22 Pdf Preview (w)dialectical Behavioral Training

In this section:

Dialectical Behavioral Therapy (DBT) is a structured outpatient treatment as defined by Marsha Linehan, PhD (Linehan, et. Al., Cognitive-Behavioral Treatment of Borderline Personality Disorder, New York: Guilford Press, 1993), which combines strategies from behavioral, cognitive, and other supportive psychotherapies. Integrating Dialectical Behavior Therapy with The Twelve Steps A program for treating substance use disorders Bari K. Platter, MS, RN, PMHCNS-BC Osvaldo Cabral, LPC, MA, LAC. Training Objectives Review of EBP trends related to DBT and Twelve Step Facilitation (TSF) Discuss key concepts of DBT and TSF Compare stages and targets of DBT with. And Dialectical Behavioral Therapy (DBT) - in a manner that builds on the strengths of both approaches, and provides effective care for challenging behavioral health and substance use issues. Presenter will review the approaches of both models and discuss the commonalities between the approaches. Triebwasser, et al.Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder J Psychiatr Res, 57 (2014), pp. 108-116 Article Download PDF View Record in Scopus Google Scholar.

HIPAA Consent Form Sample The sample provided here is just that - a sample. Please use whatever agency-approved, required consent form your clinic has in place. If you have no current form, feel free to consider the information in this form as a starting place for customizing something useful for you.

Video recording of sessions and other very helpful resources for therapists pursuing certification: https://www.practiceground.org/pages/view/dbt-therapist-wiki .

Recommendations for enhancing certification readiness:

Foundational Theory

Applicants should have thorough knowledge of the following general topics:

Behavior Therapy
Cognitive Behavioral Therapy

Applicants should have thorough knowledge of the following DBT®-specific topics:

Bio-Social Theory and framework for DBT®
Validation
Dialectics
DBT Mindfulness
DBT Consultation Team
Suicide risk assessment/intervention
Skills training

Knowledge of the content of the 4 DBT® Skills Modules.
Includes understanding and application of principles of acquisition, strengthening, and generalization.
“In session” teaching as well as “in vivo” application.

The application of other principles of behavior therapy including:

Exposure-based procedures
Cognitive modification
Contingency management
Behavioral analysis

Other Special Treatment Strategies

Supervision/Consultation recommendations (not requirements)

Applicants with little or no DBT knowledge and/or experience: consider weekly supervision for a year with regular review of videotapes or live observation from a motivated DBT clinician who is responsibly practicing DBT®. In the course of that supervision, regularly consult and reference Cognitive Behavioral Treatment of Borderline Personality (Linehan, 1993) in order to better understand what to do and how to do it.
Applicants who begin considering certification after delivering DBT with a good deal of knowledge and/or experience already: consider supervision for at least 23 hours of clinical work - eight of those hours consisting of live observation or review of audio or videotapes by the supervisor.
As we gain more experience with applicants for certification, we would recommend that Teams initiate a regular process of peer review of session videos. This could be as simple as every month watching 10 or 15 minutes of each others' tapes. Teams who have initiated this practice notice significant improvements in clincians' delivery of DBT.

Fruzzetti Clinician Adherence Coding Resource

Dr. Alan Fruzzetti has created a free tool for all to use to informally rate therapy sessions for adherence. This link will take you to that resource. https://app.box.com/s/gpll5dwwd2v7i6wdgi0bttu9rhrsc1zm

Books and Chapters about Borderline Personality Disorder

A. From a Theory and Treatment Perspective

1. John G. Gunderson, M.D., with Paul S. Links, M.D., F.R.C.P.C. Borderline Personality Disorder: A Clinical Guide, Second Edition. Arlington, Va., American Psychiatric Publishing, 2008, 366 pp.

2. Paris, Joel. Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice.. New York: Guilford Press, 2008, 254 pp.

3. Chapman, Alex and Gratz, Kim (2007) . The Borderline Personality Disorder Survival Guide. Oakland, CA: .New Harbinger Publications, Inc.

4. Friedel, Robert O. (2004) . Borderline Personality Disorder Demystified New York, NY:. Marlow & Co.

5. Gunderson, JG. & Hoffman, PD. (2005) Understanding and Treating Borderline Personality Disorder: A Guide for Professionals and Families. Washington, DC: American Psychiatric Press, Inc.

