The 4 Stages of Treatment in Dialectical Behavior Therapy

We hear a lot about learning skills in DBT and a lot about learning to manage intense emotions and the problem behaviors that are often maladaptive attempts to manage those emotions.  These are primary targets of the first stage of DBT.  Often, we don’t hear much about the other 3 stages.

In stage 1 of the treatment, therapy is focused on getting behavioral control.  People who enter treatment at this stage are actively struggling with life threatening behaviors (e.g. cutting, suicide attempts, excessive drinking), treatment interfering behaviors (e.g dropping out of treatment, hostility towards therapist, skipping therapy) and major quality of life interfering behaviors (e.g. risk of losing housing, being expelled from school, losing marriage, custody of children).

The rationale for focusing on gaining behavioral control at this point is that it is assumed that a life lived out-of-control is excruciating.  Progress cannot be made on underlying emotional issues until you have the skill to manage emotion without engaging in dangerous behaviors and are committed to the process of therapy.

Stage 2 begins to focus on emotional experiencing.  For those with Post Traumatic Stress, this is the stage where past trauma is explored and maladaptive thoughts, beliefs and behaviors are identified.  The primary goal of stage 2 is to reduce traumatic stress.  This is achieved by remembering and accepting facts of earlier traumatic events, reducing stigmatization and self-blame, reducing the denial and intrusive response syndromes and resolving dialectical tensions regarding who to blame.  Stage 2 targets are worked on only when behavior is under control.

The goal of stage 3 is to solve the problems of everyday living and improve happiness and joy in life.  This stage of treatment focuses on owning your own behavior, building trust in yourself and learning to value yourself.

And finally, stage 4.  In this stage the focus is on achieving transcendence and building a capacity for joy.  I believe that most people, from Oprah Winfrey to Madonna would feel they could benefit from work on this stage.

2 Replies to “The 4 Stages of Treatment in Dialectical Behavior Therapy”

  1. My daughter has been in DBT for 4 years. The results are very mixed and she is not well today. She likes her therapist and trusts her. She goes to therapy willingly. But I feel that we have to consider something else given what I see as a lack of results. What is an acceptable way to ask the therapist for an evaluation of the progress and current situation? How do I ensure she is accountable for the work she does with my daughter and the payment she receives in return?

    1. That’s a great question. As a parent, it can be extremely difficult to watch your daughter go to therapy and not know if it is having a positive impact, especially when you continue to see emotional and behavioral problems at home. I would suggest calling her therapist and talking with her about her concerns. There are many different ways that she can work with you. It might be helpful to have a meeting with her and your daughter to discuss how things have changed in the past 4 years. Or she may want to meet individually you. Hearing about the treatment may help you more fully assess what the struggles have been. Do you know if your daughter feels as if she’s made progress? If she’s a competent therapist she will feel accountable to your daughter regardless of the money that she receives for the sessions.

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