Engaging the Dialectical Paradox: Applications of DBT with Complex Adolescents

Name: Engaging the Dialectical Paradox: Applications of DBT with Complex Adolescents
Uploaded: 2025-12-03T14:48:43.5633333Z
Duration: 59 min 23 s
Description: YCSC Grand Rounds December 2, 2025 Rebecca Kamody, PhD Assistant Professor, Yale Child Study Center

December 03, 2025

YCSC Grand Rounds December 2, 2025
Rebecca Kamody, PhD
Assistant Professor, Yale Child Study Center

About the speakers

Rebecca Kamody, PhD
Assistant Professor in the Child Study Center

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ID: 13669
To Cite: DCA Citation Guide

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00:00Hey. Good afternoon. We're gonna
00:02get started,
00:03and let's
00:04let's open the gates for
00:05our friends on Zoom.
00:07Okay.
00:08Next, week for Grand Rounds,
00:10we're gonna have doctor Paul
00:11Marri as part of our
00:12leadership
00:13series, so that's next week.
00:16And today,
00:19we have a real treat.
00:21And this is someone
00:23who is on our faculty,
00:25but if you have not
00:26seen her of late,
00:28it's, no coincidence because she
00:29is mostly in the virtual
00:31world,
00:32but very active in the
00:33virtual world doing research with,
00:35Michael Block's lab and teaching
00:38all sorts of things.
00:39And this is no other
00:40than Rebecca Kamedy. So Rebecca
00:42trained with us
00:44and,
00:45as a psychology pediatrics fellow,
00:48and the rest has been
00:49history. She's been, setting up
00:51programs in eating disorders and
00:53treatment of adolescents with personality
00:55disorders.
00:57She is the queen literally
00:59of DBT. She knows everything.
01:01She almost invented dialectical behavioral
01:03therapy.
01:05And I'll say a couple
01:06of nice embarrassing things about
01:07her. One is that, at
01:09center left over there, Shay,
01:10say hello.
01:11That's Shay. That's,
01:13Rebecca's better half.
01:15And in the carriage, the
01:16beautiful,
01:18Sarah.
01:19So we're delighted that you
01:20are here with your family.
01:22And the other embarrassing thing
01:23that I'll say in public
01:25is that, I've known Rebecca
01:26for many years now, and
01:28I have great,
01:29fondness and admiration and respect
01:31for her.
01:32And one of the things
01:33is that when I go
01:34through my,
01:36roster of outpatients,
01:38without a doubt, the sickest
01:40patients who I have, the
01:41most complex patients who I
01:42have are the Rebecca Kamedy
01:44patients.
01:46She is a superb clinician,
01:49unflappable,
01:51always,
01:52smiling, always friendly,
01:54but,
01:55therapeutically
01:56incredible. And I think that,
01:59this is not just through
02:00force of her personality and
02:01her persona, but through all
02:02the knowledge that she,
02:04has and that she will
02:05share with us today. So
02:06let's welcome Rebecca Kamedy. Thanks
02:08for being here today.
02:16Well, it's a pleasure to
02:17be back, and really amazing
02:19to, I think, to come
02:19back full circle and to
02:21be in the child study
02:22center again and to be
02:22able to be here with
02:24my four month old and
02:25my husband. So it's a
02:26pleasure to be here.
02:27And I was thrilled when
02:29Andres had asked me to
02:30give this talk. DBT really
02:31is a passion of mine,
02:33one that we've tried to
02:33integrate into some of these
02:35different modalities here at the
02:36Child Study Center,
02:38and I'm excited to just
02:39talk about some of the
02:40nuances of it today and
02:41hopefully inspire, some more collaborations,
02:43some
02:44some ideas of where we
02:45can bring in some of
02:46the programming.
02:50No conflicts to disclose today.
02:53And in terms of the
02:54learning objectives,
02:55I hope that we'll be
02:56able to understand the tenets
02:57of DBT that make it
02:59a unique treatment from other
03:00evidence based approaches for youth
03:01with complex mental health concerns,
03:04describe the applications of DBT
03:05with transdiagnostic
03:06youth mental health presentations,
03:08and discuss some of the
03:09adaptations of DBT for different
03:11levels of care.
03:15So starting with the the
03:17history of DBT, I'm gonna
03:18be focusing quite predominantly on,
03:20adolescents and and youth today,
03:22but, for those with some
03:24familiarity
03:25or those that are newer,
03:26to the treatment, the original
03:28development was designed for adults
03:30with borderline personality disorder.
03:33Where the inspiration
03:34for the development came from
03:36was actually,
03:37from Marshall Linhan, the creator's
03:39own, lived experience. She had
03:41a diagnosis or misdiagnosis of
03:42schizophrenia as a,
03:44in her
03:46kind of growing up periods,
03:48and then was diagnosed with
03:49borderline as an adult. And
03:50she talked about this experience
03:52of living life like she
03:54had third degree burns on
03:55her skin, in terms of
03:56the emotional experience. That's something
03:58that would feel like a
03:59light gust of wind to
04:00most people felt like the
04:02most intense experience that that
04:03she would have,
04:04emotionally.
04:06And recognizing that then with
04:07that came a lot of
04:08challenges with navigating our mental
04:10health care system,
04:12that when in different programs
04:13that were specifically about change
04:15based therapeutic strategies only, about
04:17reframing cognitions, reframing,
04:20behaviors,
04:21making a lot of these
04:22changes that it led to
04:24some a lot of,
04:26increased rates of hospitalization for
04:28her and for others as
04:29well as then the the
04:30bounce back and rehospitalizations
04:32that would happen.
04:33So she found and had
04:34this experience of needing a
04:36different type of approach to
04:37her treatment, one that provided
04:39more of a balance in
04:40terms of changing the behavior,
04:44and it's something that then
04:45has been studied in terms
04:46of the differences
04:47of when we look at
04:49the DBT approaches to things
04:50versus other change based therapeutic
04:52strategies
04:53of what can we do
04:54to to reduce the need
04:56for higher levels of care,
04:58and the increase, being able
05:00to stay in one's own
05:01life.
05:03The idea here also being
05:05that if we're looking to
05:05have cohesive treatment and one
05:07that we can continue with
05:08with our patients across the
05:10the entire kind of span
05:11of their treatment that limits,
05:13again, needing to go in
05:14and out of higher levels
05:15of care,
05:16that we can reduce some
05:17of those barriers and end
05:18up having a more
05:21cohesive kind of course of
05:22treatment, leading patients to meeting
05:24their goals.
05:28So I imagine everybody here
05:29is familiar with our biopsychosocial
05:31theories, and biopsychosocial
05:33frameworks that we use in
05:35kind of understanding where, our
05:36our patients are at and
05:38understanding the challenges that they
05:39have. The biosocial theory that
05:41underlies DBT specifically looks at
05:43this biological vulnerability that one
05:45may have to the emotions.
05:46So the way that I
05:48often talk about it with
05:49patients and their families is
05:50that some of us have
05:51really big feelings. Right? We
05:52have that high sensitivity,
05:54and we feel them really
05:55intensely. There's a high reactivity,
05:57and once we experience those
05:59emotions very intensely, it's a
06:00slow return to baseline. So
06:02once we've had that experience
06:03of the emotional burn skin,
06:05it takes us a long
06:06time to get back to
06:07what feels like,
06:08our our more even keeled
06:10place.
06:11There's a transaction that happens
06:13with the the invalidation in
06:14our environment when we somehow
06:16feel that it's communicated that
06:18what we're thinking, what we're
06:19feeling, or what we're doing
06:21doesn't make sense.
06:22Or we can think about
06:23it in other ways as
06:24being a forfeit
06:25between the temperament of the
06:27person and the environment.
06:29And I think an important
06:30piece here that I often
06:31talk with families about is
06:32there's both the overt and
06:33covert invalidating environment in the
06:36way. You of course, we've
06:37all worked with parents I
06:38think that may be more
06:39critical of their children than
06:40than we would like or
06:41we may see some more
06:42of that kind of o
06:43overt invalidation
06:51even keeled or or help
06:53check the facts and recognize
06:54that something isn't that big
06:55of a deal, but how
06:56that can actually feel very
06:57invalidating than for somebody experiencing
06:59things so intensely.
07:02When we have that transaction
07:03and those things coupled together
07:05the theory behind the treatment
07:06is that that's what leads
07:07to the chronic emotional and
07:08behavioral dysregulation,
07:11and what I like about
07:12the model itself is it
07:13does give us a lot
07:13of different points of intervention.