6. Hoffman, PD, and Steiner-Grossman, P. (2008) . Borderline Personality Disorder: Meeting the Challenges to Successful Treatment. Philadelphia, PA: Haworth Press.

7. Bockian, N.R., Porr, V., & Vilagran, N.E., 2002. New Hope for People with Borderline Personality Disorder ; Roseville, CA: Prima Publishing Co. .

B. From a Personal Perspective

1. Thornton, M.F. 1998. Eclipses: Behind the Borderline Personality Disorder. Madison, AL: Monte Santo.

2. Wanklin, J. 1997. Let Me Make it Good: A Chronicle of My Life with Borderline Personality Disorder. Buffalo, NY: Mosaic Press.

3. Girl, Interrupted (Columbia Pictures, 1999).

II. Required Reading for Certification

A. Linehan, M.M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guildford Press.

B. Linehan, M.M. (1993). Skills training manual for treating borderline personality dirsorder. New York: Guilford Press.

III. Additional helpful resources

A. Linehan, M.M, & Schmidt, H. (1995). The dialectics of effective treatment of borderline personality disorder

B. Linehan, M.M. (1997) Validation and psychotherapy. In Bohart & L. Greenberg, Empathy Reconsidered

C. Swenson, C.R., Sanderson, C., Dulit, R.A., & Linehan, M.M. (2007) DBT for Inpatient Units Linehan, Bohus, Lynch (2007) DBT for Pervasive Emotion Dysregulation.

D. Lindenboim, Chapman, Linehan (2007) BPD. In Handbook of Homework Assignments in Psychotherapy

III. Theoretical Foundations of DBT

A. Validation

1. Linehan, M.M. (1997). Validation in psychotherapy. In Bohart & L. Greenberg, Empathy Reconsidered: New directions in psychotherapy (pp. 353-392). Washington, DC: American Psychological Association.

2. Koerner, K., Linehan, M.M. (2003). Validation Principles and Strategies. In O'Donohue, W. , Fisher, J.E., Hayes, S.C. (Eds.), Cognitive Bheavioral Therapy. New Jersey: John Wiley & Sons, Inc., 229-237.

B. Behavior Therapy

1. Barlow, D. H. (Ed.) (2007). Clinical handbook of psychological disorders(4thedition). New York: Guilford Press.

2. Bennett-Levy, J., Butler G., Fennell, M., Hackmann, A., Mueller, M., & Westbrook, D. (Eds.) (2004). Oxford guide to behavioural experiments in cognitive therapy. New York: Oxford Press.

3. Clark, D.M. & Fairburn, C. G. (1997).Science & practice of cognitive behaviour therapy. New York: Oxfor University Press.

4. Farmer, R.F. & Chapman, A.L. (2007). Behavioral interventions in cognitive therapy: Practical guidance for putting theory into action.American Psychological Association.

5. Foa, E. B., Hembree, E., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide (Treatments That Work).New York: Oxford Press.

6. Lieberman, D. (1999). Learning: Behavior and cognition (3rdEdition). Belmont, CA: Wadsworth Publishing Co.

7. Nezu, A., & Nezu, C. (2001). Problem solving therapy. Journal of Psychotherapy Integration, 11, (2), 187-205.

8. O’Donohue, W., Fisher, J. E.& Hayes, S. C. (Eds.) (2003). Cognitive behavior therapy: Applying empirically supported techniques in your practice. New York: John Wiley & Sons, Inc.

9. Ramnero,J. & Torneke (2008). The ABCs of human behavior.Oakland, CA: New Harbinger Publications.

10. Pryor, K. (1999). Don’t shoot the dog: The new art of teaching and training. New York: Bantam Doubleday Dell Publications [CONTINGENCY MANAGEMENT]

11. Goldfried, M. L. & Davidson, G. C. (1994).Clinical behavior therapy. New York: John Wiley & Sons, Inc.

IV. Efficacy Research on DBT

A. Randomized Controlled Trials

1. Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D., Heard, H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

2. Linehan, M.M. and Heard, H.L. (1993). Impact of treatment accessibility on clinical course with parasuicidal patients: In reply to R.E. Hoffman (letter to the editor). Archives of General Psychiatry, 50(2),157-158.

3. Linehan, M.M., Heard, H.L., Armstrong, H.E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971-974.

4. Linehan, M.M., Tutek, D.A., Heard, H.L., Armstrong, H.E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151, 1771-1776.

