Developing Competencies in Dialectical Behavior Therapy: A Tale of Two Internship DBT Programs

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Developing Competencies in Dialectical Behavior
TherapyA Tale of Two Internship DBT Programs

• Carol Kerr, Ph.D
• Marin County Health and Human Services, San
  Rafael, CA
• Diane Wetzig, Ph.D
• Laurelwood Hospital, Cleveland, OH

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This presentation is intended to be a catalyst
for programs sharing ideas about ways to provide
training and practice in DBT within the context
of a typical internship experience.
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We offer brief descriptions of two programs One
was established in a hospital based program in
Ohio, the second in a public mental health center
in California. The authors met through the APPIC
members network and continue to share resources
and training ideas.
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Why Offer DBT Training?

• DBT is an established evidence-based practice for
  which there is increasing consumer demand
• Multi-modal model extends skills in individual,
  group, and consultation practice
• DBT Model actively supports students experience
  in treating Axis II disorder(s)
• DBT practice develops interns skills in program
  development, management, and evaluation

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Basic Ingredients for Any Program

• Access to clinical staff consultation from a
  credentialed and experienced DBT practitioner.
• Interns willing and able to commit to initial
  training requirements, weekly consultation group,
  and participation in group/individual treatment.
• Service system commitment to having phone
  coaching and/or 24 hour response system available
  to clients.

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Established Program in a Hospital Setting

• Laurelwood Hospital and Counseling Centers is a
  mental health system that provides treatment for
  Adult, Adolescent, and Preteens diagnosed with
  mental, emotional, personality, addictions, dual
  diagnosis, and eating disorders. Treatment
  modalities include
• Inpatient stabilization in the 160 bed Laurelwood
  Psychiatric Hospital
• Intensive Outpatient Programming (IOP), 3 days
  weekly for 3 hours each session
• Partial Hospital Programming (PHP), 5 days weekly
  for 5 hours daily
• Continued weekly DBT Skills Groups concurrent
  with Weekly Individual Therapy for the remainder
  of the 12 month treatment year.

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Sequence of Program Development

• The Psychology Internship Training Program was
  designed to offer training in Evidence Based
  Treatment (EBT) for a range of patient
  populations. The initial DBT Adult Mental health
  track was developed and implemented 1999-2000
  with the participation of the psychology interns
  who were introduced to DBT in that year.
• The Adolescent DBT and both adult and adolescent
  DBT/Substance Abuse programs were developed and
  implemented 2000-2001 and featured psychology
  intern co-facilitation
• A program in Eating Disorders was added in 2002
  and the PTSD track came into being in 2003 with
  the participation of the 2003-2004 year interns
• The internship also provides training in William
  Millers Motivational Interviewing for the DBT
  Pretreatment stage and in Edna Foas Exposure
  Therapy for Stage 2 of DBT, treatment for Post
  Traumatic Stress Disorder (PTSD).

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Training Sequence Laurelwood Phase I Orientation

• General Orientation to setting and ethical
  standards
• Weekly Didactic Students are expected to have
  read both Linehan texts in the prior summer
  Cognitive-Behavioral Treatment of Borderline
  Personality Disorder and of the workbook Skills
  Training Manual for Treating Borderline
  Personality Disorder
• Interns are required to complete the DBT online
  learning course offered by Behavioraltech.org
• Intern exposure to variety of DBT IOP Tracks
• Interns are assigned to Initial Placement on IOP
  team
• Supervision Assignments Made
• Weekly Consultation Group Established

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Phase II Initial Placement

• Weekly DBT Didactic begins
• 4 DBT Skills Modules are reviewed
• Interns join trained DBT therapists to
  co-facilitate DBT IOP and Skills Groups through a
  complete 3 month rotation. Interns may be placed
  with the DBT Adult Mental Health, Adult Substance
  Abuse, Adolescent Mental Health, or Adolescent
  Substance Abuse DBT IOPs.
• Interns begin to provide Individual DBT Therapy
• Interns also begin weekly individual Supervision,
  DBT Consultation Group and do psychological
  Assessments

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Phase II Didactic Focus

• DBT Skills Modules
• Individual therapy process.
• For the individual therapy component of DBT,
  emphasis is on client motivational management,
  the deepening and reinforcement of the new DBT
  skills sets, and the extinction of older
  maladaptive behaviors of clients. Preparation
  begins for interns to provide telephone coaching.
  There is much use of role play in both didactic
  and supervision.

