1. DBT Implementation: How to do it well… and badly… Kate Comtois, Ph.D. PBHJP Grand Rounds 6/15/09 Kate Comtois, Ph.D. PBHJP Grand Rounds 6/15/09

2. Knowing about DBT vs. Knowing DBT I’ll be explaining that a lot of things exist in DBT and are important without actually teaching them…

3. OverviewOverview Overview of comprehensive, integrated, and informed DBT Overview of comprehensive, integrated, and informed DBT Modes and Functions of Comprehensive DBT Modes and Functions of Comprehensive DBT Key Elements of DBT Key Elements of DBT How DBT is trained How DBT is trained How DBT implementation goes bad…. How DBT implementation goes bad…. Overview of comprehensive, integrated, and informed DBT Overview of comprehensive, integrated, and informed DBT Modes and Functions of Comprehensive DBT Modes and Functions of Comprehensive DBT Key Elements of DBT Key Elements of DBT How DBT is trained How DBT is trained How DBT implementation goes bad…. How DBT implementation goes bad….

4. Three Ways to Implement DBT Comprehensive DBT Comprehensive DBT – Has all the structure – Has all the principles – Has all the strategies Integrated DBT Integrated DBT – Has specific elements of DBT integrated into another treatment (e.g., FIT) – Those DBT strategies used are adherent to DBT DBT informed DBT informed – Uses elements of DBT in non-adherent way Comprehensive DBT Comprehensive DBT – Has all the structure – Has all the principles – Has all the strategies Integrated DBT Integrated DBT – Has specific elements of DBT integrated into another treatment (e.g., FIT) – Those DBT strategies used are adherent to DBT DBT informed DBT informed – Uses elements of DBT in non-adherent way

5. DBT Modes and Functions

6. Standard Outpatient DBT Modes   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

7. Introduction to Treatment Structure: Functions DBT Needs to Achieve   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

8. Modes of Standard Adult DBT 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 group Skills training group Individual therapy Individual therapy Phone consultation Phone consultation Individual therapist during or out of session Individual therapist during or out of session Consultation meetings Consultation meetings

9. Modes of Standard Adolescent DBT Client capabilities Client capabilities Client motivation Client motivation Generalization Generalization Structuring the environment Structuring the environment Therapist capability and motivation Therapist capability and motivation Client capabilities Client capabilities Client motivation Client motivation Generalization Generalization Structuring the environment Structuring the environment Therapist capability and motivation Therapist capability and motivation Multi-family skills group Multi-family skills group Individual therapy Individual therapy Phone consultation and parents practicing at home Phone consultation and parents practicing at home Individual therapist during or out of session; family sessions Individual therapist during or out of session; family sessions Consultation meetings Consultation meetings

10. Modes of DBT in FIT (as of 5 yrs ago) Client capabilities Client capabilities Client motivation Client motivation Generalization Generalization Structuring the environment Structuring the environment Therapist capability and motivation Therapist capability and motivation Client capabilities Client capabilities Client motivation Client motivation Generalization Generalization Structuring the environment Structuring the environment Therapist capability and motivation Therapist capability and motivation DBT skills taught to kid and family in the home DBT skills taught to kid and family in the home Chain analysis and validation Chain analysis and validation Phone consultation and parents practicing at home Phone consultation and parents practicing at home MST strategies MST strategies

11. Modes of Residential DBT Client capabilities Client capabilities Client motivation Client motivation Generalization Generalization Structuring the environment Structuring the environment Therapist capability and motivation Therapist capability and motivation Client capabilities Client capabilities Client motivation Client motivation Generalization Generalization Structuring the environment Structuring the environment Therapist capability and motivation Therapist capability and motivation Skills training (i.e. group) Skills training (i.e. group) Individual therapy and behavior modification plan Individual therapy and behavior modification plan Coaching by therapist and floor staff Coaching by therapist and floor staff Primary therapist with social work, shift change, etc plus family or DCF meetings etc Primary therapist with social work, shift change, etc plus family or DCF meetings etc Consultation meetings (separate or part of team) Consultation meetings (separate or part of team)