5. Linehan, M.M., Schmidt, H., Dimeff, L.A., Craft, J.C., Kanter, J., Comtois, K.A. (1999). Dialectical Behavior Therapy for patients with Borderline Personality Disorder and Drug-Dependence. The American Journal on Addictions, 8, 279-292.

6. Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Shaw Welch, S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67, 13-26.

7. Koons, C.R., Robins, C.J., Tweed, J.L., Lynch, T.R., Gonzalez, A.M., Morse, J.Q., Bishop, G.K., Butterfield, M.I., Bastian, L.A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371-390.

8. van den Bosch, L.M.C., Verhuel, R., Schippers, G.M., van den Brink, W. (2002). Dialectical Behavior Therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 37(6), 911-923.

9. Verheul, R., van den Bosch, L.M.C., Koeter, M.W.J., de Ridder, M.A.J., Stijnen, T., van den Brink, W. (2003). Dialectical behavior therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. British Journal of Psychiatry, 182, 135-140.

10. Telch, C.F., Agras, W.S., Linehan, M.M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69(6), 1061-1065.

11. Safer, D.L., Telch, C.F., Agras, W.S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158(4), 632-634.

12. Linehan, M.M. et al (2008) Olanzapine Plus DBT for Women with High Irritability (PDF)

13. Linehan et al (2006) NIMH 3 Two-Year Randomized Control Trials and Follow up of DBT

B. Non-Randomized Trials

1. Rathus, J.H., Miller, A.L. (2002). Dialectical Behavior Therapy adapted for suicidal adolescents. Suicide and Life-Threatening Behavior, 32(2), 146-157.

2. Trupin, E.W., Stewart, D.G., Beach B., Boesky, L. (2002). Effectiveness of a dialectical behavior therapy program for incarcerated female juvenile offenders. Child and Adolescent Mental Health, 7, 121-127.

3. Bohus, M., Haaf, B., Stiglmayr, C., Pohl, U., Boehme, R., Linehan, M. (2000). Evaluation of inpatient Dialectical Behavioral Therapy for Borderline Personality Disorder -- A prospective study. Behaviour Research and Therapy, 38(9), 875-887.

4. Barley, W.D., Buie, S.E., Peterson, E.W., Hollingsworth, A.S., Griva, M., Hickerson, S.C., Lawson, J.E., Bailey, B.J. (1993). The development of an inpatient cognitive-behavioral treatment program for borderline personality disorder. Journal of Personality Disorders, 7(3), 232-240.

5. Stanley, B., Ivanoff, A., Brodsky, B., Oppenheim, S. (November, 1998). Comparison of DBT and 'treatment as usual' in suicidal and self-multilating behavior.

6. McCann, R. A., Ball, E.M., Ivanoff, A. (2000). DBT with an Inpatient Forensic Population: The CMHIP Forensic model. Cognitive and Behavioral Practice, 7, 447-456.

7. McCann, R.A., Ball, E.M. (2000). The effectiveness of DBT with forensic inpatients. Institute for Forensic Psychiatry.

V. Standard DBT Treatment and Trainings Resources

A. Mindfulness

1. Linehan, M.M. (2005). This One Moment: Skills for Everyday Mindfulness (DVD). Behavioral Tech LLC.

B. Consultation Team Resources

1. DBT Consultation Team Commitment Session for New Members

2. DBT Consultation Team Agreements

3. DBT Consultation Team Format and Tasks

4. DBT Consultation Team Member Tasks

5. Consultation Team Attendance Log

6. Consultation Team Check List

7. Consultation Team Meeting Agenda

8. Consultation Team Observer Tasks

C. Behavioral Analysis Tools

1. Behavioral Analysis

2. Chain Analysis Instructions

3. Chain Analysis Worksheet

4. Defining Problems Behaviorally

D. Case Formulation

1. Koerner, K., Linehan, M.M. (1997). Case Formulation in Dialectical Behavior Therapy for Borderline Personality Disorder. In T. Eells (Ed.) Handbook of Psychotherapy Case Formulation. New York: Guilford Press, 340-367.

VI. DBT and Treatment Costs

A. Reduced Hospitalization

1. Sunseri, P.A. (2004). Preliminary outcomes on the use of Dialectical Behavior Therapy to reduce hospitalization among adolescents in residential care (non-RTC). Residential Treatment for Children & Youth, 21(4). Haworth Press. Available for puchase at http://www.tandfonline.com/doi/abs/10.1300/J007v21n04_06#preview

VII. DBT For Specific Populations and Settings

A. Adolescents

1. Research

a. Rathus, J.H., Miller, A.S. (2002). Dialectical Behavior Therapy adapted for suicidal adolescents. Suicide and Life-threatening Behaviors 32(2), 146 -157.

