The Transition into and Journey through Stage 2 DBT

The beautiful thing about Stage 1 targets in DBT is that we know exactly what to treat and when. The big challenge for many of us is figuring out what to do once our clients are no longer cutting, attempting suicide, verbally attacking us and their loved ones, or engaging in the myriad of other problematic Stage 1 dysfunctional behaviors. Thanks to our good work together throughout the Stage 1 process, they’re shaped up but still in the midst of hell with a whole lot of quiet desperation. Now what?

Now what? The Transition into and Journey through Stage 2
Within many corners of our DBT community, from our own team consultations to the Linehan’s DBT Strategic Planning meeting comprised of DBT researchers from around the globe, this has been a topic of great interest and discussion for the past decade. A myriad of questions open up: How do you know when a person is now in Stage 2? What are the criteria? If a person has a lapse and resumes Stage I behavior, do you go back to treating them as a Stage I client or continue your Stage 2 work? And…what exactly do you do in Stage 2? As is often said anytime we seek to pin down a DBT expert on a particular clinical question, “It all depends.”

Fortunately, there are a number of guideposts as we journey with our clients into Stage 2. What we know to be certain is that Stage 2 treatment is idiographic. This means that what we do, how we do it, and what it looks like all depends on the problems they present and ultimately on developing a very tight case formulation. From there, we then build out interventions tied directly to what we learn that is reflected in this case formulation.

The good news for those of us interested in Stage 2 is that there are some givens. We know, for example, that there tends to be a strong focus on exposure-based interventions, validation and developing the capacity for self-validation, as well as skills and strategies for promoting emotional acceptance/willingness, so we will discuss these in some detail.