12. Modes of Acute Inpatient DBT Client capabilities Client capabilities Client motivation Client motivation Generalization Generalization Structuring the environment Structuring the environment Therapist capability and motivation Therapist capability and motivation Client capabilities Client capabilities Client motivation Client motivation Generalization Generalization Structuring the environment Structuring the environment Therapist capability and motivation Therapist capability and motivation Skills training through subset of skills Skills training through subset of skills Individual therapy and behavior modification plan Individual therapy and behavior modification plan Coaching by therapist and floor staff Coaching by therapist and floor staff Primary therapist with social work, shift change, etc plus family or DCF meetings etc Primary therapist with social work, shift change, etc plus family or DCF meetings etc Consultation meetings (separate or part of team) Consultation meetings (separate or part of team)

13. Key Elements of DBT 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

14. DBT is essentially radical behavior therapy What follows are the unique elements that appear crucial… We don’t yet know empirically what matters… (and I’ve left out stuff out) What follows are the unique elements that appear crucial… We don’t yet know empirically what matters… (and I’ve left out stuff out)

15. DBT Targets

16. Introduction to Treatment Structure: Stages and Targets for Individual   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

17. Stage 1 Targets: Suicidal & Life Threatening Behavior Stage 1 Targets: Suicidal & Life 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

18. Stage 1 Targets: Client Therapy Interfering Behavior (TIB) Stage 1 Targets: Client Therapy Interfering Behavior (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

19. Stage 1 Targets: Therapist Therapy Interfering Behavior (TIB) Stage 1 Targets: Therapist Therapy Interfering Behavior (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

20. Stage 1 Targets: Quality of Life Interfering Behavior (QOLIB) Stage 1 Targets: Quality of Life Interfering Behavior (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)

21. Stage 1 Targets: Increase Skills Stage 1 Targets: Increase Skills   Skill Acquisition Instructions Modeling   Skill Strengthening Behavior Rehearsal Feedback   Skill Generalization Homework Assignments Coaching Phone Calls

22. Emotion Focus and Chain Analysis

23. Pervasive Emotion Dysregulation

24. In DBT, the etiology is... Person is born (or becomes) biologically predisposed to frequent and intense emotions Person is born (or becomes) biologically predisposed to frequent and intense emotions Tasks in life are complicated by emotional arousal Tasks in life are complicated by emotional arousal Environment increases negative arousal Environment increases negative arousal Environment fails to help manage arousal Environment fails to help manage arousal Results >>> PERVASIVE EMOTION DYSREGULATION Results >>> PERVASIVE EMOTION DYSREGULATION Person is born (or becomes) biologically predisposed to frequent and intense emotions Person is born (or becomes) biologically predisposed to frequent and intense emotions Tasks in life are complicated by emotional arousal Tasks in life are complicated by emotional arousal Environment increases negative arousal Environment increases negative arousal Environment fails to help manage arousal Environment fails to help manage arousal Results >>> PERVASIVE EMOTION DYSREGULATION Results >>> PERVASIVE EMOTION DYSREGULATION

25. Understand the Moment Vulnerability Factors Vulnerability Factors Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Short and Long Term Consequences Short and Long Term Consequences Prompting Event Prompting Event Problem Behavior Problem Behavior

26. DBT is linking treatment strategies to links in the chain analysis

27. Prevent Vulnerability Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Short and Long Term Consequences Short and Long Term Consequences Prompting Event Prompting Event

28. Prevent Vulnerability Improve sleep Improve sleep Decrease physical illness symptoms Decrease physical illness symptoms Increase health behaviors Increase health behaviors Reduce background stressors Reduce background stressors Better interpersonal skills Better interpersonal skills More structured leisure time More structured leisure time Improve sleep Improve sleep Decrease physical illness symptoms Decrease physical illness symptoms Increase health behaviors Increase health behaviors Reduce background stressors Reduce background stressors Better interpersonal skills Better interpersonal skills More structured leisure time More structured leisure time

29. Prevent Prompting Event Vulnerability Factors Vulnerability Factors Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Short and Long Term Consequences Short and Long Term Consequences

