Abstract
Dialectical behavior therapy (DBT) has been shown effective for the treatment of borderline personality disorder (BPD) and other high-risk, suicidal, and diagnostically complex populations. However, little has been written about how to train therapists in DBT’s highly structured framework of target hierarchies, behavioral chain analyses, and stylistic strategies. This case study illustrates the utility of a live supervision method known as “bug-in-the-eye” (BITE) in training a novice DBT therapist. “Willow,” a 35-year-old Hispanic female with BPD, engaged in 6 months of comprehensive DBT that included 25 individual therapy sessions. BITE supervision was implemented in Sessions 12 through 17. Therapist adherence to DBT was assessed from Sessions 8 to 21. Client and therapist satisfaction with BITE was assessed after Session 21. Results indicate that therapist adherence to DBT increased following the implementation of BITE supervision. In addition, both therapist and client found BITE supervision to be acceptable and minimally intrusive, with the therapist reporting increased confidence in delivering DBT. Furthermore, results indicate that DBT was effective in reducing Willow’s suicidal ideation and self-harm urges, decreasing her feelings and displays of intense fear and jealousy, and increasing her independence. Recommendations for implementing live supervision into DBT training settings are provided.
1 Theoretical and Research Basis for Treatment
Dialectical Behavior Therapy (DBT)
DBT has gained significant empirical support in randomized controlled trials in the treatment of severe and complex patient populations. DBT was originally developed by Marsha Linehan to treat women with suicidal behaviors and borderline personality disorder (BPD). Since then, DBT has been found to be effective in reducing suicidal and self-harming behaviors, decreasing psychiatric hospitalizations, decreasing treatment dropout rates, decreasing depressive symptoms, and treating other populations such as suicidal adolescents, substance abusers, eating disordered patients, and patients in inpatient settings (Katz & Cox, 2002; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, et al., 2006; Linehan, Heard, & Armstrong, 1993; Lynch, Trost, Salsman, & Linehan, 2007).
While there is an abundance of empirical evidence supporting the efficacy of DBT, there is little written about how to train therapists in DBT. Therapists in many of Linehan’s early DBT research trials were graduate students learning to implement DBT under her supervision. However, the methods used to train graduate student therapists to adherence were not explicitly outlined in publications. This gap in the literature is concerning, as there are some unique challenges to training graduate students in DBT, compared with other models of treatment. First, DBT therapists treat an underserved population of individuals who are high-risk, suicidal, and diagnostically complex (Lungu, Rodriguez-Gonzales, & Linehan, 2012). The DBT model addresses the challenges of working with severe patients by providing a structured framework that includes a target hierarchy, multiple stages of treatment, and a myriad of therapist stylistic strategies. Second, DBT is a principle-based treatment rather than a protocol-based treatment, meaning therapists must flexibly utilize any number of strategies based on the context of a session. Adherence, therefore, requires therapists to have a thorough understanding of the theoretical underpinnings of the treatment and also have a firm grasp on all treatment strategies to make decisions that would be considered DBT adherent. One question that has not yet been addressed is how student therapists can best be trained to adherence in delivering DBT to a clinically challenging population.
The traditional model for teaching graduate students to deliver DBT is through supervision with an expert DBT clinician (Lungu et al., 2012). A goal of supervision is to provide quality assurance that treatment is being delivered as intended, thereby enhancing therapist adherence to the specific treatment model. DBT therapists deliver a complex treatment to a multi-problem population, which brings unique challenges to supervision. Clients in DBT often have numerous problems that occur over the week, and what is discussed in supervision is often not relevant in the next therapy session. For example, discussing a client’s self-harm from the prior week in supervision does not directly address the subsequent problem behavior of substance use brought up in the next session. In addition, DBT therapists must be flexible with a large number of strategies going into each session and must be able to determine which strategies will be most effective in any given moment. This flexibility can be difficult for therapists in training who are just acquiring knowledge of the many DBT strategies, and a supervisor might struggle with how to teach strategies outside of the context in which they occur (i.e., a therapy session).
