Comprehensive DBT Programs

1. Mindfulness practice → helps clients practice mindfulness skills
2. Homework review → review what happened when you practiced the skill
3. New skill lesson → skill acquisition
4. Assign homework → helps clients practice and strengthen the skills they are learning
5. Check-out

At Evolve Vanalden, individual sessions start with review of the DBT Diary Card and incorporate the use of DBT’s core treatment strategies, including skill reinforcement, restructuring thought patterns, behavior shaping, exposure to difficult emotions, etc. Behavior Chain Analysis is often used to help clients analyze problem behaviors and plan for how to prevent them in the future. Our DBT therapists balance acceptance strategies with change strategies to help clients stay motivated for treatment while doing the hard work of changing their behaviors.

DBT is similarly incorporated into the family therapy work for each client. Parents are oriented to the structure and philosophies of DBT at the time of their teen’s admission and provided with resources on DBT skills and concepts so that they can learn alongside their teen. Parent involvement in skills training is an essential part of the program and is reinforced in each family session. Behavior Chain Analysis is incorporated into family therapy as well, often with “double chains,” where parents reflect on their behavior during a crisis while the teen client does the same.

DBT Treatment Hierarchy

Since teens seeking DBT often come to RTC with multiple problems to address, the Evolve Vanalden team utilizes the DBT Treatment Hierarchy to guide when and how each problem is addressed. This hierarchy guides the agenda for individual and family therapy sessions.

Life-Threatening Behaviors are always addressed first since clients must be alive and out of the hospital to participate in treatment. These behaviors may include:

• Suicidal behaviors
• Non-suicidal self-injury
• Severe Anorexia or Bulimia
• IV drug use

Treatment-Interfering Behaviors are addressed next, or alongside life-threatening behaviors, because they get in the way of working towards a client’s goals and building a life that is experienced as worth living. Examples may include:

• Dishonesty
• Refusing to participate in individual or family therapy
• Avoiding discussion of target behaviors
• Not doing skills training homework

Behaviors that severely impact quality of life are addressed once life-threatening behaviors and treatment-interfering behaviors have been eliminated or significantly reduced. Along with life-threatening behaviors, these behaviors often play a big role in necessitating the need for residential treatment. Examples may include:

• Severe depression and anxiety
• Non-life-threatening eating disorder behaviors
• Non-life-threatening substance use
• mpulsivity
• Anger
• Opposition, defiance
• Conflict with peers and/or family
• etc.

The phone coaching provided in standard outpatient DBT has been incorporated into Evolve Vanalden’s residential setting as milieu-based skills coaching. Provided largely by the Residential Counselors on the team, milieu-based skills coaching is an important part of skill strengthening and generalization for our clients. All Residential Counselors at Evolve Vanalden receive training on DBT and milieu-based skills coaching from intensively trained clinical leaders and are expected to provide this in a way that is adherent to the goals and format of skills coaching developed by Marsha Linehan.

Newer clients typically do not know how to cope with intense emotions effectively yet– after all, that is what brought them to the program! They may experience difficult emotions and urges for Target Behaviors but not yet know what skill to use or how to use it effectively. In these cases, the Residential Counselors are available 24/7 to walk them through using a skill. Over time, clients are pushed to identify skills and use them more and more independently so that they will be able to cope effectively after discharge.

When developing DBT, Marsha Linehan understood the importance of a built-in support network to the success and efficacy of DBT providers. This led to the creation of the DBT consultation team as a required part of the full DBT treatment model. The goal of the consultation team is to enhance the motivation and capabilities of all members of the DBT team so that they can continue to apply the treatment effectively. Members of the consultation team problem solve together, validate each other, assess, and push one another to maintain empathy in the work they are doing, often using DBT skills themselves and with one another in the process. Evolve Vanalden’s consultation team meets weekly and consists of therapists, clinical leadership, and residential counselors.

In addition to Evolve’s Comprehensive DBT program, all other programs at Evolve include adherent use of the skills training component of DBT.

In order to remain effective DBT providers, the team at Evolve Vanalden maintains the following assumptions in working with each client and family. While no one can prove whether these things are true or not, assuming that they are helps each DBT provider to remain effective in applying the treatment.

1. People are doing the best they can.
2. People want to improve.
3. People need to do better, try harder, and be more motivated to change.
4. People may not have caused all of their own problems and they have to solve them anyway.
5. The lives of emotionally distressed teenagers and their families are painful as they are currently being lived.
6. Teens and families must learn and practice new behaviors in all the different situations in their lives (e.g., home, school, work, neighborhood).
7. There is no absolute truth.
8. Teens and their families cannot fail in DBT.

Evolve’s Comprehensive DBT program was developed by our Executive Clinical Director, Alyson Orcena, LMFT. Alyson is intensively trained in DBT through Behavioral Tech, the premier DBT training institute, and has over a decade of clinical experience specializing in the treatment of adolescents with emotion dysregulation and suicidal behaviors. Alyson is committed to implementing best practices in all Evolve programs by ensuring staff have the appropriate training, resources, experience, and mentorship to implement DBT in a way that helps clients most effectively.

At Evolve’s Comprehensive DBT Residential Programs, our Clinical Director and the Primary Therapists have been intensively trained in DBT through Behavioral Tech. All employees (even our chef) receive ongoing training in DBT techniques specific to the Comprehensive DBT model. Our staff are available 24/7 for teens to receive in-the-moment, face-to-face skills coaching whenever they need it.

Many members of Evolves clinical leadership team have also received intensive DBT training through Behavioral Tech, including our CEO, Michelle Gross, LMFT, our Vice President of Operations, Director of Admissions, and our Regional Program Director. This training allows key leadership to provide expert clinical oversight for every teen entering treatment at Evolve and provides ongoing training in techniques specific to DBT and the residential model.