dbt implementation: how to do it well… and badly… kate comtois, ph.d. pbhjp grand rounds 6/15/09...

DBT DBT Implementation:Implementation:

How to do it well… How to do it well… and badly…and badly…

DBT DBT Implementation:Implementation:

How to do it well… How to do it well… and badly…and badly…

Kate Comtois, Ph.D.Kate Comtois, Ph.D.PBHJP Grand RoundsPBHJP Grand Rounds

6/15/096/15/09

Kate Comtois, Ph.D.Kate Comtois, Ph.D.PBHJP Grand RoundsPBHJP Grand Rounds

6/15/096/15/09

Knowing about Knowing about DBT vs. Knowing DBT vs. Knowing

DBTDBT

Knowing about Knowing about DBT vs. Knowing DBT vs. Knowing

DBTDBT I’ll be explaining that a I’ll be explaining that a

lot of things exist in lot of things exist in DBT and are important DBT and are important

without actually without actually teaching them… teaching them…

I’ll be explaining that a I’ll be explaining that a lot of things exist in lot of things exist in

DBT and are important DBT and are important without actually without actually teaching them… teaching them…

OverviewOverviewOverviewOverview

•Overview of comprehensive, Overview of comprehensive, integrated, and informed DBTintegrated, and informed DBT

•Modes and Functions of Modes and Functions of Comprehensive DBTComprehensive DBT

•Key Elements of DBTKey Elements of DBT

•How DBT is trainedHow DBT is trained

•How DBT implementation goes How DBT implementation goes bad….bad….

•Overview of comprehensive, Overview of comprehensive, integrated, and informed DBTintegrated, and informed DBT

•Modes and Functions of Modes and Functions of Comprehensive DBTComprehensive DBT

•Key Elements of DBTKey Elements of DBT

•How DBT is trainedHow DBT is trained

•How DBT implementation goes How DBT implementation goes bad….bad….

Three Ways to Implement Three Ways to Implement DBTDBT

Three Ways to Implement Three Ways to Implement DBTDBT

•Comprehensive DBTComprehensive DBT –Has all the structureHas all the structure

–Has all the principlesHas all the principles

–Has all the strategiesHas all the strategies

• Integrated DBTIntegrated DBT–Has specific elements of DBT integrated Has specific elements of DBT integrated

into another treatment (e.g., FIT)into another treatment (e.g., FIT)

– Those DBT strategies used are adherent Those DBT strategies used are adherent to DBTto DBT

•DBT informedDBT informed–Uses elements of DBT in non-adherent Uses elements of DBT in non-adherent

wayway

•Comprehensive DBTComprehensive DBT –Has all the structureHas all the structure

–Has all the principlesHas all the principles

–Has all the strategiesHas all the strategies

• Integrated DBTIntegrated DBT–Has specific elements of DBT integrated Has specific elements of DBT integrated

into another treatment (e.g., FIT)into another treatment (e.g., FIT)

– Those DBT strategies used are adherent Those DBT strategies used are adherent to DBTto DBT

•DBT informedDBT informed–Uses elements of DBT in non-adherent Uses elements of DBT in non-adherent

wayway

DBT Modes and DBT Modes and FunctionsFunctions

DBT Modes and DBT Modes and FunctionsFunctions

Standard Outpatient DBT Standard Outpatient DBT ModesModes

Weekly individual therapy Weekly skills training

group/class Weekly consultation team

meetings Phone consultation to client

as needed Auxiliary (outside of DBT

team) Inpatient Pharmacotherapy Family interventions Other treatments

Introduction to Treatment Introduction to Treatment Structure: Structure:

Functions DBT Needs to Functions DBT Needs to AchieveAchieve Enhance capabilities of client

Improve motivation of client for treatment and long term goals

Assure generalization to home, school, sports or activities, peers, etc.