“Bug-in-the-Eye” (BITE) Supervision
Live supervision methods have been developed to address concerns with traditional supervision. Some examples of live supervision methods include supervisors using a one-way mirror to directly observe sessions, supervisors knocking on the door or calling into the session to provide feedback during a session they are observing, and utilizing “bug-in-the-ear”—a technique that allows supervisors to provide feedback to the therapist through a listening device placed in the therapist’s ear. BITE supervision is another form of live supervision that provides the therapist with visual feedback (as opposed to audio feedback) during the therapy session.
Recent advances in technology have made BITE relatively easy to implement. A typical BITE set-up includes a supervisor observing a therapy session live through the use of secure, Health Insurance Portability and Accountability Act (HIPAA)–compliant video-conferencing technology. A computer and webcam are set up in the therapy room, and the supervisor can see and hear the session on her own computer. The supervisor then types suggestions or feedback to the therapist into a word-processing document on her computer. This document is displayed via a screensharing program on a computer screen in the therapy room that is seen only by the therapist. The therapist can then incorporate the supervisor’s comments into the session as she chooses.
BITE has been found to be less invasive as compared with other live supervision strategies mainly because the therapist has the option of not attending to the visual feedback provided by the supervisor (Jakob, Weck, & Bohus, 2013; Klitzke & Lombardo, 1991). BITE supervision also addresses the disadvantages of traditional supervision, including inaccurate verbal report and delayed supervisor feedback. BITE supervision can address client problems as they are brought up in session and can help accelerate knowledge acquisition of treatment strategies for student therapists. This could lead to more effective training for therapists and more effective treatment for clients. A recent study compared BITE with standard supervision (i.e., watching video of the session after the fact) with trainees learning to implement cognitive behavior therapy (CBT) and found that BITE was associated with higher ratings of therapist competence (Weck et al., 2015). Another recent study examined the effects of BITE in training psychiatry residents in DBT (Carmel, Villatte, Rosenthal, Chalker, & Comtois, 2015). BITE group supervision was implemented with eight psychiatry residents learning DBT in a yearlong elective. Residents were randomly assigned to either BITE group supervision or supervision as usual (SAU) for DBT. Results from the study found that trainees in the BITE group supervision performed significantly better on a post-supervision DBT case conceptualization task as compared with SAU residents. These results indicate that BITE supervision increased resident competency in conceptualizing cases from a DBT perspective more so than SAU. No study to-date, however, has used DBT adherence scores to explore what effects BITE might have on therapist adherence to DBT or whether BITE can successfully improve therapist adherence to DBT. Therefore, in this case study, we describe the use of BITE supervision within a DBT training clinic. Changes in student therapist adherence to DBT are explored, and the feasibility and acceptability of BITE supervision within a DBT training clinic are discussed.
2 Case Introduction
DBT Training Clinic
The DBT Clinic (subsequently referred to as “the Clinic”) provides comprehensive DBT—comprised of individual therapy, group skills training, as-needed phone coaching, and therapist consultation team—to individuals in the community and is delivered by clinical psychology doctoral students. In addition to all components of comprehensive DBT, therapists at the Clinic participate in weekly individual supervision by a licensed clinical psychologist and DBT expert (first author), as well as a weekly seminar covering topics such as case conceptualization and practicing DBT strategies. The case presented here participated in a larger study of 16 individuals in which a mobile phone app was provided as an adjunct to comprehensive DBT to individuals meeting criteria for BPD with a recent history of suicidal and non-suicidal self-injurious behaviors (Rizvi, Hughes, & Thomas, 2015).
The case study met all eligibility criteria briefly summarized as follows: Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) criteria for BPD, a history of at least one suicide attempt or episode of self-injury in the past 6 months and a second attempt or self-injury within the past 5 years, and age between 18 and 60 years old. Exclusion criteria included the presence of life-threatening disorders (i.e., severe anorexia nervosa or acute psychotic symptoms) or other problems by which the presence or severity would preclude the person’s ability to attend or understand consent to the study or require priority treatment over the treatment being offered. Psychological diagnoses defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000) were evaluated using the Structured Clinical Interview for DSM-IV Axis I (SCID-I; First, Gibbon, Spitzer, & Williams, 2002) and Axis II (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) Disorders. Upon completion of the initial assessment, eligible participants were assigned to their individual therapists and enrolled in weekly group skills training. Treatment occurred over the course of 6 months, and participants were required to complete mid-treatment, post-treatment, and follow-up assessments at 3 months, 6 months, and 9 months, respectively.
