Monthly Archives: July 2015

Taking counseling’s cause to Capitol Hill

By Bethany Bray July 30, 2015

(Photo by Paul Sakuma)

More than 100 professional counselors visited Capitol Hill on July 23 as part of the American Counseling Association’s Institute for Leadership Training (ILT) to advocate for the profession on a range of issues, from federal funding for school counselors to hiring more counselors at the Department of Veterans Affairs (VA).

Counselors from more than 30 states visited the offices of their respective U.S. senators or members of the House of Representatives, talking with aides and distributing fact sheets. In some cases, the

Dianne Baer, president of the Arkansas branch of the American Counseling Association, talks with Rep. Steve Womack (R-Ark. 3rd district).

Dianne Baer, president of the Arkansas branch of the American Counseling Association, talks with Rep. Steve Womack (R-Ark.). (Photo by Paul Sakuma)

counselors were able to meet with members of Congress in person, including Sen. Shelley Moore Capito (R-W.Va.), Rep. Raúl Labrador (R-Idaho) and Sen. John Thune (R-S.D.).

The counselor advocates were gathered in Washington, D.C., for ACA’s annual ILT event, a four-day conference of education sessions, trainings and business meetings for leaders in the counseling profession. ACA’s government affairs team organized the institute’s Day on the Hill.

“ACA leaders had another successful visit with members of Congress and their staffs about several issues facing the counseling profession,” reported Art Terrazas, ACA’s director of government affairs. “ACA leaders were able to advocate for more hiring opportunities for counselors and improved delivery of mental health services. We’re excited that our leaders had this opportunity to exercise their constitutional rights and empower members of the counseling community.”

ACA member-leaders from Florida talk with Eduardo Sacasa, a legislative correspondent in U.S. Sen. Marco Rubio’s office. Shon Smith (center, in bow tie), Southern Region chair-elect to the ACA Governing Council, advocated for the hiring of more professional counselors within the VA. Smith, a veteran himself, quoted data from a recent VA report estimating that 22 veterans commit suicide each day – a statistic that’s “completely preventable,” Smith said. (Photo by Bethany Bray/Counseling Today)

Among the issues for which counselors advocated at the 2015 Day on the Hill:

Counselor inclusion as Medicare providers. Medicare does not currently reimburse licensed professional counselors (LPCs) for the much-needed treatment that they provide for older adults. During last week’s Day on the Hill, counselors asked for legislators’ support for a soon-to-be introduced bill, the Seniors Mental Health Access Improvement Act of 2015, which would establish Medicare coverage of LPCs. Sens. John Barrasso (R-Wyo.) and Debbie Stabenow (D-Mich.) are sponsoring the bill.

Funding for the Elementary and Secondary School Counseling Program (ESSCP), which provides grants to school districts that have a need for additional counseling services for students. ESSCP’s funding was recently cut in half. Day on the Hill counselor advocates pushed legislators to, at a minimum, keep the reduced funding ($23.3 million) in the bill.

Increased opportunities for employment of professional counselors within the VA. Currently, counselors make up less than 1 percent of the VA workforce, according to Terrazas. During the Day on the Hill event, counselors asked senators to co-sponsor bill S.1676, which would include LPCs in the VA’s health professional training program and allow LPCs with doctoral degrees to be hired by the VA.

ACA fact sheet on the VA (CLICK TO SEE FULL SIZE)

ACA fact sheet on the ESSCP (CLICK TO SEE FULL SIZE)

ACA fact sheet on Medicare (CLICK TO SEE FULL SIZE)

Stephanie Dailey, president of the Maryland branch of the American Counseling Association and senior co-chair of ACA’s Ethics Committee, talks with an aide in the office of Rep. Robert Wittman (R-Va.). (Photo by Bethany Bray/Counseling Today)

ACA member-leaders take the underground train that runs between the Senate and House buildings on Capitol Hill.

ACA member-leaders from Texas take the underground train that runs between the Senate and House buildings on Capitol Hill. (Photo by Paul Sakuma)

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By the numbers: 2015 Day on the Hill

139 ACA members participated from 39 different states, the District of Columbia, Puerto Rico and the Virgin Islands

Offices visited:

78 Senators

109 members of the House of Representatives

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Search for the hashtag #CounselorsEmpower for social media posts from ILT and the Day on the Hill

More photos are posted at the ACA flickr page: flickr.com/photos/23682700@N04/sets/72157656243041342

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Advocacy tips

Some things to keep in mind when advocating for counseling with lawmakers at the local, state or national level:

Remember that you are the expert on this subject, not the politician. Be confident!
Keep in mind that a letter sent via U.S. mail can take two to four weeks to reach your legislators because it will have to be screened for security. Email, social media and in-person meetings are often more timely and effective.
Treat your meeting with a lawmaker as if it were a job interview: Dress nicely, be on time, be courteous and follow up with a thank you email.
Advocacy tips from the ACA (CLICK TO SEE FULL SIZE)
Before you go, make sure that you thoroughly understand the issue you plan to speak about. Also be familiar with the lawmaker – his or her interests, background and platforms.
If you’re seeking support of a particular bill, be sure to mention it by name and number.
Most of all, tell your story. Oftentimes, personal anecdotes and examples are more memorable and get your point across better than facts and figures.
Social media can be a powerful tool to draw attention to a cause. All but two or three U.S. legislators have a Twitter feed or Facebook page. Keep in mind that legislators – or at least office staffers – monitor these social media accounts and look at every mention and tag that involves them.
If you don’t know the answer to a question, simply explain that you don’t know the answer but are willing to find it and get back to the legislator – then do so!

Source: Dillon Harp, grassroots organizer, ACA Government Affairs

ACA member-leaders from Florida stand with Eduardo Sacasa (center, in necktie), a legislative correspondent in Sen. Marco Rubio’s office. Pictured are (left to right) Jacqueline Swank, president of the Association for Creativity in Counseling (ACC); Seneka Arrington, president of National Employment Counseling Association (NECA); Katheryn Williams, secretary of ACA’s Southern region; Sacasa; Kristie Knight, secretary of the Florida Counseling Association (FCA); Shon D. Smith, Southern region chair-elect to the ACA Governing Council; Anne Flenner, FCA president-elect; and Michelle Bradham-Cousar, FCA president. (Photo by Bethany Bray/Counseling Today)

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

Techniques for counseling clients who have chronic pain

By Betsy Farver-Smith July 27, 2015

Clients or patients facing chronic pain require a special counseling approach that can be applied universally, no matter their source of pain or the number of months or years they have tried to deal with the pain. We have honed and practiced these techniques at the Betty Ford Center in Rancho Mirage, California, because many of the patients we see for addiction treatment also experience chronic pain.

Chronic pain and addiction do not necessarily co-occur, but there are some strong correlations. Unfortunately, because pain medication can be addictive, it is common (but not certain) to find patients with the combined condition of chronic pain and addiction. All people who abuse alcohol or other drugs experience chronic emotional pain. According to an article published by Jennifer Sharpe Potter and colleagues in the Journal of Substance Abuse Treatment in 2010, chronic physical pain affects approximately 60 percent of those struggling with alcoholism or addiction.

At the Betty Ford Center, we have a special treatment program, developed by Dr. Peter Przekop, for both chronic pain and addiction. Regarding chronic pain alone, we have learned several critical counseling techniques that help patients move forward.

Determining if an individual has chronic pain issues

Treatment, of course, begins with an assessment and diagnosis. Sometimes clients or patients will not present their chronic pain as a factor in the reason they are seeking counseling. However, certain markers will help you identify whether the person is dealing with chronic pain. Look for:

1) Symptoms of depression

2) A history of adverse events, including physical abuse, emotional abuse, sexual abuse, a bad accident or a high level of past stress

3) High present stress

4) Anxiety

5) A catastrophizing mindset — a belief that if things can go wrong, they will go wrong

A key part of your assessment is to understand any and all physical pain issues. This detailed inquiry will aid the development of your treatment plan.

There is likely to be related emotional pain as well. Often that emotional pain has early life trauma as its origin. Your assessment and treatment must take this into account. In a national survey of 1,009 chronic pain sufferers completed in 2014 by the Hazelden Betty Ford Foundation, we found a disturbing, though not unexpected, correlation between early life trauma and chronic pain. The chart below lists the top incidents of early life trauma among the survey participants.

One of the most dramatic findings in the national survey was that 97.1 percent of chronic pain sufferers had experienced at least one instance of physical or emotional trauma prior to their chronic pain. We believe this early trauma experience often trains the person’s brain to be more receptive to future chronic pain in a way that does not lead easily to treatment relief. Therapy that helps the chronic pain patient understand, accept and forgive these earlier traumas may help heal the pain center of the brain and make it less receptive to chronic pain.

Counseling techniques

1) Practice being patient with those who are dealing with chronic pain. Inexperienced counselors should know that it is not easy to sit with someone in chronic pain. Many of us in this profession can be caretakers. With clients or patients who have chronic pain, we can tend to want to take away their pain right away. Be prepared instead for a lengthy process. The longer you can comfortably tolerate sitting in session with a client or patient in chronic pain without trying to fix it, minimize it or talk about something else, the more that person will build trust with you. The client or patient will begin to feel that you don’t regard his or her pain as either imaginary or a burden, as the person may have sensed that others have done.

