Adult Dialectical Behavior Therapy Services

APPIC #118311

Overview

Located within Yale-New Haven Psychiatric Hospital’s (YNHPH) Adult Intensive Outpatient Program, this placement has a primary focus on learning to apply Dialectical Behavior Therapy (DBT) with complex, multi-problem, and self-destructive individuals who need more intensive treatment than is available with standard outpatient care. Comprehensive DBT and DBT for Substance Use Disorders are modified for this group-based day hospital setting. Clinical activities include serving as primary clinician for up to eight DBT patients, co-leading a variety of DBT and other therapy groups, risk assessment and management, skills coaching, intake interviews, family sessions, peer consultation, and supervising an advanced psychology graduate student. In addition, fellows have the opportunity to conduct individual therapy including the DBT Prolonged Exposure Protocol for individuals enrolled in the IOP DBT tracks, as well as psychodynamically-informed psychotherapy through our Long Term Care Clinic.

Placement Options

PRIMARY PLACEMENT - This track consists of a single, full-time, twelve-month placement within YNHPH's Adult DBT Intensive Outpatient Program. (There are no secondary placements within YNHH).

Number of Fellows

Two doctoral fellows will be selected into the Adult DBT Track for the 2018-2019 academic year. Assignment to the DBT-General or DBT-SUD tracks occurs after the match process and is based on fellow preferences.

The Setting

The Adult Intensive Outpatient Program (IOP) of Yale-New Haven Psychiatric Hospital treats adult patients who do not require the level of supervision and support provided by an inpatient program, but who need more intensive intervention than is readily provided in most outpatient settings. About two thirds of newly admitted patients are referred to the IOP for follow up treatment from one of the YNHPH inpatient units and about one third are referred from community providers.

The Adult IOP is divided into four main treatment tracks: a General Psychiatric track for patients with mood, anxiety and/or psychotic disorders; a Dual Diagnosis track for patients with co-occurring psychiatric and substance use disorders; a general DBT track for patients with borderline personality disorder features who struggle with chronic patterns of suicidal or other self-destructive behaviors; and a substance-focused DBT track for patients who struggle with borderline personality disorder features and substance abuse or dependence. Patients in the General and Dual-Diagnosis tracks attend the IOP for four days per week for about four to six weeks. Patients treated in the DBT tracks attend two days per week and commit to a four-month treatment contract, renewable once for a maximum length of stay of 8 months.

Modifications to standard comprehensive outpatient DBT for the IOP setting include conducting diary card review and behavioral analysis in groups, protocols for preventing contagion of crisis behaviors among group participants, treating patients who are in concurrent outpatient therapy, and targeting problems in outpatient treatment with the goal of discharging patients into an effective and productive outpatient level of care.

The Internship

Adult Intensive Outpatient Program:
Fellows serve as primary clinician for up to eight DBT patients. They co-lead a variety of DBT therapy groups including skills training, diary card review, behavioral analysis, and skills coaching, and they participate in telephone skills coaching, weekly consultation team meetings, risk assessment and management, as needed family sessions and consultation to outpatient providers, and orientation and commitment interviews for new perspective DBT patients. In addition, fellows provide DBT-oriented supervision to an advanced psychology graduate student, and they have the opportunity to provide individual DBT sessions including the DBT Prolonged Exposure Protocol and elective brief individual DBT therapy.

Fellows develop specific DBT competencies in working with patients with Borderline Personality Disorder and an array of co-morbid conditions, such eating disorders, substance use disorders, dissociation, and schizoaffective disorder. They develop proficiencies in applying behavioral strategies and structured protocols, DBT-oriented case management and consultation, dialectical clinical formulation, and observing personal limits for maintaining wellbeing and avoiding burn out.

Additional clinical activities include: co-leading topic-focused therapy groups with general psychiatric and dual-diagnosis IOP patients such as family issues, CBT for depression, and stress management, participating in multi-disciplinary treatment planning and review meetings, and conducting diagnostic and psychological evaluations.

Long Term Care Clinic:
All YNHH doctoral fellows have the option of receiving weekly supervised individual psychotherapy training within the Long Term Care Clinic. The Long Term Care Clinic is an outpatient psychotherapy training clinic operated by the Department of Psychiatry and YNHH. Individual patients are referred to this clinic by the Yale University Health Services, and as such, are typically members of the University community who are seeking insight-oriented psychotherapy for a variety of identified issues, most commonly related to developmental, relationship, mood, and/or anxiety concerns.

Within the LTCC, individual weekly supervision from a psychodynamic perspective is provided to guide the fellow in conceptualizing and implementing treatment from an insight-oriented therapeutic modality most appropriate to the assigned cases. Typically, doctoral fellows see one individual therapy patient in once-a-week psychotherapy for the full duration of their training year.

Evidence-Based Practices

The following evidence-based practices (EBPs) are used in this placement setting. Fellows generally have exposure to most of these EBPs though do not necessarily receive training or supervised experience in all of them. The EBPs include: Dialectical Behavior Therapy, Dialectical Behavior Therapy for Substance Use Disorders, Cognitive Behavior Therapy, and Seeking Safety.