BITE supervision was implemented at the Clinic to examine the possible effects of live supervision on student therapist adherence to DBT. Three client–therapist pairs participated in BITE supervision at the clinic, and one client–therapist pair’s experience with BITE supervision is presented in this case study. Prior to initiating BITE supervision, participants consented to the procedure. They were provided with a written description of the study explaining the purpose and set-up of BITE supervision. Participants were made aware that a supervisor would be watching the session and would be providing feedback to the therapist through a computer that was set up behind the client. Participants were told that therapists could incorporate that feedback into the session, as they deemed necessary. In addition to a written description and the opportunity to ask questions, participants were oriented to the BITE set-up in a baseline session to familiarize them with the presence of the equipment. Participants were encouraged to participate in the sessions as if they were not being observed, although no instructions were given to ignore the camera or computer directly.
“Willow”
The current case study describes the use of BITE supervision in the case of “Willow.” Her case was selected for write-up because objective and subjective improvements in therapist adherence to DBT, as well as treatment outcomes, illustrate the utility of BITE as a supervision and training method for novice DBT therapists.
“Willow” was a 35-year-old Hispanic female who presented for evaluation and treatment at the Clinic for problems related to lifelong anxiety, depression, negative self-evaluation, relationship difficulties, and suicidal behaviors. After an intake evaluation in which she completed semi-structured interviews and self-report measures, Willow was assigned to treatment with the second author, a therapist-in-training under the supervision of the first author.
Therapist
At the time of intake, the therapist was a third-year clinical psychology doctoral student whose existing clinical experiences included the cognitive behavioral assessment and treatment of individuals in two specialty eating disorder clinics and a primary care practice. She had completed a semester-long course in the fundamentals of DBT and attended, as a volunteer, a 2-week intensive training in DBT. The therapist had been a member of the DBT consultation team for 6 months and completed treatment with one DBT case prior to initiating treatment with Willow.
3 Presenting Complaints
Willow presented to treatment with complaints of generalized anxiety, panic episodes, agoraphobia, emotional hypersensitivity, paranoia, distorted body image, and suicidal ideation. In addition, although she described her relationships with family members as generally good, she reported intense jealousy and fear of abandonment in her marriage and difficulty developing and maintaining friendships. Therefore, Willow’s primary goals for the course of treatment were to decrease her suicidal ideation and self-harm urges; decrease the frequency and intensity of negative emotions, such as anger, fear, frustration, and jealousy; and increase her independence, particularly by engaging in activities without her husband.
4 History
At the time of intake, Willow resided with her husband and parents. She had completed high school and one semester of college before withdrawing due to severe anxiety. She had been sporadically employed in the years since leaving college, but reported having difficulty maintaining employment due to her persistent anxiety and panic. She received mental health disability benefits and spent her time caring for her aging parents, completing household chores, and surfing the Internet.
Prior to initiating treatment at the Clinic, Willow had a history of mental health treatment beginning in childhood. She had intermittently engaged in individual therapy since the age of 10 and began taking antidepressant medication at the age of 15. According to Willow, the majority of her previous psychological treatment was ineffective and invalidating—and therefore, she was both hesitant and highly motivated to begin treatment again.
During the intake assessment, Willow reported approximately 100 lifetime suicide attempts, beginning at the age of 13, in response to perceived abandonment and intense feelings of shame and despair. Notably, she did little physical damage in her attempts, citing that she rarely drew much blood when she engaged in non-suicidal self-injury or suicidal behaviors. She reported wanting to die with varying levels of intensity for most of her adult life; however, she also reported that she “did not have the guts to finish the job” and subsequently felt like a “failure” and “wimp” for not being able to complete suicide. Willow’s most recent suicide attempt occurred 3 months prior to the initiation of treatment as a result of her being overwhelmed by the idea that her husband would fall in love with another woman and leave her. At home in her bedroom, she tied one end of a belt to an overhead lamp, the other around her neck, and climbed onto a stool. When she stepped off the stool and began to feel the pressure of the belt around her neck, however, she became scared and climbed back onto the stool, aborting the attempt. She reported no injuries other than redness around her neck.