07:15So of course, one of
07:16the things that we'll talk
07:17about in, when we're thinking
07:18about youth specifically is how
07:20do we create more validating
07:21environments in the home and
07:23their environments.
07:24But also when it comes
07:25to the biological vulnerability
07:27there there's, of course, a
07:27piece that we may think
07:28about through psychiatric intervention, and
07:31then there's also the piece
07:32that comes from the skill
07:33acquisition, and that's a big
07:34part of the treatment that
07:35we'll be talking more about.
07:40In terms of then specifically
07:41applications
07:42of, DBT with youth, there
07:45has been, of course, DVTA,
07:47which is something that we
07:48do a lot of work
07:49in here with the skills,
07:51with our fellows and with
07:52some of our clinicians,
07:53and there has more recently
07:55will hit on, been the
07:56DBTC or the child DBT.
07:59Focusing just for a moment
08:01on the DBTA, it is
08:03when it comes to youth
08:04our most robust evidence based,
08:06compared to the DBTC,
08:08and some of the reason
08:09for that is
08:11as we'll talk more about,
08:13when thinking about some of
08:14the targets of the treatment,
08:16a lot of what we
08:16consider borderline tendencies, some of
08:18the impulsivity, some of the
08:19intensity of the emotion, some
08:19of the lability, some of
08:19the challenges in relationships,
08:20intensity of the emotions, some
08:21of the lability, some of
08:22the challenges in relationships
08:24are also some developmentally normative
08:26things in adolescence, so for
08:28our teens with big feelings
08:30and those really intense reactions
08:32to those, it's a very
08:33effective treatment, of adapting to
08:35to this age group,
08:37and has been, again, found
08:38as
08:39a evidence based treatment for
08:41youth age thirteen to eighteen.
08:44There's some writing about what
08:45they call the extrapolation
08:47of an adult module,
08:48specifically in interpersonal effectiveness,
08:52and how that in dbt
08:53a we then target that
08:54specifically related to the parent
08:56child dynamic. So I'll talk
08:58a little bit later on
08:59on what that looks like
09:00in terms of the walking
09:01the middle path module.
09:03But one of the things
09:04that this that the DBT
09:06for adolescents also highlights are
09:07these typical dialectical dilemmas that
09:09can come up between,
09:11teens and their parents. Now
09:13there's of course, and we'll
09:14always say to patients that
09:15there may be more than
09:16this, but these are some
09:17of those primary ones that
09:18were that ends up becoming
09:20this
09:21dilemma or conflict that can
09:22happen of, of course, when
09:23the parent feels that they're
09:24being maybe too strict, too
09:26loose, the child feels that
09:27they're being too strict.
09:29How does a parent find
09:30that middle ground between fostering
09:32dependence and forcing independence?
09:34And then said, how do
09:35we foster independence?
09:37And one of the ones
09:38that comes up for I
09:39think a number of us
09:40who work with higher risk
09:41patients,
09:42helping parents and teens with
09:44the dilemma of not making
09:46light of problem behaviors, but
09:48also how do we not
09:48make too much of typical
09:50teen behaviors?
09:51This is something that comes
09:52up all the time in,
09:54my our trials with Michael,
09:56and thinking of our patients
09:57who have been hospitalized and
09:59patient and parents who don't
10:00know exactly
10:02when do we start to
10:03to loosen the reins on
10:04things again. So there these
10:06are typical, again,
10:08teen and parent dilemmas that
10:09happen, but in the context
10:11of high risk behavior, it
10:13ends up making it much
10:14more challenging to navigate and
10:15can lead to to more
10:17conflict in the home.
10:21In terms
10:22of then thinking about the
10:23the DBT for children, I'll
10:25hit on briefly to give
10:26the overview, but we'll be,
10:28talking more about the area
10:29that we have more of
10:30the evidence base for currently.
10:33The DBT for children is
10:35was developed
10:37for youth ages six to
10:38twelve actually started here at
10:40Yale. Francesca was a fellow
10:42in the adult DBT program
10:43when she was developing the
10:45the protocol for for children
10:48and it's meant to be
10:49used for youth with any
10:51presentations of childhood dysregulation
10:53including predominantly DMDD.
10:56They talk about in the
10:57treatment itself children who are
10:58super sensors. So again we
11:00we all talk with families
11:02about, having those big feelings,
11:03and we're thinking about those
11:04younger ones where we may
11:06not have seen self harm
11:07or like threatening behaviors, but
11:08still an intensity and dysregulation
11:10in their presentation.
11:14One of the things that
11:15I think is really apt,
11:16especially thinking about at the
11:18child study center where we
11:19so often and so importantly
11:20think about family systems,
11:22and the role of parents
11:24is that there is a
11:25crucial nature of the parenting
11:27component here. Right? It would
11:28be very atypical that we
11:29are thinking of a six
11:30year old who can fully
11:31regulate their emotions, and we
11:32would have more concern about
11:33that for maybe other reasons.
11:35And so really what we're
11:37thinking of here though for
11:38those who have really intense
11:39emotions and are those super
11:41sensors
11:41is when there is a
11:43secure attachment with the parents
11:44and there is that safe
11:45modeling, the developing modeling and
11:47coaching of forms of self
11:49regulation.
11:51An important piece is it's
11:52actually grounded primarily in the
11:53parents ability to even mentalize
11:55their child's experience. And so
11:57oftentimes we're having to think
11:58before an intervention like this,
11:59how are we building up
12:00the parent's own mentalization of
12:02their their child's,
12:03state.
12:05And that leads to some
12:06challenges and assumptions about the
12:08family's ability. Right? Where are
12:09they at psyche psychologically
12:12and and the family's ability
12:13to understand these concepts and
12:15model in a regulated way?
12:17What is their availability to
12:18do this and what resources
12:20they have available, to be
12:21able to engage in that
12:22type of work?
12:27Some of the so so
12:28with that background in mind
12:30and thinking about just what
12:31what has been adapted for
12:32for children and then for
12:33adolescents,
12:34thinking about some of the
12:35unique aspects of DBT itself,
12:39I want to hit on
12:40some of the aspects that
12:41make it a bit different
12:42from other treatments and again
12:43some of the things that
12:44we may think about how
12:45these are integrated into different
12:47approaches.
12:48So one of the most
12:49unique aspects of DBT from
12:51some of the other change
12:52based approaches is the integration
12:55with the acceptance based techniques.
12:57So, we're taking what we
12:58know are a lot of
12:59evidence based change based strategies
13:01from CBT,
13:03integrating in with some more
13:04Zen and Buddhist philosophies.
13:07When it comes to the
13:08change based strategies that we
13:09focus on in the treatment
13:10we're thinking about basic behaviorism,
13:12how are we reinforcing,
13:14learned new behaviors and replacing
13:16behaviors that we want to
13:18change that may be distractive
13:19or destructive,
13:20excuse me self harm,
13:22substance use,
13:24lashing out,
13:26using cognitive techniques to in
13:28terms of understanding distortions and
13:31cognitive reframes
13:33of of one's experience,
13:35And then quite and one
13:36of the most important pieces,
13:37the skill building. So if
13:38we're yes, we need to
13:40use behavioral strategies and cognitive
13:41techniques to get there, but
13:42the skill acquisition being one
13:44of the most, important parts
13:46of the treatment itself.
13:49On the acceptance based side
13:51of things, and these are
13:52some of the the nuance
13:53pieces that we bring in
13:54as part of the the
13:55framing of the treatment,
13:57it's critical to the treatment
13:59itself to for there to
14:00be a validating environment of
14:02finding a kernel of truth
14:03no matter how ineffective the
14:04patient is presenting or in
14:07terms of their approach to
14:08things of finding something that
14:09we can validate in terms
14:10of their experience and making
14:12their emotional experience,
14:14something that is known and
14:15understood in the therapeutic room.
14:18The non judgmental approach,
14:20these are two things both
14:21the validating environment and non
14:23judgmental approach that have been
14:25identified through some of the
14:26research and the mechanisms of
14:27change of being crucial,
14:29as opposed to just pushing
14:30for the behavioral change and
14:32then the acceptance of wherever
14:33the patient is at.