Psychological Assessment

Doctoral fellows at YNHH conduct a variety of brief and comprehensive psychological and neurocognitive diagnostic testing protocols during the year. Most diagnostic assessments include evaluations of newly admitted patients on the psychiatric inpatient units, patients who have been participating in treatment for longer periods in the intensive outpatient ambulatory services programs, and patients who are receiving care within the hospital acute inpatient and outpatient specialty medical services.

Each assessment involves administering and interpreting a variety of instruments, participating in individual testing supervision, consulting with the treatment team about the implications of test results for the patient's treatment, providing feedback to the patient in consultation with the treatment team, and writing a final report. Doctoral fellows conduct structured diagnostic interviews, a minimum of two traditional full battery assessments, as well as brief forms of personality assessment and neuropsychological screening.

Diversity

At Yale-New Haven Hospital diversity and inclusion are important components of its organizational values. The hospital is committed to providing an environment of inclusion that supports the diversity of its patients, visitors, employees, business partners and communities. Serving the Greater New Haven area and surrounding Southern New England region, YNHH admits a diverse population of patients, both diagnostically as well as demographically. Approximately 65 percent of patients admitted to the hospital are Caucasian, 15 percent Black, 15 percent Hispanic and 5 percent Asian. Likewise, nearly 60 percent of patient’s hospital costs are paid for through Medicare or Medicaid. The hospital is committed to providing the highest standard of care to all patients regardless of socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography, disability and age.

Scholarly Activity

Four hours per week of protected time is provided to allow fellows with the opportunity to design and conduct a scholarly project of their choice. Individual project objectives are coordinated with the primary advisor, and/or another faculty mentor involved in a program of active research. Fellows may design a project with faculty within their primary training placement, or request to be matched with other faculty in the Yale School of Medicine based on their shared interests and faculty availability. The fellow’s scholarly activity can take many forms. In consultation with the faculty advisor, the fellow may choose to engage in an ongoing research project, evaluate a clinical service or program, or help design and implement a new project that will benefit the individuals receiving services within the YNHH system.

Fellows also have the opportunity to co-review manuscripts for research journals and to assist with the annual Yale NEA-BPD Conference.

Faculty

Seth Axelrod, Ph.D., Clinical Supervisor
Emily Cooney, Ph.D., Primary Advisor
Debra Bond, Ph.D., Clinical Supervisor
Christine Dauser, Ph.D., Clinical Supervisor
Christine DeMaio, Ph.D., Clinical Supervisor
Marie-Paule de Valdivia, LCSW, MBA, Clinical Supervisor
Rachel Litwin, Psy.D., Clinical Supervisor
Connie Nickou, Psy.D., Clinical Supervisor
Megan Warner, Ph.D., Clinical Supervisor
Wendy Levy, Ph.D., Assessment Supervisor

Supervision

Fellows have weekly individual supervision with a primary advisor and with secondary clinical supervisors, weekly DBT consultation team meetings, and as needed individual or group assessment supervision. Fellows may receive additional individual supervision for optional clinical activities such as with the Long Term Care Clinic or the Refugee Clinic. Formal evaluations are completed that serve as opportunities to review progress on training goals and address progress toward core competency areas.

Seminars and Specialized Training

In addition to the core didactic seminars within the Department of Psychiatry and general hospital-based seminars, Adult DBT Service fellows also attend the Foundations of Dialectical Behavior Therapy Seminar (July and August) and the Dialectical Behavior Therapy Prolonged Exposure Protocol (DBT-PE) Seminar (September and October). The Foundations of DBT Seminar covers theory, formulation, and major strategies of DBT as it is applied to treating severe borderline personality disorder in outpatient and day hospital settings. The DBT-PE seminar covers the application of prolonged exposure for post-traumatic stress with individuals who struggle with chronic emotional dysregulation and high-risk behaviors who are enrolled in DBT. Attendees of both seminars actively engage the material through discussions of cases and video examples, skills practice, self-monitoring and problem solving exercises, and role play.

Applicant Qualifications

Competitive applicants for this placement generally have prior experience working with individuals struggling with chronic emotional dysregulation and high-risk impulsive behaviors. In addition, they have experience conducting evidence-based therapies including at least some components of Dialectical Behavior Therapy (i.e., DBT skills groups, consultation team, phone consultation, and/or individual therapy). Fellows who match with this placement typically have demonstrated promise in scholarly work in areas related to personality pathology, emotional dysregulation, trauma, or impulsivity, and they show potential for developing into leadership roles.

Applicants selected for this placement must successfully pass background checks conducted by Yale University and Yale-New Haven Hospital.

For Further Information

For more information about this placement site, please e-mail seth.axelrod@yale.edu and/or emily.cooney@yale.edu.

Axelrod and Fehon

Dr. Seth Axelrod, left, and Dr. Dwain Fehon

Yield

Yale Instruction/Investigation/Intervention in Emotional Lability and Dysregulation (YIELD)

Annual Yale NEA Borderline Personality Disorder Conference