A year of your life, most of a year of somebody's fees, and one of the few treatments in psychiatry with a serious evidence base behind it. Fifteen minutes on the phone decides whether you get the treatment that was tested or a version of it with the working parts taken out.
The short answer: standard dialectical behaviour therapy has four components — weekly individual therapy, a weekly skills group, phone coaching between sessions, and a consultation team the therapist attends. Every trial that built its evidence delivered a year of that. Six questions establish whether a programme has all four and what happens if it doesn't. Score it, and stop calling when someone scores five or six.¹ ² ³
Write down what you are trying to change
One line each, before you dial. You will be asked, and having it written stops the call becoming an intake.
- The three things that go wrong most weeks: · ·
- What has already been tried, and for how long:
- Current prescriber, if any: · Current medications:
- What "better" looks like in six months, in observable terms — something on a calendar, not a feeling:
- Must-haves: ☐ evenings ☐ telehealth ☐ in person ☐ takes my plan ☐ sliding scale ☐ adolescent programme ☐ other:
The six questions
Read them as written. Tick the column the answer lands in.
| # | Ask | Usable answer (1 point) | Stop answer (0 points) | ☐ |
|---|---|---|---|---|
| 1 | "Does your programme include all four components — individual therapy, a skills group, phone coaching between sessions, and a therapist consultation team?" | A clear yes to all four, described without prompting | "We use DBT techniques" · "It's DBT-informed" | ☐ 1 ☐ 0 |
| 2 | "How long is the full programme, and does the skills group cover all four modules?" | Around six to twelve months, and mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness all named | "As long as you need" · only distress tolerance | ☐ 1 ☐ 0 |
| 3 | "What happens if I call at eleven at night in a crisis?" | A specific answer: who I reach, what happens, how long it lasts | "We don't do that" · "Go to the emergency room" as the only answer | ☐ 1 ☐ 0 |
| 4 | "Who is on your consultation team and how often does it meet?" | A team, and a weekly meeting | Hesitation, or "I consult when I need to" | ☐ 1 ☐ 0 |
| 5 | "What will we measure at three and six months, and will any of it be about my life rather than my symptoms?" | Named measures, repeated, plus at least one functional target | "You'll know when you feel better" | ☐ 1 ☐ 0 |
| 6 | "Which licence do you hold, and what is the number?" | Licence type and number, said plainly | Hesitation, or a coaching certificate as the only credential | ☐ 1 ☐ 0 |
Total: / 6
Why these six. The four components come from the developer's own research group's description of standard DBT.¹ The trials that established DBT's evidence — the 1991 original, the 2006 trial against community experts, and the 2015 component analysis — all delivered a year of treatment.¹ ² ⁴ Question 5 exists because symptom remission and functional recovery come apart: in a two-year follow-up, two-thirds of participants had remitted while 53 percent were neither employed nor in school.⁵ A programme that measures only symptoms will report success you cannot spend.
The three questions about money and fit
Not scored; written down.
- "What is the total cost of a full programme at your rate — individual, group, and anything else — and what changes if I use insurance?" —
- "Is the skills group open enrolment, or do I wait for a new cohort to start?" — Wait: weeks
- "What happens if I miss sessions, or if I need to stop for a while?" —
If a plan is involved, get the authorisation position in writing before the first session. A denial of a structured programme is appealable, free, and reviewed by a regulator. Appeal a denial → · If nothing in-network has an opening →
Verify before you book
- Licence number from question 6, checked on the state's own lookup rather than the practice's website: ☐ done — how to verify a California licence →
- The licence is one that can provide psychotherapy in California — psychologist, LMFT, LCSW, LPCC, or a registered associate under supervision: ☐ yes — what an associate is →
- If the only credential offered is a coaching certificate: ☐ this is coaching, not psychotherapy
- For an adolescent programme, ask what the family component is and whether parents attend a skills group: ☐ asked · Answer:
Score and decide
- 5–6 points, licence verified. Book. Ask that the first two sessions include the systems review and the target list from Step 1.
- 3–4 points. Ask one follow-up: "Would you be willing to run the full four-component programme, or refer me to somewhere that does?" A yes with specifics moves them up. A hedge does not. A partial programme may still be worth doing — skills training on its own has moderate-quality evidence as an add-on⁶ — but you should know that is what you are buying.
- 0–2 points. Thank them and call the next name. This is not a judgment of the clinician; it is a mismatch between what the trials tested and what this practice provides.
