First Do No Harm: Client and Staff Experiences of Negative Effects from Dialecetical Behaviour Therapy

Background: Research has shown that Dialectical Behaviour Therapy (DBT) is effective in reducing self-harm and suicidal ideation. However, research regarding experiences of DBT, particularly those of a negative nature, is sparse. The limited findings suggest that clients have reported difficulties in the therapeutic relationship, and staff have observed DBT to overly rigid, and constrained by organisational factors. However, no research has focused on both groups’ understandings of negative effects.

Aims: To explore client and staff experiences of the negative effects from DBT and investigate how their understandings compare. In addition, to explore how staff address any negative effects that arise.

Methodology: Underpinned by critical realism, this research adopted a qualitative approach. Eight client participants and seven staff participants, who had experienced or witnessed negative experiences from DBT, engaged in semistructured interviews, the transcripts of which were analysed using reflexive thematic analysis.

Analysis: Four themes relating to client experiences were generated: “I’m the problem”, “DBT can do no wrong”, “No understanding of trauma”, and ‘An unhealthy “blueprint for relationships”’. Five themes relating to staff experiences were generated: “It’s not me, it’s the client”, ‘DBT or nothing’, “We don’t do ‘why’ in DBT”, “We did make some changes”, and ‘Organisational “restrictions”’.

Conclusion: Both staff and clients understood negative effects from DBT to include pathologization and re-traumatisation. However, whilst clients related negative effects to the therapeutic relationship, staff highlighted the impact of organisational restrictions. Given the study design and selection bias, this study cannot ascertain the prevalence of negative effects from DBT. Nonetheless, the findings support recommendations for practice, including adapting DBT to become trauma-informed, and prioritising informed consent.