I attend weekly peer supervision groups with GWM, known as “consult groups”, to ensure we adhere to DBT guidelines. I trained in DBT with GWM and was pleased to be invited to work with the organisation after qualifying.
Will DBT work well for your problems?
The central problem addressed in BPD / EUPD is emotional dysregulation.
DBT is likely to be an effective therapy for you if your problems meet the diagnostic criteria for borderline personality disorder BPD / emotionally unstable personality disorder EUPD.
The UK National Institute for Health and Care Excellence (NICE) recommends DBT for BPD/EUPD. (N.B. NICE also recommends schema-focused therapy and mentalisation therapy which I do not provide.)
I can help with an assessment if you think your problems meet the criteria for BPD/EUPD, but you have not been diagnosed.
DBT is also proven effective for:
- eating disorders, especially bulimia and binge-eating
- substance and alcohol misuse
- pornography addiction
- other addictive and impulsive behaviours
What is BPD/EUPD?
The American Psychiatric Association definition: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:
- Frantic efforts to avoid real or imagined abandonment.
- Unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation
- Identity disturbance:
- Potentially self-damaging impulsivity in at least two areas (such as: spending, sex, substance abuse, reckless driving, binge eating).
- Recurrent suicidal behaviour, gestures, or threats of self-mutilating behaviour.
- Affective instability
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
What has caused your BPD/EUPD?
It's thought to be a combination of nature and nurture.
“Nature” or biological factors include high sensitivity and hyper-responsiveness due to genetic and epigenetic factors with innate physical/neurological characteristics.
“Nurture” or social factors include growing up in an invalidating environment, where you might have been neglected, abused, humiliated, ignored, mocked, told you are worthless, forced to be perfect.
What does DBT involve?
You will have a period of “pre-commitment” work, where we will discuss any diagnoses you have as well as your life story and current problems. The pre-commitment phase is to ensure you understand exactly what you will be committing to if you sign up for DBT and that we can work well together. During this pre-commitment stage, both parties are free to walk away and say the contract is not for them.
The DBT contract is six months minimum, more usually one year. You will need to agree to work weekly with an individual therapist on reducing all the problem behaviours that are ruining your life, as well as attend a skills group to learn new more effective emotion-regulation skills.
The commitment is considered binding once the DBT contract is signed.
If you sign up for skills group-only DBT you will need to attend weekly for at least six months.
If you sign up for individual DBT (full programme) you will attend weekly individual sessions and weekly group sessions as well as receiving coaching on-demand from your therapist.
You cannot receive individual-only DBT. If you are on the ASD spectrum and cannot tolerate groups at all, I will consider teaching the group skills individually on separate weekly sessions.
If you miss four sessions of DBT in a row (individual and group) you will be considered to have dropped out of DBT and will not able to return for at least six months.
DBT is highly structured and very validating. DBT provides the opportunity to develop a genuine and healthy relationship with the therapist, within which you can turn your life around.
How effective is DBT?
It depends what we are using DBT to work on. There is good evidence for the effectiveness of DBT for all of the problems mentioned above. There is good evidence for both individual plus skills group and coaching as well as for skills group only. The choice of which model usually depends on the severity of the problems we are working with. For BPD/EUPD, around half of those who undertake DBT do not meet the criteria for BPD at the end of therapy. DBT is very good at reducing behaviour which occurs often and has been difficult to change. It increases our ability to manage intense emotions, handle relationships, and get a life worth living.
Risk management in DBT
I am unable to provide therapy for anyone who self-harms or has suicidal behaviours. This is because I do not have a multi-disciplinary team including psychiatrists and care co-ordinators to manage the risk safely and effectively.
What will I do with my individual therapist in DBT?
Every session starts with mindfulness practice.
You will meet me weekly and keep a daily diary of the main behaviours which are ruining your life, “target behaviours”. We will screen share your diary at every session and pick out a target behaviour to study together. You will do something called a “chain analysis” where you work out your thoughts, feelings, behaviours (and urges) and body sensations in the run up to the target behaviour, as well as what happens in the short and longer-term afterwards. The aim is to work out what “reinforces” the behaviour (makes it stronger and makes it keep happening). This might be a pleasurable feeling (positive reinforcement) but more often is the chance to avoid aversive (bad) internal feelings and states (negative reinforcement).
We will then carry out a “solution analysis”, thinking of things you could do differently next time, and make a plan for you to take away.
If you find yourself having a strong urge to carry out a target behaviour between sessions, you are expected to call me, within specified hours. Outside those hours you should know who else you might call. This is known as phone coaching.
When I am on leave or if I am unwell, I will arrange for a colleague in GWM to be available for you if needed.
What will I do in the skills group sessions?
Because all our groups are online, they often involve people from all around the world. There are 3 modules which each last 8 weeks: Interpersonal Skills, Emotion Regulation, Distress Tolerance. A Mindfulness module is taught in a 2-week period at the start of each of the other 3 modules to accommodate new members of the group and revise the skills for others.
Agenda for a typical DBT Skills Group:
review of your skills homework diary from the last session
short comfort break
new skills teaching session
Marie Wassberg (DBT therapist adolescents only, and trainer)
What is the Consult Group?
The Consult Group is the peer supervision group which is compulsory for DBT therapists with current clients to attend weekly. This group is used to do DBT with ourselves, to make sure we stick to DBT (are DBT adherent) and stay compassionate and effective. It means you will receive expertise from a group of us not just your own therapist.
What is the cost of DBT?
DBT costs £130 per individual session plus £60 per session for skills group: £180 per week for the first 6 months.
Skills group fees are paid at the start of each module (£480). You may or may not need or choose to repeat the group for a further six months. You may decide with your therapist that you have adequately learned the skills and can continue just doing individual sessions. The duration of therapy is a minimum six months more usually a year. This can be ended earlier if the therapy is proving ineffective for you, or extended later if you decide you need more.
If you are suitable for and choose skills group only, the cost is £60 per session weekly for at least six months, paid at the start of each module (£480).