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Why DBT was Designed to be an Outpatient Treatment

DBT is not the ideal treatment for all clients. It is, however, a fantastic treatment for clients who have trouble managing large and intense emotions. DBT is also purposefully structured as an outpatient treatment. These two ideas go together.


Emotions are great. That’s a pretty big premise in DBT. They motivate us to affect change, communicate information to others, and are a way in which we communicate with ourselves. Humans need them and they also make life much richer. For some, emotions are experienced as gigantic and hard to manage, influence, and control. We call this “emotion dysregulation.” This dysregulation can lead to large life disruptions such as suicidal ideation, self-harm, substance abuse, and eating disorders, as well as other life disruptions like difficulties in relationships, mood swings, extreme thinking, and anxiety disorders.


For a person who struggles with emotion dysregulation, her life is often not manageable and certainly far from any ideal life that she might want to live. For example, if she is constantly battling suicidality and extreme moods, it can be impossible to make good life choices that are not fully informed by an emotional frame of mind. If her relationships are chaotic and stressful then she will fall time and again in the face of self-sabotage.


Therefore, for a person struggling with emotion dysregulation, her first goal in treatment is to reach a place of safety and stability. Once that groundwork is established over some time, then there is a foundation for her to start working on her quality of life and ultimately building meaning and purpose and a life worth living.


So, why is DBT specifically designed as an outpatient treatment? If someone is struggling so much, does it not make more sense to be in a more intensive level of care? Yes, in an inpatient or residential treatment setting, people can receive high-quality and frequent if not round-the-clock care. At the same time, these milieus do not mirror people’s actual lives. People stop their actual lives to be in a higher level of care.


This is problematic for two reasons:


  1. The person learns that she is not capable of being responsible for herself, as she needs to be cared for, she is dangerous and ill, and

  2. The person does not learn how to manage in the life she is struggling to manage in, so removing her from that life only reinforces that problem.


A person coming to DBT struggles when her emotions interact with the real world. And though it may seem harder, it is most beneficial for her to learn right from the very start how to manage her emotions in the real world and not only in the therapy space. For that reason, DBT treatment is specifically structured as an outpatient treatment so that as a person learns skills they can immediately be implemented in her life, phone coaching helps her figure out how to generalize skills learned to real-life situations, and, when things do not go as planned, they can be analyzed in session to plan better for the next time. The main point is - new behavior needs to be learned in all relevant contexts, not just where it is first learned.


At first glance, it may seem harsh, to want a client to go home and struggle in a very real way. And, at the same time, through immediately practicing skills in her real life and continuing therapy at the same time, the client develops the ability to make her real life manageable, achieving the number one goal.


Life for a DBT client does not need to be manageable during therapy; it needs to be manageable when dinner burns, when a friend does not respond, and when anxiety arrives during a crucial business meeting or school test. If she learns how to manage behind the strong gates of a protected facility, medication, and a constant string of providers responsible for her care, then the learning would be theoretical at best. Outpatient treatment enables the client to immediately manage in her real world, troubleshoot what goes wrong, and improve for the next time.


Eventually, it will click, new learning will happen, get repeated, absorbed, and become automatic. And when that does, those learned skills will be firmly embedded in her automatic toolbox. The skills might not always get used perfectly, and they will not go anywhere.


And neither will the client. Because she will know that she is able to manage her emotions and build her meaningful life.

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