What Comprehensive DBT Asks of You Before You Start

In crisis or thinking about suicide? Call or text 988 now (in Colorado it reaches the 988 Colorado Mental Health Line). If you are in immediate danger, call 911.

Deciding whether you can take this on right now

If you are in danger right now, do not wait to plan treatment. Call or text 988, or call 911 if your life is at risk. The rest of this guide is for planning once you are safe.

Maybe a therapist has suggested full DBT, or you have read that it was built for people with intense emotions, self-harm or suicidal urges. Before you start, it helps to know what the program will ask of your week. Comprehensive DBT is more structured than most therapy, and it is easier to plan when you know the deal up front.

The Linehan Institute says DBT was first developed for chronically suicidal people diagnosed with borderline personality disorder, and that research has since supported its use for substance use, depression, PTSD and eating disorders. You do not need any of those labels to ask about it. What matters for this decision is whether the structure fits your life right now.

This guide covers the commitment itself. For what happens in the first appointment, see your first DBT session. For questions to put to a program, see questions to ask a DBT therapist.

The four parts, and what each one asks of you

Behavioral Tech, a DBT training institute, lists four modes of standard outpatient DBT. Three of them involve you directly. The fourth happens behind the scenes.

• Individual therapy. In the standard model it takes place once a week for as long as you are in treatment. This is where you work on your own goals and apply skills to your week.
• Skills group. The Linehan Institute says groups typically meet weekly for about 2.5 hours and take 24 weeks to cover the full curriculum. Group leaders assign practice between meetings.
• Phone coaching. You can contact your individual therapist between sessions for help using a skill in a hard moment. It is meant to coach skills, not replace sessions.
• Consultation team. Your therapists meet with other DBT clinicians to stay faithful to the model and keep up their own skills and motivation. You never attend, but it is part of what you are signing up for.

Pre-treatment: the commitment sessions

Standard DBT begins with a pre-treatment phase. Published descriptions based on Linehan's manuals say this is when therapy agreements, your personal goals and the treatment goals are set.

Goals are put in a set order. Life-threatening behavior comes first, then anything that gets in the way of therapy itself, then problems that seriously affect your quality of life. Knowing this order helps sessions make sense later, when your therapist starts with the hardest item on your card.

Therapy-interfering behavior can come from either side. Missing sessions or breaking agreements counts, and therapists can slip too. Naming this early makes it easier to talk about without shame.

Before these sessions, it can help to jot down what you want to be different in your own words. Your therapist will likely ask what is at stake for you, what has gotten in the way before, and whether you are willing to try the full program for a set period. You can say yes to some parts and voice doubts about others. Therapists usually treat doubts as something to work on together.

Attendance, coaching rules and the four-miss rule

One rule comes before all the others: if you are hurt or in danger, call 911, or call or text 988. The agreements below are about planned treatment, not emergencies.

Standard DBT includes what is known as the 4-miss rule. In research from Linehan's group, missing four weeks in a row of individual or group sessions counted as dropping out of treatment. Programs can adapt the rule. Behavioral Tech describes college programs that build contracts around the school term and sometimes waive the rule over summer break.

Phone coaching has its own agreements. As a 2016 review describes Linehan's model, clients are asked to reach out for coaching before acting on a self-harm urge, not after. The model also limits coaching contact for 24 hours after self-harm, unless there is a life-threatening injury.

These rules are not meant as punishment. They are designed so that help arrives early, while a skill can still make a difference.

The homework between sessions

DBT also asks for practice between sessions. That means a short daily entry on a diary card that tracks urges, emotions, behaviors and skills, plus the practice your group leader assigns. The four skill areas are covered on our page of DBT techniques.

Plan for this the way you would plan for a class. Pick a time of day for the card, keep it somewhere private, and expect some weeks to go better than others. A missed week is something to bring to session, not a reason to quit.

A 2016 review notes that people in skills group can talk with the group about how they used a skill, but the diary card itself is mostly reviewed with the individual therapist. So you do not have to read out your urges or behaviors in front of other group members.

After the first stage: what comes later

DBT is organized in stages. Published summaries adapted from Linehan describe a first stage focused on safety and behavioral control: fewer suicidal and self-harm behaviors, fewer things that block therapy, fewer crises that wreck daily life, and more skills.

Later stages can address trauma and grief, everyday problems in living and self-respect, personal goals, and, last, feelings of emptiness or incompleteness. Not everyone moves through every stage, and your therapist will usually revisit goals as you go. Knowing the map can help on hard weeks, because the work of stage one is meant to build the footing for whatever comes next.

If you cannot commit to all of it yet

Some people are not ready for the full program. Work, school, child care or a crisis that needs a higher level of care can all get in the way. That does not mean DBT is closed to you. Our guide to comprehensive DBT, DBT-informed therapy and skills groups explains the lighter options and what you give up with each. The Linehan Institute notes that shorter skills formats exist for some groups and settings.

If daily life feels unsafe right now, weekly therapy may not be enough. See choosing a level of care and the Denver mental health resources page.

If you are ready to talk it through, Mountainside offers DBT for teens and adults, an adult DBT skills group and a teen multi-family DBT skills group, plus a free 15-minute consultation. Start with DBT therapy in Denver.

Frequently asked questions