Extended acknowledgment of the pain and listening for the roots of the trauma or concurrent emotional pain builds a capacity within the client or patient for self-exploration and self-awareness. This longer process also helps the client or patient look inward instead of outward, which will benefit the overall therapy process.

2) Offer clients (or refer them to) group therapy in addition to your individual counseling. Unfortunately, a frequent characteristic of people with chronic pain is a tendency to isolate themselves. Because the pain has lingered and feels severe, these individuals talk about it often and intensely with family members and friends. In turn, they have likely eventually experienced being “tuned out.” These clients decide that nobody can relate to what they have gone through. Worse, they may reach an unhealthy conclusion: “My pain is imagined. I’m a wimp. I must be crazy.”

Group therapy, particularly in a community of others dealing with chronic pain, can reduce these clients’ or patients’ sense of loneliness, shame and isolation and help them feel they are not alone. By seeing other chronic pain sufferers who are further along in the process of emotional recovery, your client or patient will gain hope that the day might come when he or she will experience less pain.

Individual counseling provides a different benefit, which is why I recommend both types of therapy concurrently. I begin by recognizing with the patient that pain is pain. By this I mean that our minds and bodies are one unit, and pain will register as pain regardless of whether it is physical or emotional. Emotional pain is just as valid and just as much a contributor to chronic pain as is a medical condition that affects the body. For example, chronic knee pain can be influenced by the pain of unresolved emotional pain.

In this way, it becomes the primary focus of individual therapy to gather information from the client about unresolved emotional pain. As a counselor, you must witness that emotional pain and validate it. Out of this discussion emerges a real gift for the client: a new level of positive self-acknowledgment and self-esteem.

3) Consider adding mindfulness exercises. In addition to traditional emotional counseling, we provide mindfulness training to our patients at the Betty Ford Center who are experiencing chronic pain. Patients spend time in group settings each day becoming aware of how chronic pain has changed their way of thinking, coping and judging themselves and others. Patients learn how to restore normal brain function, in part by working on planned movement exercises that have been taken from the disciplines of tai chi, qigong, kung fu and yoga. Manual medicine and acupuncture also are key parts of the treatment mix. These additional treatment approaches allow patients to learn to refocus attention and help them gain strength, flexibility and confidence. Mindfulness exercises also allow the patients to slow down their minds, control their thoughts and gain a sense of presence. Pain literally steals this ability from people.

Group settings for mindfulness exercises can be helpful as chronic pain sufferers share new skills on how not to focus on the physical pain. Mindfulness helps these patients know where in their bodies they tend to carry the emotional pain from the past. Is it in the same place where they feel the physical pain or elsewhere, such as in the stomach? Patients will come to the realization, for example, that they have internalized and physicalized emotional pain.

4) Help clients learn not to judge the pain. Physical pain is intensified by the person’s judgment of the pain. For example, if your client or patient has a “bad back” and suddenly feels a twinge in the back muscle, that person could spend a significant amount of emotional and mental energy assessing or judging that pain. How much did that hurt? Will it come back? How does it compare with past pains? If you teach clients not to judge or assess the pain, but rather to move on and refocus on something positive, it can actually lessen the sensation of physical pain.

5) Look for signs of chemical addiction. As mentioned earlier, there is, unfortunately, a strong correlation between chronic pain and addiction. Often the addiction is attributable to the pain medication. Your clients or patients may be reluctant to address this issue. I have heard patients say, “I can’t possibly be addicted. After all, these medications were prescribed to me by a doctor.” Or they will say to me, “Addicts live under bridges. I am far from that!” Remember, denial and resistance are typical responses of addicted personalities.

In our 2014 national survey, 48.2 percent of those studied were taking at least three concurrent pain medications prescribed for their chronic pain situation. More than one-third (35 percent) thought they were drug dependent because of the chronic pain treatment. Given that people are reluctant to admit addiction, this number likely is underreported.

The most common drugs prescribed for chronic pain are opioids, which are highly addictive. Likewise, there are more negative consequences for opioid use than for any of the other prescribed pain drugs. For instance, our study showed that half of patients taking opioids for chronic pain said they had suicidal thoughts. Opioid use (through legal prescriptions) reportedly caused multiple problems that counselors should understand and address with their clients who are dealing with chronic pain. The chart above, taken from our national survey, lists some of those negative consequences.