2. Books, Chapters

a. Adolescent DBT Supervision/Consultation. Miller, AL, & Hartstein, JL. (2006). Dialectical behavior therapy supervision and consultation with suicidal, multi -problem youth: The nuts and bolts. In, Helping others help children: Clinical supervision of child psychotherapy. Neill, T. (Ed.). American Psychological Association Press.

3. Therapy Manuals and Materials

a. Adolescent Dialectics. Miller, A.L., Rathus, J.H. (2002). Adolescent dialectical dilemmas. Behavioral Tech, L.L.C.

b. Adolescent Skills Training Handouts Miller, A.L., Rathus, J.H., Landsman, (1997). DBT Multifamily Skills Training for Suicidal Adolescents. Adapted from Marsha M. Linehan's Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1992.

B. Inpatient Units

1. Research

a. Swenson, C.R., Sanderson, C., Dulit, R.S. (2001). The application of Dialectical Behavior Therapy for patients with Borderline Personality Disorder on inpatient units. Psychiatric Quarterly, 72(4). Behavior, 32(2). Human Sciences Press, Inc. The American Association of Suicidology.

b. Katz, L.Y., Gunasekara, S., Cox, B.J., & Miller, A.L. (2004). Feasibility of dialectical behavior therapy for parasuicidal adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 276-282.

C. Community Mental Health Settings

1. Fox, T. (1998). Integrating dialectical behavioral therapy into a community mental health program. Psychiatric Service, 49 (10), 1338-1340.

D. Substance Abuse/Dependence

1. Research

a. Dual Dx Randomized Controlled Trial Linehan, M.M., Schmidt, H., Dimeff, L.A., Craft, J.C., Kanter, J., Comtois, K.A. (1999). Dialectical Behavior Therapy for patients with Borderline Personality Disorder and Drug Dependence. The American Journal on Addictions, 8, 279-292.

b. Dual Dx Randomized Controlled Trial Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Shaw Welch, S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67, 13-26.

E. Eating Disorders

1. Resesarch

a. Telch, C.F., Agras, W.S., Linehan, M.M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69(6), 1061-1065. (Randomized Controlled Trial)

b. Telch, C.F., Agras, W.S. and Linehan, M.M. (2000). Group Dialectical Behavior Therapy for Binge Eating Disorder: A Preliminary Uncontrolled Trial. Behavior Therapy, 31, 569-582.

2. Books, Chapters and Manuals

a. Wiser, S. and Telch, C.F. (1999). Dialectical Behavior Therapy for Binge-Eating Disorder. In Session: Psychotherapy in Practice, 55(6), 755-768. John Wiser & Sons.

b. Astrachan-Fletcher, E. and Maslar, M. (2009). The Dialectical Behavior Therapy Workbook for Bulimia: Using DBT to Break the Cycle and Regain Control of Your Life. New Harbinger Publications.

F. Families of DBT Clients

1. Hoffman, P., Fruzetti, A., and Swenson, S. (1999). Dialectical Behavior Therapy - Family Skills Training. Family Process, 38(4), 399-414.

2. Rother, K., Friedman, F.B. (2003). Surviving a Borderline Parent. New Harbinger Publications.

3. Manning, S.Y., Linehan, M.M. (2011). Loving Someone with Borderline Personality Disorder. Guilford Press.

4. Porr, V. ( 2010 ). Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change. Oxford University Press.

5. If Only I Had Known: A Family Guide to Borderline Personality Disorder (5 DVD Set). Dawkins Productions.

6. Gunderson, JG. & Hoffman, PD. (2005) Understanding and Treating Borderline Personality Disorder: A Guide for Professionals and Families. Washington, DC: American Psychiatric Press, Inc.

7. Hoffman, PD, and Steiner-Grossman, P. (2008) . Borderline Personality Disorder: Meeting the Challenges to Successful Treatment. Philadelphia, PA: Haworth Press.

G. Couples

1. Fruzzetti, A.E., (2006). The High Conflict Couples: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy & Validation. New Harbinger Publications, Inc., Oakland, CA.