Willow also reported previously engaging in weekly self-harm behaviors in response to feelings of anxiety, frustration, jealousy, and sadness. She described episodes in which she scratched her skin to the point of drawing blood and subsequently felt a sense of relief. She reported, though, that she had stopped self-harming approximately 3 months prior to treatment. Willow also reported daily suicidal ideation in which she imagined killing herself by various methods. At the time of intake, she denied any current intent to harm herself or attempt suicide, though she did admit to current, mild suicidal ideation, that is, rated a “1” or “2” on a scale of 1 to 5.
5 Assessment
During Willow’s initial assessment, she met criteria for BPD as evidenced by frantic efforts to avoid abandonment, especially related to fears that her husband would cheat on her and leave her; recurrent suicidal behavior such as cutting with the intent to die, overdosing on medication, and attempting suicide using auto exhaust and suffocation; mood lability marked by feeling great one moment and “feeling really defeated” the next; inappropriate and intense anger that lasted for several days; and transient stress-related paranoia in which she became suspicious that her husband was having an affair. Willow met criteria for a number of DSM-IV (APA, 2000) Axis I disorders including generalized anxiety disorder, panic disorder with agoraphobia, past major depressive disorder, and body dysmorphic disorder. Willow also met criteria for dependent personality disorder and obsessive-compulsive personality disorder. At intake, Willow scored a 34 on the Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996), indicating severe depression. Information gathered from other self-report measures indicated that Willow had pervasive thoughts that she was a failure, that she was to blame for bad things, and that she was an inadequate person. She reported high anger, hopelessness, and guilt and was notably ashamed of having intense emotions. For example, she endorsed the item, “When I get upset, I feel guilty for feeling that way,” on the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004). Her total score on the DERS was 113, indicating extreme problems with emotion regulation.
Therapist adherence to DBT was assessed by a trained, independent rater using the DBT Global Rating Scale (Linehan & Korslund, 2003). The measure rates adherence to each category of DBT strategies (e.g., dialectical strategies, contingency management strategies) and also includes an overall score of adherence. The rating scale comprises 66 items, each operationalized with behaviorally defined anchor points. Item anchor points range between 0 and 5. Conditions for scoring (in the form of “if/then” rules) take into account the necessity and sufficiency of each strategy given the context of the session and the prescriptions and proscriptions of the DBT treatment manual. Because the measure takes into account both necessity and sufficiency of the use of strategies, the Global Rating Scale can be considered a measure of certain aspects of therapist competence, as well. For the purpose of this article, however, we used the measure as an assessment of adherence only. Global Scores greater or equal to 4.0 reflect DBT adherence (Linehan & Korslund, 2003).
Therapist and client satisfaction of the use of BITE supervision was assessed using the BITE Satisfaction Scale, adapted from the Purdue Live Observation Scale (Sprenkle, Constantine, & Piercy, 1982). This scale was modeled after a previous adaptation used in a study by Jakob et al. (2013). The BITE Satisfaction Scale rates the perceived acceptability and feasibility of BITE supervision on a 4-point Likert-type scale ranging from 1 = strongly disagree to 4 = strongly agree. Areas of satisfaction include perceived usefulness, degree of disruption, comfort level, usage intention, applicability, mental effort, and therapeutic relationship. The therapist version contains eight items including statements such as “The use of BITE increases the effectiveness of my work” and “It was difficult to divide attention between monitor and client.” The client version contains five items including statements such as “Therapy sessions were more effective because of the supervisor’s observation” and “The presence of a computer was disruptive.”