6) For follow-up as counseling ends, consider recommending more group therapy. As mentioned earlier, group therapy is an excellent treatment for patients with chronic pain because it puts them in contact with others who are learning ways to cope with the pain. For this reason, after concluding individual counseling with a client or patient, a good ongoing support to suggest would be a chronic pain group.

When making recommendations, avoid two specific types of chronic pain groups. The first is a group in which members are still reliant on medication. We have seen too many patients come to the Betty Ford Center addicted to their pain medication yet still in chronic pain. Medication complicates and often defeats recovery from chronic pain. The second is a group focused on one specific type of pain. In these groups, patients may end up comparing symptoms and aches and pains rather than continuing to move forward with emotional self-exploration and learning new coping skills.

If your clients or patients have chemical addiction issues, I recommend that they participate in a 12-step recovery group. This group will help them focus on recovery from substance abuse, while simultaneously helping them heal related emotional pain issues that pertain to chronic pain.

A proven approach

We use these counseling techniques at the Betty Ford Center. We possess the benefit of treating the patient daily for anywhere from 45 to 60 days, compared with typical counseling schedules of once or twice weekly. We believe this intensity of treatment leads to exceptional results. Retrospective case reviews show that 74 percent of our pain management patients report being free of pain a year after concluding treatment.

This is why we feel so strongly about these suggested counseling techniques for chronic pain. Even if the counseling sessions you provide are less frequent, we believe these techniques will promote healing of the chronic pain and make your clients more emotionally available to address other issues that are causing them difficulty in life.

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Betsy Farver-Smith holds a master’s degree in addiction counseling from the Hazelden School of Addiction Studies. She has been with the Betty Ford Center for 13 years. Her positions include serving as the executive director of clinical services, and she was recently appointed executive director of philanthropy for the Hazelden Betty Ford Foundation. Contact her at bfarver@hazeldenbettyford.org.

Letters to the editor: ct@counseling.org

CEO’s Message: Reflecting on senseless tragedies to empower the counseling profession

By Richard Yep

Richard Yep, ACA CEO

I was half a world away, literally, when nine innocent people were gunned down and killed during their Bible study in Charleston, South Carolina. As part of the planning team for the ACA-Asia Pacific Counseling Conference, I was in Singapore on that dark day in June. But, with the Internet and social media being what they are, I was as horrified as many others by what I read and watched in the hours and days that followed.

The following individuals had their lives taken by a young man whom they had welcomed into their Bible study: Cynthia Hurd, Susie Jackson, Ethel Lee Lance, DePayne Middleton Doctor, Clementa C. Pinckney, Tywanza Sanders, Daniel L. Simmons Sr., Sharonda Coleman-Singleton and Myra Thompson. They ranged in age from 26 to 87. Dylann Roof, the 21-year-old shooter, later said that he almost didn’t go through with his plan because everyone at the Bible study had been so nice to him.

Among the victims were a state senator, a librarian, a speech therapist, members of the clergy and one of our own — Myra Thompson, who had worked as a professional school counselor.

I call attention to their names, just as I would ask you to remember four other names: Addie Mae Collins, Cynthia Wesley, Carole Robertson and Carol Denise McNair. These four girls, ages 11 to 14, were the victims of another race-based hate crime, the 16th Street Baptist Church bombing in Birmingham, Alabama, which took place 52 years ago, on Sept. 15.

I ask you to remember all of these victims, not to generate outrage but to encourage us to redouble our efforts to do whatever we can to improve our communities. Everyone, in his or her own way, both personally and professionally, can have a profound effect on the way our society will evolve.

Professional counselors are at the epicenter of helping others to heal through the good work that all of you do, each and every day, with millions of adults, adolescents, families, couples and children. I am honored to work for an organization that represents more than 56,000 caring people who are also such dedicated helping professionals. When we think about the horror of what happened earlier this summer in Charleston or back to events such as the 16th Street Baptist Church bombing, it can put us into the mind frame of “what’s the difference?” But I encourage you to think, “How can I make a difference?”

Being the best possible professional counselor or counselor educator you can be requires a great deal of time, dedication, practice and experience. Although ACA doesn’t possess all the answers, we do have some resources, and I hope you will let me know what else we can do on your behalf. In addition, engage with your colleagues through ACA Connect or as part of an ACA division or interest network.

Professional counseling can be the linchpin in efforts to avert senseless tragedies, just as it can help people work toward a more open, just, caring and respectful society. Working with diverse populations in an increasingly multicultural and cross-cultural society is bound to present challenges. But listening to, caring for and facilitating greater understanding among groups is a wonderful start. When I think about the best candidates to meet this challenge, I need only to look as far as the ACA member database. Making a difference does begin with you.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800.347.6647 ext. 231 or email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.

