Dialectical Behavior Therapy (DBT) Services

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 dangerously impulsive individuals who need more intensive treatment than is available with standard outpatient care. Comprehensive DBT and DBT for Substance Use Disorders (DBT-SUD) are modified for this group-based day hospital setting. Clinical activities include serving as primary clinician for up to four DBT IOP patients, co-leading a variety of DBT groups within the IOP setting, conducting risk assessment and management, providing DBT phone coaching, facilitating family sessions, participating in a DBT consultation team, supervising an advanced psychology graduate student, and conducting integrative psychological assessments throughout the training year.

DBT fellows will also participate in an Outpatient DBT Skills Training group, and may also choose to participate in their choice of several electives for their training, including: co-leading an outpatient DBT graduate group for clients with prior experience in DBT skills training and providing psychodynamically-informed psychotherapy through our Long-Term Care Clinic. DBT fellows serve an instrumental role in program leadership, including the oversight and implementation of measurement-based care for patients engaged in DBT services across outpatient at IOP levels of care at YNHPH.

Primary Placemtn - 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).

One doctoral fellow will be selected into the Adult DBT Track for the 2024-2025 academic year.

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 five 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 Mood Disorders track for patients with treatment-resistant mood disorders, Transitional Age Youth track for young adults aged 18-25 years, and a DBT track for patients with borderline personality disorder features who struggle with chronic patterns of suicidal or other self-destructive behaviors, including patients who struggle with substance use disorders. Patients in the non-DBT tracks attend the IOP for four days per week for about four to six weeks. Patients treated in the DBT tracks attend three days per week and commit to an eight-week treatment contract. Of note, while the DBT IOP team (including the fellow placed here) will interface regularly with clinicians from the other tracks listed above, the DBT fellow will only train/provide clinical services within the DBT track.

Modifications to standard comprehensive outpatient DBT for the IOP setting include (1) conducting diary card review and behavioral chain analysis in groups; (2) facilitating patient commitment to treatment and the reduction of life-threatening behaviors (consistent with a pre-treatment phase of the standard DBT model); (3) coaching patients through behavioral and imaginal rehearsal of DBT coping strategies within the IOP group setting; (4)applying protocols for preventing contagion of crisis behaviors among group participants; (5) treating patients who are in concurrent outpatient therapy; and (6) targeting problems in outpatient treatment with the goal of discharging patients into an effective and productive outpatient level of care.

At the current time, all DBT IOP services take place on-site, in person. Fellows placed within the site should anticipate a fully on-site year. However, individual and group-based psychotherapy services may be provided via telehealth and/or a hybrid (in-person + telehealth) model as needed based on hospital policy and/or emergency preparedness procedures.

Adult Dialectical Behavior Therapy (DBT) Program:

Fellows in this placement serve as primary clinician for up to four DBT IOP patients. They co-lead a variety of DBT therapy groups including skills training, diary card review with behavioral chain analysis, skills coaching groups with guided behavioral and imaginal rehearsal of DBT coping strategies, and a weekly measurement-based care group where patients reflect on self-report data that are linked to their life worth living goals. DBT fellows participate in telephone skills coaching, weekly consultation team meetings, risk assessment and management, as-needed family sessions, and consultation to outpatient providers. In addition, fellows provide DBT-oriented supervision to an advanced psychology graduate student.

Fellows develop specific DBT competencies in working with patients with borderline personality disorder and an array of co-morbid conditions, such as eating disorders, substance use disorders, post-traumatic stress disorder, 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 burnout.

The core DBT team is made up of one psychologist/program director, three social workers (one of whom works exclusively in the outpatient DBT skills and graduate groups), and one psychiatrist. For the 2024-2025 training year, it is anticipated that there will be one psychology practicum student and one advanced social work trainee in addition to the psychology fellow. Additionally, there are likely to be second year psychiatry residents who complete a rotation within DBT services.

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.

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, Prolonged Exposure, and Cognitive Behavior Therapy.

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 or patients who have been participating in treatment for longer periods in the Intensive Outpatient Program ambulatory 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 routinely conduct structured diagnostic interviews, and may perform brief forms of assessment as required.

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 funded 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.

In providing a team-based approach that continuously strives to identify and incorporate alternative viewpoints in its decision making (i.e., searching for dialectical synthesis), the DBT program strongly values diversity among its staff and training clinicians.

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. Previous examples of scholarly projects at DBT Services include examining the role of DBT homework completion and phone coaching utilization on DBT treatment outcomes; examining the relation between perceived burdensomeness and thwarted belongingness on DBT patients’ suicide ratings; and developing and implementing a mindful movement/taekwondo group into the DBT IOP curriculum.

Fellows also have the opportunity to attend regular research meetings. These are an opportunity to network with other researchers with shared interests, collaborate, share ideas, present data for focused consultation, and generally work together to support research productivity in a relatively intimate and supportive setting. Finally, fellows have the opportunity to co-review manuscripts for research journals and to assist with the annual Yale NEA-BPD Conference.

Fellows receive, on average, at least four hours of supervision each week. 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. Formal evaluations are completed that serve as opportunities to review progress on training goals and address progress toward core competency areas.

Fellows may also be assigned the role of "peer supervisor" to junior trainees at DBT Services. Typically, junior trainees are third- or fourth-year graduate students from regional doctoral psychology programs who are participating in clinical practicum placements at YNHH. As a "peer supervisor", fellows meet weekly with their supervisee and have the opportunity to develop basic skills as a clinical supervisor by processing this experience within the context of their own primary supervisory relationship.

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 are invited to attend the Dialectical Behavior Therapy Prolonged Exposure Protocol (DBT-PE) Seminar. 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 with the material through discussions of cases and video examples, skills practice, self-monitoring and problem-solving exercises, and role play. In addition to the DBT-PE seminar, students have an opportunity to learn about specialized topics within DBT during a yearlong seminar series. Invited guest experts as well as faculty present topics such as: DBT for the treatment of eating disorders, DBT for substance use disorders, antiracism applications of DBT, risk assessment in DBT, troubleshooting common barriers to treatment engagement in DBT, and more.

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.