Please include the following information in your program’s policies and procedures manual:
DBT Program Elements
1. Describe the basis for your DBT program
2. DBT Program’s mission statement
3. Describe your agency and the community of clients served
a. Specify children, adolescents, adults
b. Specify any special populations served
4. Describe how clients are referred to your program
5. Describe how the following elements are executed in your program:
Individual Therapy
Skills Training Group
Skills Coaching
Consultation Team
Auxiliary Modes of Treatment
6. Provide information on:
Admission criteria to your DBT Program
Structure of Treatment (Including expectations about participation, duration of treatment)
Inclusion and Exclusion Criteria
Policy for 4-misses
Policy for 24-hour rule
Policy for treatment continuation
Policy for how progress is measured and evaluated
Discharge criteria
Policy for including caregivers (if applicable) (Detail how they are included in treatment, what commitments are required of them during the process of treatment, frequency of contact with the therapist, etc.)
Policy for vulnerable or dependent clients
Policy for assigning therapists to clients
Policy for assigning clients to skills groups
Policy for auxiliary providers (including psychiatrists, dieticians, case managers, etc.)
7. Protocol for Delivering Stages of Treatment
Please detail what each of the following stages of treatment entail in your program, how a client’s treatment stage is determined, and how you determine the need for treatment continuation, and how a client moves between the following stages:
Pretreatment
Stage I
Stage II
Stage III
8. Discharge criteria
9. Policy for discharge from treatment
10. Policy for re-entering treatment after being discharged for any reason
Adolescent versus Adult Programs If your program sees both adolescent and adult clients, please specify programmatic differences between the two programs. Please specify any differences in policies and procedures.
Staff Policies Please describe:
Hiring practices for DBT therapists, students, and interns
Policy for primary source verification
Attendance requirement and responsibilities for DBT therapists, students, and interns
How Team members are oriented to DBT Team
How DBT Team commitment is obtained
When a staff member is eligible to join the DBT Team
Staff onboarding and training plan for new DBT Team members
Ongoing staff training plan
In-service or continuing education requirements for staff
Procedures for clinical supervision
Documentation of clinical supervision
Outside Referral Sources
Description (and example) of any outside provider contracts (These may include working with outside primary therapists, medication management, etc.)
Policies for outside providers to attend Consultation Team (if applicable)
Crisis Planning, Policies and Procedures Please detail your:
Crisis Intervention Plan (for clients)
Egregious Behavior Protocol (for your program)
Crisis Response Protocol (for your program)
Policy for client emergency and/or between-session contact with therapists
Risk assessment protocols used (LRAMP, etc.)
Between-Session contact between client and DBT therapist(s)
Phone coaching
Please detail your policy on phone coaching and if this includes phone calls, text messages, emails, etc.
Therapist availability outside of sessions
How clients are oriented to skills coaching
Program expectations around clinician limits and response time to client phone coaching contact
How client contact is documented and followed-up on
How can clients reach their therapist between sessions and after hours
If pager is shared, how do other therapists access client treatment plans or emergency contact information
How is coverage for out of town therapists selected and communicated to clients?
Please detail other strategies for skills generalization within your program
Please detail additional limits related to skills coaching
Please identify how clients obtain crisis management/ support from DBT program
Please identify how clients are instructed to engage in relationship repair outside of sessions
DBT Adaptations (if applicable)
If DBT has been adapted in any way (i.e., does not meet standards in any of the above criteria), please describe:
The barriers to standard implementation
Efforts to apply standard implementation and outcomes
How you would describe the adaptation made
Any client data collected and assessed to determine the impact of the adaptations
How you are preserving the principles of DBT
Any relevant research that informed your adaptations
Non-DBT Program Elements (if applicable)
If there are any non-DBT Program Elements, please describe how these are delivered as to not conflict with the principles of DBT or confuse DBT practices or content
Quality Monitoring and Improvement
What outcome data is collected by your program
How is data analyzed and or reported
How is data analysis reviewed and put to use (Individually and Programmatically)
Rationale for how data is collected and reported (By the therapist and Program)
Please detail any quality monitoring procedures your program has in place to assess for adherence
Please specify how your program monitors drift from DBT Program Adherence
Please detail any improvement procedures your program has in place
Please detail your Program Continuity Plan in case the identified Team Lead leaves the clinic, is out for an extended period of time, etc.
Multiple Locations (as applicable) If your program has multiple locations, please specify how the sites differ from each other, how therapists are assigned to each location, are there therapists that are endemic to one location, how adherence is monitored, etc. If there are multiple locations or teams, you will need a certified clinician on all teams.
Appendix: Program Forms Please submit the following documentation with your Program Manual as an Appendix. Please be sure all forms submitted either have client information de-identified or they are a blank templated sample. If you submit blank forms that are not DBT specific, please provide instruction as to where you identify DBT-specific information (i.e., targets, information from chains, information from solution analysis, case conceptualization, etc.). Please submit these sample forms for each program so your program reviewers can get a true sense of how your documentation appears in a client chart.
Consent forms for treatment
Therapy contract
Intake assessment form
Informed consent
Emergency contact form
Treatment plan forms
Phone coaching forms
Blank diary cards
Behavior Chain Analysis Form
Suicide Risk Assessment and Intervention Protocol
Crisis intervention plan
Individual progress note
Skills group progress note
Past year’s schedule of modules with time frames for each
Consultation Team note for client’s chart (please include specific issues addressed for a client and recommendations by the Team)
Consultation Team agenda form (blank)
Client handouts provided other than from the Linehan Training Manual
Clinic brochures provided to others
Links to website detailing the DBT Program
Data collection forms
Sample data analysis within the past year
Consultation Team Meeting notes for past 2 months. Must include:
Review of Team Members over time
Meeting elements recorded
TIB of therapists noted and followed-up
Solutions adequate to therapist’s request
Risk of 4 misses discussed and client progress and recommitment addressed