6 Case Conceptualization
According to Linehan’s (1993) biosocial theory for the development of BPD, emotion dysregulation occurs as a result of a transaction between an individual’s biological predisposition to emotional vulnerability and an invalidating environment. Consistent with this theory, Willow’s difficulty regulating her anger, fear, frustration, and jealousy and her desire to escape these emotions were understood in the context of having a family history of anxiety, suicidal ideation, and suicide attempts, as well as being taught as a child to suppress negative emotions such as anger, fear, and sadness. In her initial therapy sessions, Willow disclosed that her mother had suffered from severe anxiety and depression most of her life, often spoke about her desire to die, and had previously attempted suicide. She also reported that throughout her childhood, her father had chastised her whenever she appeared angry, unhappy, or upset and urged her to “always put a smile on [her] face.” As a result, Willow reported that she came to view negative emotions, experiences, and stress as bad or extremely uncomfortable, such that she would rather kill herself than live with them. Thus, with the biosocial theory in mind, Willow and her therapist conceptualized her suicidal behavior as resulting from a learned belief that she had to escape or suppress negative emotions and stressful experiences.
Consistent with the principles and structure of DBT, treatment focused on first decreasing Willow’s life-threatening behaviors, then subsequently decreasing any therapy-interfering behaviors, and quality of life-interfering behaviors. Simultaneously, behavioral skills were taught in the weekly skills group and incorporated into individual therapy as solutions to employ. Specifically, Willow and her therapist first worked on decreasing Willow’s suicidal ideation and self-harm urges; decreasing her feelings and displays of intense anger, fear, frustration, and jealousy; and increasing her independence, particularly by having her engage in activities without her husband. As Willow did not exhibit any behaviors that interfered with her engaging in treatment (e.g., canceling appointments, arriving late, etc.), treatment did not focus on specific therapy-interfering behaviors.
7 Course of Treatment and Assessment of Progress
Over 6 months of comprehensive DBT, Willow presented for a total of 25 individual sessions and 23 group skills training sessions. Therapist adherence to DBT was assessed from Sessions 8 to 21, and BITE was implemented in Sessions 12 through 17 (described more fully below; see also Figure 1). Adherence ratings and subsequent BITE sessions were implemented in the middle of treatment for two reasons. One reason is that the early sessions of DBT (usually Sessions 1-4) are considered “pre-treatment” until the client commits to fully participating in DBT treatment, are more structured, and therefore less likely to need in-the-moment supervision. Second, we wanted Willow and the therapist to “settle in” to treatment before adding a new intervention. In this section, we describe Willow’s course of treatment over the 6 months generally and then specifically describe the implementation of BITE and the feedback the therapist incorporated into her sessions with Willow.
Therapist adherence scores before, during, and after BITE supervision.
Course of Treatment
The first four sessions of treatment were devoted to introducing Willow to the theory and structure of DBT, assessing her presenting problems (particularly her self-harm and suicidal behavior), and eliciting her goals for treatment. In the first session, Willow reported moderate suicidal ideation and no self-harm behaviors; however, she did report urges to self-harm that occurred three to four times per week. Willow also reported that her goals for treatment were to decrease her feelings of intense anger, fear, frustration, and jealousy, and increase her engagement in activities independent from her husband. As Willow discussed these problems and goals, it was pointed out to her that to work toward her goals, she would have to commit to living and coming to treatment. Willow agreed, committing at the end of her first session to attending treatment for six months and ceasing all self-harm and suicidal behavior for the duration of treatment.
With these commitments, treatment began by targeting Willow’s life-threatening behaviors. Chain analyses (Linehan, 1993; Rizvi & Ritschel, 2014) were completed in several sessions to identify the prompting events, vulnerability factors, and consequences that maintained her suicidal ideation and self-harm urges—and how to intervene. These chain analyses revealed two themes. The first was that two types of cognitions appeared to be antecedents for Willow’s suicidal ideation and self-harm urges. One was the thought that she was the only person who could care for her aging parents, leading to feelings of intense anger, fear, resentment, and responsibility, as well as a desire to escape so that she could not be held responsible for her parents’ health. The other was the cognition that her husband was cheating on her or had lost interest in their relationship, leading to feelings of anger, jealousy, and sadness that caused Willow to want to escape her intense negative emotions. The second theme was that Willow was most vulnerable to suicidal ideation and self-harm urges when she stopped engaging in routine self-care activities such as showering and brushing her teeth, as doing so indicated that Willow did not deserve or need to take care of herself. Therefore, sessions were focused on teaching Willow specific DBT emotion regulation and distress tolerance skills, as outlined in Linehan’s (2015) most recent DBT skills training manual, to help her survive crises and reduce her vulnerability to intense emotions. These included the “TIP” skills (Temperature, Intense Exercise, Progressive Relaxation, Paced Breathing) designed to get through difficult situations with her husband and parents without engagement in self-harm or suicidal behavior, “Mindfulness of Current Emotion” to bring non-judgmental awareness to her emotions, “Self-Soothe” by being kind to oneself to tolerate painful emotions, “Opposite Action” to reduce the intensity of negative emotions, and the “PLEASE” skills designed to help a person to engage in self-care and reduce vulnerabilities to negative emotions. Practicing these skills resulted in Willow’s suicidal ideation and self-harm urges reducing to 0 or 1 (out of 5) each day on her diary card.