VIII. Websites and Organizations

A. Behavioral Research and Therapy Clinics -

B. BPD Central - www.bpdcentral.com

C. Mental Health Sanctuary -

D. National Education Alliance for Borderline Personality Disorder (NEA-BPD) - http://www.neabpd.com/

E. TARA (The Treatment and Research Advancements Association for Personality Disorder) - www.tara4bpd.org.

F. Practice Ground is part of the Learning Community (a yearly subscription training group), which also provides a DBT Clinician WiKi where great resources are available to clinicians for free. http://www.practiceground.org/dbt-therapist-wiki/

Consultation Team Resources

DBT Consultation Team

“I have come to believe that it is extraordinarily difficult to deliver effective treatment to most borderline patients without consultation or supervision. I have been amazed at how many very good therapists end up conducting ineffective therapy or making major mistakes with this patient population.”

– Marsha Linehan (1993, p. 424)

Ongoing participation in a DBT Consultation Team is required for DBT-LBC certification. Consultation team is often referred to as “therapy for the therapist.” The team's role is to “help the therapist think clearly about how to conceptualize the patient, the relationship, and behavioral change in DBT theoretical terms, and how to apply the treatment skillfully.” (Linehan, 1993, p. 428). The team also helps each member maintain balanced attitudes and behaviors toward clients and members act as cheerleaders to maintain the motivation of each member.

DBT consultation teams fulfill their function most effectively when they consistently meet these five standards:

1. Orientation and Commitment

Being a member of a DBT Consultation Team means assuming certain responsibilities, agreeing to interact in particular ways, and accepting certain foundational assumptions about one's self as a DBT therapist as well as one's clients and consultation teammates. An orientation and commitment process helps new members understand these expectations in advance so that they can make an informed choice about team participation. See a detailed DBT Consultation Team orientation and commitment list for new members below.

2. Behavioral Agreements: Members agree to do the following:

remain compassionate, non-judgmental, mindful and dialectical,
be engaged in team and not be silent observers or only focused on their own work,
treat the meeting as vital to the DBT process and to avoid distractions or cancellations,
do homework and come prepared,
give advice even to those with more clinical experience,
have humility to admit mistakes,
assess problems before giving solutions,
call out the “elephant in the room”,
be willing to undergo chain analysis for one’s own problem behaviors,
ask for permission, prepare for and repair after, when missing team,
speak up when concerned or frustrated by the process,
carry on even when feeling burnt out, frustrated, tired, overworked, under-appreciated, hopeless, ineffective…

3. Consultation Team Agreements: Team members accept these fundamental perspectives as a shared foundation for thinking about themselves, their clients, and each other. A detailed description of the Agreements is available [here: DBT Team Agreements.doc]

Dialectical Agreement (to follow a dialectical philosophy);
Consultation to the client agreement (to empower and not fragilize clients);
Consistency Agreement (to not insist on consistency, but accept diversity and change);
Phenomenological empathy agreement (to find empathic, non-pejorative interpretations of ours and others' behaviors);
Fallibility agreement (to admit to mistakes, humanness and to recognize and let go of defensiveness).

4. Roles during DBT Consultation Team Meetings

Members agree to assume any one of these roles (as needed) at each meeting. A detailed description of each role is available [here: Team Roles.doc]

Meeting Leader – manages the agenda and how time is spent. Although teams may have a member who is considered a leader based on DBT experience, the role of meeting leader is rotated.
Observer – is mindful of deviations from Team Agreements and other ineffective behaviors during the meeting. Brings the team's attention to those as they arise.
Note Taker – takes notes on the content of the meeting, including issues brought for consultation and advice given by the team.
Member – Actively participates in assessment of issues brought for consultation, including defining the problem behaviorally and helping to formulate solution strategies.

5. Structure of DBT Consultation Team Meeting: A detailed example of a DBT meeting is available [here: DBT Consultation Team Format]. Meetings happen weekly and for at least 60 minutes – ideally for 90 minutes. Generally, meeting activities occur in this order:

Mindfulness practice;
Agenda Setting (an agenda template is available [here: DBT Consultation Team Agenda Signup.doc]);
Case Consultation (based on hierarchy of targets and urgency rating);
Teaching

DBT Consultation Team Commitment for New Members

All new DBT team members should meet with the team leader, a team member, or, in some cases, the entire team, for a commitment session before they join the team. The following items are reviewed during the commitment session with the emphasis on assuring that the potential new consultation team member understands:

1. What a DBT consultation team is and how the team functions.

2. What the obligations of team members are.

3. The ramifications of each commitment that is made (i.e.; the upside and downside of each commitment).

4. That participation in a DBT team must be voluntary, but that once a commitment is made, there will be every expectation that the member abides by the commitments made.

