While it is believed by many that an inpatient stay for an individual with a diagnosis of borderline personality disorder can be counterintuitive, a number of clinical research findings advocate for DBT within an inpatient unit.

Relevant articles

Use of Dialectical Behavior Therapy in Inpatient Treatment of Borderline Personality Disorder: A Systematic Review
Jill Myerow Bloom , M.A., Eva N. Woodward , M.A., Teresa Susmaras , M.A., and David W. Pantalone , Ph.D. Published Online: 1 Sep 2012
Link: https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201100311

Potential Benefits of Dialectical Behavioral Therapy for Adolescents Receiving Treatment for Borderline Personality Disorder Traits: Implications for Psychiatric Nurses
Sara Hagen, Cheryl L. Woods-Giscombe, , Jeehae Chung, Linda S. Beeber Published 2014
Link: https://pdfs.semanticscholar.org/1992/96504f6e42d7ec9b28fd62c5dcc8cf6ea452.pdf

PROPOSED NURSING PRACTICE FOR DBT IMPLEMENTATION ON PSYCHIATRY INPATIENT UNITS: A REVIEW AND SYNTHESIS OF THE LITERATURE
by Morgan Alexa Fankboner B.S.N., University of British Columbia, 1995
Link: https://pdfs.semanticscholar.org/41d5/df666350f017f6c502f0fb0a4651d51f9cda.pdf

DBT IPU Program
DBT Primer is a program which can be run either in the inpatient setting or outpatient setting. The focus of DBT Primer is to provide an overview of DBT, increase a client’s motivation to enter a DBT program and develop a level of commitment to stay in treatment for the full duration of a DBT program. DBT Primer is ideal for an organisation with both an inpatient and outpatient program.

Three components of DBT Primer

  • Group (1hr and 45 min group x 3-4 times a week)
  • Individual Coaching (30 minute individual sessions twice a week)
  • Clinical Team Meetings – for Clinicians (45 minutes once a week)

Skills in DBT Primer

Sample Agenda for DBT Primer Group

1.00pm: Start Group 

1.00 – 1.05: Mindfulness Practice

  • Five minutes practice of a mindfulness exercise.
  • Group leaders take turns leading the exercise.
  • People running late to group are asked not to enter the room until after mindfulness is complete.
  • If participants arrive late they will spend the time until 1.05pm doing a mindfulness activity on their own. Stick a piece of paper on the group room door with a description of a mindfulness activity on it so that when late comers arrive they can practice at the door.

1.05 – 1.15 Group Orientation

  • Read two of the group guidelines
  • Housekeeping and general information
  • If anyone is late to group, missed group the previous week or an upcoming absence think about repair (this includes therapists).
  • Sharing: go around the group and ask each participant to share something positive that happened since last session. Could be sporting team had a win, used a skill with a good outcome, birthday, finishing a course or a new purchase. Process is meant to be short and sweet!

1.15 – 1.35 Homework review – One of four DBT Skills (Self Soothing, Mindfulness, Pleasurable Events or Challenging Myths)

  • Review the homework task and then go around to each participant and have them discuss their homework
  • This is an opportunity to think about the skills in terms of what worked and what did not as well as to learn how others to it.
  • Extend the experience for each participant and cheerlead! “Wow… hadn’t thought of doing it that way. I am going to try that tonight” “You really seemed to put all your energy into that activity…
  • Participants may also ask other group participants to give them suggestions of strategies they have found helpful in practicing skills.
  • For participants that have not done homework since the last session, the aim is to discuss obstacles to completing homework and strategies that may help them to try skills in the future.

1.35 – 1.40 BREAK (Orientate the group that this is a brief break to attend bathroom, get some water, stretch your legs. Avoid any big discussions or commencing a task that will make you late in retuning to the group)

1.40 – 2.20 Furthering DBT knowledge

  • Group covers the Middle Path (Dialectics, Validation & behaviourism)
  • Group leaders introduce new knowledge from the identified Middle Path component.  This is followed by group discussion.
  • Teach the background of the new skill like you are lecturing
  • Look at the DBT manual/Adolescent DBT manual for discussion and lecture points identifying points for discussion in group
  • Have plenty of examples of when and how the skill can be used in every day life situations
  • Involve the group in applying the new knowledge in group