14:35And that is where then
14:36the idea of the dialectics
14:37come in is that if
14:39we we can get imbalanced
14:40in either way. Right? If
14:41we push for change too
14:42much that and we create
14:43that sense of invalidation,
14:45a patient may rebuff treatment,
14:47may disengage,
14:48may not have the space
14:49to be able to work
14:50through where they're at. But
14:52if we lean too heavily
14:52on the acceptance, then we
14:53don't make change, and we
14:54see it stagnant. And we
14:55have I see a lot
14:56of head nods. I think
14:57we've all been there in
14:57the therapy room where it
14:58does kinda feel like you
14:59are just very stuck. So
15:00we're we're constantly on this
15:02teeter totter of the integration
15:04of the both of both
15:05and how do we accept
15:06where somebody is in order
15:08to make change rather than
15:09than leaning too heavily in
15:10the either or.
15:16So in terms of the
15:17other one of the other
15:18unique aspects related to the
15:20application
15:21of the the dialectics behind
15:23the treatment is actually an
15:24introduction to the concepts.
15:26So there is this important
15:27piece of helping youth and
15:29their families understand the whole
15:30concept of dialectics,
15:32and the assumptions that underline
15:34the treatment.
15:35The idea of the both
15:37and rather than the either
15:38or that is such a
15:40integral piece of working with
15:42with both youth and with
15:43their parents in the treatment
15:45modality
15:46that we can go to
15:47extremes in either direction in
15:48terms of our emotion mind
15:50and and what is when
15:51the emotions drive the bus.
15:52Right? That we're very impulsive.
15:53We do whatever those big
15:54feelings are telling us to
15:56do
15:56versus the other end of
15:57the extreme if we're too
15:59rational and we're only in
16:00rational mind how that can
16:01be very invalidating.
16:02How do we find this
16:04middle path of actually getting
16:05to what we call the
16:06wise mind place
16:07where we validate our emotions
16:09and use and are appreciative
16:10of what they give us,
16:12but also bring facts and
16:13logic into things.
16:17And true to then the
16:18modality itself, there's the assumptions
16:20that underlie the treatment, that
16:21make it unique, that that
16:22lean heavily into the dialectics.
16:25There's these are some of
16:26the assumptions that if you're
16:28doing the treatment that you're
16:29saying I will agree to
16:30this is that we're all
16:31doing the best we can,
16:32and we all can try
16:33harder increase our motivation for
16:35change and be more skillful.
16:37An important piece here is
16:38that it doesn't just apply
16:39to patients. It is something
16:40that I often talk about
16:41with patients is that that's
16:42true for me in the
16:43room with them. That's true
16:44for their parents. Right? That's
16:45true for everybody involved.
16:47So we're not blaming anyone.
16:48We are assuming we're all
16:49doing our best that maybe
16:51because of different emotions at
16:52different times where we're less
16:53effective,
16:54and so we can all
16:55keep trying harder.
16:57And I think what's really
16:58nice about some of these
16:59assumptions in that way is
17:01it it takes the blame
17:02away from any one individual,
17:03right, of being on the
17:04parent, of being on the
17:05teen, but also gives agency
17:07in in continuing to make
17:08change.
17:10One of the other assumptions
17:11of the treatment, we may
17:12not have caused our problems,
17:14and we can also still
17:15have agency in finding solutions
17:17to change our circumstances and
17:18responses.
17:19I think that this is
17:20crucial when we're working with
17:22our our patients with chronically
17:24invalidating environments whether that is
17:26because of their their home
17:28environment, whether that is larger
17:30systems or or world issues.
17:32I'm looking at Christy thinking
17:33about what our our patients
17:35in the gender program are
17:36navigating and how do we
17:38still find ways of navigating
17:39these
17:40impossible situations as
17:42effectively as possible.
17:46That figuring out and changing
17:48the cause of behavior is
17:49more effective is a more
17:51effective change than judging and
17:52blaming,
17:53so often I think when
17:55we're working with families or
17:56with individuals who may be
17:58internalizing some of their feelings
18:00that there there's often a
18:01lot of self judgment, self
18:02blame,
18:04or judgment or blame from
18:05others in the system. And
18:06so it's said if we
18:07can get curious about what
18:09is causing a behavior that
18:11we're assuming that all behavior
18:12including actions, thoughts, and emotions
18:14are caused, which gives us
18:16again a place to to
18:17really jump in and to
18:19get,
18:20to get very curious about
18:21what is leading to these
18:22higher risk behaviors.
18:25So there there is an
18:26assumption of the treatment that
18:27if every behavior is caused,
18:29right, whether that is because
18:30of something internally or externally
18:32in the environment, that if
18:34we can understand it, it
18:35gives us a place to
18:36make change.
18:38And so there is DBT
18:39though that we'll talk and
18:41we have been talking some
18:42about,
18:43some of the more,
18:45intellectual underpinnings of it, it
18:47is a very behavioral treatment.
18:49So one of where it
18:50comes down to it and
18:51when we're thinking about all
18:52behavior is caused, if we
18:53can under it, if we
18:54can do a chain analysis
18:55on it, if we can
18:56start with what that behavior
18:57is, whether it's self harm,
18:59suicide suicidality,
19:01again externalizing
19:02behaviors, avoidance.
19:04If we can understand what
19:05is reinforcing it by understanding
19:07the consequences, if we can
19:08understand the prompting event that
19:10started it and understand every
19:11single link in that chain,
19:13even starting back with the
19:14vulnerability factors, it gives us
19:16a multitude of points of
19:18intervention. So really the the
19:21whole behavioral focus of the
19:22treatment is to to imbue
19:24and and to give, the
19:26patients that we work with
19:27in that agency to make
19:28change.
19:30A critical point that the
19:32the image doesn't actually show
19:33itself is the solution analysis,
19:35which has to come after
19:36the chain analysis and and
19:37is quite critical because once
19:39we understand the behavior, we
19:41understand that it's caused, which
19:42is so important. We also
19:43wanna know what to do
19:44about it. Right?
19:46And that is one of
19:47the pieces that will come
19:48into play as we're talking
19:49more about the the unique,
19:51components with the skills.
19:55Importantly, there's an assumption to
19:57the treatment that new behavior
19:59must be learned in all
20:00relevant contexts, so we can
20:02learn all the skills that
20:03we want when we're in
20:04the hospital or in the
20:05therapy room, but if we
20:06don't know how to apply
20:07them in the other relevant
20:08contexts in the home, at
20:09school, in the different stressful
20:10context that we're in, that
20:10it won't be effective, and
20:10so that the
20:13that it won't be effective.
20:14And so that that's a
20:15a critical part of the
20:16treatment is that generalizability.
20:21And then the the ultimate
20:22dialectic of the treatment itself
20:23that change is the only
20:24constant. So that we're thinking
20:26about that there will continue
20:27to be change in terms
20:28of behavior, how our patients
20:29will relate to us, what
20:31is evolving in the therapy
20:32room, what's happening at home,
20:34and that really then the
20:35treatment is always about how
20:36can we respond to that
20:37most effectively and work towards
20:39our goals.
20:43So in addition to the
20:46the applications of the,
20:48these kind of underlying,
20:50components of the dialectics,
20:52one of the other things
20:53really unique to DBT and
20:55I think to the piece
20:56that, Andres had brought up
20:58of some of our high
20:59risk,
21:00patients that we've shared or
21:01that we see coming through,
21:03the child study center and
21:04other contexts is DBT was
21:06developed specifically to manage high
21:08risk behaviors at the outpatient
21:09level of care.
21:11The idea being again from
21:13that first slide is that
21:14it leads to
21:16a disruption in cohesive treatment
21:17if somebody's constantly needing to
21:19go to a higher level
21:20of care. So it's specifically
21:22designed to manage these at
21:23a lower level of care
21:25in a way that both
21:25the patient and the provider
21:27feel supported,
21:28and that leads to the
21:29multi component nature of it,
21:32which for folks not familiar
21:34with the treatment, before I
21:35pop it up here, you'll
21:35see where it's not your
21:36even though it's outpatient, it's
21:38not your typical once weekly
21:39therapy,
21:40which is one of the
21:41things that can make it
21:42challenging as well, in terms
21:44of how to be implemented.
21:46So to truly be, implementing
21:48DBT and when we're thinking
21:50about the most robust evidence
21:51base, it's anything that's not
21:53in italics is a requirement.
21:55So we have the the
21:56four modes of the treatment
21:57including individual therapy one to
21:59two times per week,
22:00a separate skills training group
22:02so that you're keeping the
22:03skills separate from therapy itself,
22:06The ability to engage in
22:08intersession phone coaching,
22:10so the idea that you're
22:11probably gonna need your therapist
22:13outside of those sessions, but
22:14how do we have it
22:15be a coaching,
22:17type of contact rather than
22:18intersession therapy.
