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, and supervising an advanced psychology graduate student. In addition, fellows conduct individual psychodynamically-informed psychotherapy through our long-term therapy clinic.

Placement Options

This track consists of a single, full-time, twelve month placement within YNHPH's Adult DBT Intensive Outpatient Program.

Number of Fellows

Two doctoral fellows will be selected into the Adult DBT Track for the 2014-2015 academic year. Assignment to the DBT-General or DBT-SUD tracks follows 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 YPH inpatient units, and about one third are referred from community providers.

The 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, 9:30 am to 1:00 pm, 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

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 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 cognitive-behavioral, psychodynamic, and topic-focused groups such as family issues, managing bipolar symptoms, and discharge planning; conducting admission interviews and psychological evaluations, participating in multi-disciplinary treatment planning and review meetings.

Doctoral fellows also have the opportunity to conduct psychological diagnostic testing protocols during the year. Most diagnostic assessments include evaluations of newly admitted patients on the psychiatric inpatient units and patients who have been participating in treatment for longer periods in the intensive outpatient ambulatory services programs. 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, traditional full battery assessments, as well as brief forms of personality assessment and neuropsychological screening.

Doctoral fellows within the Adult DBT track also receive weekly supervised individual psychotherapy training within the Department of Psychiatry’s Long Term Care Clinic.

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.

Scholarly Activity

One-half day per week of protected research time is provided to allow fellows the opportunity to pursue and conduct clinical research within the Yale School of Medicine. Research training objectives are individually designed and achieved through an apprenticeship model where the fellow works closely with a faculty mentor involved in a program of active research. Fellows are matched with faculty mentors based on their shared interests and faculty availability. The faculty member serves as supervisor and role model, with the goal of integrating clinical and research skills as well as professional role identity.

Within the Adult DBT track, 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., Primary Advisor
Michael Barrios, Ph.D., Clinical Supervisor
Ellen Nasper, Ph.D., Clinical Supervisor
Donald Quinlan, Ph.D., Clinical Supervisor

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 have the opportunity to attend the Dialectical Behavior Therapy Summer Seminar (July and August). This seminar covers theory, formulation, and major strategies of Dialectical Behavior Therapy (DBT) as it is applied to treating severe borderline personality disorder in outpatient and day hospital settings. Attendees actively engage the material through discussions of cases and video examples, skills practice, self-monitoring and problem solving exercises, and role play.

For Further Information

For more information about this placement site, please e-mail seth.axelrod@yale.edu.