From the President: The synergy to make things happen

By Thelma Duffey

Thelma Duffey, ACA’s 64th president

Greetings, fellow counselors. I am on an airplane returning from Singapore as I write this column, inspired by the experience and mindful of the great energy around me. A small group of us from the United States participated in the first American Counseling Association-Asia Pacific Counseling Conference and met with counselors, students and professional leaders from throughout the area. It was a wonderful thing to see people from across the globe, representing 12 countries, invested in the profession of counseling, sharing their ideas and areas of research, and seeking information and new knowledge.

I was taken by the positive energy, the humble appreciation and the keen interest in learning that so many attendees communicated. Participants would come up after the sessions and discuss their cultures and the ways that the information could be adapted to their worlds. The exchanges were hopeful, truly genuine and mutually respectful. There can be wonderful synergy when counselors come together, and this experience was both celebratory and a clear reflection of its benefits.

Two weeks before leaving for Singapore, I spent several days in a setting with a starkly different purpose: consulting with teachers, staff, administrators and families in Newtown, Connecticut. I didn’t know much about Newtown and its village of Sandy Hook prior to the horrific school shootings that took place there on Dec. 14, 2012. Since then, of course, the community’s courage, pain and efforts toward recovery have become well known.

I was asked to travel to Newtown, and I invited three counselors to join me. With the able coordination and collaboration of the Newtown Recovery and Resiliency Team, we were immersed in an experience that simultaneously left me in awe of the human spirit and reminded me of how challenging life can be. It also left me with a deep sense of humility and gratitude — for my life, for those I love, for my profession and for this day. Through our work, we are reminded that life can turn on a dime. We belong to a profession that regularly reminds us of what is important. I see this as a definite benefit of being a counselor.

Counseling is a wonderful profession — one that we must safeguard, support and advance. As we seek to do this, I am inspired by my two recent experiences. I believe that if, like our colleagues in Singapore, we come together with positive energy, humble appreciation, respect and a keen interest in learning ways to be resourceful and solve problems, we can be successful. And if we allow the Sandy Hook community and the very capable counselors who are leading the way there to provide some perspective, I believe it will encourage us to be mindful of how privileged we ultimately are and that we can work through any challenges we encounter.

In July, counselors and students from across the country will come together at the ACA Institute for Leadership Training (ILT) to share ideas, learn from one another and advocate on behalf of professional counselors everywhere. Together we will meet with legislators on Capitol Hill and let them know about the many contributions that counselors make across diverse settings. We will join in advocacy for counselors’ inclusion in national initiatives and legislation related to mental health. I will have an opportunity to discuss in detail the goals and possibilities for the professional advocacy and anti-bullying/interpersonal violence initiatives I have proposed for this year, and I will engage with ILT participants on ways to invite and include all interested counselors. In turn, I look forward to sharing the progress of these initiatives with you as they unfold.

Beginning in September, there will be a column in Counseling Today and information on the ACA website detailing the work that counselors are doing on behalf of our profession and our communities through these initiatives. Please follow these updates and consider finding ways to contribute and connect. I believe that as we collectively advocate for our profession, and as we collaborate in social action in our communities, we will not only strengthen our profession and the communities we serve, we will also forge bonds and strengthen our professional relationships. Good relationships are not only enjoyable but also help us find common ground when challenges arise. And through our relationships, we set the stage for creative problem-solving and for the synergy that makes things happen!

This can be a year of powerful impact. Who must we be to do this? Counselors coming together.

With thanks and appreciation,

Implementing DBT in your counseling practice

By K. Michelle Hunnicutt Hollenbaugh, Jacob M. Klein and Michael Lewis

Dialectical behavior therapy (DBT), developed by Marsha Linehan, is one of the few evidence-based treatments for borderline personality disorder. However, since its origination 20 years ago, DBT has been implemented with populations in various settings with positive results. DBT is intensive and involves many techniques, including cognitive behavioral skills training, mindfulness meditation and behavioral interventions.

Counselors who wish to introduce DBT in their own practice often struggle with where to begin regarding implementation and training. The implementation of full, “standard” DBT can be costly and time intensive. However, it also has the most evidence base and increases the likelihood and strength of positive outcomes.

On the other hand, counselors may be interested in implementing only some modes of DBT (for example, the skills training group) or making adaptations to the current skills curriculum and handouts. This has been termed as “DBT-informed” treatment, and it can be beneficial as well, depending on the setting and population with which the counselor is working. This article discusses basic considerations for counselors who are thinking about implementing either standard or DBT-informed practices.