The strategies used in this meeting are identical to those used in commitment sessions with new clients in DBT, including, for example, orienting to DBT team, all of the commitment strategies, troubleshooting, etc.

The most fundamental commitments required to be on the team are the following:

1. The primary function of a DBT team is to increase the therapist’s motivation and capability in applying DBT with clients. Thus, when joining a team, members agree to participate in team consultation meetings and make every effort to increase their own and other team members’ effectiveness as DBT therapists and adherence to DBT principles.

2. DBT is a community of therapists treating a community of clients. Therefore, when joining a team, members agree to be responsible for the outcomes of ALL clients treated by the team. It is not a minor responsibility to worry about the other therapists and clients on the team and to agree to be a full-fledged member of the community of therapists treating the community of clients. For example, by extension, members are agreeing that if a client seen by any therapist on the team commits suicide, all therapists will say “yes” when asked if they have ever had a client commit suicide.

Further commitments that must be discussed and agreed upon when joining a DBT consultation team include the following:

1. To keep the agreements of the team, especially remaining compassionate, mindful, and dialectical.

2. To be available to see a client in whatever role one has joined the team for, e.g., individual therapist, group skills trainer, clinical supervisor, pharmacotherapist.

3. To function as a therapist in the group (to the group) and not just be a silent observer or a person that only speaks about his or her own problems.

4. To treat team meetings in the same way as one treats any other group therapy session, i.e., attending the weekly meetings (not double scheduling other events or clients), on time, until the end, with pagers, PDAs, and phones out of sight and off or, if necessarily on, on silent.

5. To come to team meetings adequately prepared.

6. To be willing to give clinical advice to people that have more experience than you (especially when it’s hard to imagine yourself as being able to offer anything useful).

7. To have humility to admit your mistakes/difficulties and the willingness to have the group help you solve them.

8. To be nonjudgmental and compassionate of your fellow clinicians and clients. To ring the bell of nonjudgmentalness to remind yourself to not be judgmental or to be mindful, but not to ring it as a proxy for criticizing someone. The bell is a reminder, not a censor.

9. To properly assess the problem before giving solutions (Do unto others as you wish they would more often do unto you).

10. To call out the “elephant in the room” when others are ignoring or not seeing the elephant.

11. To be willing to got through a chain analysis even though you were only 31 seconds late and you would have been there on time if it wasn’t for that traffic light that always takes all day to change and is nothing but a huge pain in the (I digress…)—show up on time or call.

12. To participate in team by sharing the roles of Leader, Observer, Note Taker or other tasks critical to team functioning.

13. If you feel that the consult team is not being useful or you don’t like the way it is being run, to say something about it rather than silently stewing in frustration.

14. To ask the team for permission when planning to go out of town.

15. To repair with the team in some way when team meetings are missed.

16. To carry on even when feeling burnt out, frustrated, tired, overworked, underappreciated, hopeless, ineffective (easier committed to than done, of course).

DBT Consultation Team Agreements

1. Dialectical Agreement: We agree to accept a dialectical philosophy: There is no absolute truth (nor is truth relative). When caught between two conflicting opinions, we agree to look for the truth in both positions and to search for a synthesis by asking such questions as, “What is being left out?”

2. Consultation to the Client Agreement: We agree that the primary goal of this team is to improve our own skills as DBT therapists, and not serve as a go-between for clients to each other. We agree to not treat clients or each other as fragile. We agree to treat other team members with the belief that others can speak on their own behalf.

3. Consistency Agreement: Because change is a natural life occurrence, we agree to accept diversity and change as they naturally come about. This means that we do not have to agree with each other’s positions about how to respond to specific clients, nor do we have to tailor our own behavior to be consistent with everyone else’s.

4. Observing Limits Agreement: we agree to observe our own limits. As therapists and team members, we agree to not judge or criticize other members for having different limits from our own (e.g.: too broad, too narrow, “just right”).

5. Phenomenological Empathy Agreement: All things being equal, we agree to search for non-pejorative or phenomenologically empathic interpretations of our client’s, our own, and other members’ behavior. We agree to assume we and our clients are trying our best, and want to improve. We agree to strive to see the world through our clients’ eyes and through one another’s eyes. We agree to practice a nonjudgmental stance with our clients and one another.