Structure the environment to support treatment and long term goals Direct intervention with family

or friends Intervention with other

treatment providers or social services

Enhance the capabilities and motivation of therapists to do the treatment

Modes of Standard Adult Modes of Standard Adult DBTDBT

Modes of Standard Adult Modes of Standard Adult DBTDBT

•Client capabilities

•Client motivation

•Generalization

• Structuring the environment

• Therapist capability and motivation

•Client capabilities

•Client motivation

•Generalization

• Structuring the environment

• Therapist capability and motivation

• Skills training groupSkills training group

• Individual therapyIndividual therapy

• Phone consultationPhone consultation

• Individual therapist Individual therapist

during or out of during or out of

sessionsession

• Consultation meetingsConsultation meetings

• Skills training groupSkills training group


• Phone consultationPhone consultation


during or out of during or out of

sessionsession


Modes of Standard Modes of Standard Adolescent DBTAdolescent DBT

Modes of Standard Modes of Standard Adolescent DBTAdolescent DBT

• Client capabilitiesClient capabilities

• Client motivationClient motivation

• GeneralizationGeneralization

• Structuring the Structuring the

environmentenvironment

• Therapist Therapist

capability and capability and

motivationmotivation




• Structuring the Structuring the

environmentenvironment

• Therapist Therapist

capability and capability and

motivationmotivation

•Multi-family skills groupMulti-family skills group


• Phone consultation and Phone consultation and

parents practicing at parents practicing at

homehome


during or out of session; during or out of session;

family sessionsfamily sessions


•Multi-family skills groupMulti-family skills group




homehome


during or out of session; during or out of session;

family sessionsfamily sessions


Modes of DBT in FIT (as of 5 Modes of DBT in FIT (as of 5 yrs ago)yrs ago)

Modes of DBT in FIT (as of 5 Modes of DBT in FIT (as of 5 yrs ago)yrs ago)




• Structuring the Structuring the environmentenvironment

• Therapist Therapist capability and capability and motivationmotivation






• DBT skills taught to kid DBT skills taught to kid and family in the homeand family in the home

• Chain analysis and Chain analysis and

validationvalidation



homehome

• MST strategiesMST strategies


• DBT skills taught to kid DBT skills taught to kid and family in the homeand family in the home

• Chain analysis and Chain analysis and

validationvalidation



homehome



Modes of Residential DBTModes of Residential DBTModes of Residential DBTModes of Residential DBT











• Skills training (i.e. group)Skills training (i.e. group)

• Individual therapy and Individual therapy and behavior modification planbehavior modification plan

• Coaching by therapist and Coaching by therapist and floor stafffloor staff

• Primary therapist with Primary therapist with social work, shift change, social work, shift change, etc plus family or DCF etc plus family or DCF meetings etcmeetings etc

• Consultation meetings Consultation meetings (separate or part of team)(separate or part of team)

• Skills training (i.e. group)Skills training (i.e. group)



• Primary therapist with Primary therapist with social work, shift change, social work, shift change, etc plus family or DCF etc plus family or DCF meetings etcmeetings etc


Modes of Acute Inpatient Modes of Acute Inpatient DBTDBT

Modes of Acute Inpatient Modes of Acute Inpatient DBTDBT











• Skills training through Skills training through subset of skillssubset of skills



• Primary therapist with social Primary therapist with social work, shift change, etc plus work, shift change, etc plus family or DCF meetings etcfamily or DCF meetings etc


• Skills training through Skills training through subset of skillssubset of skills



• Primary therapist with social Primary therapist with social work, shift change, etc plus work, shift change, etc plus family or DCF meetings etcfamily or DCF meetings etc


Key Elements of Key Elements of DBTDBT

Key Elements of Key Elements of DBTDBT

•Targets•Emotion Focus and Chain Analysis•DBT skills•Dialectics and Validation•Commitment to Treatment•Consultation team•Evaluation of outcomes

•Targets•Emotion Focus and Chain Analysis•DBT skills•Dialectics and Validation•Commitment to Treatment•Consultation team•Evaluation of outcomes

DBT is essentially radical behavior

therapy

DBT is essentially radical behavior

therapy What follows are the unique What follows are the unique

elements that appear crucial…elements that appear crucial…

We don’t yet know empirically We don’t yet know empirically what matters… (and I’ve left what matters… (and I’ve left

out stuff out)out stuff out)

What follows are the unique What follows are the unique elements that appear crucial…elements that appear crucial…

We don’t yet know empirically We don’t yet know empirically what matters… (and I’ve left what matters… (and I’ve left

out stuff out)out stuff out)

DBT TargetsDBT Targets DBT TargetsDBT Targets

Introduction to Treatment Introduction to Treatment Structure: Structure:

