What does "dialectical" mean? The term "dialectical" means a synthesis or integration of opposites. The primary dialectic within DBT is between the seemingly opposite strategies of acceptance and change. For example, we accept our clients as they are while also acknowledging that they need to change in order to reach their goals. In addition, all of the skills and strategies taught in DBT are balanced in terms of acceptance and change. For example, the four skills modules include two sets of acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness).
How does DBT prioritize treatment targets? Our clients who receive DBT typically have multiple problems that require treatment. DBT uses a hierarchy of treatment targets to help our therapist determine the order in which problems should be addressed.
The treatment targets in order of priority are:
1. Life-threatening behaviors: First and foremost, behaviors that could lead to a client's death are targeted, including all forms of suicidal and non-suicidal self-injury, suicidal ideation, suicide communications, and other behaviors engaged in for the purpose of causing bodily harm.
2. Therapy-interfering behaviors: This includes any behavior that interferes with a client receiving effective treatment. These behaviors can be on the part of a client and/or a therapist, such as coming late to sessions, canceling appointments, and being non-collaborative in working towards treatment goals.
3. Quality of life behaviors: This category includes any other type of behavior that interferes with a clients having a reasonable quality of life, such as mental disorders, relationship problems, and financial or housing crises.
4. Skills acquisition: This refers to the need for clients to learn new skillful behaviors to replace ineffective behaviors and help them achieve their goals.
What are the stages of treatment in DBT? DBT is divided into four stages of treatment. Stages are defined by the severity of a client's behaviors, and the therapists work with their clients to reach the goals of each stage in their progress toward having a life that they experience as worth living.
In Stage 1, the client is miserable and their behavior is out of control: they may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When the client first starts DBT treatment, they often describe their experience of their mental illness as "being in hell." The goal of Stage 1 is for the client to move from being out of control to achieving behavioral control.
In Stage 2, they're living a life of quiet desperation: their behavior is under control but they continue to suffer, often due to past trauma and invalidation. Their emotional experience is inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.
In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that the client leads a life of ordinary happiness and unhappiness.
In Stage 4, finding a deeper meaning through a spiritual existence is for a client for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom. This stage is not needed for all of the clients.
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