6. Fallibility Agreement: We agree ahead of time that we are each fallible and make mistakes. We agree that we have probably either done whatever problematic things we’re being accused of, or some part of it, so that we can let go of assuming a defensive stance to prove our virtue or competence. Because we are fallible, it is agreed that we will inevitably violate all of these agreements, and when this is done, we will rely on each other to point out the polarity and move to a synthesis.

DBT Consultation Team Member Tasks - examples

Meeting Leader (same as mindfulness leader):

1. Develops agenda with team members

2. Determines the order of the agenda

3. Manages time

4. Reads one of the Dialectical Agreements

Observer (leader from previous week) observes and rings bell lightly when:

1. A dialectic is unresolved

2. Anyone (client or therapist) is treated as fragile (is an elephant in the room?)

3. A judgmental/non-compassionate comment is made

4. Defensiveness arises, forgetting that we are all fallible

5. Non-mindfulness, doing two things at once appears

6. Solutions given before the problem is assessed

7. Treatment recommendations/comments violate DBT principles

8. Consultant-to-the-team/DBT team leader intervening, doing rather than teaching

Note Taker (next up as meeting leader) takes notes during the meeting of:

1. Therapist-client dyads discussed

2. Problems brought up

3. Advice given

4. Topics unaddressed due to time

5. Issues/agreements for follow-up at next meeting

Consultation Members:

1. Participate, remembering that therapists always have something to say, i.e.: staying silent throughout an entire consultation meeting is not participating

2. Consult with members who want consultation

a. First, get agreement on problem presented and get it defined behaviorally (client behavior is problem; therapist behavior is problem; therapist wants to summarize and get validation/cheerleading/sympathy

b. Second, assess problem behaviorally:

i. Look for reinforcers

ii. Look for aversive consequences

iii. Look for inadequate or inappropriate stimulus control

iv. Consider skills deficits

v. Ask about secondary targets that might be contributing

c. Third, suggest strategies based on assessment/formulation

d. Fourth, check if more help is needed

3. Give feedback to and coach team members who fall out of DBT in their therapy or during the meeting

4. Highlight “elephants in the room” and topic avoidance when they arise

5. Listen to and validate (when appropriate) members who wish to share or process experiences with clients or other team members.

CONSULTATION TEAM MEETING CHECKLIST

Part A: Structure of the Consultation Team Meeting

The Team designated:

□ A Team Leader (TL)

Training Courses Dialectical Behavior Therapy

□ An Observer

□ A Note Taker (NT)

□ The TL led a mindfulness practice

□ The TL read one of the Consultation Team Agreements

□ The NT read the notes from last team meeting

□ The TL Identified a Dyad of the Week to discuss

□ The TL checked if anyone was going out of town

□ The Team identified back-up coverage

□ No clinician expressed plans to go out of town

□ The TL asked for updates to the emergency contact sheet

The TL checked if anyone had clients with:

□ Life-Threatening Behavior (including imminent risk)

□ Therapy Interfering Behavior (including approaching 4 misses)

□ Serious Quality of Life Interfering Behavior

The TL checked if any therapists were engaging in:

□ Unethical, severely irresponsible behavior

□ Team interfering behavior

□ Therapy Interfering Behavior

The TL checked if any therapists were approaching burnout

The TL rang the bell to end the meeting

General Team Process

□ The team discussions focused on primarily THERAPIST behavior vs. client

□ Highlighting, targeting, and problem-solving conducted with easy manner

□ A strong position was expressed about a clinical or related issue

□ Someone on the team brought up an opposing issue

□ The dialectic or tension was highlighted

□ The team worked to achieve synthesis

□ The team meeting involved a balance of acceptance and change-based styles

Part B: Behaviors During the Consultation Team Meeting

□ A therapist was doing 2 things at once (i.e.: reading and listening, talking on the telephone, chatting out of turn with other members)

□ The Observer range the bell

□ The behavior was highlighted and blocked by the team

□ A therapist was treated as fragile. An obvious issue came up that needed to be targeted (i.e.: defensiveness, judgmental talking, lateness) that was not highlighted or discussed by the team. Or, feedback clearly was needed, but was not provided.