2.20 – 2.40 Homework/practice commitments

  • Group leaders set homework from the One of four DBT Skills (Self Soothing, Mindfulness, Pleasurable Events or Challenging Myths) skills taught during DBT Skills Training using the Homework Sheets or making adaptions and coming up with your own homework to best integrate skills learnt today into everyday life.
  • Explain the homework task and give examples
  • Set expectations
  • Support completion of task by giving examples how and where the task can be completed (in what situation)

2.40 – 2.45 Check out and Mindfulness

  • Briefly go around the group and request participants express how you found group. E.g. what was un/helpful, what was surprising, what did you dis/agree with etc
  • Conclude with a brief (1-2 min) mindfulness activity

2.45 pm Finish

DBT Primer Group WEEK 1: VALIDATION

Week 1 – FOCUS ON VALIDATION

Session 1 (Monday)

  • Introduction
    • Overview of Program
    • What is DBT Primer? What is DBT?
    • Expectations
  • Furthering DBT knowledge – Mindfulness Introduction
    • Introduce Mindfulness briefly and partake in a mindfulness activity
    • How much is mindfulness used in DBT?
    • Why is it useful?
    • How has it been useful for you as a clinician?
  • Homework/Practice Commitment: Mindfulness
    • Mindful cup of tea
    • Discuss alternatives if tea is really not liked (Hot chocolate, warm water, herbal tea)

Coaching Session: 30 minutes (Tuesday)

Session 2: (Wednesday)

  • Homework Review – Mindfulness
    • Describe thoughts
    • How did it taste?
    • Temperature?
  • Furthering DBT knowledge – Validation
    • Introduce validation (Handout One)
  • Homework/Practice Commitment – Validation Homework Sheet
    • Set homework
    • Role play homework to give clients a quick practice run

Session 3 (Thursday)

  • Homework Review – Validation
    • Describe thoughts
    • How did it feel to validate?
    • How can this new Knowledge be useful?
  • Furthering DBT knowledge – Validation continues
    • Explore validation (Handout two)
  • Homework/Practice Commitment – Challenging Myths
    • Identify Challenging Myths homework task
    • Role play homework to give clients a quick practice run

Coaching Session: 30 minutes (Friday)

Session 4 (Friday or Saturday)

  • Homework Review – Challenging Myths
    • Describe thoughts on challenging myths
    • How can this new knowledge be useful?
  • Furthering DBT knowledge – Validation continues
    • Watch validation video
    • Identify characters on TV who validate and those who are invalidating
    • Briefly review the week and focus on Validation
  • Homework/Practice Commitment – Self-Soothing
    • Identify Self-soothing homework task
    • Role play homework to give clients a quick practice run

DBT Primer Group WEEK 2: DIALECTICS

Week 1 – FOCUS ON DIALECTICS

Session 1 (Monday)

  • Introduction
    • Overview of Program – Introduction of new participants
    • What is DBT Primer? What is DBT?
    • Expectations
  • Furthering DBT knowledge – Mindfulness Introduction
    • Introduce Mindfulness briefly and partake in a mindfulness activity
    • How much is mindfulness used in DBT?
    • Why is it useful?
    • How has it been useful for you as a clinician?
  • Homework/Practice Commitment: Mindfulness
    • Mindful eating a grape
    • Discuss alternatives if grapes are really not liked (chocolate, raisin… something small. Practice different items in consult  meeting)

Coaching Session: 30 minutes (Tuesday)

Session 2: (Wednesday)

  • Homework Review – Mindfulness
    • Describe thoughts
    • How did it taste?
    • Did you feel full?
  • Furthering DBT knowledge – Dialectics
    • Introduce dialectics (Handout One)
  • Homework/Practice Commitment – Dialectics Homework Sheet
    • Set homework
    • Role play homework to give clients a quick practice run

Session 3 (Thursday)

  • Homework Review – Dialectics
    • Describe thoughts
    • How does it make someone feel to not have black and white thinking?
    • How can this new Knowledge be useful?
  • Furthering DBT knowledge – Dialectics continues
    • Explore dialectical dilemmas
  • Homework/Practice Commitment – Challenging Myths
    • Identify Challenging Myths homework task
    • Role play homework to give clients a quick practice run