Once Willow’s suicidal ideation and self-harm urges had started to reduce, treatment focused on decreasing quality-of-life interfering behaviors that would further reduce her urges. Specifically, several sessions in the middle of Willow’s treatment were focused on helping her re-assess her cognitions that she was the only one who could care for her parents and that her husband was cheating on her. BITE supervision occurred in this phase of treatment, beginning in Session 12 and ending after Session 17 (see below). In this phase of treatment, Willow reported spending several hours per day worrying about her parents’ health, completing chores around the house so her mother would not physically exert and possibly injure herself, and researching “the best” doctors and hospitals that could treat her father’s knee pain. Her anxiety led to thoughts that she could possibly lose her parents and that it would be her fault if her parents became ill or injured. As a result, she engaged in self-invalidation, believing that she did not deserve to care for herself and had to sacrifice her own self-care to take care of her parents. In session, Willow and her therapist worked on modifying this belief in two ways. First, Willow was encouraged to continue practicing PLEASE and Self-Soothe skills to engage in self-care so that she could indeed care for her parents. In particular, Willow developed a daily schedule that reminded her to eat regularly and set aside time for fun activities. Second, Willow was taught to use the skill of “Radical Acceptance” to acknowledge and understand that her parents’ health was largely outside of her control. Willow reported that practicing these skills resulted in increased self-care and self-respect and enabled her to see that she could not control her parents’ health.
Related to Willow’s belief that her husband was cheating on her, she reported believing that she could not trust her husband. Therefore, she spent several hours each week asking him if he still loved her, checking his cellular phone bill to see if he had spoken to any women, and questioning her father (who worked with her husband) about what her husband had done during the day. Her checking behaviors reinforced feelings of jealousy, sadness, and shame, as well as the urge to escape by engaging in self-harm or suicidal behavior. She was stuck in the beliefs, “I cannot trust him because if I do, I will get hurt” and “I cannot trust him, so I might as well kill myself.” Understanding this encouraged Willow to commit to reducing and tolerating any remaining feelings of jealousy. She began by practicing the skill of “Check the Facts” to see whether the facts of a situation merited feelings of jealousy. She also used Mindfulness of Current Emotion to notice her jealousy and Opposite Action to reduce her urge to check or seek reassurance when feeling intense jealousy. Willow reported that practicing these skills resulted in decreased jealousy and an increased desire to engage in activities independent of her husband. Her suicidal ideation and self-harm urges, as reported on her diary card, reduced to 0.
Next, treatment focused on simultaneously decreasing Willow’s quality-of-life interfering behaviors and increasing her behavioral skills. Specifically, later sessions were focused on helping Willow increase her engagement in independent, enjoyable, and masterful activities. Willow reported that she rarely participated in activities alone and was fearful and unsure of how to begin. Therefore, in one session, Willow and her therapist developed an “independence exposure hierarchy,” a list of 11 activities that Willow wanted but avoided doing because of her fear and uncertainty. Activities included driving on her own, socializing with family and friends without her husband, and joining a photography or writing group. In subsequent sessions, Willow was assigned one or more activities for homework to increase her independence while practicing the mindfulness skill of “Participate” to throw her mind, body, and soul into each activity. As a result of completing items on the hierarchy, Willow reported decreased jealousy, increased self-confidence, increased fulfillment, and an improved relationship with her husband.
