1. PARAMETER GOAL
   1. To provide staff with an overview of measures and treatment techniques related to Dialectical Behavioral Therapy. 
2. TERMINOLOGY
   1. Dialectical Behavior Therapy (DBT): A comprehensive treatment that balances principles of acceptance (mindfulness) and change (behavioralism). Specialized training is required to develop the skills necessary to practice standardized DBT.
   2. DBT Skills group: A weekly group where client learn and apply skills. The series of skills and activities include:
      1. Mindfulness Skill Module: Designed to focus on the here and now to recognize and release strong emotions.
      2. Emotional Regulation Skill Module: Aims to equip individuals with a set of skills to change and manage unwanted strong emotions.
      3. The Distress Tolerance Skill Module: Directs clients to increase the skills necessary to tolerate negative emotions.
      4. The Interpersonal Effectiveness Skill Module: Supports individuals in developing healthy communication skills with others, upholding self-esteem, and strengthening relationships.
   3. Phone Coaching: Client-initiated phone calls to the therapist to practice a DBT skill to alleviate a personal issue they are having. Clinician sets specific time when they will be available for phone coaching. Typically, a phone coaching session is brief around 15 minutes or less. The phone coaching is not a replacement for crisis interventions.
   4. Therapy Interfering Behavior (TIB): An action by a client or therapist that hinders progress in therapy.
   5. Quality of Life Interfering Behaviors: Actions or patterns that disrupt a client's life such as disordered eating, substance abuse, financial difficulties like excessive shopping, impulsive behaviors, and behaviors which impact housing, employment, or social functioning.
   6. Consultation Agreement: A set of shared guidelines and expectations that DBT therapists agree to follow when discussing their clients' cases in order to maintain high quality treatment delivery; essentially, it outlines how team members will interact with each other during consultation meetings to effectively problem-solve and support one another. This includes utilizing specific empathy, a non-judgmental approach, following privacy guidelines, and focusing on dialectical thinking.
3. MEASURES
   1. DBT should be considered for clients who present with:
      1. A history of dysregulation of emotions, interpersonal functioning, behaviors and cognitions 
      2. Suicidal behavior as the initial treatment focus
      3. Severe dysfunctional behaviors
      4. Chronic patterns of emotion dysregulation
      5. Substance use and dependence (Not as a replacement for specialized substance rehabilitation centers)
      6. Symptoms of depression
   2. Considerations for Treatment:
      1. Four missed rule: Client cannot miss four (4) consecutive sessions of therapy and/or group sessions.
         1. Clients will be removed from DBT treatment.
         2. Clients can be re-evaluated for admission for treatment at a later time.
      2. Historically DBT has been a yearlong commitment; however, recent research indicates efficacy with a six-month course of DBT.
   3. Key treatment targets in DBT are addressed by level of risk posed to the client.
      1. Level 1- Suicidal ideation, plan or intent, client at risk of dropping out of treatment
      2. Level 2- Addressing TIBs
      3. Level 3- Quality of Life Interfering Behaviors
   4. Other assessments for readiness to participate in DBT include time commitments to therapy components.
      1. Individual therapy occurs once a week for 45-90 minutes
      2. Group Skills Training occurs once a week for 90 to 120 minutes
      3. Phone coaching as needed
   5. NOTE: Addiction Substance Use Disorder - DBT is not an addiction treatment model however, many clients who would benefit from DBT treatment also may have issues with addiction. In DBT treatment the clients are taught coping skills to cope with challenging addiction.
4. TREATMENT STRATEGY
   1. DBT is conducted as a weekly skills group, a weekly individual session, and phone coaching as needed.
      1. Skills Group occurs weekly from 90-120 minutes
         1. Focus is on skill development from one of the four (4) modules: Mindfulness, Emotional Regulation, Distress Tolerance, or Interpersonal Effectiveness
