When other counselors find out my specialty is Dialectical Behavioral Therapy (DBT) and BorderlinePersonality Disorder (BPD) I am often looked at with disbelief. The stigma is there and I have been told there is something wrong with me to want to work with "the hardest group of people there is in mental health." I sometimes find myself having to explain that "Borderlines" are not bad people, the stigma isn't true and that the proper term is "people with Borderline Personality Disorder." So, what is it like to be a DBT counselor in person?
First off I have done DBT groups for 6 years online and 1 year in person at an outpatient clinic, as well as phone coaching, group consult and individuals, not all the clients have been identified as BPD. Most of this is because BPD often isn't covered by insurance as a diagnosis and clinicians are hesitant to diagnosis it. The following is what it is like, both good and bad about running DBT groups. I understand each group is different and forms it's own culture. Here is a list of my experiences as a DBT counselor. The following is my opinion from my experience in an outpatient setting. Note the use of the word "some."
Some DBT clients will hold counselors accountable. The group was 2 hours long with a 10-15 minute break, the one time we (co-facilitators) were late we were asked to apologize by multiple members of the group as when a client was late they were not allowed in. I appreciated the reminder and never was late again.
Some DBT clients are initial combative regarding "changing their ways." I have been open about this in the first session of group. DBT is hard to initially get into, first off being told that what you have been doing is ineffective and now here some tools to get you to be more effective is uncomfortable. Some clients get upset, over personalize and feel judged by this. I have had one person cock back his fist to hit me (security guard grabbed him by his hood and pulled him back before we made contact), one person curse me out then protested outside with a sign and 2 threatened lawsuits. Resistance is part of the norm for DBT groups, although it can be both uncomfortable and triggering for others. All of this was handled outside the classroom and with management swiftly.
Some DBT clients have issues with the Zen Buddhist part. I have had numerous clients have huge issue with this. Even the idea of mindfulness or regulating your breathe has drawn criticism. At one point we as co-facilitators had (per upper management) to allow a client to sit in the lobby with their bible for the 10-15 minute mindfulness pending a lawsuit over mindfulness.
Some DBT clients often need concrete examples to understand DBT. This included a 2 hour session just to cover the definition of dialectics. We spent a lot of time with examples, neither of us were bothered by this, but some students felt like it was too much and it changes the pace of the course.
Some students filled the diary cards as we were entering the room or in the lobby. We saw them and personally took no issue. I was glad they got completed.
Some DBT clients who have been in groups before were often the most engaged and the most honest. I think part of this is due to how open 12-step groups are and how much some have shared in the past.
Some DBT clients find it difficult not to get "stuck in the story," and it is often hard to re-direct back to the skills they used when discussing diary cards. This was a struggle for us clinicians to manage time wise.
In 2 years we "graduated" 2 people; with 8-10 people in the group at the beginning and slowly people dwindling down this was a remarkably small number of people. I would guess in 2 years we had a total 40 clients start DBT. Some of this was due to people "dropping out" due to scheduling conflict, insurance issues and medical issues.
In our DBT group women outnumbered men 4:1, men were more likely to "drop out" of the group and stop showing up to individual sessions suddenly.
Rarely did anyone use the phone coaching, although it was strongly encouraged.
I am a huge fan of DBT and am still a firm believer in how great it can be for all people. I also will say that most of the clients were not like the bullets listed above; completed modules, grew and gained skills even if they did not complete the year long program. I still enjoy doing DBT and working with those with BPD, although running the groups can be very stressful at times. Part of the problem with the agency I did DBT groups was economic as all the clients were on state insurance and their coverage would get dropped for various reasons. We also didn't have a DBT team (just the 2 counselors who co-facilitated) and some of the other counselors/case managers did not understand DBT, so they weren't getting the one-on-ones focusing on DBT. I will also admit we did a quick screening process for new clients, meet with them for 30 minutes and made sure they understood what they were going to begin- I think a lot of clients had heard of DBT from someone or read an article and were quick to sign up without truly understanding what DBT is. I do take responsibility for some of these issues as well as some of the bullet points, including some of the client's behaviors.
I still recommend DBT to many of the people I work with now. I feel free to leave any comment about your experiences in DBT groups. Did you see some of the same things? Was your experience different?