30. Prevent Prompting Event Sometimes feasible Sometimes feasible – Violent partner – Problematic work hours Often not possible or would cause more problems than it helps Often not possible or would cause more problems than it helps – Loss – Relationship breakup – Criticism Sometimes feasible Sometimes feasible – Violent partner – Problematic work hours Often not possible or would cause more problems than it helps Often not possible or would cause more problems than it helps – Loss – Relationship breakup – Criticism

31. Add Skills Vulnerability Factors Vulnerability Factors Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events, Skills Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events, Skills Short and Long Term Consequences Short and Long Term Consequences Prompting Event Prompting Event

32. Goals of Skills Training in DBT Goals of Skills Training in DBT Behaviors to decrease Behaviors to Increase Acting w/o ThinkingCore Mindfulness Skills Behaviors that triggerInterpersonal Skills conflict and strife Emotion DysregulationEmotion Regulation Skills Impulsive BehaviorDistress Tolerance Skills

33. Add Skills Mindfulness Mindfulness – Focus attention on the moment (rather than past or future) – Avoid judgment – Being effective rather than right Acting opposite of your impulse Acting opposite of your impulse Radically accepting your situation Radically accepting your situation Mindfulness Mindfulness – Focus attention on the moment (rather than past or future) – Avoid judgment – Being effective rather than right Acting opposite of your impulse Acting opposite of your impulse Radically accepting your situation Radically accepting your situation

34. Change Consequences Vulnerability Factors Vulnerability Factors Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Short and Long Term Consequences Short and Long Term Consequences Prompting Event Prompting Event Problem Behavior Problem Behavior

35. Change Consequences Understand what reinforces the client Understand what reinforces the client – Validation – Attention or interest – Praise – Concrete help, advice, didactics – Being left alone – Soothing Block reinforcement for dysfunctional behaviors Block reinforcement for dysfunctional behaviors Up reinforcement for functional behaviors Up reinforcement for functional behaviors Put reinforcers on time vs. crisis basis Put reinforcers on time vs. crisis basis Understand what reinforces the client Understand what reinforces the client – Validation – Attention or interest – Praise – Concrete help, advice, didactics – Being left alone – Soothing Block reinforcement for dysfunctional behaviors Block reinforcement for dysfunctional behaviors Up reinforcement for functional behaviors Up reinforcement for functional behaviors Put reinforcers on time vs. crisis basis Put reinforcers on time vs. crisis basis

36. Change Other Links Vulnerability Factors Vulnerability Factors Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Links=Emotions, Thoughts, Physical Sensations, Urges, Actions, Events Short and Long Term Consequences Short and Long Term Consequences Prompting Event Prompting Event

37. Change the Links (few examples) Thoughts Thoughts – Block suicide expectancies – Block rumination about suicide – Highlight patterns of thinking Urges Urges – Teach client to “surf the urge” Actions Actions – Teach “buying time” strategies like graceful exit Thoughts Thoughts – Block suicide expectancies – Block rumination about suicide – Highlight patterns of thinking Urges Urges – Teach client to “surf the urge” Actions Actions – Teach “buying time” strategies like graceful exit

38. Thus, change in DBT is Linked closely to the chain of events Linked closely to the chain of events Choosing the best “bang for the buck” Choosing the best “bang for the buck” – Do the most common links first – Do the links closest to the problem behavior first – Do the simple things first Model persistence and creativity Model persistence and creativity Linked closely to the chain of events Linked closely to the chain of events Choosing the best “bang for the buck” Choosing the best “bang for the buck” – Do the most common links first – Do the links closest to the problem behavior first – Do the simple things first Model persistence and creativity Model persistence and creativity

39. Dialectics and Validation

40. Dialectics (oversimplified) The synthesis between a thesis and an antithesis

41. Primary Dialectic in DBT You must accept yourself just as you are You must accept yourself just as you areAnd You must work as hard and as fast as you can to change You must work as hard and as fast as you can to change You must accept yourself just as you are You must accept yourself just as you areAnd You must work as hard and as fast as you can to change You must work as hard and as fast as you can to change Validation Validation Mindfulness MindfulnessAnd Behavior therapy Behavior therapy

42. Dialectical Behavior Patterns Dialectical Behavior Patterns   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

43. Dialectical Strategies Dialectical Strategies   Metaphor   Extending   Devil’s advocate   Asking “What is left out?”

44. Other DBT Strategies Other DBT Strategies AcceptanceChange   Communication strategies Reciprocal Irreverence communication   Case management strategies EnvironmentalConsultation Intervention to patient

45. 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.