Toward the end of treatment, sessions were dedicated to helping Willow prepare for her next treatment. Willow was interested in entering her regional hospital’s comprehensive DBT program. After calling the program coordinator for information, Willow was placed on a wait list. Therefore, Willow and her therapist devised a plan to help Willow receive support and maintain her progress in the transition between treatments. Willow contacted a previous therapist with whom she reported excellent rapport, who agreed to provide supportive counseling during the transition. Willow also stated that she would set aside time to review and practice DBT skills each week. In addition to this transitional plan, the last month of treatment focused on helping Willow identify her goals for the next treatment. These included continuing with her independence exposures and pursuing part-time employment.
Following her final individual therapy session, Willow completed a post-treatment assessment that, similar to her intake assessment, included several self-report questionnaires and semi-structured interviews. Willow’s responses to these post-treatment measures indicated that she had benefitted from DBT. For example, her BDI-II score of 6 indicated that she was much less depressed from her initial score of 34. Her score on the DERS was 91, indicating improvement in emotion regulation from the 113 score at baseline.
Implementing BITE: Process and Effects
As previously stated, BITE supervision took place during Sessions 12 through 17. In these sessions, the supervisor’s comments and feedback enabled the therapist to make real-time decisions about which DBT skills and strategies to employ in session to help Willow identify and begin to change maladaptive thoughts and behaviors. For example, in Session 13, the supervisor provided live feedback that reminded the therapist of the DBT stylistic strategy of balancing acceptance with change when the therapist was eager to help Willow change her jealous behaviors. Prompted by the message, “Validate the difficulty of experiencing these emotions,” the therapist said, “Willow, it must be so difficult for you to feel so jealous in your marriage.” When Willow responded that it was indeed difficult and she no longer wanted to experience such intense jealousy, the therapist then asked whether she was really willing to let go of her jealousy. When Willow responded affirmatively, the supervisor suggested several strategies to enact change, including “Wise Mind” and “Pros and Cons.” During the Pros and Cons exercise, the supervisor also encouraged the therapist to balance reciprocal communication with irreverent communication. Prompted by the message, “But it makes her want to harm herself! And think of suicide!” the therapist matter-of-factly pointed out to Willow that even though she believed being jealous and checking on her husband protected her, it also drove her to want to kill herself. In this session, the supervisor’s real-time communication enabled the therapist to employ several stylistic strategies that encouraged Willow to increase her work on changing problematic thoughts and behaviors while also demonstrating the therapist’s understanding of the difficulty of doing so.
In Session 15, when Willow reported ambivalence to continue working on her jealousy, the supervisor’s live feedback reminded the therapist to highlight a dialectic in Willow’s thinking. Willow came to session believing that she really could not trust her husband because if she did, she would stop checking to make sure he had not or would not cheat on her and inevitably get hurt. The therapist attempted to address Willow’s ambivalence by reviewing the Wise Mind and Pros and Cons skills the two had previously practiced in session. However, Willow still reported being unsure of whether and how much to trust her husband. Upon hearing this, the supervisor advised, “There is a dialectic here” and highlighted the discrepancy between Willow’s aforementioned beliefs, “I cannot trust him because if I do, I will get hurt” and “I cannot trust him, so I might as well kill myself.” The therapist highlighted this dialectic to Willow, stating, “Willow, you’re stuck. You say that you cannot trust your husband because you will get hurt, yet you say that you cannot trust your husband so you need to kill yourself.” Hearing this dialectic, and remembering her commitment to not killing herself and building a life worth living, motivated Willow to continue working on her jealousy.
In Session 17 the supervisor also highlighted a paradox that enabled Willow to see how letting go of jealousy in fact improved her marriage. Willow had recently begun engaging in independence exposures, experimenting with doing activities alone. At the beginning of one session, the supervisor asked the therapist to ask Willow how it felt to be separated from her husband during her exposures. When Willow responded that it felt good and even seemed to be improving her marriage, the supervisor pointed out, “There’s a paradox here—the more independent she becomes, the better her relationship will be.” Stating this to Willow appeared to maintain her motivation for the exposures throughout the final sessions of treatment.
