Tuesday, October 16, 2012

What is it like to be a DBT Counselor?

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 still 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 those seeking services are looking to change.  So, what is it like to be a DBT counselor?

First off I have done DBT groups for almost 2 years, as well as phone coaching, group consult and individuals, not all the clients have been identified as BPD.  Most of this is because BPD isn't covered by insurance.  The following is what it is like, both good and bad about running a DBT group. 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 in it's most blunt form.

  • 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.
  • 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 what you have been doing is ineffective and here some tools to get you to be more effective.  Some clients get upset, over personalize and feel judged by this.  I have had 1 person cock back his fist to hit me (security guard grabbed him by his hood and pulled him back), 1 person curse me out then protest 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.
  • Some DBT clients have issues with the Zen Buddhist part.  I have had numerous clients have huge issue with the non-Christian base for DBT.  Even the idea of mindfulness or regulating your breathe has drawn criticism.  At one point we as co-facilitators had (per higher up staff) to allow clients to choose to be in the mindfulness exercise that took up the first 10-15 minutes due to a pending lawsuit.
  • Some DBT clients often need concrete examples to understand DBT.  This includes a 2 hour session just to cover the definition of dialectics.
  • Some DBT clients with addiction issues are often the "best" clients in group; the most engaged and the most honest.  I think part of this is due to how open 12-step groups are and how much they 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. 
  • 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 attendance.
  • In DBT women outnumbered men, men were more likely to "drop out" of the group and need more examples to understand concepts.
  • 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.  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 has 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 a lot of my current clients (incarcerated females with substance abuse issues) and feel it is the best chance of a successful life if you have BPD.  Feel free to leave any comment about your experiences in DBT groups or any questions about DBT or BPD.


  1. I am fascinated with the differences in DBT between the UK and the US.

    Obviously each hospital is different but in the main there are some standard differences.
    In order to attend a DBT course the client must go through a lengthy (mine was 6 weeks) assessment, during that time it was made very clear what the expectations would be for me (the client) and the Nursing team. During that time we could be told that we would not be suitable and offered CBT or MBT alternatives.
    The unit I attend only has 6 spaces in the one and only DBT group. We were expected to commit to a year, possibly two year course.
    I have been crying out for telephone coaching, but currently they don't have the resources to offer out of hours support with nothing at the weekend. Its interesting that your experience is very different.
    Obviously we are lucky not to have issues with insurance with the drop out rate being very low.
    We definitely don't have a security guard, and have not experienced the need for one either. Neither have I come across people refusing to take part in the mindfulness exercises, maybe that is in part because they may not have been offered the treatment if they were unwilling to partake in arguably the most important element.

    I had to smile at your first comment about being held accountable for being late. I smile because it is a classic BPD-ism to hate people being late so in some ways that can be expected. Within the group we look at these therapy hindering behaviours, not just from the staff I should hastily add.

    I wonder what Marsha Linehan would make of the differences, some subtle and others not so much.

    Thank you for sharing you experience with candour.

    Best wishes

  2. Thanks for your comment (and on Twitter) I certainly agree that DBT is not effective if it is set up the way I wrote about. I think the 6 week ongoing assessment makes a huge difference especially with the motivation factor. When I was in H.S and trying out for the soccer team, the try-outs began on Monday and was to end on the Friday with a "test" of sorts to check ability and then you would be either in/out of the team. Day 1 we worked out so hard someone vomited, Day 2-4 were about the same grueling, sweaty and painful. By Friday only half of us had made it 5 days and the coach announces we all made it. The "test" was seeing if you would make it to Friday!

    I debated and re-read, re-edited for a few hours after writing the article. I had just finished Buddha and the Borderline and Kiera has similar experience with her first DBT group (minus the safety issue) and since I have on Twitter been hearing so much great stuff about those in DBT groups thought I would share my experience. If nothing else I think people who have good DBT should be grateful.