□ The Observer range the bell

□ The behavior was highlighted

□ The team discussed the avoided issue or provided the needed feedback

□ A therapist displayed defensiveness in response to feedback

□ The Observer range the bell

□ The behavior was highlighted

□ The therapist was asked to rephrase the statement

□ A therapist offered solutions before the problem was defined

□ The Observer range the bell

□ The behavior was highlighted

□ The problem was clarified

□ A therapist engaged in self-invalidation (denigrating self, judgmental toward self, presenting as incompetent)

□ The Observer range the bell

□ The behavior was highlighted

□ The therapist was asked to rephrase the invalidating statement

□ A therapist spoke in a judgmental or derogatory manner about his or her clients

□ The Observer range the bell

□ The behavior was highlighted

□ The therapist was asked to rephrase the judgmental statement

□ A therapist was late for the meeting

□ The behavior was highlighted

□ A chain analysis was conducted

□ Solutions were agreed upon

□ A commitment to implement a solution was elicited

□ A therapist was obviously unprepared

□ The behavior was highlighted

□ A chain analysis was conducted

□ Solutions were agreed upon

□ A commitment to implement a solution was elicited

□ A therapist did not speak during the meeting

□ The behavior was highlighted

□ A chain analysis was conducted

□ Solutions were agreed upon

□ A commitment to implement a solution was elicited

In this section:

Video recording of sessions and other very helpful resources for therapists pursuing certification: https://www.practiceground.org/pages/view/dbt-therapist-wiki .

Recommendations for enhancing certification readiness:

Foundational Theory

Applicants should have thorough knowledge of the following general topics:

Behavior Therapy
Cognitive Behavioral Therapy

Applicants should have thorough knowledge of the following DBT®-specific topics:

Bio-Social Theory and framework for DBT®
Validation
Dialectics
DBT Mindfulness
DBT Consultation Team
Suicide risk assessment/intervention
Skills training

Knowledge of the content of the 4 DBT® Skills Modules.
Includes understanding and application of principles of acquisition, strengthening, and generalization.
“In session” teaching as well as “in vivo” application.

The application of other principles of behavior therapy including:

Exposure-based procedures
Cognitive modification
Contingency management
Behavioral analysis

Other Special Treatment Strategies

Supervision/Consultation recommendations (not requirements)

Applicants with little or no DBT knowledge and/or experience: consider weekly supervision for a year with regular review of videotapes or live observation from a motivated DBT clinician who is responsibly practicing DBT®. In the course of that supervision, regularly consult and reference Cognitive Behavioral Treatment of Borderline Personality (Linehan, 1993) in order to better understand what to do and how to do it.
Applicants who begin considering certification after delivering DBT with a good deal of knowledge and/or experience already: consider supervision for at least 23 hours of clinical work - eight of those hours consisting of live observation or review of audio or videotapes by the supervisor.
As we gain more experience with applicants for certification, we would recommend that Teams initiate a regular process of peer review of session videos. This could be as simple as every month watching 10 or 15 minutes of each others' tapes. Teams who have initiated this practice notice significant improvements in clincians' delivery of DBT.

Fruzzetti Clinician Adherence Coding Resource

Books and Chapters about Borderline Personality Disorder

A. From a Theory and Treatment Perspective

1. John G. Gunderson, M.D., with Paul S. Links, M.D., F.R.C.P.C. Borderline Personality Disorder: A Clinical Guide, Second Edition. Arlington, Va., American Psychiatric Publishing, 2008, 366 pp.

2. Paris, Joel. Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice.. New York: Guilford Press, 2008, 254 pp.

3. Chapman, Alex and Gratz, Kim (2007) . The Borderline Personality Disorder Survival Guide. Oakland, CA: .New Harbinger Publications, Inc.

4. Friedel, Robert O. (2004) . Borderline Personality Disorder Demystified New York, NY:. Marlow & Co.

5. Gunderson, JG. & Hoffman, PD. (2005) Understanding and Treating Borderline Personality Disorder: A Guide for Professionals and Families. Washington, DC: American Psychiatric Press, Inc.

6. Hoffman, PD, and Steiner-Grossman, P. (2008) . Borderline Personality Disorder: Meeting the Challenges to Successful Treatment. Philadelphia, PA: Haworth Press.

7. Bockian, N.R., Porr, V., & Vilagran, N.E., 2002. New Hope for People with Borderline Personality Disorder ; Roseville, CA: Prima Publishing Co. .

B. From a Personal Perspective

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