The four modes of DBT

There are several treatment modes in DBT to consider, and each covers one or more specific functions of the standard model. Although Linehan states that other ancillary modes may be included in DBT treatment (for example, pharmacotherapy and case management), these are the four standard modes.

1) Skills training: The DBT skills group is one of the most frequently implemented modes of DBT because it often requires the least amount of resources and features tangible handouts and instructions for group leaders. A strong research base also exists for the effectiveness of exclusively using skills training to address a variety of treatment goals and mental health symptoms. The skills training experience is structured and psychoeducational. During this mode of DBT, clients focus solely on obtaining new skills, enhancing their capabilities and generalizing skills to other aspects of their lives. There are four skills modules: mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness.

Skills training can be completed during individual sessions. However, as Linehan notes in the DBT Skills Training Manual, it can be difficult for the counselor to be directive and structure time for skills training within the therapy session. Therefore, group sessions tend to be the preferred method. In the group setting, sessions are traditionally offered weekly for two to two and a half hours. The first hour is devoted to review of homework from the previous session, whereas the second hour focuses on the acquisition of new skills.

The modules typically span five to seven weeks. However, the time frame and format can be altered based on the needs of the site and the clients. For example, a shorter time frame can be used, or group sessions can be offered more than once per week. Linehan also notes that although groups can be open or closed, open groups seem to be the most beneficial for skills training purposes. In my practice, I (Michelle) closed the group after the commencement of a new module and then opened the group to new members when the next module began. This allowed for group members to work and learn together during each module.

2) Phone coaching: Intersession phone coaching is often considered the most demanding mode of standard DBT. This is understandable because counselors expend significant energy being present for their clients during regularly scheduled sessions and may want to focus solely on personal time and their families outside of work. Counselors also may have concerns about clients — especially clients with a history of acute needs — abusing the ability to call them anytime after hours.

However, Linehan has emphasized the importance of intersession coaching to help clients generalize the skills they have learned in training to everyday life. The duration of a skills coaching call is often short, typically between 10 and 20 minutes. Though the frequency of calls will vary by client, Linehan and her colleagues note that the frequency should decrease with the amount of time spent in the program.

Several guidelines are outlined regarding the use of phone calls between sessions for skills coaching. This structure reinforces the client for using skills instead of engaging in life-threatening behaviors (for example, nonsuicidal self-injury) or seeking unnecessary hospitalizations. Linehan states that if DBT is implemented in an inpatient or residential setting, skills coaching interactions with nurses, mental health technicians and other staff members can take the place of traditional phone coaching.

3) Therapist consultation team: Linehan and her colleagues emphasize the importance of support for therapists. The consultation team is composed of therapists providing DBT who meet weekly for case consultation and support and to maintain the fidelity of the treatment. Counselors considering implementing DBT at their current sites can start a new consultation team or approach another DBT consultation team in the community.

Finding a DBT team to join can be difficult, especially in rural areas. However, Linehan notes that team members may use online tools to coordinate weekly meetings if necessary. For those starting a new team on-site, Linehan and her colleagues recommend assigning a team leader. A competent leader helps keep the team focused and invigorated and provides guidance throughout the treatment process. This person will also be helpful in determining who will fill various roles on the team based on interests, experience and strengths. The consultation team addresses the function of enhancing therapists’ skills and motivation in standard DBT.

4) Individual treatment: Individual treatment in standard DBT is conducted weekly and mainly covers the function of improving the client’s motivation. The skills trainer is usually different from the individual counselor. Individual therapy also offers the client a dedicated place in which to process nonsuicidal self-injury and suicidal thoughts because the group sessions are more psychoeducational in nature. Per Linehan’s original text on treating borderline personality disorder, in standard DBT, the individual therapist adopts dialectical and validation treatment strategies, in addition to a behavioral approach to quality-of-life, life-threatening and therapy-interfering behaviors.

Overall factors to consider

In addition to the modes of DBT, there are several other factors for counselors to consider before implementation. An initial needs assessment will help identify where DBT can be implemented successfully into current systems. This includes assessment of the target population and available resources (human and otherwise) for treatment. Major factors to consider are:

Population: Although DBT was initially developed for adults diagnosed with borderline personality disorder, research has shown support for its use with adults and adolescents struggling with eating disorders, mood disorders, anxiety disorders and substance use disorders. Narrowing the focus on the target population will ground program creation and implementation. Admission criteria are also an important consideration, along with any possible client exclusions or exceptions. Client admission may not necessarily be narrow or broad. However, it should be consistent. Counselors should also consider how the chosen population fits the gaps in current services in the community (e.g., availability of chemical dependency treatment facilities, eating disorder clinics and existing community support groups). Furthermore, any potential adaptations to the skills worksheets and handouts should be considered. Many publications by Linehan and other professionals are available that address adaptations to fit the needs of specific diagnoses and age groups.

