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Dialectical Behavior Therapy: Stages of Treatment

The Pre-Treatment Stage of Dialectical Behavior Therapy focuses on assessment, commitment and orientation to therapy.

Stage 1 focuses on suicidal behaviors, therapy interfering behaviors, and behaviors that interfere with the quality of life, together with developing the necessary skills to resolve these problems.

Stage 2 deals with Post-Traumatic Stress related problems (PTSD).

Stage 3 focuses on self-esteem and individual treatment goals.

The targeted behaviors of each stage are brought under control before the patient with Borderline Personality Disorder can move on to the next phase. In particular, Post-Traumatic Stress related problems, such as those problems related to childhood sexual abuse, are not dealt with directly until Stage 1 has been successfully completed. To do so, would risk an increase in serious self-injury. Problems of this type (flashbacks, for example) that might emerge while the patient is still in Stages 1 or 2 are dealt with using “Distress Tolerance” techniques. The treatment of PTSD in Stage 2 involves exposure to memories of the past trauma.

At each stage, treatment is focused on the specific targets for that particular stage, which are arranged in a definite hierarchy of relative importance. This hierarchy of targets varies between the different modes of therapy, but it is essential for therapists working in each mode to be clear what these targets are. An overall goal in every mode of therapy, however, is to increase “dialectical thinking.”

The hierarchy of targets in individual therapy is as follows:

1. Decreasing suicidal behaviors.
2. Decreasing therapy interfering behaviors.
3. Decreasing behaviors that interfere with the quality of life.
4. Increasing behavioral skills.
5. Decreasing behaviors related to Post-Traumatic Stress.
6. Improving self esteem.
7. Individual targets negotiated with the patient.

In any individual session, these targets must be dealt with in this particular order. In particular, any incident of self-injury which may have occurred since the last session must be dealt with first.

The importance given to “therapy interfering behaviors” is a particular characteristic of Dialectical Behavior Therapy, and reflects the difficulty of working with these particular patients (i.e., patients who have Borderline Personality Disorder). It is second only to suicidal behaviors in importance. These behaviors are any behaviors by the patient or therapist that interfere in any way with the proper conduct of therapy, and risk preventing the patient from getting the help he/she needs – including, for instance, the failure to attend sessions regularly/reliably, failure to keep to contracted agreements, and/or behaviors that overstep the limits set by the therapist. Behaviors that interfere with the quality of life are such things as substance abuse, sexual promiscuity and other high risk behaviors, etc. The patient with Borderline Personality Disorder is required to record instances of targeted behaviors on weekly diary cards. Failure to do so is regarded as therapy interfering behavior.

About the Author

David Oliver is the founder of BorderlineCentral.com a one stop source of information on how to cope and deal with borderline personality disorder.

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