBT schedule is not feasible.
What funding sources do you accept?
The program accepts certain Medicaid, Medicare, and commercial insurance plans. An insurance review is conducted prior to screening in order to clarify what is covered and what is part of your obligation to pay.
Can my family participate in treatment?
Yes, on a periodic basis. Family members may participate in some therapy sessions if there are issues that the family wants to present or at the request of client or therapist. Involving family members in a session requires permission of the individual client and therapist, as it is not a regular part of the DBT treatment program. It can be very helpful for family members to participate in programs specifically for loved ones. Your DBT therapist can provide information about this, or please click here for additional information in regards to your family's participation in your treatment.
What if I have an active substance abuse problem?
We currently do not have a substance abuse track in the DBT program. If you have active substance dependence, it is not the right time to start DBT treatment. After 1-3 months of clean time (one month if in good standing in substance treatment or three months if you are not in treatment) if you have less severe substance abuse problems, we will treat problematic substance use as part of the normal course of DBT. If your substance abuse substantially interferes with DBT, you may be asked to pursue addiction treatment in order to remain in DBT.
What if I have an eating disorder?
We also do not have a specific track for individuals with eating disorders, but will treat an eating disorder as part of the normal course of DBT. If an eating disorder is life-threatening or substantially interfering with treatment, additional treatment specific to eating disorders may be required to remain in DBT.
I have a chronic medical condition. What is the DBT policy on missing therapy due to medical problems?
DBT is a rigorous and time-consuming program that requires attendance at multiple sessions each week. The DBT program will consult with your medical provider on what DBT services and recommendations are appropriate for you given your medical condition. If you have medical problems requiring appointments or bed rest that your medical provider believes are in conflict with the demands of DBT, we recommend you postpone DBT treatment until these problems are resolved. If your medical provider supports participation in DBT, your therapist will work with you to manage your time, energy, and symptoms to participate effectively and according to your medical provider’s recommendations.
If Harborview DBT-ACES (optional second year) is about working, could I lose my disability or medical benefits?
A long-term goal of the DBT-ACES program is to help clients achieve living wage employment so that there is no need for disability benefits. The process of going off of disability benefits can be stressful and anxiety provoking. Different benefits programs have different rules about how much you can make, and for how much time, before disability and medical benefits are stopped. A consultation early in treatment can be arranged for you with a benefits expert at Harborview so you can understand how to make the best decision for you.