Stages and Targets for Stages and Targets for IndividualIndividual Stage 1: Behavior Dyscontrol

• Suicidal and Life-Threatening Behavior • Therapy Interfering Behavior• Quality of Life Interfering Behavior• Skills Training• Personal Project

Stage 2: Traumatizing emotions

Stage 3: Self-invalidation and lack of self- respect

Stage 1 Targets: Stage 1 Targets: Suicidal & Suicidal & Life Threatening BehaviorLife Threatening Behavior

Suicide Crisis Behaviors: Behaviors convince others that pt is at high risk for imminent suicide

Parasuicidal Acts: Self-harm with intention to harm oneself

Changes in Suicidal Ideation and Communications

Suicide-Related Expectancies or Beliefs

Suicide-Related Affect

Stage 1 Targets: Stage 1 Targets: Client Client Therapy Interfering Behavior Therapy Interfering Behavior

(TIB)(TIB)Behaviors that interfere with receiving therapy- Non-attending- Non-collaborative- Non-compliant

Behaviors that interfere with other patients Behaviors that burn the therapist out Behaviors that interfere with receiving therapy- Push therapist’s limits- Reduce motivation to treat client

Stage 1 Targets: Stage 1 Targets: Therapist Therapist Therapy Interfering Behavior Therapy Interfering Behavior

(TIB)(TIB)Behaviors that unbalance the therapy, e.g.,

- Imbalance of change vs. acceptance- Imbalance of rigidity vs. flexibility- Imbalance of nurturing vs. demanding- Imbalance of reciprocal vs. irreverent communication

Behaviors that show lack of respect to the client

Stage 1 Targets: Stage 1 Targets: Quality of Quality of Life Interfering Behavior Life Interfering Behavior

(QOLIB)(QOLIB) Creating a life worth living

Includes:• Axis I & IV Psychiatric Disorders/ Life stressors• Basic needs: housing, finances, employment• Relationships• Legal problems• High risk sexual behaviors

Hierarchy - most severe (or most changeable)

Stage 1 Targets: Stage 1 Targets: Increase Increase SkillsSkills

Skill Acquisition• Instructions• Modeling

Skill Strengthening• Behavior Rehearsal• Feedback

Skill Generalization• Homework Assignments• Coaching Phone Calls

Emotion Focus and Emotion Focus and Chain AnalysisChain Analysis

Emotion Focus and Emotion Focus and Chain AnalysisChain Analysis

Pervasive Emotion

Dysregulation

Pervasive Emotion

Dysregulation

In DBT, the etiology is...In DBT, the etiology is...In DBT, the etiology is...In DBT, the etiology is...

•Person is born (or becomes) Person is born (or becomes) biologically predisposed to frequent biologically predisposed to frequent and intense emotionsand intense emotions

•Tasks in life are complicated by Tasks in life are complicated by emotional arousalemotional arousal

•Environment increases negative arousalEnvironment increases negative arousal•Environment fails to help manage Environment fails to help manage

arousalarousal•Results >>> Results >>> PERVASIVE EMOTION PERVASIVE EMOTION

DYSREGULATIONDYSREGULATION

•Person is born (or becomes) Person is born (or becomes) biologically predisposed to frequent biologically predisposed to frequent and intense emotionsand intense emotions

•Tasks in life are complicated by Tasks in life are complicated by emotional arousalemotional arousal

•Environment increases negative arousalEnvironment increases negative arousal•Environment fails to help manage Environment fails to help manage

arousalarousal•Results >>> Results >>> PERVASIVE EMOTION PERVASIVE EMOTION

DYSREGULATIONDYSREGULATION

Understand the MomentUnderstand the MomentUnderstand the MomentUnderstand the MomentVulnerability

Factors

VulnerabilityFactors Links=Emotions, Thoughts, Physical

Sensations, Urges, Actions, EventsLinks=Emotions, Thoughts, PhysicalSensations, Urges, Actions, Events

Short and Long TermConsequences


PromptingEvent

PromptingEvent

ProblemBehaviorProblemBehavior

DBT is linking DBT is linking treatment strategies treatment strategies

to to links in the chain links in the chain

analysisanalysis

DBT is linking DBT is linking treatment strategies treatment strategies

to to links in the chain links in the chain

analysisanalysis

Prevent VulnerabilityPrevent VulnerabilityPrevent VulnerabilityPrevent Vulnerability