22:20And then also the idea
22:22of the consult team.
22:24As a plug, I I
22:25believe in consult team for
22:26DBT or outside of DBT.
22:28The idea is that, it
22:30is hard for providers to
22:31work with high risk patients.
22:33And so,
22:34anybody who does DBT will
22:35say if they're not on
22:36the team then it's not
22:37DBT. And it's the idea
22:38of providers coming together weekly
22:40or biweekly and to talk
22:41about their own burnout with
22:42working with these clients,
22:44in order to to prevent
22:46any impact on the clinical
22:48work itself or if there
22:49is impact on the clinical
22:50work to be able to
22:51get support with that and
22:52has a a very kind
22:53of clear structure to it
22:55so that it's different than
22:56something like supervision or peer
22:58supervision and is really meant
22:59to be support and therapy
23:01for therapists.
23:03Then in addition to those,
23:05of course, that I have
23:06these ones in it, the
23:07italics that are often a
23:08part of of what the
23:10multiple components look like for
23:11coheed for comprehensive treatment.
23:14So often these high risk
23:15patients do have psychiatric,
23:16concerns that do require
23:18psychiatric intervention in the medication
23:20management piece.
23:22I don't know any of
23:23the teens that I work
23:23with that we're not also
23:24doing some type of family
23:26therapy because often as we're
23:27talking about the importance of
23:28the family system.
23:30And then I have under
23:31the skills group here ideally,
23:33we're doing what we'd consider
23:35multifamily skills group. So not
23:36just being the kid learning
23:37skills, but parents being there
23:39as well.
23:41The challenge there that we'll
23:42come to to some of
23:43the barriers
23:44is for working families having,
23:45you know, two parents be
23:46able to attend a multifamily
23:48skills group at the same
23:49time as their child requires
23:51a lot of resource and
23:52time in terms of time
23:53availability,
23:54and yet we do know
23:55that it is the most
23:56successful
23:57in terms of managing and
23:58changing behaviors.
24:01As you can imagine from
24:02the multifamily and the way
24:03the multifamily skills groups can
24:05work, it not only, provides
24:07the ability to teach the
24:08parents the skills themselves, but
24:09then can create more of
24:10that validating environment as well
24:12that they're understanding more of
24:14what their child's experience is
24:16and how to be more
24:17effective and can understand more
24:18of where they they play
24:19a role in that in,
24:21in what occurs.
24:27So importantly, I I hit
24:28on these two pieces,
24:31a bit briefly, but I
24:32do want to to hit
24:33on them a bit more
24:34to think about kind of
24:35what makes again the treatment,
24:37unique in and of itself.
24:38The idea of the intersession
24:40support is often a really
24:41scary thing for new providers.
24:43Starting dbt it can feel
24:46like the idea of that
24:47you're on call twenty four
24:48seven or that the the
24:49therapist is a crisis line.
24:51And that there's this really
24:53important piece of the the
24:54intersession communication
24:56and the phone coaching being
24:57very structured. So what makes
24:59it different than just being
25:00on call twenty four seven
25:02is in a lot of
25:02ways a contract that one
25:04enters into with the client,
25:06before starting the treatment
25:08of the true focus being
25:10coaching in between sessions. So
25:12if there is something that
25:13really requires another session then
25:15another session should be scheduled,
25:16but if it is somebody
25:18trying to generalize their skills,
25:19they're having urges coming up
25:21and they just can't problem
25:22solve and figure it out
25:23on their own, I always
25:24tell my patients I would
25:25rather spend five minutes on
25:26the phone with them or
25:27ten minutes on the phone
25:28with them problem solving, being
25:29skillful to then resist the
25:31urge rather than us having
25:32to spend our whole therapy
25:33session figuring out why that
25:34behavior happened, right? So it's
25:36this very structured,
25:38very time limited way of
25:40providing support in between session
25:42and the theory again behind
25:44it being that as these
25:46patients are trying to make
25:47a lot of changes across
25:48these different contexts,
25:49it's almost unfair of us
25:51as providers to expect that
25:52they're just gonna remember everything
25:53that happened in session and
25:54know how to implement it
25:55perfectly. Right? And so that
25:57idea of reaching out for
25:59specifically for phone coaching.
26:01So there's even scripts that
26:02can go along with it.
26:03I will say every time
26:05a patient reaches out for
26:06phone coaching, I ask what
26:07did they try why are
26:08they coaching, like, what is
26:09the urge, what do they
26:11need help with, and that
26:12we can be very, very
26:13targeted and have it, again,
26:14stay very time limited. I've
26:16heard from other providers that
26:17if it's more than ten
26:18minutes, it's not a coaching
26:19session. I will say sometimes
26:20it gets a little bit
26:21longer than that, but you
26:22try to keep it very
26:23truncated. Right? And and the
26:25other important piece here is
26:26that because it's not a
26:27hotline is that you're not
26:29always available. Right? And so
26:31that idea of when a
26:32patient does reach out, I
26:33will get back to them
26:33as soon as I can.
26:35But having a new baby
26:36is that I, you know,
26:37I won't always be available
26:39twenty four seven and that
26:40that's okay and that there's
26:41also the contingency plans in
26:42place for how that then
26:44they can have that support
26:45in in case an emergency
26:46does come up. So there's
26:48this very important explicit discussion
26:50as part of the treatment
26:51is again that you're you're
26:52not the a crisis line
26:53but rather an intercession form
26:55of support to generalize the
26:57skills.
26:59One of the other really
27:00unique pieces that I think
27:02is crucial and will hit
27:04on as a piece of
27:05the mechanism of change is
27:06the skills training component actually
27:08being separate from the therapy
27:10itself.
27:11So the idea being that
27:13the therapy and the therapeutic
27:14relationship is so critical to
27:17to making gains that learning
27:18skills is a completely separate
27:20thing. Right? It's almost more
27:21didactic in a way. It's
27:22like a class. If If
27:24anybody has ever been part
27:25of the skills training session,
27:26it is you really are
27:28following a curriculum in a
27:29way, right, and just teaching
27:30certain emotion regulation skills or
27:32certain distress tolerance skills.
27:34And while your therapist may
27:35also be your skills trainer
27:36that we're thinking about those
27:37as very separate roles to
27:39allow the therapy to continue
27:41to say the processing,
27:43of of the therapy and
27:44the skills learning and training
27:45is separate.
27:49In terms of the skills,
27:50themselves, I I think a
27:51number of people on the
27:52Zoom and some I see
27:53in this room have have
27:54done, DBT skills,
27:56seminars with me.
27:58It is one of the
27:59the most crucial,
28:00parts of the treatment.
28:02I will probably keep saying
28:03that about all parts of
28:04the treatment as we're trying
28:05to think about what which
28:06aspects are are the most
28:07effective, but that there is
28:09there's these different areas of
28:10the skills that we're believing
28:11that patients with the intensity
28:13of these emotional experiences and
28:14dysregulation,
28:15may have deficits in that
28:17we're having to build up.
28:19So the five that come
28:20into play for our adolescents,
28:23are gonna be mindfulness,
28:25distress tolerance, emotion regulation, interpersonal
28:28effectiveness,
28:29and then this additional
28:30module of the walking the
28:31middle path. In the adult
28:33curriculum you don't have that
28:34one it's just integrated into
28:36interpersonal effectiveness.
28:38But in hitting on on
28:40each of these briefly because
28:41of the we won't be
28:42hitting on the skills too
28:43much today, but we always
28:45happy to talk with folks
28:47about those more.
28:49It's true to the dialectical
28:51underpinnings of the treatment itself
28:52of we have to balance
28:53acceptance and change, so when
28:55we're learning the full modules
28:57and the course of things,
28:59if you're going through the
29:00entire curriculum, your change based
29:01skills are gonna be those
29:02that focus on actually changing
29:04your emotions and regulating them.
29:05So emotion regulation,
29:07actually learning how to be
29:08more interpersonally
29:09effective with the idea if
29:11we have more fulfilling,
29:13more effective relationships that we
29:15have less we're less prone
29:16to dysregulation in our experiences.
29:20And those are gonna be
29:21a lot of the skills,
29:22especially the ones related to
29:23emotion regulation that are gonna
29:24feel a little more similar
29:26to your more traditional kind
29:27of CBT approaches.
29:29Comparatively
29:30there's entire modules of learning
29:32just how do we not
29:32make the situation worse. Right?
