What is the 4-miss rule in DBT?

The 4-miss rule in DBT is quite simple: clients who miss four weeks of individual sessions OR four skills classes in a row must leave the program. This rule is stated upfront, to set up a clear expectation: if you miss four appointments, that is considered a premature dropout. Until you miss four, you’re still in.

This information is provided to DBT clients during the early part of treatment, before a commitment to the program is made. By clearly laying out this expectation, clients know the difference between simply missing appointments and dropping out.

In many types of therapy, clients are allowed to “drift in and out” of treatment. When some people get relief, or their situation improves, they think they don’t need therapy anymore and they stop coming. Then, when symptoms return or they encounter some obstacle, they return to therapy. This makes lasting progress impossible. The DBT 4-miss rule helps to prevent this.

Return to a DBT program is contingent upon availability, and clients must generally wait many months before being able to return (depending on when they dropped out). The rule is that a client is eligible to return once their contracted period is over (generally a year from when they began formal treatment). Readmission generally requires the client to make a strong recommitment to treatment, and to address the reasons for their premature dropout to ensure it does not happen again.

“DBT has only one formal termination rule: Patients who miss 4 weeks of scheduled therapy in a row, either required skills training or individual therapy, are out of the program. They cannot return to therapy until the end of the current contracted period, and then return is a matter of negotiation. There are no circumstances under which this rule is broken. There are no good reasons in DBT for missing 4 weeks of scheduled therapy.”

Linehan, Cognitive-Behavioral Treatment of Borderline Personality Disorder