Guidelines for Client Selection

The most important (and obvious) consideration in determining whether a client is a good match for DBT is if the client's problems are the types of problems that DBT aims to treat. As mentioned above, one of the primary reasons we advocate for diagnostic interviewing is that it provides a means of reliably assessing constellations of presenting problems and effectively utilizing the relevant treatment outcome literature. DBT would be recommended to the extent that the client falls into a diagnostic group for which there are data supporting the efficacy/effectiveness of DBT. Again, most studies have been conducted on individuals who meet criteria for BPD with current suicidal behavior, and emerging data support the application of DBT to other diagnostic groups as well.

A related consideration of particular relevance to the application of DBT to novel populations is the extent to which the client's presenting problems can be conceptualized according to theories upon which DBT is based. The existing studies seem to suggest that DBT is effective for clients whose problems can be conceptualized according to the biosocial theory as well as the behavioral theory (which emphasizes motivational factors and skills deficits in the maintenance of problem behavior). Because the problems of many clients with severe trauma histories or PTSD can be conceptualized this way (described further below), DBT may be effective for this population as well.

DBT, as with many behavioral therapies, emphasizes fully orienting clients to the goals and expectations of therapy before it begins. Clients are not considered to be "in" DBT until they agree to the goals and expectations of the treatment; therefore, clients who do not demonstrate a moderate degree of commitment are likely poor candidates for the treatment. Nonetheless, lack of motivation for therapy (and change, in general) is viewed as a central problem for many clients and, as such, a set of strategies exist within DBT to generate and strengthen commitment (e.g., evaluating the pros and cons, devil's advocate, shaping). Emphasis is also placed on eliciting clients' own goals and linking these goals to the goals and targets of DBT. Orienting to the structure and expectations of therapy has been emphasized by others in the treatment of PTSD and trauma-related problems (e.g., Foa & Rothbaum, 1998) as well as exposure-based treatments, in general (e.g., Barlow, 2004).

Several initial therapy sessions are typically spent in the pretreatment phase, and behavioral analyses are used to assess obstacles to commitment. Although for some clients the pretreatment phase can be lengthy, and some clients never commit, for the majority of cases this process is sufficient to obtain the commitment necessary to proceed in DBT. As mentioned above, many studies have shown that DBT is particularly effective at reducing treat ment dropout. This achievement may be due, in part, to the emphasis placed on providing orientation and eliciting commitment.

The above considerations for client selection are equally applicable to stage I and stage II DBT. We propose additional criteria for the consideration of beginning clients in stage II DBT (discussed later, in the section "From Stage I to Stage II DBT").

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