Links=Emotions, Thoughts, PhysicalSensations, Urges, Actions, Events

Links=Emotions, Thoughts, PhysicalSensations, Urges, Actions, Events



PromptingEvent

PromptingEvent

Prevent VulnerabilityPrevent VulnerabilityPrevent VulnerabilityPrevent Vulnerability

• Improve sleepImprove sleep

•Decrease physical illness Decrease physical illness symptomssymptoms

• Increase health behaviorsIncrease health behaviors

•Reduce background Reduce background stressorsstressors

•Better interpersonal skillsBetter interpersonal skills

•More structured leisure timeMore structured leisure time

• Improve sleepImprove sleep

•Decrease physical illness Decrease physical illness symptomssymptoms

• Increase health behaviorsIncrease health behaviors

•Reduce background Reduce background stressorsstressors

•Better interpersonal skillsBetter interpersonal skills

•More structured leisure timeMore structured leisure time

Prevent Prompting EventPrevent Prompting EventPrevent Prompting EventPrevent Prompting EventVulnerability

Factors





Prevent Prompting EventPrevent Prompting EventPrevent Prompting EventPrevent Prompting Event

• Sometimes feasibleSometimes feasible–Violent partnerViolent partner–Problematic work hoursProblematic work hours

• Often not possible or would cause Often not possible or would cause more problems than it helpsmore problems than it helps–LossLoss–Relationship breakupRelationship breakup–CriticismCriticism

• Sometimes feasibleSometimes feasible–Violent partnerViolent partner–Problematic work hoursProblematic work hours

• Often not possible or would cause Often not possible or would cause more problems than it helpsmore problems than it helps–LossLoss–Relationship breakupRelationship breakup–CriticismCriticism

Add SkillsAdd SkillsAdd SkillsAdd SkillsVulnerability

Factors


Sensations, Urges, Actions, Events, SkillsLinks=Emotions, Thoughts, Physical

Sensations, Urges, Actions, Events, Skills



PromptingEvent

PromptingEvent

Goals of Skills Training in DBTGoals of Skills Training in DBT

Behaviors to decrease Behaviors to Increase Acting w/o Thinking Core Mindfulness Skills

Behaviors that triggerInterpersonal Skills conflict and strife

Emotion Dysregulation Emotion Regulation Skills

Impulsive Behavior Distress Tolerance Skills

Add SkillsAdd SkillsAdd SkillsAdd Skills

• MindfulnessMindfulness–Focus attention on the moment Focus attention on the moment

(rather than past or future)(rather than past or future)

–Avoid judgmentAvoid judgment

–Being effective rather than rightBeing effective rather than right

• Acting opposite of your impulseActing opposite of your impulse

• Radically accepting your situationRadically accepting your situation

• MindfulnessMindfulness–Focus attention on the moment Focus attention on the moment

(rather than past or future)(rather than past or future)

–Avoid judgmentAvoid judgment

–Being effective rather than rightBeing effective rather than right

• Acting opposite of your impulseActing opposite of your impulse

• Radically accepting your situationRadically accepting your situation

Change ConsequencesChange ConsequencesChange ConsequencesChange ConsequencesVulnerability

Factors





PromptingEvent

PromptingEvent

ProblemBehaviorProblemBehavior

Change ConsequencesChange ConsequencesChange ConsequencesChange Consequences• Understand what reinforces the clientUnderstand what reinforces the client– ValidationValidation– Attention or interestAttention or interest– PraisePraise– Concrete help, advice, didacticsConcrete help, advice, didactics– Being left aloneBeing left alone– SoothingSoothing

• Block reinforcement for dysfunctional Block reinforcement for dysfunctional behaviorsbehaviors

• Up reinforcement for functional behaviorsUp reinforcement for functional behaviors• Put reinforcers on time vs. crisis basisPut reinforcers on time vs. crisis basis

• Understand what reinforces the clientUnderstand what reinforces the client– ValidationValidation– Attention or interestAttention or interest– PraisePraise– Concrete help, advice, didacticsConcrete help, advice, didactics– Being left aloneBeing left alone– SoothingSoothing

• Block reinforcement for dysfunctional Block reinforcement for dysfunctional behaviorsbehaviors