46. 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?

47. What isn’t Validation What isn’t Validation   Soothing   Praise   Chit - chat   Global, nonspecific positive feedback

48. Levels of Validation 1. Staying Awake: Unbiased listening and observing 2. Accurate reflection 3. Articulating the unverbalized emotions, thoughts, or behavior patterns 4. Validation in terms of past learning or biological dysfunction 5. Validation in terms of present context or normative functioning 6. Radical Genuineness 1. Staying Awake: Unbiased listening and observing 2. Accurate reflection 3. Articulating the unverbalized emotions, thoughts, or behavior patterns 4. Validation in terms of past learning or biological dysfunction 5. Validation in terms of present context or normative functioning 6. Radical Genuineness

49. Orientation and Commitment DBT is a voluntary treatment ONLY DBT is a voluntary treatment ONLY If not agreeing, client is in Pre-Treatment stage If not agreeing, client is in Pre-Treatment stage – Orient – Increase commitment to long term goals and DBT targets – Agreement to treatment and its limits Commitment strategies in DBT designed to move clients from Pre-Treatment to DBT Commitment strategies in DBT designed to move clients from Pre-Treatment to DBT (Applies to therapists as well as clients) DBT is a voluntary treatment ONLY DBT is a voluntary treatment ONLY If not agreeing, client is in Pre-Treatment stage If not agreeing, client is in Pre-Treatment stage – Orient – Increase commitment to long term goals and DBT targets – Agreement to treatment and its limits Commitment strategies in DBT designed to move clients from Pre-Treatment to DBT Commitment strategies in DBT designed to move clients from Pre-Treatment to DBT (Applies to therapists as well as clients)

50. DBT Consultation Team “Therapy for the therapist” “Therapy for the therapist” – “Therapist” means anyone clinically working with client/family – Goal is to change therapist behavior in general not just toward one client/family in moment – Focus is on increasing therapists motivation and skills capacity to do DBT and stay with team Structure, principles, and strategies Structure, principles, and strategies – Consultation team agreements – Only those who are actively providing DBT in individual, group, or coaching participate “Therapy for the therapist” “Therapy for the therapist” – “Therapist” means anyone clinically working with client/family – Goal is to change therapist behavior in general not just toward one client/family in moment – Focus is on increasing therapists motivation and skills capacity to do DBT and stay with team Structure, principles, and strategies Structure, principles, and strategies – Consultation team agreements – Only those who are actively providing DBT in individual, group, or coaching participate

51. Evaluation of Outcomes DBT is only done as long as it is working DBT is only done as long as it is working – DBT done for predetermined fixed duration – DBT re-up only if substantial improvement on key outcomes Important at the Important at the – Client/family level – Team/agency level – System level Data collected by Data collected by – Diary cards and session notes – Incident reports and other system collected data – Other data methods for evaluation purposes DBT is only done as long as it is working DBT is only done as long as it is working – DBT done for predetermined fixed duration – DBT re-up only if substantial improvement on key outcomes Important at the Important at the – Client/family level – Team/agency level – System level Data collected by Data collected by – Diary cards and session notes – Incident reports and other system collected data – Other data methods for evaluation purposes

52. How we train and implement DBT

53. Individual DBT training modes Academic training (varies a lot) Academic training (varies a lot) 2-day CE trainings 2-day CE trainings Video and CD trainings Video and CD trainings – Skills – Mindfulness On-line learning On-line learning – Skills – Chain analysis – Validation Academic training (varies a lot) Academic training (varies a lot) 2-day CE trainings 2-day CE trainings Video and CD trainings Video and CD trainings – Skills – Mindfulness On-line learning On-line learning – Skills – Chain analysis – Validation

