Comprehensive DBT Program For Adolescents and Young Adults
What is it?
Dialectical Behavioral Therapy (DBT) is a comprehensive and evidenced-based intervention that has been shown to decrease emotional dysregulation (reactivity) and a wide range of crisis oriented impulsive behaviors such as suicidal ideation, self-harm, and avoidance behaviors significantly impacting functioning. “Dialectical” means there are two opposing truths that are accepted and addressed at the same time. The fundamental “dialectic” in DBT is the concept that we are both accepting what is happening now and working to change it. DBT is a type of psychotherapy that emphasizes both cognitive and behavioral strategies and relies on learning a new set of skills to replace ineffective coping behaviors that create secondary problems. This intervention was developed by Marsha Linehan in the 1980s and was originally designed to treat people with borderline personality disorder. Over the years and more recently, it has been utilized with a wide variety of populations who struggle with a high emotional sensitivity and reactivity and need ways to be more effective in managing their emotions and relationships. It has been found to work well with both adolescent and adult groups and there are skills curriculums designed for each. It is also important for parents to learn DBT skills.
Raising children who experience their emotions intensely can be very challenging. Typical parenting strategies tend not to work very well with this population, who require more thoughtful, deliberate, and directed approaches. It is as important for parents to learn DBT philosophy and skills as it is for the client. When all parties in the home environment are utilizing common language and skill sets, it allows the environment to become a safe and validating place to allow for practice and integration of the DBT skills and improved functioning and relationships.
What will Comprehensive DBT look like if my family chooses this treatment?
1) There will be pre-treatment first.
Before beginning skills training, clients engage in 4-6 sessions of pre-treatment. During this time the therapist establishes a relationship with the client and conducts a thorough assessment (including a parent interview session), establishes goals, orients the client to the process and tools of DBT, and addresses any barriers that may interfere with the client engaging successfully in the treatment. Clients are asked to demonstrate a willingness and commitment to the DBT process and tasks and to give the intervention an honest chance by agreeing to maintain safety and commit to creating a life worth living.
2) There are essential DBT program components
In order for DBT to be adherent to the evidence-based model it must have the following:
Individual Therapy- Weekly sessions are prioritized to address 3 things (safety, therapy interfering behaviors, and quality of life). These are prioritized in this order. When safety is the focus, everything else takes a back seat until safety is achieved. Therapy interfering behaviors include missing or arriving late to sessions or skills group, not tracking on the diary card, or engaging in behaviors that can affect the alliance with the therapist. Quality of life covers everything else (relationships, school, activities, etc). Expect that goals in this area will not be addressed if there is still work needed on the first 2 priorities. Priorities are assessed week to week.
Diary Card- DBT utilizes a goal behavior, emotions, and skills tracker that allows the client to both increase awareness of and work deliberately on their treatment goals and skills use. It is expected to be completed daily, though therapists understand this is a difficult skill to master so work with clients to increase compliance over time. Inconsistent use of the diary card is addressed as a treatment interfering behavior and is used to prioritize the weekly session. The diary card is to be used between the client and individual therapist and not reviewed or managed by the parent.
Skills Training Group- Separate 1.5 hour weekly skills training groups for both the client and the parent. For parents of adolescents, attendance by one parent at a time for each module is mandatory. If the client repeats a second cycle of skills group and there is a second parent in the adolescent’s life, that other parent is required to attend the next cycle of parent group (see attendance policy). For young adults over 18 who live at home with parents we highly encourage a parent to commit to attending parent skills group. Each group includes a short mindfulness practice activity, review of the homework (these are short assignments designed to reinforce the skill taught each week), and teaching 2-3 new skills. Each member will be provided with a binder and all the materials needed for participation. Group members share experiences in group that demonstrate skills practice. Summary notes from group sessions will be emailed weekly to the client, the parents and any treatment providers requested.
Phone Coaching- DBT recognizes that it is difficult to generalize the demonstration of skills learned in group to real life situations. Phone coaching is offered and encouraged so when clients feel challenged by emotions, thoughts, or urges, they can seek support from their individual therapist/skills coach in a difficult moment. Coaching calls or texts are designed to be brief and focus on targeting skills use. This in vivo work is critical for skills integration. Parents are also encouraged to contact the parent skills group leader for parent skills coaching.