• Up reinforcement for functional behaviorsUp reinforcement for functional behaviors• Put reinforcers on time vs. crisis basisPut reinforcers on time vs. crisis basis

Change Other LinksChange Other LinksChange Other LinksChange Other LinksVulnerability

Factors





PromptingEvent

PromptingEvent

Change the Links (few Change the Links (few examples)examples)

Change the Links (few Change the Links (few examples)examples)

• ThoughtsThoughts– Block suicide expectanciesBlock suicide expectancies– Block rumination about suicideBlock rumination about suicide– Highlight patterns of thinkingHighlight patterns of thinking

• UrgesUrges– Teach client to “surf the urge”Teach client to “surf the urge”

• ActionsActions– Teach “buying time” strategies like Teach “buying time” strategies like

graceful exitgraceful exit

• ThoughtsThoughts– Block suicide expectanciesBlock suicide expectancies– Block rumination about suicideBlock rumination about suicide– Highlight patterns of thinkingHighlight patterns of thinking

• UrgesUrges– Teach client to “surf the urge”Teach client to “surf the urge”

• ActionsActions– Teach “buying time” strategies like Teach “buying time” strategies like

graceful exitgraceful exit

Thus, change in DBT isThus, change in DBT isThus, change in DBT isThus, change in DBT is

• Linked closely to the chain of Linked closely to the chain of eventsevents

• Choosing the best “bang for the Choosing the best “bang for the buck”buck”–Do the most common links firstDo the most common links first

–Do the links closest to the problem Do the links closest to the problem behavior firstbehavior first

–Do the simple things first Do the simple things first

• Model persistence and creativityModel persistence and creativity

• Linked closely to the chain of Linked closely to the chain of eventsevents

• Choosing the best “bang for the Choosing the best “bang for the buck”buck”–Do the most common links firstDo the most common links first

–Do the links closest to the problem Do the links closest to the problem behavior firstbehavior first

–Do the simple things first Do the simple things first

• Model persistence and creativityModel persistence and creativity

Dialectics and Dialectics and ValidationValidation

Dialectics and Dialectics and ValidationValidation

Dialectics (oversimplified)Dialectics (oversimplified)

The synthesis between a thesis and an antithesis

Primary Dialectic in DBTPrimary Dialectic in DBTPrimary Dialectic in DBTPrimary Dialectic in DBT

•You must You must accept yourself accept yourself just as you arejust as you are

AndAnd

•You must work You must work as hard and as as hard and as fast as you can fast as you can to changeto change

•You must You must accept yourself accept yourself just as you arejust as you are

AndAnd

•You must work You must work as hard and as as hard and as fast as you can fast as you can to changeto change

•ValidationValidation

•MindfulnessMindfulness

AndAnd

•Behavior Behavior therapytherapy

•ValidationValidation

•MindfulnessMindfulness

AndAnd

•Behavior Behavior therapytherapy

Dialectical Behavior Dialectical Behavior PatternsPatterns

Skill enhancement vs. self acceptance

Problem solving vs. problem acceptance

Affect regulation vs. affect tolerance

Independence vs. dependence Pathologizing normal behavior

vs. normalizing pathological behavior

Dialectical StrategiesDialectical Strategies

Metaphor Extending Devil’s advocate Asking “What is left out?”

Other DBT StrategiesOther DBT Strategies

Acceptance Change

Communication strategies

Reciprocal Irreverencecommunication

Case management strategies

EnvironmentalConsultation Intervention

to patient

What is Validation?What is Validation?

Communicates Acceptance

Finding wisdom/ correctness in client’s response - “Kernel of truth”

Therapist believes in client’s ability to get out of misery and create a life worth living.

What is Validation? (cont’)What is Validation? (cont’)

Confirming that which is true, accurate, and understandable given the person’s current situation or past history

Well grounded or justifiable in terms of empirical facts

Gives client accurate feedback. Is the behavior appropriate given client’s goals?