54. Standard – Intensive Training Course Apply to participate as a team Apply to participate as a team Part 1: 5 days of didactic training Part 1: 5 days of didactic training – Practice exercises for strategies and developing DBT program and team Homework (over 6-8 month window) Homework (over 6-8 month window) – Reading and exam – Practice DBT strategies (individual and team) – Program and Case Presentation (including data) Part II: 5 days of case-based learning Part II: 5 days of case-based learning Apply to participate as a team Apply to participate as a team Part 1: 5 days of didactic training Part 1: 5 days of didactic training – Practice exercises for strategies and developing DBT program and team Homework (over 6-8 month window) Homework (over 6-8 month window) – Reading and exam – Practice DBT strategies (individual and team) – Program and Case Presentation (including data) Part II: 5 days of case-based learning Part II: 5 days of case-based learning

55. DBT Implementation Training Apply to participate as county/state/province Apply to participate as county/state/province Kick-off: Kick-off: – 2 days overview training – 1 day administrator training Part 1: 5 days of didactic training about the treatment Part 1: 5 days of didactic training about the 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 using homework Part II: 5 days of problem-based learning using homework Homework (over 6-8 month window) Homework (over 6-8 month window) Part III: 2 days of intermediate training Part III: 2 days of intermediate training Apply to participate as county/state/province Apply to participate as county/state/province Kick-off: Kick-off: – 2 days overview training – 1 day administrator training Part 1: 5 days of didactic training about the treatment Part 1: 5 days of didactic training about the 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 using homework Part II: 5 days of problem-based learning using homework Homework (over 6-8 month window) Homework (over 6-8 month window) Part III: 2 days of intermediate training Part III: 2 days of intermediate training

56. How DBT implementations go bad…

57. When DBT goes bad…. Functions of DBT are left out and not replaced Functions of DBT are left out and not replaced – No skills taught – No one is dealing with therapy interfering behavior or motivating the client – No generalization of skills – System is reinforcing dysfunctional behavior – Therapists burned out or can’t work together Functions of DBT are left out and not replaced Functions of DBT are left out and not replaced – No skills taught – No one is dealing with therapy interfering behavior or motivating the client – No generalization of skills – System is reinforcing dysfunctional behavior – Therapists burned out or can’t work together

58. When DBT goes bad…. No primary therapist No primary therapist – Complex and extreme behaviors cannot be managed by committee or standard behavior modification System is managing the client System is managing the client – rather than teaching client to manage the system Alliance is not with the client Alliance is not with the client – Especially when treating child and family No primary therapist No primary therapist – Complex and extreme behaviors cannot be managed by committee or standard behavior modification System is managing the client System is managing the client – rather than teaching client to manage the system Alliance is not with the client Alliance is not with the client – Especially when treating child and family

59. How DBT implementation goes bad… Non-acceptance that DBT increases agency costs and staff time substantially Non-acceptance that DBT increases agency costs and staff time substantially Training “paper teams” Training “paper teams” – 1-2 folks from each unit of a hospital – 1-2 folks from each agency in a county Missing out on middle management Missing out on middle management – No orientation nor contingencies on agency CEOs and supervisors Non-acceptance that DBT increases agency costs and staff time substantially Non-acceptance that DBT increases agency costs and staff time substantially Training “paper teams” Training “paper teams” – 1-2 folks from each unit of a hospital – 1-2 folks from each agency in a county Missing out on middle management Missing out on middle management – No orientation nor contingencies on agency CEOs and supervisors

60. How DBT implementation goes bad… Poor orientation and commitment skills Poor orientation and commitment skills – Clients not required to commit to enter or – Clients required in toxic way Focus on process instead of outcomes Focus on process instead of outcomes – What matters is not how much of program is in place or how much kids participate – Lose focus on what was outcome to start with - less suicidal behavior, incidents… Poor orientation and commitment skills Poor orientation and commitment skills – Clients not required to commit to enter or – Clients required in toxic way Focus on process instead of outcomes Focus on process instead of outcomes – What matters is not how much of program is in place or how much kids participate – Lose focus on what was outcome to start with - less suicidal behavior, incidents…

61. Questions?Questions?