Extending an adult DBT program to adolescent clients

In June 2010, with all components of the Adult Dialectical Behavior Therapy (DBT) program in place at Jewish Family and Children's  Service (JF&CS) in St. Louis (see “New Approach Energizes Agency,” June 2010), we anticipated expanding our DBT program to adolescents, pending the availability of funding through the St. Louis County Children’s Service Fund or another source. When this funding came through, the first group of DBT program adolescents and parents began skills training in October 2010.

The Adolescent DBT skills group covers the same modules as the Adult DBT program: distress tolerance, emotion regulation, and interpersonal effectiveness. Each of these modules is preceded by one session of “core mindfulness”—an essential element of training for every DBT component.

In addition to these modules, there is an additional module—specific to the Adolescent DBT skills group—that is called “Walking the Middle Path.” This module teaches clients how to find a balance between acceptance and change by thinking and acting dialectically, validating self and others, employing behaviorism supports (positive/negative, reinforcement/punishment), and improving relationships with parents.

Results to date
The adolescent DBT program requires attendance of a parent or other reliable adult to participate in weekly skills group side-by-side with the adolescent. Results seen thus far from the adolescent DBT program include:

•    Development of healthier relationships between parents and their adolescent, among adolescents and the other adolescent participants, and among the participating parents.
•    Development of common goals and team mentality among the adolescent and parent participants.
•    Development of effective communication skills for the participants.
•    Use of DBT skills by adolescent and parent participants between sessions
•    Parent and adolescents learn from the experiences of their peers.

DBT coaching by phone
Another element of the DBT program that we have further developed over the last year is a telephone coaching element. A DBT therapist uses a phone coaching format to help keep the client (or the parent of a client in the case of the adolescent DBT program) on track with skills coaching.

Coaching calls may be in response to an emergency on the part of the client; however, our DBT structure for the call requires that the client make an attempt to utilize at least one DBT skill before making the call. The purpose of the call is to troubleshoot why the skills didn’t work for the client and for the therapist to possibly recommend additional DBT skills. Over the past two years, our DBT team members have grown in their ability to handle the coaching calls.

As more clients have begun to understand the value of contracting with their therapist for the “full” DBT program, which includes the telephone coaching, there has been a great demand for the full model of DBT from our clients. The clients see the full model of DBT as a significant support for their recovery beyond usual and customary psychotherapy.

In keeping with the current technology, and because of the structure and brevity of a telephone coaching call, a number of adolescent and adult clients opt to use “texting” as a way of making the “coaching call.” Our revised coaching contracts with DBT clients spell out their consent to use of cell phones and related technology for the purposes of coaching calls.

A new “graduate” group
Just recently, one of our original DBT staff members began facilitating our first adult DBT “graduate” group, which is composed of clients who have gone through all of the DBT skills training modules and stabilized sufficiently to be considered graduates. The clients are not considered finished with therapeutic work, but they have sufficient skills to begin and complete trauma work, usually in individual therapy.

A seasoned staff member who recently trained in DBT volunteered to co-facilitate the graduate group. This group supports  successful individual therapy by reinforcing the use of DBT skills in everyday life and by learning advanced techniques.
The DBT consultation team (consisting of both staff of the adolescent and the adult DBT programs) has matured, having worked through many program developmental tasks/issues and stages. The weekly DBT consultation meetings have been vital to the growth and development of the program. Team members have pushed to have our program become a more comprehensive, full-model (evidence-based) DBT program, as opposed to a DBT-informed program. They have worked with the DBT model long enough that most elements of the program flow easily for them, including group skills training, telephone coaching, and  the use of specific techniques such as chain analysis in individual DBT therapy.

The DBT team has benefited from periodic, free consultation from the Missouri Department of Mental Health DBT consultant. We set up a HIPAA compliant Business Associate Agreement with the state DBT consultant, allowing the consultant to visit our site and staff cases by phone with our staff. Through the state DBT consultant’s guidance, four of our DBT staff became DBT-certified. Three have obtained a provisional certification and shortly will become DBT-certified.

JF&CS staff members are proud of their mastery in a wide assortment of evidence-based practices and are actively utilizing those practices in treating many clients. In addition to DBT, other evidence-based practices in which staff members have been trained include Cognitive Enhancement Therapy (CET), Trauma-Focused CBT (TF-CBT), Eye Movement Desensitization & Reprocessing (EMDR), and Motivational Enhancement Therapy (MET).

        ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

The intervention called Dialectical Behavior Therapy (DBT) was originally developed by Marsha Linehan, Ph.D. to treat consumers with Borderline Personality Disorder and has been shown to be helpful in treating other high-risk clients as well. Dr. Linehan’s research demonstrated that clients who participated in DBT experience a significant reduction in hospitalizations, self-injurious behavior, substance use, trauma-related symptoms, anxiety, and depression, along with an overall improvement in their quality of life.
DBT treatment principles combine cognitive behavioral therapy with eastern philosophical techniques, especially “mindfulness” skills. A complete DBT treatment program must include the following components to maintain fidelity with its evidence base:

•    DBT skills training groups: Group classes teach clients skills that help them cope with very painful experiences, improve their relationships, focus on important priorities, and handle emotional ups and downs more effectively;
•    DBT individual therapy: Psychotherapy is used to coach the client in applying skills learned in groups to individual issues;
•    DBT consultation team: Weekly DBT therapist meeting that enables consultation, training, and support for each other in maintaining a most effective balance (client validation and client challenge) in their therapeutic work; and,
 

Other critical components of a DBT program include:
•    Elimination of the traditional therapy “hierarchy,” a relationship that positions staff not as experts/superiors to clients, but as equals.
•    Practice of DBT skills taught to consumers by both staff and consumers.
•    Creation of a specific treatment contract between a therapist and a consumer;
•    Dialectical interventions, which are characterized by a balance of validating and challenging the client; and
•    Use of daily diary cards by consumers to reinforce their own use of skills.