29:34And these are gonna be
29:35the acceptance based skills.
29:37Learning very concretely what and
29:39how do we do mindfulness
29:41and also the distress tolerance
29:43which is I think one
29:45of the the most difficult
29:46to get buy in with
29:47some teens because really the
29:49focus of all those skills
29:50is again how do we
29:51not make the situation better,
29:53but how do we not
29:53make it worse for them?
29:56Because what is often happening
29:57for patients coming to this
29:59treatment
30:00is that their responses to
30:01their emotions, the behavioral responses
30:03ends up creating more distress
30:05in their life and hasn't,
30:07solved the original problem. Right?
30:08So if there is a
30:09crisis where you've broken up
30:11with your girlfriend or boyfriend
30:12or you failed the test
30:13or got in a fight
30:14with mom and dad and
30:15you self harmed, there's still
30:17the issue to deal with,
30:18and we've also then created
30:19this big problem that we
30:20have to solve. And so
30:21we're teaching both those skills
30:23of when we can change
30:24the situation, but also when
30:25we just have to tolerate
30:26the situation.
30:29And then in the synthesis
30:30in the middle, we're thinking
30:31of again that the idea
30:32of the walking the middle
30:33path, which is really gonna
30:35hit on the ideas of
30:36the dialectics of the both
30:37and, in those parent teen
30:39relationships,
30:41and and finding that balance
30:42between acceptance and change.
30:49One of the other,
30:50areas that that is really
30:52unique
30:53about the treatment that I
30:53think often gets lost,
30:55that is one of the
30:56things that I'm excited to
30:57hit on today is actually
30:58the multistage nature of the
31:00treatment. When we're thinking about
31:01the comprehensive
31:02treatment,
31:04a lot of people often
31:05only think about stage one,
31:07and this is the the
31:08DBT house which kinda illustrates
31:10what the full course of
31:11treatment looks like. So a
31:12lot of times when when
31:13we're thinking of of the
31:14treatment itself, we're thinking just
31:15that stage one of when
31:16somebody is experiencing that severe
31:18behavioral dis control. Right? That
31:20we're thinking about a house
31:21is on fire, you're on
31:22that bottom floor and we're
31:24having to get in control
31:25of behavior. So we're thinking
31:26about any of those life
31:27threatening behaviors
31:28and what do we have
31:29to do or any high
31:30risk behaviors that are causing
31:31us problems that we have
31:33to bind a certain amount
31:35of behavioral control in order
31:37to move on to the
31:38next floor of the house.
31:40When we get to stage
31:41two, if we have behavioral
31:42control of our emotional and
31:44behavioral responses to things, then
31:46we can actually address the
31:47idea of the emotional experiencing
31:49and getting in touch. Now
31:51I think the what I
31:52really like about the framing
31:53of the house is that
31:54it shows why that oftentimes
31:56we or why we need
31:58to have behavioral control first
31:59even if the part that
32:00is more important to our
32:01patient is the emotional experiencing.
32:04I you know, I've had
32:05a number of patients that
32:06will be very frustrated when
32:07we're having to focus on
32:08the behavioral piece to start
32:10because there is a lot
32:11of valid truth in,
32:13how important the emotional component
32:15and what they're wanting to
32:16hit on related to,
32:18the things that they're getting
32:19in touch with are. And
32:20the framing of the treatment
32:22is that in order to
32:23do that, we have to
32:24have enough behavioral control to
32:25not be in the hospital,
32:29crisis. And so you're getting
32:31this buy in to the
32:32treatment that I can that
32:33if we can get that
32:34end of control, let's spend
32:36all the time in stage
32:37two that that we need,
32:38right, to be able to
32:39to get more in touch
32:40with the actual emotional experiencing.
32:43That allows once we're able
32:45to address,
32:46when we're thinking about kind
32:47of what is being addressed
32:48in that stage, any experiences
32:49of quiet or internal desperation
32:51to move on to stage
32:52three of the problems with
32:54living. So actually getting connected
32:56to a life that feels
32:57worth living,
32:58identifying values, working towards kind
33:00of value based action and
33:02dealing with the ins and
33:03outs of the ordinary happiness
33:05and unhappiness.
33:07For patients with those very
33:09intense emotional experiences that can
33:10be a new phase, right?
33:12That there can just be
33:13typical ups and downs and
33:14that it doesn't have to
33:15be a crisis, and how
33:16do we navigate that and
33:18engage in value based action
33:20that ultimately gets us up
33:22to stage four where we
33:24are thinking of more dynamic
33:25kind of nature to the
33:27the therapeutic,
33:29the the therapeutic modality. So
33:30we're focusing on the capacity
33:32for sustained joy. What I
33:33say is kinda ultimately we
33:35would get to that very
33:36peak experience of, like, self
33:38actualization, but that ongoing work
33:40that that we're all doing
33:41throughout our life.
33:43And what the house really
33:44illustrates I think nicely is
33:46that there are the ladders
33:47we want to keep moving
33:48up, but sometimes we do,
33:49end up down on the
33:50lower floors, and when that
33:52does happen we might have
33:53to go back to focusing
33:55on behavioral control. Right? If
33:56we're doing some very intensive
33:58trauma focused work, on in
34:00the second stage and that's
34:01causing more behavioral dysregulation, we
34:03have to go back and
34:03get that behavioral control to
34:05continue,
34:06to be able to keep
34:07a cohesive
34:08a cohesive treatment and moving
34:09forward.
34:14And lastly, in terms
34:15of the of the unique
34:17aspects of the treatment itself,
34:18the commitment phase that I
34:20think often gets overlooked,
34:23that the the commitment phase
34:24is the pretreatment part of
34:26DBT
34:27that lasts as long as
34:28it needs to, and it
34:29makes it very effective. It
34:31also can make it a
34:32a very challenging part of
34:34the treatment. So the idea
34:35with the commitment phase is
34:37that
34:38when you're entering into the
34:39treatment with your client in
34:40this modality, you are entering
34:42into the behavioral contract of
34:44what you're both committing to.
34:46If somebody has any ambivalence
34:47about that, you spend all
34:49the time getting commitment, to
34:51what behavioral change they're being
34:52willing to make until that
34:54until,
34:55there is a commitment to
34:56it. Because otherwise you can
34:57throw every skill you want
34:59at them. It's probably not
35:00gonna be the most effective,
35:02and so there's the ins
35:03and outs of all the
35:04different commitment strategies that we
35:05might be trying to increase
35:07motivation
35:07to see the buy in
35:09of what you can get.
35:10I have absolutely with clients
35:12gotten the commitment of the
35:14goal to be like to
35:15fire me. And if we,
35:15you know, if we you
35:16don't wanna see me anymore.
35:17Right? Like, can we both
35:18be committed
35:20to getting enough behavioral control
35:21to not need to do
35:22therapy anymore? So we're trying
35:23to find whatever nugget we
35:25can to get a buy
35:26in. Is it that you
35:26want your parents off your
35:27back? Is it that you
35:28don't wanna have to keep
35:29going to the hospital? Is
35:30it that you do want
35:31more freedom, and that then
35:32you can get that commitment
35:34to be working on the
35:34things that maybe they're not
35:36in in and of themselves,
35:38motivators that might be motivators
35:40for the parents or the,
35:41the provider?
35:44To that point, it's one
35:46of the things that I
35:46really appreciate of the treatment
35:48itself is that it's viewed
35:49as a relationship between equals,
35:51and the idea that any
35:52patient we have regardless of
35:54age is just as much
35:55of an expert in themselves
35:56as we are in our
35:57fields.
35:59And so that that's why
36:00we need to have that
36:01commitment because it's not gonna
36:02work if one person is
36:03trying is, more invested than
36:05the other. And to give
36:07the analogy of you're in
36:08the boat, right,
36:09you don't wanna be just
36:10sitting in the back seat
36:11of the or the back
36:12of the boat and your
36:13clients having to do all
36:14the work,
36:15which I I think clients
36:16do experience that that sometimes,
36:19or have that perception and
36:20it's something then to be
36:21addressed.
36:22But you also don't wanna
36:23be if we're thinking about
36:24we're trying to get them
36:25to the other side of
36:26the lake, which is their
36:27life worth living, you don't
36:28wanna be doing all the
36:29rowing, and then they're drilling
36:30holes in the back of
36:31the boat. Right? And that's
36:32an
36:33analogy that we often use
36:34in the commitment phase to
36:36get that buy in that
36:37of why we we can't
36:38be the only one, driving
36:39things forward.
