How is DBT 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:
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:
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:
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.
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[1] 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.
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.
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.
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.
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.
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[2].
[2]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.
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[2].
[2]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.
