Like most types of psychotherapy, DBT individual sessions will involve the client discussing their thoughts, feelings, behaviors, some insights, and future plans. The DBT therapist will also try to listen attentively, conceptualize what is happening in the session and in the client's life outside of the therapy room, and respond to the client with compassion. Unlike other types of psychotherapy, DBT therapists will also attempt to adhere to a specific structure and the principles of DBT. Also unlike other types of therapy, the therapist is required to attend DBT Consultation meetings to help support them in sticking to the structure and principles of DBT.
DBT sessions look different depending on the stage of treatment that the client is in. The stage of treatment is determined by the client's behaviors and needs. This post is going to outline the structure of sessions for clients in Stage 1. In my experience, most Comprehensive DBT clients start in Stage 1. If they are not "Stage 1 clients," there is a good chance that they were never referred to start DBT to begin with. In my opinion, Stage 1 work is where DBT really shines in terms of making improvements that other therapies cannot. The other stages, 2 through 4, are more similar to other types of therapies, including other types of CBT, exposure, behavioral activation, Acceptance and Commitment therapy, or sometimes even humanistic or psychodynamic approaches.
In "Stage 1" of DBT a client is having a wide range of difficulties, including behaviors that may be dangerous or maladaptive and are making their lives feel miserable and unmanageable. During this stage, sessions are very structured and clients may have less time to talk about the things they came to session wanting to talk about in favor of talking about the things DBT says we must talk about first. That is part of the reason clients have to be really committed to DBT- it might not be as fun, especially when they first start. But what are these things DBT says we must discuss? Target behaviors. Target behaviors fall into three hierarchical categories and DBT says we must discuss them in order, starting with Target 1, not to be confused with Stage 1... stages and targets are different but both are numbered so stay with me!
At the beginning of each DBT session (after 4 sessions of pre-treatment) the client will be asked to provide their diary card. The diary card contains information about the client's target behaviors over the last week. The therapist and client will then set the agenda based the diary card and anything else the pair believe they need or want to discuss. Most often, there is time to discuss the things clients want to discuss, but if there are many target 1 and 2 behaviors occurring, time in session may be limited to discussing just the top agenda items and the bottom agenda items will have to be postponed. Perhaps those other agenda items could be discussed briefly in a scheduled phone consult or perhaps they will have to wait until next session or later.
Target 1 behaviors are life-interfering behaviors, including suicide attempts, self-harm behavior (e.g. cutting, burning, but not other types of "self-sabotage" just yet), and physical aggression towards others. These are the behaviors that, if we do not address them, can become seriously dangerous or life-threatening to ourselves or others. Disordered eating, while unhealthy, is not usually a target 1 behavior--except when it is so serious that a medical doctor determines that there is a need for hospitalization (e.g. anorexia that is leading to imminent starvation).
Target 2 behaviors are "therapy-interfering behaviors," that is, any behaviors on the part of the client OR therapist that are getting in the way of therapy being effective. Labeling behaviors as therapy-interfering is something many people interpret as judgmental, which is understandable, but it is really not meant to be. We ALL engage in some therapy interfering behaviors and DBT assumes that this is not anyone's fault, and it is something to work on so that we can get the most out of treatment. Some therapy interfering behaviors are things like tech issues during a telehealth session! Hopefully, this makes it obvious that things that are labeled "therapy-interfering" are not meant to be judgmental towards the client or therapist. Who hasn't had internet connectivity issues? And yet, these are still important problems to be solved in order to actually engage in therapy without constant pauses and distraction. Some common therapy-interfering behaviors (TIBs) include being late to session, not completing homework, not completing the diary card, not asking the client for the diary card, "colluding" with the client in ignoring the diary card or treatment hierarchy, being distracted during session, not using phone coaching before engaging in target 1 behaviors, not offering or providing phone coaching when it was needed, and not observing personal limits on phone coaching or other types of communication. Usually, when therapy-interfering behaviors are present, both the clinician and client need to make changes to help solve the problem.
The final target category is target 3 behaviors which are "quality of life-interfering" behaviors. This category more or less represents "everything else" such as depressive symptoms, a lack of housing, financial difficulties, substance use problems, interpersonal conflicts (that are not physically violent; physical violence would be target 1), disordered eating that is not (yet) causing imminent starvation, loneliness, avoidance urges and behaviors (besides those that are therapy interfering), non-attendance of work or school, or panic attacks.
Once the agenda is set, the client and therapist will start with the topmost item and usually conduct a chain analysis of the target behavior(s). A chain analysis involves an in-depth exploration of the vulnerability factors, prompting events, thoughts, feelings, sensations, and behaviors that occurred prior to the target behavior, as well as the consequences that followed the behavior. This often takes a majority of the session. The discussion focuses on determining the possible functions of the behavior (What is causing this behavior to happen again and again? What might be reinforcing the behavior?). Ideally, the discussion will pivot from "chain analysis" to "solution analysis" where the client and therapist will brainstorm ideas for how the behavior can be prevented the next time a similar prompting event occurs. Modifying vulnerability factors (e.g. getting enough sleep, making sure to eat enough so as not to get "hangry") or finding ways to prevent the prompting event to begin with may also be discussed. Specifically, the discussion will include inquiries about which DBT skills were used or could be used in the future.
The therapist and client will then go down the agenda until time has expired. The therapist will often assign the client homework of some kind, or may ask the client to assign their own homework based on their wise mind understanding of what they need. Session can then be wrapped up for the week and the client can reach out for phone coaching in between sessions to gain assistance in completing the homework or applying the skills they have learned.