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Phase III Second Placement

• Interns switch to a different rotation for the
  following 3 months experience in either another
  of the DBT IOPs or in the PTSD IOP.
• Continue to provide Individual Therapy
• Weekly Individual Supervision (2 hours)
• Weekly Didactic focus on Motivation and Change
• Didactic and supervision focus more intensely on
  the individual therapy and telephone coaching
  areas and emphasize motivation management and
  commitment strategies. Also behavioral,
  cognitive, problems solving, and exposure-based
  procedures are highlighted. The interns begin
  telephone coaching under the close supervision of
  the licensed psychologist.

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Phase IV Consolidation and Termination

• Evaluation of intern skills sets and needs
• This phase is individualized to the specific
  needs of each intern.
• Individual therapy is continued and concluded or
  patient is transferred when intern leaves.
• Skills Groups continue for patients

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Laurelwood DBT Case Case Consultation Model

• All group and individual therapists involved in
  DBT treatment attend weekly case consultation
  teams. For the first half hour, some aspect of
  DBT treatment is discussed
• Each therapist presents a case. Presentations
  are ranked in order according to degree of
  severity of client presenting issues from
• Target 1 issues (suicidality/parasuicidality)
• Target 2 issues (therapy interfering behaviors)
• Target 3 issues (quality of life issues).
• Progress reports on all patients are given.

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Challenges Encountered in a Hospital Based System

• Program development and management in a large
  hospital system requires very close attention to
  the political issues of the organization and
  lobbying for the interests of the patients.
• Health care economics and corporate decision
  making may undermine program stability.
• Despite excellent outcomes to the treatment
  program and satisfaction in the training program,
  recent changeovers in hospital administration
  were followed by staff cuts and reorganization
  that has led to the closing of this Internship
  site as of July 1, 2007.

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Developing Program in a County CMHS

• Marin County Community Mental Health provides
  outpatient and acute care to low income county
  residents with serious mental illness or acute
  behavioral emergencies.
• Funding cuts in the last decade eliminated
  outpatient psychotherapy services provided by
  staff, but by maintaining and expanding an
  Internship Program we have been able to continued
  services to those with the highest level of need.
• Emerging management priority for Evidence-Based
  Practices for Co-Occurring Disorders has
  identified DBT as a target for program
  development with goal of reducing acute care
  rates and improving levels of functioning

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Stages of Program Development CMHS Year One

• Didactic seminar on DBT led to student initiative
  to pilot a DBT program
• Intensive training with clinician with Behavior
  Tech certification (Marian Cremin, LCSW)
• Readings and homework as assigned by trainer
• 24 hours of direct instruction time
• Weekly group consultation meeting for program
  planning and development
• Definition of program criterion, curriculum and
  structure
• Identification of potential clients and screening
• Initial Skills Group series (16 weeks)
• Review of program and feedback

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Stages of Program Development CMHS Year Two

• Transition to Year 2 cohort and initial training
• Refinement of training process two clinic staff
  begin supervising weekly consultation group
• Initiation of second skills group series
• Initiation of time-limited advanced group
• Ongoing monthly consultation team trainings
  including outside clinicians to extend services
  in local contract agencies
• Review of program and feedback/planning

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Stages of Program Development CMHS Year Three

• Transition to Year 3 group
• Expansion to include both Youth and Family
  interns and Adult interns
• Expansion to include interns in external private
  practice groups
• Ongoing group and individual treatment program
• Development of modified skills group for Juvenile
  Hall

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Stages of Program Development CMHS Year Four

• Transition to Year 4 group
• Ongoing group and individual treatment program
• Ongoing consultation group, including outside
  providers of individual treatment
• Development of training curriculum tailored to
  site and client population

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Essential Challenges in a CMHS System

• Maintaining funding for outside consultation when
  budgets are very restricted
• Providing adequate training rapidly at the
  beginning of the year so that students can
  integrate DBT model into ongoing cases from the
  outset.
• Having resources and time for program evaluation
  and documentation of client progress in
  systematic ways.

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Basic Building Blocks for DBT

• Interested and motivated students.
• Clients who will benefit from skills in
• Mindfulness, Emotional Regulation, Distress
  Tolerance, and Interpersonal Effectiveness.
• Experienced DBT clinician to teach, consult, and
  help with modifications to accommodate demands
  and limits of the public system.
• Administrative commitment to evidence based
  practice and feedback from patients and staff.
• Space for groups
• Patience, imagination, and a dialectical attitude.

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Resource Sharing for Developing DBT Programs

• http//behavioraltech.org/resources/tools_clinicia
  ns.cfm
• http//www.nimh.nih.gov/publicat/bpd.cfm
• Both of the presenters are happy to respond to
  questions on program development or share
  curriculum materials
• Diane Wetzig, PhD. diane.wetzig_at_laurelwoodhospita
  l.com
• Carol Kerr, Ph.D.
• ckerr_at_co.marin.ca.us