DBT Consultation Team- The individual DBT therapists as well as the parent skills leader meet weekly to collaborate on delivering thoughtful treatment. The purpose of the consult team is to help the therapists stay adherent to the DBT model, explore their own thoughts or feelings that may become treatment interfering with clients, and coordinate so families feel they have a team that is working in concert to help clients achieve their goals. As a result, confidential information is shared amongst the team and stays in the team. There may be times that treatment recommendations for your care come from “the team.” The DBT team is a peer collaboration of self-employed clinicians. The individual DBT therapist functions as the “case manager” in coordinating services for their client and is the point of contact for any and all concerns regarding treatment of your child. Julie Baron is the point of contact for any programmatic or billing concerns unless she is also the individual therapist. Otherwise “the team” together consults to assist each clinician in making DBT treatment compliant recommendations.
Parent Support- Due to the intense nature of the concerns that bring clients to DBT, we encourage individual therapists to focus on treating the behaviors and goals for their adolescent or young adult clients. They are available to parents for parent communication, feedback and coordination, regarding situational concerns and to assess progress toward goals. When parents need guidance on parenting approaches and behavior plans, such as ways to structure the home environment or develop and implement effective contingencies, or if they are struggling with their own ability to understand or accept the philosophy or skills of DBT, it is helpful for them to seek parent phone coaching and/or have some extra sessions with the parent skills coach for parent guidance work.
3) There are DBT Skills “Modules”
In DBT there are 5 key skill sets or Modules (make up a cycle) that are taught and practiced in the groups.
Core Mindfulness: Skills to live in the present moment by accepting what is, not
judging things and exhibiting compassion.
Emotion Regulation: Skills to be more in touch with the experience of emotions
and take care of ourselves regularly to limit vulnerabilities
that can make us more susceptible to our emotions.
Distress Tolerance: Skills to tolerate difficult and uncomfortable emotions and
body sensations associated with intense emotions.
Interpersonal Effectiveness: Skills to communicate effectively that help to
develop and maintain relationships.
Walk the Middle Path: Skills that move us away from all or nothing patterns of
thinking and allow for greater choices, compromise, and
consideration of others’ perspectives.
How does the “DBT Skills Group” work?
Each module is taught in 5 weeks with core mindfulness taught for 1 week in between the other modules. There are 4 modules plus the core mindfulness sessions = 24 sessions per cycle. Parent skills groups may meet for fewer total sessions though cover all the same skills. A full round of skills training takes approximately 24 weeks (give or take). It is common for clients to repeat a second cycle or more of skills training if skills are not yet integrated and goals not yet met. The team will consult with clients and families on progress toward treatment goals and the recommendation for continued skills group training beyond one cycle. It has been our experience that due to the focus on safety and stability for most clients during the first cycle, this is a time when skills are introduced though are not yet absorbed. Once greater stabilization has been achieved, a second cycle helps to integrate and apply the skills with greater awareness and thoughtful deliberation. Thus DBT can take anywhere from 6-24 months to achieve best and lasting results.
Due to the intense nature of this intervention there are very few weeks that are cancelled for holidays or vacations. (See attendance policy)
Once skills training is complete, a graduate DBT group is available to help clients continue to utilize skills in their day to day and access support and coaching in session from peers. Parents do not attend a parent group once their adolescent is in graduate group.
Attendance Policy and Fee Agreement
Participation in a DBT program requires commitment of time and resources. It is not right for everyone. DBT has been found to be very effective in reducing significant risk taking and unsafe or maladaptive behaviors when adhered to with full commitment by the client and their parents. Thus it requires a willingness to engage in all the components of the intervention. A thoughtful decision is encouraged before entering into this commitment.
Some insurance companies are now covering DBT though may require that members seek a “single case exception”. If your therapist can be of assistance in providing information to your insurance company please let them know. More information on how to advocate with insurance may be found on the Metropolitan Washington, D.C. DBT Consortium website www.dbtmetro.com.
At this time we are offering one parent skills group each week (see schedule). We understand this means some families will need to make an extra trip to the office. A video session option is available to participate in the parent skills group remotely through a platform called Secure Video. To access this HIPPA compliant service, there will be a nominal additional fee (see fee agreement). If you choose this option, instructions will be provided on how to access the video platform for group participation. Secure Video allows the remote participants to both be visible to the group and see the group in the room using a wide angle camera.
If you opt for the video session, you commit to the additional weekly fee through the entire cycle though it does not preclude you from coming to the office for group.