What What isn’tisn’t Validation Validation

Soothing

Praise

Chit - chat

Global, nonspecific positive feedback

Levels of ValidationLevels of ValidationLevels of ValidationLevels of Validation1.1. Staying Awake: Unbiased listening and Staying Awake: Unbiased listening and

observingobserving

2. 2. Accurate reflectionAccurate reflection

3. 3. Articulating the unverbalized emotions, Articulating the unverbalized emotions, thoughts, or behavior patternsthoughts, or behavior patterns

4. 4. Validation in terms of past learning or Validation in terms of past learning or biological dysfunctionbiological dysfunction

5. 5. Validation in terms of present context Validation in terms of present context or normative functioningor normative functioning

6. 6. Radical GenuinenessRadical Genuineness

1.1. Staying Awake: Unbiased listening and Staying Awake: Unbiased listening and observingobserving

2. 2. Accurate reflectionAccurate reflection

3. 3. Articulating the unverbalized emotions, Articulating the unverbalized emotions, thoughts, or behavior patternsthoughts, or behavior patterns

4. 4. Validation in terms of past learning or Validation in terms of past learning or biological dysfunctionbiological dysfunction

5. 5. Validation in terms of present context Validation in terms of present context or normative functioningor normative functioning

6. 6. Radical GenuinenessRadical Genuineness

Orientation and Orientation and CommitmentCommitment

Orientation and Orientation and CommitmentCommitment

•DBT is a voluntary treatment ONLYDBT is a voluntary treatment ONLY

• If not agreeing, client is in Pre-If not agreeing, client is in Pre-Treatment stageTreatment stage–OrientOrient

– Increase commitment to long term goals Increase commitment to long term goals and DBT targetsand DBT targets

–Agreement to treatment and its limitsAgreement to treatment and its limits

•Commitment strategies in DBT Commitment strategies in DBT designed to move clients from Pre-designed to move clients from Pre-Treatment to DBTTreatment to DBT

(Applies to therapists as well as clients)(Applies to therapists as well as clients)

•DBT is a voluntary treatment ONLYDBT is a voluntary treatment ONLY

• If not agreeing, client is in Pre-If not agreeing, client is in Pre-Treatment stageTreatment stage–OrientOrient

– Increase commitment to long term goals Increase commitment to long term goals and DBT targetsand DBT targets

–Agreement to treatment and its limitsAgreement to treatment and its limits

•Commitment strategies in DBT Commitment strategies in DBT designed to move clients from Pre-designed to move clients from Pre-Treatment to DBTTreatment to DBT

(Applies to therapists as well as clients)(Applies to therapists as well as clients)

DBT Consultation TeamDBT Consultation TeamDBT Consultation TeamDBT Consultation Team•““Therapy for the therapist”Therapy for the therapist”– ““Therapist” means anyone clinically Therapist” means anyone clinically

working with client/familyworking with client/family–Goal is to change therapist behavior Goal is to change therapist behavior in in

generalgeneral not just toward one client/family not just toward one client/family in momentin moment

– Focus is on increasing therapists Focus is on increasing therapists motivation and skills capacity to do DBT motivation and skills capacity to do DBT and stay with teamand stay with team

•Structure, principles, and strategiesStructure, principles, and strategies–Consultation team agreementsConsultation team agreements–OnlyOnly those who are actively providing DBT those who are actively providing DBT

in individual, group, or coaching in individual, group, or coaching participateparticipate

•““Therapy for the therapist”Therapy for the therapist”– ““Therapist” means anyone clinically Therapist” means anyone clinically

working with client/familyworking with client/family–Goal is to change therapist behavior Goal is to change therapist behavior in in

generalgeneral not just toward one client/family not just toward one client/family in momentin moment

– Focus is on increasing therapists Focus is on increasing therapists motivation and skills capacity to do DBT motivation and skills capacity to do DBT and stay with teamand stay with team

•Structure, principles, and strategiesStructure, principles, and strategies–Consultation team agreementsConsultation team agreements–OnlyOnly those who are actively providing DBT those who are actively providing DBT

in individual, group, or coaching in individual, group, or coaching participateparticipate

Evaluation of OutcomesEvaluation of OutcomesEvaluation of OutcomesEvaluation of Outcomes• DBT is only done as long as it is workingDBT is only done as long as it is working

– DBT done for predetermined fixed durationDBT done for predetermined fixed duration– DBT re-up only if substantial improvement DBT re-up only if substantial improvement

on key outcomeson key outcomes

• Important at theImportant at the– Client/family levelClient/family level– Team/agency levelTeam/agency level– System levelSystem level

• Data collected byData collected by– Diary cards and session notesDiary cards and session notes– Incident reports and other system collected Incident reports and other system collected

datadata– Other data methods for evaluation purposesOther data methods for evaluation purposes