      2. Individual therapy occurs weekly from 45-90 minutes.
         1. Focus is on weekly diary card review
      3. Phone coaching may be utilized as needed with specific windows of time when the therapist is available
   2. Therapist Consultation Agreement: A typical therapist consultation team meets weekly. This team may be referred to as "Therapy for the Therapist." Each week team members are assigned to the following tasks:
      1. Leader
         1. Develops and manages the agenda
         2. Leads the team meeting, including asking each team member who presents a consultation how much time is needed for the item and the degree of burnout the team member is experiencing
         3. Conducts a mindfulness exercise at the start of the team meeting
         4. At conclusion of meeting, asks the team for any reactions or feedback on the exercise
      2. Observer
         1. Reads a consultation agreement
         2. Takes action when a specified activity is engaged in that conflicts with DBT principles
         3. Manages time
      3. Note-taker
      4. Backup is a substitute for other roles should the assigned team member be out of the office
5. PROVISION OF SERVICE
   1. Pre-Treatment phase includes series of foundational assessments and orientation sessions
      1. Therapist:
         1. Evaluates the client's suitability for DBT
         2. Establishes rapport, and
         3. Ensures that the client understands the structure, expectations and commitment required for the therapy
      2. Clients:
         1. Identify their goals and readiness for the treatment process
         2. Prepare and establish their commitment to effective engagement
      3. Together the therapist and client assess their compatibility for collaboration
      4. Phone Coaching: Throughout all therapy stages, Phone Coaching calls with the therapist are available during specified time frames.
         1. Therapist coaches the client during a phone call to model a DBT skill.
         2. Therapist or programs set after hours periods of time for phone coaching sessions with clients.
         3. Phone coaching is not a replacement for crisis interventions.
   2. Stage 1 goal is stabilization - Mindfulness
      1. Group therapy focus - Wise mind includes:
         1. Core skill of being fully present in the current moment
         2. Observing thoughts, feelings, and physical sensations non-judgmentally
         3. Being aware of surroundings
         4. Living in the current moment
         5. Focus on breath
      2. Individual therapy focus - Stabilization of client behaviors
   3. Stage 2 goal is addressing emotional pain
      1. Group therapy focus - Distress Tolerance Skills
         1. Focus on self-emotional regulation
         2. Staying calm in an emotional crisis
         3. How to not make situation worse
         4. Crisis survival
         5. Use the REST strategy
            1. Relax: Pause to create space between clients' desire to act impulsively and their actual reaction
            2. Evaluate: Evaluate the situation by taking a moment to reflect on the situation and ask what emotions or thoughts are behind the reaction before doing anything
            3. Set an Intention: Set a goal, intention, or target about what to do
            4. Take Action: Put the plan into action, proceeding mindfully
         6. Distraction skills can temporarily stop clients from thinking about the past and allow time to find an appropriate coping response.
         7. Self-soothing skills help clients to soothe themselves before facing the cause of the distress which allows clients to build compassion with themselves.
         8. Radical Acceptance helps clients to acknowledge their present situation, without judging the events or criticizing themself. It helps to recognize the present situation exists because of a long chain of events that began far in the past and seeing it as it really is.
      2. Individual therapy focus - Behavioral stabilization, when clients exhibit:
         1. Life-threatening behaviors
         2. Self-harm
         3. Therapy Interfering Behaviors (TIB)
         4. Quality of life changes
      3. It is essential for clients to remain in this stage until stabilization is achieved.
         1. NOTE: If after stabilization is achieved and issues arise, therapist and client should re-establish safety which allows for:
            1. Prioritizing client's safety and well-being, and
            2. Establishing a secure foundation before advancing to subsequent stages of therapy
         2. This stage is critical to effectively addressing the challenges faced by clients in distress.
         3. Clients must have a commitment to abstain from life-threatening behavior.
         4. Clients will complete weekly diary cards to document life-threatening behaviors, which will be reviewed during therapy sessions to facilitate discussion and model important life skills.
   4. Stage 3 goal is improving Quality of Life
      1. Group therapy focus - Emotional Regulation
         1. Understanding and naming emotions
         2. Understanding the function of emotions
         3. Identifying obstacles to changing emotions
         4. Changing unwanted emotions
         5. Comparing the situation to the emotional reaction and see if they are congruent
         6. Problem Solving the unwanted emotions
         7. Reducing vulnerability to extreme emotions
         8. Managing extreme emotions
      2. Individual therapy focus -
         1. Reinforcing learned skills to achieve client goals
         2. Addressing emotional experiences while managing intense emotions, and having emotional control
      3. NOTE: If suicidal thinking or behaviors return, therapist and client will move back to Stage 1
   5. Stage 4 goal is Finding Meaning
      1. Group therapy focus - Interpersonal Effectiveness by learning how to work through conflict and challenges in relationships.
         1. Building effective relationships with others
         2. Boundary Setting: communicating personal limits and expectations clearly within relationships
         3. Objective Effectiveness: learning how to ask for what you want and take steps to get it
         4. Assertive Communication
         5. Conflict Resolution: the process of addressing and resolving disputes or disagreements between individuals or groups
         6. Self-respect effectiveness: building greater respect for the self
      2. Individual therapy focus - Therapy is marked by a concentration on personal development, self-trust, and the pursuit of individual goals.
         1. Fostering a sense of autonomy and direction; some clients seek a deeper understanding of themselves and their aspirations.