36:45Thinking about the whole treatment
36:47itself and then the goals
36:48and the benefits, a lot
36:49of times, we think about
36:51the overall goal being a
36:52reduction in suicidality,
36:54that DBT is
36:56a treatment for life threatening
36:58behaviors, for suicidality.
37:00And it's not actually the
37:01goal to to reduce suicidality
37:03or high risk behaviors. Truly
37:04the idea is building a
37:05life worth living. So if
37:07we're thinking instead of yes,
37:08we we do wanna reduce
37:10those high risk behaviors, those
37:11things related to behavioral dis
37:13control, but if we can
37:14have life feel worth living,
37:16what are we working towards?
37:18That that actually gives,
37:19patients
37:20a much more,
37:22much more something to be
37:23invested in. And the benefits
37:25and the way that we
37:26end up getting there are
37:27by enhancing emotion regulation,
37:29improving relationships,
37:32yes, reducing life threatening and
37:33self destructive behaviors that get
37:35in their way of life
37:35worth living, but that not
37:36being the ultimate priority, priority,
37:38and then managing crises more
37:39effectively that allows for an
37:41increased self awareness.
37:46So with the goals and
37:48benefits in mind,
37:49and thinking about the very
37:50comprehensive treatment, one of the
37:52things that often comes up
37:53is what actually makes it
37:54effective. We do know that
37:56it's a, that there's a
37:57robust evidence base for DBT
37:59and we'll talk more about
38:00some of the different applications
38:02for it and what's been
38:02effective,
38:04but
38:05what what makes it effective,
38:06and some of the the
38:08analyses that have actually looked
38:09at identifying the mechanisms of
38:11change have identified kind of
38:13five areas that that tend
38:15to to be when rated
38:16tend to be tied to
38:17the greatest change.
38:20So first actually increasing self
38:21regulation capacity, the piece of
38:23actually learning the skills, skills
38:24right if we're going through
38:25this whole curriculum
38:26learning the ability of some
38:28of these different skills to
38:29help with self regulating that
38:30there is that actual kind
38:31of skill acquisition.
38:33But then second is actually
38:34the skill use right. So
38:36that important piece that will
38:37go through the entire curriculum.
38:39Is somebody actually practicing it
38:41and whether or not they're
38:42practicing it outside of session,
38:44leads to more significant changes,
38:46of course, in terms of
38:47the treatment.
38:49Third, very importantly, the validating
38:51therapeutic environment.
38:52That I think is true
38:54of course across treatments but
38:55the importance of the providing
38:57that in this treatment of
38:59especially if we're pushing for
39:00changing some very life threatening
39:01behaviors that it's critical to
39:03have that validating environment.
39:05And then fourth is that
39:07commitment to the treatment
39:09they do not they find
39:09it is not effective unless
39:11somebody has engaged in the
39:13commitment phase and is, that
39:14there is something that they're
39:15bought in to be working
39:16towards.
39:18And then lastly, the structure
39:20of the sessions themselves.
39:22So when we were talking
39:23about those different stages of
39:24treatment that the the
39:26treatment itself actually sets up
39:28a hierarchy of targets. Right?
39:29And so your first targets
39:31are always going to be
39:31if there's like threatening behaviors
39:33And that that has to
39:34that we have to focus
39:35on those followed by anything
39:37that interferes with treatment before
39:38we even get into quality
39:39of life. And that providing
39:41that structure,
39:42and those guardrails to moving
39:44forward actually allows patients to,
39:46again, continue to engage even
39:48when there might be things
39:49that feel like higher priorities
39:51to them.
39:57When thinking about,
39:58where DBT has actually been
40:00effective, the positive is that
40:02it's been found to have
40:03an evidence base across different
40:04presentations of dysregulation,
40:07so we do see in
40:08terms of the research the
40:10the evidence base of it
40:12reducing
40:14experiences of suicidality and action
40:16on self harm.
40:17There has also been the
40:18research particularly
40:19in patients with,
40:21diagnoses of borderline personality disorder
40:23of reduced hospitalizations,
40:25related to suicidality or other
40:27high risk behaviors,
40:28and so in that way
40:30actually ends up
40:31despite the cost of the
40:32treatment itself being a cost
40:34saver for the systems
40:36of just mood lability
40:38in general, and so when
40:40we think about again what
40:41BPD tendencies might look like
40:42across the developmental
40:43spectrum.
40:45For depression and other mood
40:46disorders including bipolar disorder in
40:48terms of reduction again in
40:50high risk behaviors
40:51and as well as,
40:53the hospitalizations
40:55associated,
40:56and depress and ratings of
40:58depression,
40:59for anxiety disorders, for substance
41:01use disorders.
41:03For eating disorders, predominantly
41:05those of, dysregulation, so we're
41:07thinking more bulimia and binge
41:09eating.
41:10There's as a plug a
41:12DBT flipped on its head
41:13called radically open DBT that's
41:15used more for, over control
41:16presentations like anorexia.
41:19But then traditional DBT also
41:20being effective with impulsivity and
41:22ADHD
41:23as well, and some research
41:25most recently on ADHD
41:27and then in, presentations of
41:29PTSD as well.
41:31But underlying all of these
41:32are the emotional and behavioral
41:34dysregulation,
41:35which is where actually the
41:37workbook,
41:38that that is often used
41:40it has been adapted for
41:41the idea of the complex
41:42PTSD as well. So if
41:43we're understanding
41:45how,
41:46some experiences of having,
41:49some complex trauma in our
41:50life may lead to emotional
41:51or behavioral dysregulation
41:53how then we can still
41:54build a life worth living.
41:58So importantly to that point,
42:00I did just wanna highlight
42:01one of the things that
42:01often comes up in the
42:02the work with the CPTSD
42:04is the how that actually
42:05looks like borderline tendencies in
42:07and of themselves,
42:08but where the treatment regardless
42:10of what we call it
42:11or what the diagnosis is
42:12where the where it can
42:13still be effective for that
42:15transdiagnostic
42:16application.
42:17So when we're thinking truly
42:18but about like DSM criteria
42:20with borderline,
42:21we're thinking about that unstable
42:22sense of self, unstable relationships,
42:25impulsive behaviors, fear of abandonment,
42:27the chronic sense of emptiness.
42:29Those with experiences of complex
42:31trauma have some similar kind
42:33of overlap in symptoms. They
42:34have negative views of sense
42:35of self, a difficulty trusting
42:37others, They have a hyper
42:38vigilance, often and intrusive
42:40thoughts that need to be
42:41addressed as well as the
42:42loss of their own belief
42:43system.
42:44And with these overlaps we
42:45still see avoidant and impulsive
42:47behaviors, difficulties, regulating emotions,
42:50depression, anxiety, and anger, and
42:52trauma, and all things that
42:53the the treatment can target.
42:55So it's often we get
42:56away from what is diagnostically
42:57going on, is there dysregulation
42:59happening, is there something that
43:00we need to target towards
43:01a life worth living.
43:05And so to that point,
43:06thinking about the applications across
43:08levels of care,
43:10while the treatment itself was
43:11originally developed outpatient, it has
43:13been, used and adapted at,
43:16in inpatient modalities, residential, and
43:18PHPs, and IOPs. So often
43:20they're adapting how we're teaching
43:21the skill curriculum in a
43:23truncated way. That was my
43:24first experience in grad school
43:26was working at a a
43:27DBT adherent PHP program,
43:29and and then thinking about
43:31how that that carried over
43:32into outpatient work.
43:35The gold standard being, again,
43:36the the comprehensive outpatient treatment,
43:38which if you think about
43:39is more like three to
43:40four contact hours a week,
43:42so more than traditional just,
43:43weekly outpatient.
43:45And then the lower levels
43:46of care, DBT informed outpatient.
43:48How are we pulling some
43:49of this work into weekly
43:51therapy?
43:52Skills training only. So just
43:54focusing on on equipping folks
43:56with learning, the skills related
43:58to self regulation.
44:00And actually that's the work
44:01that's been done in SEL
44:02curriculum in school. And so
44:04some trainings that that I've
44:06done with some of our
44:06local schools here in Connecticut
44:09as well as in, New
44:10York. And the this one
44:12on the right just recently
44:13came out for elementary schools.
44:15The the one on the
44:16left, the steps a, has
44:17been, used the the last
44:19few years, and the idea
44:21being that this is just
44:22as important to one's kind
44:24of health curriculum than anything
44:26else. Right? And so if
44:27we're learning throughout the education
44:29how to
44:31be mindful, how to tolerate
44:32distress, how to regulate emotions
44:34and be interpersonally effective that
44:36that can really change trajectory.