• DBT is only done as long as it is workingDBT is only done as long as it is working– DBT done for predetermined fixed durationDBT done for predetermined fixed duration– DBT re-up only if substantial improvement DBT re-up only if substantial improvement

on key outcomeson key outcomes

• Important at theImportant at the– Client/family levelClient/family level– Team/agency levelTeam/agency level– System levelSystem level

• Data collected byData collected by– Diary cards and session notesDiary cards and session notes– Incident reports and other system collected Incident reports and other system collected

datadata– Other data methods for evaluation purposesOther data methods for evaluation purposes

How we train and How we train and implement DBTimplement DBT

How we train and How we train and implement DBTimplement DBT

Individual DBT training Individual DBT training modesmodes

Individual DBT training Individual DBT training modesmodes

•Academic training (varies a lot)Academic training (varies a lot)

•2-day CE trainings2-day CE trainings

•Video and CD trainingsVideo and CD trainings– SkillsSkills

–MindfulnessMindfulness

•On-line learningOn-line learning– SkillsSkills

–Chain analysisChain analysis

–ValidationValidation

•Academic training (varies a lot)Academic training (varies a lot)

•2-day CE trainings2-day CE trainings

•Video and CD trainingsVideo and CD trainings– SkillsSkills

–MindfulnessMindfulness

•On-line learningOn-line learning– SkillsSkills

–Chain analysisChain analysis

–ValidationValidation

Standard – Intensive Standard – Intensive Training CourseTraining Course

Standard – Intensive Standard – Intensive Training CourseTraining Course

•Apply to participate as a teamApply to participate as a team

•Part 1: 5 days of didactic training Part 1: 5 days of didactic training – Practice exercises for strategies and Practice exercises for strategies and

developing DBT program and teamdeveloping DBT program and team

•Homework (over 6-8 month window)Homework (over 6-8 month window)–Reading and examReading and exam

– Practice DBT strategies (individual and Practice DBT strategies (individual and team)team)

– Program and Case Presentation Program and Case Presentation (including data)(including data)

•Part II: 5 days of case-based learningPart II: 5 days of case-based learning

•Apply to participate as a teamApply to participate as a team

•Part 1: 5 days of didactic training Part 1: 5 days of didactic training – Practice exercises for strategies and Practice exercises for strategies and

developing DBT program and teamdeveloping DBT program and team

•Homework (over 6-8 month window)Homework (over 6-8 month window)–Reading and examReading and exam

– Practice DBT strategies (individual and Practice DBT strategies (individual and team)team)

– Program and Case Presentation Program and Case Presentation (including data)(including data)

•Part II: 5 days of case-based learningPart II: 5 days of case-based learning

DBT Implementation DBT Implementation TrainingTraining

DBT Implementation DBT Implementation TrainingTraining

• Apply to participate Apply to participate as as county/state/provincecounty/state/province

• Kick-off: Kick-off: – 2 days overview training 2 days overview training – 1 day administrator training1 day administrator training

• Part 1: 5 days of didactic training about Part 1: 5 days of didactic training about the treatmentthe treatment

• Monthly phone consultation Monthly phone consultation • Homework (over 6-8 month window)Homework (over 6-8 month window)• Part II: 5 days of problem-based learning Part II: 5 days of problem-based learning

using homeworkusing homework• Homework (over 6-8 month window)Homework (over 6-8 month window)• Part III: 2 days of intermediate trainingPart III: 2 days of intermediate training

• Apply to participate Apply to participate as as county/state/provincecounty/state/province

• Kick-off: Kick-off: – 2 days overview training 2 days overview training – 1 day administrator training1 day administrator training

• Part 1: 5 days of didactic training about Part 1: 5 days of didactic training about the treatmentthe treatment

• Monthly phone consultation Monthly phone consultation • Homework (over 6-8 month window)Homework (over 6-8 month window)• Part II: 5 days of problem-based learning Part II: 5 days of problem-based learning

using homeworkusing homework• Homework (over 6-8 month window)Homework (over 6-8 month window)• Part III: 2 days of intermediate trainingPart III: 2 days of intermediate training

How DBT How DBT implementations go implementations go

bad…bad…

How DBT How DBT implementations go implementations go

bad…bad…

When DBT goes bad….When DBT goes bad….When DBT goes bad….When DBT goes bad….