Training: A multitude of training options are available for counselors interested in DBT. Behavioral Tech (behavioraltech.org), the organization Linehan founded to train others and facilitate research in DBT, offers what many consider to be the gold standard in DBT training. The initial 10-day intensive course is open only to treatment teams, but it allows for counselors to use the skills in their practices as they learn them. Counselors who wish to join an existing DBT team may attend an abridged version of this course that runs for five days. In addition to online resources and additional training resources for individuals, Behavioral Tech offers an advanced intensive training for providers who have been practicing DBT for a year or more. Recently, Linehan and her colleagues began offering an official certification in DBT. Certification requires a minimum of 40 training hours related to DBT, successful completion of a certification exam and submission of a client case conceptualization with three taped sessions (for more information, visit dbt-lbc.org).

Other organizations offer numerous local and regional DBT trainings for individuals throughout the country. Multiple online and text resources are available as well. Finances and the intended level of DBT implementation are both important considerations in choosing the best training venue. Regardless of the level or type of training chosen, a cohesive and sound foundation in DBT will be necessary for all counselors and other staff involved before moving forward.

Setting and facility: The setting will have a significant impact on decisions made regarding the adaptation and implementation of DBT. Those working in inpatient or intensive outpatient settings may need to make significant adaptations to provide DBT in shorter time frames. Facilities that only treat certain populations may have very specific needs regarding adaptations of skills and modes of treatment.

Space and other on-site resources are also important considerations. Needs may vary depending on the number of clients expected and, if applicable, the number and frequency of groups being implemented. Optimally, there will be enough space for all involved counselors and other staff to work comfortably. It is also important to consider whether certain on-site resources, such as a lending library, space for other professionals and paraprofessionals, and a personal respite space for clinicians, will be provided. Analyzing the costs and benefits associated with each of these aspects is important.

Finances and billing: Full implementation of standard DBT can be costly, especially when considering training, resources and time. However, Linehan and her colleagues have found that DBT is often more cost-effective to the community than “treatment as usual” with chronically suicidal individuals because outcomes lead to a reduction of emergency hospitalizations. However, reimbursement for all modes of DBT may be difficult to obtain, especially for those in private practice. DBT researchers have suggested that community mental health centers may be the best fit for implementing full DBT because these centers often bill Medicaid and Medicare, which may be more flexible with regard to reimbursement for treatment and session limits. Conducting a cost-benefit analysis is important when deciding which modes of DBT to implement and for how long.

Assessment and program evaluation: Linehan and her colleagues have consistently emphasized that one of the most important aspects of any DBT program is assessment. Regardless of the level of DBT implementation or adaptation, it is important for all stakeholders to possess knowledge of client outcomes. Early in the implementation process, the symptoms or behaviors the program will address should be clearly identified, and the methods of assessment via psychometric tests and other means should be determined. Linehan provides a list of several options for assessment instruments in the DBT Skills Training Manual.

Administrative and structural support: DBT researchers have found that one of the major limitations to implementation of DBT is the investment of administrators. Administrators may not understand the comprehensive nature of the treatment or be aware of the evidence base for implementing all modes of DBT. Counselors will need to engage administrators with this information initially and emphasize the treatment’s benefits based on current published research.

Agency structure and support for counselors engaged in DBT is also an important consideration. Counselors need to determine if their entire caseload will be DBT focused or if they will work with other type of cases. With standard DBT, a full-time caseload may vary but will generally include 14-18 clients. This allows time for individual sessions, skills groups, phone consultation (15-30 minutes per client per week) and paperwork.

Length and adaptation of treatment: Standard DBT requires both time and commitment from the client and counselor. Because most clients with borderline personality disorder have historically received long-term mental health services, successful treatment can be expected to be intensive. Pretreatment commitment to therapy is crucial and is often a collaborative agreement between the counselor and client. Typically, this initial commitment is six months to one year (optimally, clients will complete two six-month cycles of skills training). This timeline can be extended, but the parameters of this extension — for example, duration and expectations — should be clear to help prevent a dependency on treatment or malingering. Uniform protocol for what constitutes successful graduation and how to celebrate that occasion is also helpful.

Benefits and limitations of DBT implementation

The following section outlines the benefits and limitations to consider when deciding whether to implement standard DBT or DBT-informed treatment at your agency or practice.