44:43So thinking about then how
44:45the comprehensive
44:46treatment itself varies from what
44:48might be some of the
44:49lower levels of care or
44:50just informed models,
44:52the adherent model for it
44:54to
44:55truly be DBT is recommended
44:57for the higher risk presentations.
44:59All four modes are required.
45:01So the individual therapy, separate
45:03skills training, consulting for the
45:05therapist, and intersession coaching.
45:08To the point of the
45:09commitment, it requires a commitment
45:10of at least six months.
45:11Now you may spend months
45:13even in that that pretreatment
45:15commitment phase first, and it's
45:16the most effective, right, because
45:18we're having, the
45:19having it tied in, and
45:21and having that buy in.
45:24DBT informed treatment can be
45:25appropriate for patients with less
45:27severe presentations. It incorporates some
45:29but not all,
45:30components, and there's no specific
45:32time commitment,
45:33but it still helps with
45:35relationships and coaching. Right? And
45:36so if you don't have
45:37that commitment and buy in
45:38there's still the ways to
45:39bring in some of these
45:40really evidence informed kind of
45:42pieces to, to help it
45:44be most effective for patients.
45:48And so thinking about the
45:49relevance for today's youth,
45:51and and why I've continued
45:53to have a passion for
45:54I think the treatment approach
45:55itself
45:56is its effectiveness for patients
45:58with higher risk presentations
45:59are,
46:01we continue to see the
46:02complexity of youth mental health
46:05increasing, right? We're continuing to
46:06see an increase in the
46:07severity of presentations. We've seen
46:08that since pre pandemic,
46:10but especially now and and
46:11with the evolving
46:13escalations in our world and
46:14the complexity of what our
46:15our youth are are having
46:17to navigate.
46:19That it allows us to
46:20to, again, address mood lability
46:22and dysregulation
46:23transdiagnostically,
46:25and that that can hit
46:26be helpful for a number
46:27of presentations
46:28and the idea of learning
46:30how to effectively regulate your
46:31emotions benefits all of us.
46:34I always I always say
46:35that it's,
46:37it's humbling to teach the
46:39skills themselves because I always
46:40catch myself of, like, I
46:42didn't do that this week.
46:43Right? Like, of any of
46:43the skill that I'm teaching,
46:44so it's always helpful for
46:45any of us to to
46:46revisit and to to bolster
46:48those skills.
46:50The greater understanding of the
46:51nuances of a history of
46:53complex trauma, right, whether there
46:54is trauma with a capital
46:55t, in somebody's history or
46:57more experience with that chronic
46:59invalidation
47:00and how that may lead
47:01to presentations of dysregulation
47:03throughout one's life developmentally.
47:07Relevance of the importance of
47:08the systems perspective.
47:10It is one of the
47:11treatment approaches that I I
47:13do think lends well with
47:14when we're thinking about how
47:15do we address both the
47:16system and for the individual
47:17so that we can teach
47:19youth again learning these skills
47:20to self regulate and work
47:22with the families on creating
47:23a more validating environment.
47:27That there's some very unique
47:28skill deficits with, today's youth
47:30when we're thinking about how
47:32they're growing up on phones
47:33and with screens and things
47:34of that some of the
47:35challenges with mindfulness and some
47:37inabilities to tolerate distress,
47:39or to spend time away
47:40from more stimulating activities and
47:42that those are really important
47:44skills to be bolstering.
47:45And then to that point
47:46that there's this really just
47:48kind of chronically mismatch with
47:50the environment. Right? Today's youth
47:51grow up in a completely
47:52different context than any of
47:54us. Right? And and what
47:55it's like developmentally
47:56to to have the screen
47:58so available, social media, all
47:59of these things. And so
48:01there is this inherent kind
48:02of mismatch with the environment,
48:04and learning to effectively regulate
48:06any of the big feelings
48:07about that being so important.
48:11Thinking about the barriers themselves,
48:14there's a number despite it
48:15being a wonderful treatment.
48:17There's a a number that
48:19we that we'll hit on
48:20of just what can get
48:21in the way of the
48:21implementation
48:22and one, paper that I
48:24put out with Andres, actually,
48:25just as a clinical perspective
48:27a couple years ago about
48:28some of the barriers to
48:29accessing,
48:30DBT
48:31especially among youth with experiences
48:33of racism,
48:34and what we highlight in
48:35the article,
48:36kind of transcends
48:37just that specific population, but
48:39what makes it a barrier
48:40of,
48:41to to be implementing this
48:42more comprehensive treatment
48:44of the cost of the
48:46training and the treatment in
48:47terms of both time and
48:48financially. Right? It takes a
48:50long time to be trained
48:50in a very comprehensive treatment.
48:53The multi component nature of
48:54it, it's a lot to
48:56ask families to commit to,
48:57like, four hours a week
48:58in a sense. Right? That
48:59you have to have skills
49:00group and individual therapy and
49:02the buy in. So it's
49:03also what why it's what
49:04makes it effective. It also
49:06causes barriers.
49:08One of the big issues
49:09insurance wise is that there's
49:11a lot of components that
49:12aren't covered, financially and why
49:14often DBT is done in
49:15private pay settings,
49:16because while you will get,
49:18of course, you we'd all
49:20know the CPT codes for
49:21individual therapy.
49:23There are no CPT codes
49:24for phone coaching or consult
49:25team which are a crucial
49:26part,
49:27component of the treatment. And
49:29then also skills training,
49:31receives very low reimbursement,
49:33rates. And it's often a
49:34a conversation on on the
49:35DBT listservs of what to
49:37do about that especially at
49:38mental health clinics.
49:41What is required in terms
49:42of for adherence is a
49:43lot, in order to become
49:45an adherently trained,
49:46provider and that there's then
49:48understandable
49:49discomfort and fear withholding higher
49:51risk patients at a lower
49:52level of, of care, especially
49:54one that's been a different
49:55way of navigating high risk
49:56behaviors than than one may
49:57traditionally be used to. And
49:59then the burnout,
50:00working with high risk patients,
50:02it can be burnout inducing.
50:04Interestingly, so there's been some
50:06research on four patients working
50:07with suicidal,
50:09patients for providers working with
50:11suicidal patients that being trained
50:13in DBT reduces burnout, but
50:14just working with that population
50:16in general, is burnout inducing.
50:20And so where we go
50:21from here,
50:22and and
50:23even with thinking about all
50:24those barriers, but we're kind
50:26of hoping to go,
50:27thinking about some of the
50:28efforts that made with colleagues
50:30here at the Child Study
50:32Center.
50:33In terms of clinically,
50:35in the past past we've
50:36worked with Michelle and we've
50:37had outpatient skills groups. I
50:39don't believe any currently running
50:40but we had though weren't
50:41able to do multifamily. We've
50:43tried both having the teen
50:44and parent equivalent, even doing
50:46single drop in, skill session
50:47groups.
50:49Laurie and I had worked
50:50on doing some DBT informed
50:52skills training on the inpatient
50:53unit, and we thought about
50:54the to that point co
50:55facilitation by fellows to be
50:57learning about some of the
50:58skills, in the clinical implementation.
51:01We continue to have skills
51:02seminars.
51:03So we have an ongoing
51:05seminar right now that I
51:06teach with our fellows on
51:07Friday afternoons for anybody who
51:08wants to join, on the
51:10skills curriculum, and we, do
51:12that with, some of the
51:13the clinical,
51:15faculty as well, and successfully
51:15did that last spring and
51:15something that there's been a
51:15lot of interest in in
51:15having ongoing.
51:17Something that there's been a
51:19lot of interest in in
51:20having ongoing and then some
51:21individual supervision
51:22and mentorship in the area.
51:25And then in terms of
51:26thinking about how we enter
51:28or have integrated this in
51:29into the research,
51:30working with our high risk
51:31populations in the interventional
51:33psychiatry and treatment resistant depression
51:35team,
51:36and where some of the
51:37the skill components come in
51:38there, and also some of
51:40the game based research,
51:42that actually with some of
51:43our colleagues in pediatrics,
51:45Deepa and Kim, who I
51:46know many of the folks
51:47here know, and the VR
51:48team,
51:49recently got a a r
51:51o one, specifically on smoking
51:53cessation,
51:54that we're actually doing DBT
51:56skills and and teaching,
51:57youth,
51:58DBT skills as a way
52:00of regulating emotions to prevent,
52:02any substance use.