Coaching Session: 30 minutes (Friday)

Session 4 (Friday or Saturday)

  • Homework Review – Challenging Myths
    • Describe thoughts on challenging myths
    • How can this new knowledge be useful?
  • Furthering DBT knowledge – Dialectics continues
    • Identify characters on TV who act/think/display a dialectic stance. Identify TV characters that display black and white thinking
    • Briefly review the week and focus on Dialectics
  • Homework/Practice Commitment – Pleasurable Events
    • Identify Pleasurable events homework task
    • Role play homework to give clients a quick practice run

DBT Primer Group WEEK 3: BEHAVIOURISM

Week 1 – FOCUS ON BEHAVIOURISM

Session 1 (Monday)

  • Introduction
    • Overview of Program (Introduce new participants)
    • What is DBT Primer? What is DBT?
    • Expectations
  • Furthering DBT knowledge – Mindfulness Introduction
    • Introduce Mindfulness briefly and partake in a mindfulness activity
    • How much is mindfulness used in DBT?
    • Why is it useful?
    • How has it been useful for you as a clinician?
  • Homework/Practice Commitment: Mindfulness
    • Mindful cup of tea/Mindful eating a grape
    • Discuss alternatives if tea/grape is really not liked

Coaching Session: 30 minutes (Tuesday)

Session 2: (Wednesday)

  • Homework Review – Mindfulness
    • Describe thoughts
    • How did it taste?
    • Temperature?
  • Furthering DBT knowledge – Behaviourism
    • Introduce Behaviourism
    • Explore reinforces & punishment
  • Homework/Practice Commitment – Behaviourism practice exercises (reinforces & punishment)
    • Set homework
    • Role play homework to give clients a quick practice run

Session 3 (Thursday)

  • Homework Review – Behaviourism
    • What was the Behaviour?
    • How did you do?
    • What was the outcome?
  • Furthering DBT knowledge – Behaviourism continues
    • Explore extension and shaping
  • Homework/Practice Commitment – Challenging Myths
    • Identify Challenging Myths homework task
    • Role play homework to give clients a quick practice run

Coaching Session: 30 minutes (Friday)

Session 4 (Friday or Saturday)

  • Homework Review – Challenging Myths
    • Describe thoughts on challenging myths
    • How can this new knowledge be useful?
  • Furthering DBT knowledge – Behaviourism continues
    • Watch a short TV show (friends, big bang theory) and identify behaviours. (Look for a scene that you can identify shaping, extinction, reinforces and punishment)
    • Briefly review the week and the focus on behaviourism
  • Homework/Practice Commitment – Self-Soothing
    • Identify Self-soothing homework task
    • Role play homework to give clients a quick practice run

Coaching Sessions - 30 mins (1-2 sessions a week)

Individual coaching sessions are provided to each client and serve to:

  • support group function by clarifying skills and new knowledge when needed
  • provide support with homework tasks
  • role play skills
  • sell commitment and orientate to full DBT programs
  • gather further information
PRIORITY 1: Sell Commitment
  • Support the development of new knowledge from group. Clarify and practice new knowledge and skills in coaching session
  • Evaluating Pros and Cons of DBT for client
  • Play the Devil’s Advocate
  • Connect present commitments with prior commitment
  • Freedom to choose and absence of alternatives
  • Become the cheerleader of your client
  • Use benefit statements
PRIORITY 2: Orientate to program
  • Become a role model for your client. When you use a DBT strategy point it out “See how we did that… this is a DBT strategy we will be using to ensure that you are supported to stay in treatment”
  • Explain what DBT is: “supportive”; “behavioural”; “cognitive”; “skills orientated”; “balances acceptance and change”; “requires a collaborative relationship” between clinician and client.
  • Use an adapted diary card. Keep it simple with minimal content. Remember this is a program to orientate and get clients connected to DBT
  • Explore Biosocial theory, look at options for treatment (DBT or DBT+)
PRIORITY 3: Assessment Tasks
  • Start to identify treatment goals
  • Complete the McLean Screening (MSI- BPD)
  • Make an appointment to complete the full assessment if not already completed
  • Gather other information from GP. Psychiatrist and other sources.