Julie Baron and Associates does not participate in insurance panels and therefore is an "out of network" provider. Clients are responsible for submitting invoices to seek any out of network reimbursement benefits. There have been some successful efforts at assisting families in advocating with insurance for a "single case exception" to cover DBT as an in network benefit when there is no other in network provider who provides comprehensive DBT or can provide this service within a reasonable time and distance as per Maryland insurance laws. For more information please ask your therapist.
The total fee for BOTH groups is $185/week. For families opting to use the video attendance format for a full 24 week cycle of parent group the fee is $200/week to accommodate the additional technology fees.
Skills group is billed for the client using the CPT code 90853, 90 minutes. The fee is the same every week regardless of whether the parent group meets. Participating in the DBT Skills Group is similar to signing up for a class. Participants agree to attend for a full 24-week cycle, and are billed for the full 24-week cycle unless they have “dropped out” of skills group (see below). When you commit to the cycle it means we are potentially turning others away because slots are full. If you choose to leave DBT before the end of the cycle you will continue to be billed weekly until the end of your 24 week time frame and those will be coded as missed appointments. If your reserved slot for the skills group cycle can be filled by a new referral before the end of your 24 weeks, the fee may be waived for the remaining sessions.
Client phone coaching with the individual therapist is included in the regular individual session fee. Parent phone coaching with the parent skills group leader is included in the group session fee. All other phone calls and collateral services (such as time spent advocating with insurance companies or writing letters) are billed as consistent by the terms of the Julie Baron and Associates fee agreement. We understand that a reasonable amount of time (10-15 mins per week) may be needed for parents to communicate with their child’s therapist without additional fees.
If the adolescent/young adult misses a skills group for any reason (including hospitalization, vacation or illness) the full group fee will be billed as a missed or cancelled appointment. Missed or cancelled appointments are typically not insurance reimbursable. If an adolescent misses more than 5 sessions in a 24-week cycle for any reason, they will have “dropped out” of skills group and will no longer be billed for group sessions. They may apply for readmission after one full module has been completed in their absence, during which time commitment may be re-established. For graduate group, consistency of attendance is critical to the therapeutic value of the group. A separate attendance policy will be provided should you choose to participate.
Parents (1 parent per client) are expected to attend regularly and come to parent skills group even if their adolescent misses the adolescent skills group for any reason. The parent group focuses on the use of DBT skills to help parents exhibit effective and skillful responses to their adolescent’s behaviors. Modeling consistent use of skills and commitment to the treatment are critical for encouraging your child do the same. If a parent misses more than 5 parent sessions they (and therefore their adolescent) will have “dropped out” of skills group and will no longer be billed for group sessions. Parents no longer attend skills group if their teen/young adult transitions to graduate group.
I have read this summary and understand the fee and attendance commitments required in this comprehensive DBT treatment program. Please check which parent skills group option you prefer:
_____ I would like to have the option to participate remotely through Secure Video for $200/group
Please notify me of session appointments via (please check one):
email ______________________________ or text _____________________________________
_____ I would like to attend parent skills group in person weekly for $185/group
Client Signature _______________________________ Date ___________________
Parent Signature _______________________________ Date ___________________
Julie Baron and Associates DBT Group Schedule
Adolescent Skills Groups:
Tuesdays from 5:00-6:30 PM (ages 13-15)
Thursdays from 5:00-6:30 PM (ages 16-20)
Skills Group Leader: Gale Greenstein, LCSW-C
Graduate DBT Groups:
Tuesdays from 7:30-8:30 PM (young adults)
Mondays 5-6 PM (teens)
Group Leader: Gale Greenstein, LCSW-C
Parent Skills Group
A video session option is available to participate in the parent skills group remotely through a platform called Secure Video. To access this HIPPA compliant service, there will be a nominal additional fee (see fee agreement). If you choose this option, instructions will be provided on how to access the video platform for group participation. Secure Video allows the remote participants to both be visible to the group and see the group in the room using a wide angle camera.
If you opt for the video session, you commit to the additional weekly fee through the entire cycle though it does not preclude you from coming to the office for group.
Skills Group Leader: Dr. Jeffrey Kranzler, PhD, LCSW-C
DBT Consultation Team
Julie Baron, LCSW-C (Program Coordinator/DBT Therapist) firstname.lastname@example.org
Gale Greenstein, LCSW-C (DBT Therapist) email@example.com
Jeff Kranzler, PhD, LCSW-C (DBT Parent Skills Group Leader and Parent Guidance Therapist) firstname.lastname@example.org
Masha Levy, LGSW (DBT therapist) email@example.com
Dr. Jennifer Merrill, PsyD (DBT therapist)