Benefits of standard DBT

Standard DBT is a highly structured and evidence-based intervention. This can actually make implementation easier because counselors, administrators, other service providers and clients will have clear expectations of what will be included and the protocol that will be followed.
The evidence-based nature of the approach can make DBT appealing to funders when trying to secure grant money for programs. Note that this is more likely when funders are aware of what DBT entails and the associated benefits (for example, reduced overall costs of treatment, reduced hospitalizations and a decrease in suicide attempts and nonsuicidal self-injury).
Each mode of DBT addresses the major functions of DBT treatment: improving motivation, enhancing capabilities, ensuring generalization, enhancing environment and maintaining the skills and motivation of treatment providers.
The overwhelming amount of research on the effectiveness of DBT is based on standard DBT.

Limitations of standard DBT

The cost of the extensive training and the necessity of a team for implementation can be prohibitive for some agencies and practitioners.
Practitioners must be fully committed to the DBT approach for implementation to be effective. Adherence to the model includes accepting the basic principles that guide treatment, which include 1) creating a life worth living for clients, 2) believing that clients can improve by learning how to get needs met through more functional and adaptive means and 3) realizing that DBT has an inherent amount of risk because of the generally volatile emotional states and suicidal thoughts and behaviors being experienced by the client at the onset of treatment.
Implementing all modes of DBT can be costly, and counselors may find billing for standard DBT to be difficult with insurance companies. It can also require a significant time commitment from counselors, including making themselves available after hours for the necessary phone consultations with clients.

Benefits of DBT-informed treatment

The skills taught in the four DBT modules can be of benefit to clients with a wide range of presenting problems, including anxiety, adjustment disorders, stress and decision-making issues. For example, interpersonal effectiveness skills can be used with social skills groups because this module addresses ways to maintain relationships, make requests and say no, and maintain self-respect in relationships.
Research supports the effectiveness of partial implementation of DBT, with most of the research showing support for implementation of the skills-group-only approach or the skills group combined with one or two other modes of treatment.
Implementing certain aspects or adaptations of DBT may be more cost effective for clients and counselors.
An adaptation of DBT with partial implementation of certain modes can create flexibility for clients, counselors and administrators.

Limitations of DBT-informed treatment

Although research supports the effectiveness of partial implementation of DBT, this research remains limited. In addition, more research is needed on the specific aspects of DBT that are most curative with regard to treatment targets.
Those who are adapting DBT will have increased difficulty structuring treatment and ensuring that all functions of the treatment are addressed without the implementation of all four standard modes.
Fewer resources are available for those who wish to adapt the skills and handouts for specific diagnoses, and counselors may need to create their own resources to fit the needs of their clients.

Conclusion

In summary, full implementation and training are necessary to practice standard DBT to fidelity. However, parts of the model can be used effectively with many clients in a variety of settings and to address many presenting issues and diagnoses. If implementing DBT-informed treatment, counselors and administrators need to communicate this clearly to clients, including providing information on the strengths and limitations of the treatment approach.

Finally, throughout the material published by Linehan and her colleagues, they emphasize the importance of assessment. Regardless of whether the counselor implements standard DBT or DBT-informed treatment, some form of assessment should be used to ensure proper evaluation of the program.

For further reading on implementing DBT, the following texts may be helpful:

Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings edited by Linda A. Dimeff and Kelly Koerner (2007). Specifically, Chapter 2 addresses the importance of maintaining the fidelity of the treatment while adapting DBT.
Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan (1993)
DBT Skills Training Manual and DBT Skills Training Handouts and Worksheets by Marsha M. Linehan (2014). This long-awaited second edition to the original training manual includes handouts for each module and guidelines for implementing standard DBT.
Dialectical Behavior Therapy With Suicidal Adolescents by Alec L. Miller, Jill H. Rathus and Marsha M. Linehan (2007)
DBT Skills Manual for Adolescents by Jill H. Rathus and Alec L. Miller (2014)

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

K. Michelle Hunnicutt Hollenbaugh, a licensed professional counselor supervisor, is an assistant professor in the Department of Counseling and Educational Psychology at Texas A&M University-Corpus Christi. Contact her at Michelle.Hollenbaugh@tamucc.edu.

Jacob M. Klein, a licensed professional clinical counselor in Ohio, is currently working in private practice with a focus on gender therapy and is a Ph.D. candidate at Ohio State University. Contact him at jklein.216@gmail.com.

Michael Lewis is a licensed professional clinical counselor and supervisor in Ohio. He is the director of counseling services at Ohio Dominican University in Columbus and is a Ph.D. candidate at Ohio State University with a focus in online gaming addiction. Contact him at lewism2@ohiodominican.edu.

Letters to the editor: ct@counseling.org