52:05So in terms of the
52:05future directions for there, hoping
52:07that there will continue to
52:08be opportunities
52:10for additional DBT and DBT
52:11informed programming.
52:13I think our best way
52:14into that is by trying
52:15to figure out how do
52:16we latch on to those
52:17mechanisms of change, right? There's
52:18so many pieces to the
52:20treatment, but how do we
52:21really latch on to to
52:22what we know is effective?
52:24Opportunities for more teaching and
52:26training, more, more seminars. I'm
52:28always happy to talk with
52:29folks about any interest in
52:30those. The into continual integration
52:33into some of our research
52:34trials and partnerships both with
52:36our colleagues in the department
52:37department of psychiatry with the
52:39the formal DBT program as
52:41well as at other sites.
52:52Yeah. Any questions?
53:03Hello? We have time for
53:05questions. Laurie.
53:10Thank you for that exceptional
53:12overview.
53:12So inspiring, particularly in the
53:14end when you talk about
53:15its applications
53:16across diagnostic groups and settings
53:18and research.
53:19It occurs to me that
53:21if you are a beginning
53:22student
53:23of DBT,
53:25that in some ways, there
53:26are already tenants philosophical tenants
53:29that you can draw upon.
53:30And so could you talk
53:32about
53:32the cousins
53:33of
53:34MI
53:36and ACT and just,
53:37CBT?
53:40It seems to me that
53:41if you can integrate
53:43all those philosophies,
53:45you're well on your way
53:46of DBT dumb, but maybe
53:49I am seeing it too
53:50simplistically.
53:52No. I think it's a
53:53great point, Laurie. And that's
53:54where I think that the
53:55treatment itself pulls from a
53:57lot of these areas. Right?
53:58And anybody who's been in
53:59a seminar with me, especially
54:00with the skills, they'll say
54:01these skills aren't really unique
54:03to DBT. Right? It's the
54:04packaging that we might be
54:05pulling from from a lot
54:06of these different,
54:08treatment modalities and the philosophical
54:10underpinnings
54:11that as you're saying, if
54:11we can start to pull
54:12on those parts that are
54:13effective, right, change based strategies
54:15and learning ways to self
54:16regulate is a mechanism of
54:17change. Creating a validating environment
54:20is effective and is something
54:21that is important in a
54:23number of our treatment modalities.
54:24The piece of creating the
54:26validating environment at home and
54:27the mentalization for parents, right,
54:29is an evidence based approach.
54:30And
54:31while this is the packaging,
54:32right, in a very kind
54:33of synthesized way, that is
54:35something that we can really
54:36build on from other approaches
54:38that they may be trained
54:39in.
54:41Next question, doctor Pius.
54:43Thank you for the presentation.
54:45My question is more along
54:46the lines of the coaching
54:48or the crisis line ish,
54:50approach of the the gold
54:51standard of care. Do you
54:53know or have you experienced
54:54with, like, the use of
54:55chatbots
54:56or AI aided, you know,
54:58kind of like or text
55:00based kind of,
55:02coaching sessions, for this population?
55:04It's a great question and
55:06very controversial one. I think
55:07in terms of because there
55:08there have been, you know,
55:09a number of those articles
55:10put out there of some
55:11of the dangers that happen
55:13with it.
55:14The the biggest challenge that
55:15I've seen in my understanding
55:17with it is that while
55:18the chatbots can give very
55:20direct skills to you. So
55:21if we have a patient
55:22who says I really need
55:23to tolerate distress, can you
55:25give me ideas for it?
55:26They're not as good as
55:27picking up the,
55:29some of the nuances of
55:30more high risk language. Right?
55:31And that is something that
55:32is part of the coaching
55:33call while you're trying to
55:35keep it very directed and
55:36time sensitive. If somebody is
55:37in in immediate harm, we
55:39have to act, and it's
55:40something the chatbot just can't
55:41do effectively yet.
55:43Rebecca, we have, more questions,
55:44but we have one from
55:45Zoom and then one from
55:46doctor Block. So doctor Stover,
55:48I don't know if you
55:49can hear us, or do
55:49you wanna you're gonna be
55:50the ventriloquist for doctor Stover.
55:52Sure. I can Cara, if
55:53you want to unmute, please
55:54do. Yeah. I'm not sure
55:56if you Otherwise, Carla's
55:57Can you hear me?
55:59Can we turn the volume
56:00up on
56:01Sorry. I couldn't be there
56:02in person, but I Just
56:03one moment, Carla. We're gonna
56:04turn the volume up so
56:05we can hear you properly.
56:09Hello, Carla?
56:10Hello. Sorry. I didn't wanna
56:12brave the rain from George
56:13Street.
56:16I I I saw Rebecca,
56:17I was really interested in
56:18this talk, and I saw
56:19that that you said that
56:20there are DBT skills groups
56:22that have been run at
56:23the child study center.
56:25But it sounds like no
56:26one is delivering DBT
56:28fully. Is that accurate? Because
56:30it seems like it would
56:31be difficult to carry out
56:33because of the reimbursement
56:34issues for some parts.
56:36So do you
56:38related to that, are there
56:39policy efforts,
56:41underway related to reimbursement for
56:43this kind of model given
56:44the the evidence base?
56:48Yeah. It's it's a great
56:49question, Carla. And, yes, we've
56:50we've done the skills group
56:51at the Child Study Center.
56:52We haven't for the reasons
56:53that you're saying, but there's
56:55not the infrastructure, right, especially
56:56in a child guidance clinic,
56:58unfortunately.
56:59There are efforts to actually
57:01and and some, policy work
57:03that is being done by
57:04the DBT community of submitting
57:06at the different
57:07kind of state levels. So
57:08both in Connecticut and New
57:09York of getting reimbursement
57:11for some of those other
57:12critical pieces,
57:14starting with just having higher
57:15reimbursement rates for
57:17the skills training groups. Right.
57:19And more adequate kind of
57:20reimbursement for that. And then
57:22if there's more structured ways
57:23that we can build on
57:24things like case management codes
57:25to to be able to
57:26cover things like phone coaching,
57:28or even things like consult
57:30team, I think that one's
57:31gonna be a big ask.
57:32But but some efforts that
57:33haven't been successful yet, but
57:35we'll keep trying.
57:37Thank you.
57:38Last,
57:40I think last question is
57:41gonna come from doctor Block,
57:43but, doctor Kamadhi is gonna
57:44be giving autographs afterwards.
57:46I I should just note
57:47that we peaked at seventy
57:48something people, so plus these
57:50thirty ish people. There were
57:51about a hundred people,
57:52which is high for us,
57:53which is a reflection of
57:54the interest in the topic
57:55and how what a wonderful
57:56job you did. But, your
57:57partner in crime, doctor Block.
57:59So,
58:00two part question so you
58:02can pick, which part to
58:03talk if you want to.
58:05I guess I just want
58:06to hear a little bit
58:06more about your past experiences
58:08running the outpatient DBT groups
58:11here.
58:12And then, also, if you
58:13could just touch on the
58:15idea of using sort of,
58:17delivering them virtually and whether
58:18that's something that's evidence based
58:20or makes sense.
58:22Yeah. I kinda see this
58:23one kind of a both
58:24end. I will say that
58:25question.
58:26Because the the skills group
58:27we did here was primarily
58:28virtual, so we had done
58:29them in person pre pandemic
58:31and then, virtually afterwards.
58:34It allows more accessibility but
58:36it is less effective in
58:37terms of the engagement, right,
58:38is that patient if you're
58:39thinking about patients who might
58:40want to be avoidant, hard
58:41time getting them on the
58:43screen of addressing any like
58:44group interfering behaviors in that
58:46way so it's harder to
58:47manage.
58:49We did have a higher
58:50census when it was, virtually
58:52than than when we were
58:53doing it in person,
58:55but it it does make
58:55it much much more challenging
58:57especially when you have higher
58:58risk behaviors that are happening.
59:01And we had also in
59:02terms of increasing
59:03accessibility at the when we
59:04were doing the group's outpatient,
59:06didn't require the commitment to
59:07the full six month curriculum,
59:08so it was more of
59:09a drop in. But we
59:10did have more parents involved
59:12in the parent group as
59:13well, so it was a
59:14nice to be able to
59:15to generalize there as well.
59:17So Again, sorry we don't
59:18have time for, more questions,
59:19but please comment up if
59:20you have questions, and please
59:21join me in thanking doctor
59:22Kamedy.