•Functions of DBT are left out Functions of DBT are left out and not replacedand not replaced–No skills taughtNo skills taught–No one is dealing with therapy No one is dealing with therapy

interfering behavior or motivating interfering behavior or motivating the clientthe client

–No generalization of skillsNo generalization of skills–System is reinforcing dysfunctional System is reinforcing dysfunctional

behaviorbehavior–Therapists burned out or can’t Therapists burned out or can’t

work togetherwork together

•Functions of DBT are left out Functions of DBT are left out and not replacedand not replaced–No skills taughtNo skills taught–No one is dealing with therapy No one is dealing with therapy

interfering behavior or motivating interfering behavior or motivating the clientthe client

–No generalization of skillsNo generalization of skills–System is reinforcing dysfunctional System is reinforcing dysfunctional

behaviorbehavior–Therapists burned out or can’t Therapists burned out or can’t

work togetherwork together

When DBT goes bad….When DBT goes bad….When DBT goes bad….When DBT goes bad….

•No primary therapistNo primary therapist–Complex and extreme behaviors Complex and extreme behaviors

cannot be managed by committee or cannot be managed by committee or standard behavior modificationstandard behavior modification

•System is managing the client System is managing the client –rather than teaching client to rather than teaching client to

manage the systemmanage the system

•Alliance is not with the client Alliance is not with the client – Especially when treating child and Especially when treating child and

familyfamily

•No primary therapistNo primary therapist–Complex and extreme behaviors Complex and extreme behaviors

cannot be managed by committee or cannot be managed by committee or standard behavior modificationstandard behavior modification

•System is managing the client System is managing the client –rather than teaching client to rather than teaching client to

manage the systemmanage the system

•Alliance is not with the client Alliance is not with the client – Especially when treating child and Especially when treating child and

familyfamily

How DBT implementation goes How DBT implementation goes bad…bad…


•Non-acceptance that DBT increases Non-acceptance that DBT increases agency costs and staff time agency costs and staff time substantiallysubstantially

•Training “paper teams”Training “paper teams”– 1-2 folks from each unit of a hospital1-2 folks from each unit of a hospital

– 1-2 folks from each agency in a county1-2 folks from each agency in a county

•Missing out on middle managementMissing out on middle management–No orientation nor contingencies on No orientation nor contingencies on

agency CEOs and supervisorsagency CEOs and supervisors

•Non-acceptance that DBT increases Non-acceptance that DBT increases agency costs and staff time agency costs and staff time substantiallysubstantially

•Training “paper teams”Training “paper teams”– 1-2 folks from each unit of a hospital1-2 folks from each unit of a hospital

– 1-2 folks from each agency in a county1-2 folks from each agency in a county

•Missing out on middle managementMissing out on middle management–No orientation nor contingencies on No orientation nor contingencies on

agency CEOs and supervisorsagency CEOs and supervisors



•Poor orientation and commitment Poor orientation and commitment skillsskills–Clients not required to commit to enter Clients not required to commit to enter

oror

–Clients required in toxic wayClients required in toxic way

•Focus on process instead of outcomesFocus on process instead of outcomes–What matters is not how much of What matters is not how much of

program is in place or how much kids program is in place or how much kids participateparticipate

–Lose focus on what was outcome to start Lose focus on what was outcome to start with - less suicidal behavior, incidents…with - less suicidal behavior, incidents…

•Poor orientation and commitment Poor orientation and commitment skillsskills–Clients not required to commit to enter Clients not required to commit to enter

oror

–Clients required in toxic wayClients required in toxic way

•Focus on process instead of outcomesFocus on process instead of outcomes–What matters is not how much of What matters is not how much of

program is in place or how much kids program is in place or how much kids participateparticipate

–Lose focus on what was outcome to start Lose focus on what was outcome to start with - less suicidal behavior, incidents…with - less suicidal behavior, incidents…

Questions?Questions? Questions?Questions?

dbt implementation: how to do it well… and badly… kate comtois, ph.d. pbhjp grand rounds 6/15/09...

Documents

functions dbt

dbt implementation

dbt strategies

informed dbt modes

specific elements of

knowing dbt ill

motivation of client

capabilities of client