         2. Establishing priorities, cultivating meaningful relationships, and achieving a sense of fulfillment as they navigate the complexities of life.
         3. Emphasizing self-trust, empowering them to make decisions that align with their values, ultimately leading to a more purposeful and rewarding life experience.
         4. Transitioning to lower level of care for client during the final stage.
   6. Final Stage
      1. Group therapy focus - Transition to Graduation
         1. Reinforcing their skills
         2. Recognizing their achievements and triumphs
         3. Preparing for transition to a lower level of care
      2. Individual therapy focus - Achieving transcendence and developing a capacity for joy.
         1. Deepening connections with oneself and others
         2. Fostering fulfillment
         3. Promoting practices like mindfulness and gratitude
         4. Encouraging personal growth, emotional resilience, and finding joy in various life aspects
         5. Consolidating and reinforcing their achievements
         6. Preparing clients for transition to lower level of care
6. OUTCOMES AND MONITORING
   1. Group goals: To teach and learn DBT skills
   2. Individual goals:
      1. Individualized therapeutic plan created
      2. The client’s goal in individual therapy is to build a life worth living and steps for how to get to their goal
   3. Outcome Measure:
      1. Difficulties and Emotions Regulation Scale (DERS) - Outcome Measures Table
      2. One Page scale given every 6 months.
      3. The DERS is completed an initial DERS outcome measures table and then every six months after.
      4. DBT providers should monitor client's bio-psycho-social adjustment to:
         1. Life changes- Events or decisions that have a significant impact on client's life Role transitions- Moving from one role to another.
         2. Role disputes- Where there are conflicting expectations or demands placed on an individual due to multiple roles they hold, such as being a wife, financial support, and mother.Presence or Absence of major life events- Events that can result in significant changes in a person's circumstances, roles, and responsibilities, or an absence of such events. 
7. STAFF TRAINING
   1. Therapist Training
      1. Therapists must have a working knowledge of DBT techniques.
      2. Therapists must be available for consultation.
      3. Required training protocols
         1. Commit to maintain DBT Team (1 DBT team leader; minimum of 4 clinicians total)
         2. 3-Day (6 hour/day) Live Introductory DBT training
         3. Two 1 day (6 hour/day) Live DBT Booster Training
         4. Provide Comprehensive DBT treatment to a minimum of w clients per clinician
         5. Attend a minimum of 21/24 weekly DBT Consultation Team meetings (1.5 hours/week) with a DBT expert trainer during the training period.
         6. Submit 2 case conceptualizations for two separate clients (pass at least 1)Submit 3 DBT individual session recordings on at least 2 separate clients (pass at least ½)
         7. Pass 1 mock skills coaching call
         8. Complete and collect all required Pre and Post Clinician measures
      4. Team requirements:
         1. Submit a recording of at least 1 passing DBT skills group session
         2. Submit a recording of at least 1 passing DBT team consultation session
         3. All work samples must be evaluated by expert consultants who demonstrate interrater reliability and calibrate with the developer of the competency measures.
   2. Other DBT trainings completed by staff will be evaluated for approval on an individual basis by Practice Leads.
   3. DMH Therapists must complete 3-day live introductory DBT training before they are permitted to utilize the therapy with clients. Therapists must complete pre-training measures and participate in ongoing weekly in DBT team consultation meetings. 
8. SUPERVISION AND CONSULTATION
   1. Weekly Consultation with DBT Team
   2. Monthly DBT Team Leader Meeting (available but not mandatory)
   3. Regular and as-needed supervision and consultation with the supervisor and consultation treatment team
   4. Multi-disciplinary case consultations
   5. Supervision training recommended 
9. RESOURCES
   1. DMH DBT Resources- Prevention and Early Intervention
   2. Three required DBT books at DMH
      1. Cognitive-Behavioral Treatment of Borderline Personality Disorder 1st Edition by Marsha M. Linehan PhD ABPPDBT
      2. Skills Training Manual 2nd Edition by Marsha M. Linehan PhD ABPPDBT
      3. Skills Training Handouts and Worksheets, Second Edition by Marsha M. Linehan PhD ABPP
      4. NOTE: if you attend a DMH sponsored training, these books are provided per team.
   3. Emotions Matter
   4. National Education Alliance for Borderline Personality Disorder
   5. Treatment and Research Advancements
   6. Treatment Implementation Collaborative
   7. World Dialectical Behavior Therapy Association

Published with recognition to:
Erica Gutierrez
Intern, MSW student at California State University Northridge
and
Jessica "Jess" Shaffer, LCSW