Program presentation

Team Telemark
General description
Location: Telemark county, Norway
 Aprox. 170.000 inhibitants

Educational setting leading to certification

Telephone supervision from USA

Therapists from two cooperating clinics

Adult outpatient setting

6 therapists in the team

6-8 clients in the first group

Each therapist has got 1-2 clients in individual

treatment
Planned 2 complete rounds, total duration of 60

weeks
Organizational map
Narrative description of our DBT-program

Outpatient setting.
In the first round we have chosen to only take in

female patients with BPD (SCID II) and self-harm

to tissue
We are 6 therapists from different clinical divisions

and geographical locations.

The therapists will circulate as leader/co-leader of

the skills training group

We offer a full comprehensive DBT program
Our DBT-program

• Individual therapy – Each patient will have a

primary therapist to develop and monitor the
treatment plan. The primary therapist is a
member of our DBT team.
• Skills training modules - All four skills training
modules are taught during weekly classes over a
30-weeks cycle. The clients are encouraged to
participate in two complete cycles. Modules
cover Interpersonal Effectiveness, Core
Mindfulness, Emotion Regulation, and Distress
Tolerance skills. New members may join a group
during any of the Core Mindfulness modules.
Our DBT-program, cont…
• Phone consultations – The therapists are available 24/7
for skills coaching on the phone. There may be some
individual modifications. This helps to assure that
individuals have the skills they need to manage
situations effectively.
• DBT Consultation Team Meetings - To ensure that the
structure of each person’s treatment is maintained, the
consultation team meets weekly for case review,
ongoing training and supervision.
• Complementary/Environmental Support Services –
These services include psychiatric consultation to
review medication issues and referral for inpatient
services, when needed. It may also include involvement
of community services, couples therapy, cooperation
with GP, etc.
Functions and modes
- Five functions…
Enhancing capabilities
Improving motivation
Ensuring generalization to natural
environment
Structuring the environment
Enhancing therapist capabilities &
motivation
Therapists

From two cooperating clinics

Four therapists from Sykehuset Telemark, Skien

Two therapists from DPS Notodden/Seljord

Two therapists are psychologists

Two therapists are medical doctors

Two therapists are nurses

Five therapists work in an inpatient setting

One therapist work in an outpatient setting

Clients in the first group

Six clients, can be expanded to eight

Recruited from our two clinics

Recruited from a wider geographical area

Age 19 to 32

Five of six have had several admissions to hospital

Variable coping skills

Variable ways of coping

Some clients well known to the therapist, some

new to the therapist

Criteria for inclusion/exclusion

Inclusion  Exclusion
− F 60.3 Borderline − Psychosis (MINI)
diagnosis (SCID − Drug
II) dependence, not
 Emotional
dysregulation necessarily drug
 Impulsive abuse
behaviour − Bipolar disorder
− Women
− Self-harming (to (MINI)
tissue) − Low IQ (<70)
− Suicidal/parasuicida
l ideations
− Probable ability to
adhere to the
treatment
− Geographical
Pre-inclusion psychiatric
evaluation
SCID II
MINI (General psychiatric screening)

SIMS (Self Injury Motivation Scale)

HAD (Hospitality Anxiety and Depression Scale)

SCL-90 R (Symptom Check List)

GAF
DBT-presentation to the Clients

Biosocial theory
Elements of the treatment, rationale

The working model

Presentation of mutual rights and duties

Treatment contract
Therapist’s Agreement

•Adherence to the treatment model

•Continuing education
•Accepting external supervision
•Participation in the Consultation Team
•Rotating participation in the Skills Training Group
•Mutual obligation with the clients
– Individual treatment
– Telephone consultations
– Backup case management
Client’s agreement

•Commitment to the treatment targets

•Commitment to the treatment program
– Participate in the Skills Training Group
– Adherence to the individual treatment
•Adherence to the rules for telephone consultations
•Accept confidentiality
•Establish and work towards individual goals
Protocol: Individual therapy

• Recognize current emotional state

• If necessary: Repair relationships
• If necessary: Follow-up phone consultations
• Mindfulness training
• Review progress (diary cards, priority: suicidality)
• Targets as way of organizing sessions:
– Suicidality, self-harming
– Therapy interference
– Quality of life
• Attend to relevant stage
• Progress in other modes
• Closure:
– Homework, summarize session
– Cheerleading, reassuring, troubleshooting
Protocol: Telephone Consultation

• Be available during crisis, attend to the contract

• Two conditions:
– Skills management
– Relational repair
• Focus on the current problem
• 24-hour rule
• Keep available the crisis protocols
• Consider scheduling phone calls
• Consider therapist initiated phone calls
• No psychotherapy on the phone
• No pejorative interpretations



Protocol: Skills training group

• Welcome and agenda

• Mindfulness exercise
• Examine diary cards
• Examine homework from last session
• Questions about new material last session
• Presentation of new material
• Homework assignments for next session


• Minor modification from standard DBT:

– Sessions of 4 x 30 minutes, with three breaks lasting
10-15 minutes each
Protocol: Crisis Intervention

• Assess suicide risk, eventually self-harm risk

– (If necessary: move to the suicidal crisis protocol)
• Give priority to affect over content
• Focus on the situation here and now
• Explore the immediate problem
• Start problem solving:
– Advice and direct suggestions
– Suggest use of behavioural skills (DBT-skills)
– Discuss consequences of actions, confronting
believes
– Reinforce productive actions
• Focus on affect tolerance
• Obtain a commitment to a plan
Protocol: Suicidal behaviour

• Assess the risk of suicide

• Try to remove lethal items
• Emphatically instruct the client not to commit
suicide or to stop parasuicidal activities
• While validating pain, maintain that suicide is not a
good solution.
• Generate hopeful statements and solutions
• Reinforce non-suicidal responses
• When suicidal risk is imminent and high: Keep
contact, else adhere to the treatment plan.
• Get a commitment to a non-suicidal behavioural
plan
Protocol: Suicidal behaviour (cont.)

• When the situation is unstable in spite of the

intervention, with no real commitments, and the
risk of suicide is continued high and imminent:


–Consider emergency services

Evaluation procedures

• Inpatient days
– Before, during and after the DBT program
• Psychometrics before, during and at termination
– SCL-90, GAF, HADS
• Attendance
– Skills-training group, individual therapy
• Homework accomplishment
• Monitoring client’s self-reported behaviour and
thoughts from diaries:
– Suicidal behaviour and thoughts, self-harming
episodes, use of alcohol and drugs, reported
suffering

Coordination: Clients impression

• The clients are informed that behind the treatment

there is a consultation team, coordinating the
DBT program.
• Each client have met, and have been presented to,
all the members of the consultation team
• Skills trainers are recruited from the consultation
team, so that the leaders of the group rotates
amongst all the individual therapists
• In the case that the primary therapist for some
reason is not available, another therapist from the
consultation team will step in.
Coordination: Team aspects

Increasing coordination
 Decreasing coordination
• •
• Therapists get to know each • Therapists have other duties,
other better interfering with the DBT
• Therapists get a better program
understanding of the concept • Therapists come from two
of DBT different clinics, with different
• Therapists spend time together tasks and priorities
beyond the consultation team • Therapists work in different
meetings clinical and geographical
• The consultation team has a settings
steadily focus on coordination
of the program
 DBT Blog…
•
• http://dbtnorge.posterous.com/
•
•
• If you are interested, please contact us:
•
• kjetil.dale@nenett.no
•
• fred.rune@rahm.me