Calls made: · Highest score: · Booked with: · First session: /
If there is no DBT programme within reach
This is common in much of California, and it is not the end of the road. In a randomised trial of 180 people with recent suicidal or self-injurious behaviour, a year of DBT was compared with a year of well-organised general psychiatric care, and "no significant differences across any outcomes were found between groups."³ The Cochrane review of 75 trials found no evidence of a difference between therapy types at all.⁷
So the fallback is not "nothing." It is a clinician who runs a structured treatment: a clear frame, a written plan, a hierarchy of what gets addressed first, between-session work, measurement, and a colleague they consult. Ask for those six things by name.
☐ No DBT within reach · Structured alternative found: Mentalization-based, transference-focused, schema and general psychiatric management, and what each was tested against →
What happens in the first three months
Roughly a quarter of participants leave outpatient trials of BPD psychotherapy, and most of that happens in the first half of treatment.⁸ Knowing that in advance is worth more than resolving not to be one of them.
Two things to do at the start. Tell the therapist, in session one, if you have left a treatment before and what happened. And put a date in your calendar three months out with one question on it: what is different that I could describe to someone else? If the answer is nothing, that is a conversation to have in the room, not a reason to disappear.
Started: / · Three-month review date: / · What is different:
Q&A
Q: How do I know if a DBT programme is real? A: Ask whether it includes all four components — individual therapy, a skills group, phone coaching between sessions, and a therapist consultation team — and how long the full programme runs.¹ Those two questions separate standard DBT from a programme using the name.
Q: Is "DBT-informed" a bad thing? A: Not necessarily, and it may be all you need. It is a different product from what the trials tested, and you should be told which one you are getting before committing.
Q: Does the skills group alone work? A: As an add-on, DBT skills training improved BPD severity and psychosocial functioning on moderate-quality evidence — a better certainty rating than most findings in this field.⁶ In the component analysis, though, all three conditions improved similarly on suicide attempts, and standard DBT had the lowest dropout.²
Q: What if my insurance won't cover a year? A: Get the denial in writing, name the level of care rather than the brand, and appeal — the review is free and the decision binds the plan if it goes your way. The appeal worksheet →
Q: Can I do this for my teenager? A: Yes, and the adolescent trials tested adapted versions with a family component. Ask specifically what parents are expected to attend. Diagnosing and treating BPD before 18 →
Ready to make the calls? Filter therapists by approach, evening availability and payment route → · What DBT is and isn't → · The full BPD map →
Sources
- Linehan MM, Korslund KE, Harned MS, et al., "Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis," JAMA Psychiatry 72(5), 2015, 475–482 — "DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team" — doi.org.
- Linehan MM, Korslund KE, Harned MS, et al., 2015, as above — 99 women; all three conditions produced similar improvements in suicide attempts, ideation and crisis service use; standard DBT had lower dropout than DBT without skills training, 24% against 48%.
- McMain SF, Links PS, Gnam WH, et al., "A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder," American Journal of Psychiatry 166(12), 2009, 1365–1374 — 180 patients; "No significant differences across any outcomes were found between groups" — doi.org.
- Linehan MM, Comtois KA, Murray AM, et al., "Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder," Archives of General Psychiatry 63(7), 2006, 757–766 — one year of treatment; "Subjects receiving DBT were half as likely to make a suicide attempt (hazard ratio, 2.66; P = .005)" — doi.org; Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL, "Cognitive-behavioral treatment of chronically parasuicidal borderline patients," Archives of General Psychiatry 48(12), 1991, 1060–1064 — "The treatment lasted 1 year" — doi.org.
- McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS, "Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up," American Journal of Psychiatry 169(6), 2012, 650–661 — "even though two-thirds of the participants achieved diagnostic remission… 53% were neither employed nor in school, and 39% were receiving psychiatric disability support after 36 months" — pubmed.ncbi.nlm.nih.gov.
- Stoffers-Winterling JM, Storebø OJ, Kongerslev MT, et al., "Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysis," British Journal of Psychiatry 221(3), 2022, 538–552 — "moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, P = 0.002; psychosocial functioning: SMD -0.45, P = 0.002)" — doi.org.
- Storebø OJ, Stoffers-Winterling JM, Völlm BA, et al., "Psychological therapies for people with borderline personality disorder," Cochrane Database of Systematic Reviews 5, 2020, CD012955 — 75 trials, 4,507 participants; "Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies" — doi.org.
- Iliakis EA, Ilagan GS, Choi-Kain LW, "Dropout rates from psychotherapy trials for borderline personality disorder: a meta-analysis," Personality Disorders: Theory, Research, and Treatment 12(3), 2021, 193–206 — "Dropout rates were 22.3% considering all studies, and 28.2% when only considering outpatient randomized controlled trials… Most dropouts occurred in the first half of treatment" — pubmed.ncbi.nlm.nih.gov.
Paid for by participating therapists. Inclusion is computed from availability data — never purchased. No ads, no data sold.