Initial Evaluation
The initial evaluation will consist of two parts: The first
part will include completion of a structured history and one or
more of the following:
SCL-90 (Symptom Checklist 90)
Personality Diagnostic Questionnaire-IV
Beck Depression Inventory
The second part of the initial evaluation will be a clinical
interview. This interview will be conducted using motivational
interviewing techniques (Miller, Rollnick and Conforti 2002).
Goals will be outlined and a contract for safety (including
self mutilation), attendance, and adherence to medications as
prescribed will be made. The patient will be given an overview
of the program and the ground rules. A written contract will
be reviewed and signed.
Five Functions of Comprehensive Treatment
Pathways to Healthy Living is committed to
the five functions of comprehensive treatment as developed by
Marsha Linehan, Ph.D. The five functions are: To enhance the
capabilities of the patients, improve the motivation of the
patient, to assure generalization from the treatment program
to the patient’s environment, to structure the patient’s
environment to help with recovery, and to motivate the therapists
working with the patient to use effective treatment strategies.
These functions are addressed by our program in the following
ways, outlined originally by Dr. Linehan:
Enhance Patients’ Capabilities to Recover
Skills Training
Psychoeducation
Handouts Readings
Pharmacotherapy
Improve Patients’ Motivation to Recover
Contingent Reinforcement
Extinction
Exposure/response prevention
Cognitive modification
Assure Generalization to the Patients’ Natural
Environments
After hours/crisis phone coaching
E-mail consultation
Review of session tapes
Homework/practice
Enhance Therapist Capabilities and Motivation to Treat
Effectively
Supervision
DBT Consultation Team
Continuing Education
Treatment manuals
Staff incentives
Structure the Patients’ Environment
Contingency management within the treatment program as a whole
Contingency
management within the community (family, marital interventions)
PATHWAYS TO HEALTHY LIVING
GROUP SCHEDULE
In individual therapy the following phases will be followed,
with important goals for each phase. These goals may be modified
to meet the needs of the individual patient.
Tuesday
9:00 to 10:30 Skills Training Group
10:45 to 12:45 a.m.
Mindfulness Group
Thursday
9:00 to 10:30 am Interpersonal Effectiveness
10:45 to
11:45 am Chain Analysis/Self Management Group
Friday
9:30 to 11:00 am Skills Training Group
11:00 to 11:30
am Goal Setting Group
Description of Groups
Skills Training Group
The Skills Training Groups on Monday
and Thursdays focus on Emotion Regulation and Distress Tolerance.
Emotion Regulation is taught for about four weeks and Distress
Tolerance is taught for the following four weeks. The groups
start with a mindfulness exercise and are followed by homework
review. Then a new skill is taught and often practiced, followed
by a homework assignment. The purpose of this group is to help
the patient learn how to manage a crisis without making it worse
and how to manage their emotions so they do not feel overwhelmed
by them.
Mindfulness Group
Mindfulness is at the core of all the skills
learned and therefore is given a strong emphasis in the program.
In this group patients learn what mindfulness is, the ways in
which many people are not mindful and do not see or accept the
world as it is, and ways to being to see reality in a more accurate
way. Many Cognitive Behavior Therapy techniques will be discussed
here as ways to not cognitively distort what you experience.
Mindfulness will address grounding techniques, living in the
present, and learning self validation as well.
Interpersonal Effectiveness Group
Often much of the stress for patients comes
from relationships with other people or the lack of relationships
with others. In this group, issues important to being effective
interpersonally will be explored and discussed. Resolving conflicts,
setting relationship priorities, learning to say no, learning
to ask for what you need, and learning to maintain relationships
will be included in the topics.
Behavior Chain Analysis/Self Management
Group
Learning how events affect emotions and behavior
and how to understand these reactions is one of the goals of
this group. In addition the concepts of reinforcement, shaping,
extinction, exposure, aversive consequences, modeling, classical
conditioning and contingency management will be discussed. The
basic problem solving skills of DBT will be the focus of this
group.
Goal Setting Group
In this group you how to set goals, monitor
goal progress, reviewing and reassessing goals in terms of what
works versus failure is addressed. Setting goals for the coming
week will be done in this group. These goals become the patient’s
personal plan for recovery, one step at a time. You will also
review your goals from last week to see what progress you made.
Individual Sessions
You will meet with your individual therapist
twice weekly. In these sessions, you will learn about the Biosocial
Theory, address any self harm urges, therapy interfering behavior,
and quality of life interfering behavior. Your diary card will
be reviewed and areas of concern addressed according to the
problem solving options you are learning. In your individual
sessions you will have the opportunity to apply the skills you
are learning in group to your unique situation and learn and
apply problem solving options (skills, behavior analysis, insight
or pattern highlighting, solution analysis, cognitive modification,
contingency management, exposure therapy or opposite action)
to help you improve your ability to manage your life stresses.
Skills Coaching
Skills Coaching is provided by your individual
therapist to help you think about and use the skills that you
are learning. You will work out how to get skills coaching with
your individual therapist. Phone contact and email (for nonemergency
situations) between sessions will be made available on an as
needed basis and will be determined between the individual therapist
and the patient.
Program Length
The anticipated length of treatment is 4
to 12 weeks. A seamless transition is available, as each patient
will stay with their individual therapist and be able to attend
a weekly outpatient DBT Group. An aftercare group will be available.
Generalization of Skills
Phone and/or email contact between sessions will be made available
to the patient and discussed between the patient and the individual
therapist. The goal of the phone contact is to help the patient
apply the coping skills being learned outside of the therapy
sessions. This interaction is handled according to the guidelines
set forth by Linehan (1993) in order to focus on increasing
independent, not dependent, functioning on the part of the patient.
Homework (practicing the skill being learned) will be emphasized.
Homework diary cards will be collected each week. Homework will
be reviewed by both the group and the individual therapist.
Practice of the skills being learned is believed to be a major
criterion of who benefits from the program and is thus emphasized
repeatedly.
Tapes and/or Videotapes of the Skills Training Modules will
be made available to the patients for review between sessions.
Handouts concerning all the skills will be given during the
group sessions and a patient handbook concerning the DBT skills
will be given to each patient. Reference materials and books
will be made available as well.
Aftercare
An aftercare group will be available. Aftercare is seen as
transition to once weekly psychotherapy. Tapes, videos and books
will continue to be used. Part of the program includes developing
more social support in the community and assisting the patient
with being willing to seek and utilize community opportunities
as available and appropriate.
If the patient is from out of town, efforts will be made to
seek resources in the hometown prior to discharge. In addition,
email and phone consultation will still be made available during
the transition.
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