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  • Writer's pictureAlicia Paz

What It's Really Like to Be a DBT Therapist

When other counselors find out my specialty is Dialectical Behavioral Therapy (DBT) and Borderline Personality 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 and that the stigma isn't true. 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 I have served have been diagnosed with BPD. 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 its own culture. The following is my opinion from my experience in an outpatient setting. Note the use of the word 'some.'

  1. Some DBT clients will (fairly) hold counselors accountable. The group was 2 hours long with a 10-15 minute break, the one time we (the 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 was never late again.

  2. Some DBT clients are initially combative regarding "changing their ways." I was always open about this in the first group session. DBT can be hard to get into at first. Being told that what you have been doing is ineffective and that you're here to become more effective is uncomfortable. Some clients get upset, over-personalize, and feel judged by this. I have had one person hold up his fist to hit me (a security guard pulled him back before we made contact), one person curse me out and then protested outside the clinic with a sign, and two people threaten 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.

  3. Some DBT clients have issues with Zen Buddhist Mindfulness. I have had numerous clients have huge issues with this. Even the idea of mindfulness or regulating your breath has drawn criticism. At one point we had (per upper management) to allow a client to sit in the lobby with their bible for the 10-15 minute mindfulness exercise pending a lawsuit.

  4. Some DBT clients need concrete examples to understand DBT. We spent a lot of time on examples. We weren't bothered by this, but some students felt like it was too much and it changes the pace of the course.

  5. Some students filled out their diary cards right before group. We saw them do this and personally took no issue. I was glad they got them completed.

  6. Some DBT clients who had been in group treatment before were 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.

  7. 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 to manage time-wise.

  8. In 2 years we "graduated" only 2 people. I would guess that in those 2 years we had a total 40 clients start DBT. Some of this was due to people "dropping out" due to scheduling conflicts, insurance issues and/or medical issues.

  9. In our DBT group, women outnumbered men 4 to 1. Men were more likely to suddenly "drop out" of the group and stop showing up to individual sessions.

  10. 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. Most of the clients were not like those listed above. Most completed the 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 at 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). Some of the other counselors/case managers did not understand DBT, so students weren't getting the one-on-ones focusing on DBT. We also had a quick screening process for new clients. We met with them for 30 minutes and made sure they understood what they were going to undertake. 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 the commitment DBT requires. I do take responsibility for some of these issues as well as some of the bullet points, including some of the clients' behaviors.

I still recommend DBT to many of the people I work with now. Feel free to leave any comment about your experiences in DBT groups. Did you experience some of the same things? Was your experience different?


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