Throughout BITE supervision, the supervisor’s comments and feedback enabled the therapist to become an increasingly confident DBT therapist. The supervisor’s communication not only provided suggestions on which DBT strategies and skills to use but also provided clear instruction on what to say (and how to say it) to Willow. Such clear, real-time instruction helped decrease any anxiety, confusion, or uncertainty for the therapist.
Assessment of Progress
The four sessions prior to Session 12 were considered “baseline” sessions to determine the therapist’s initial adherence to DBT; the four sessions after were considered “maintenance” sessions to determine the therapist’s continued adherence to DBT. Therefore, the audio-recordings of Sessions 8 to 21 were sent to an independent rater for adherence coding. The independent rater was blind to what was being studied in this case; that is, he was not aware that BITE was occurring during some of the sessions.
Figure 1 displays the therapist’s adherence scores. During baseline, the therapist’s adherence scores remained below adherence (i.e., <4.0) for all but one session. During BITE, the scores trended upward. The therapist scored below 4.0 in just one session during BITE, and it was the second session in the series of six sessions. During the last four sessions of BITE, the therapist was rated as delivering DBT adherently. During those four sessions, her scores ranged from 4.0 to 4.2. When BITE ceased, the therapist’s scores remained above the cutoff for adherence in the subsequent four sessions. Her scores ranged from 4.0 to 4.3.
The results of the therapist’s adherence scores indicate that the therapist’s adherence to DBT improved over the course of BITE supervision. She began with scores below adherence and ended with scores that were consistently at or above the adherence cutoff. In other words, there was a point during BITE that the therapist reached adherence in delivering DBT, and she continued to deliver treatment adherently for the remainder of the protocol. Furthermore, the therapist’s scores demonstrate that once BITE was removed, gains in adherence scores were maintained.
BITE Satisfaction Scale Results
Results from the BITE Satisfaction Scale indicate that BITE was acceptable to both Willow and therapist (see Table 1). The therapist “somewhat agreed” and “strongly agreed” with a number of statements about the ease of implementing BITE and the usefulness of the live supervision. The therapist agreed that her work was enhanced through the use of BITE. She thought BITE was easy to implement and reported that she would utilize BITE in the future. One of the therapist’s responses points to an area of improvement in making the set-up and operation of BITE more user-friendly.
BITE Satisfaction Scale Results.
Note. Key: 1 = strongly disagree; 2 = somewhat disagree; 3 = somewhat agree; 4 = strongly agree. BITE = bug-in-the-eye.
Willow also agreed that therapy session seemed more effective as a result of the supervisor’s observation. Her responses suggest that neither the observation of a supervisor nor the presence of a computer were perceived as disruptive, and she did not think BITE negatively affected her relationship with the therapist.
8 Complicating Factors
Some complicating factors presented through the use of BITE supervision and technology. First, BITE supervision requires the coordination of at least three different schedules—in this case, those of Willow, her therapist, and the supervisor. In Willow’s case, sessions conducted during the BITE supervision period were held on late weekday evenings. Second, BITE supervision also requires specific equipment and technology. A laptop computer equipped with word-processing software, a web camera, and access to the Internet is necessary for supervision. Prior to each BITE session, the therapist had to ensure that the computer was available and working appropriately.
9 Access and Barriers to Care
Clinicians and researchers have previously documented numerous barriers to accessing DBT and other treatments for individuals with BPD (Swenson, Torrey, & Koerner, 2002). These include having to discontinue treatment with other therapy providers, committing time to DBT (Swenson et al., 2002), and cost of a quality DBT program. Several of these barriers were illuminated by Willow’s case. Entering DBT often means that clients must terminate treatment with another clinician. This can be particularly difficult for individuals with BPD, who tend to get attached to others. Prior to entering the Clinic, Willow had worked with an individual therapist at her primary care doctor’s office for several months. She greatly admired and respected the therapist and noted in her initial phone screen and intake evaluation that she was nervous about beginning anew. Therefore, Willow’s therapist worked diligently in early sessions to build rapport with Willow and put her at ease in her new therapy setting.
Entering DBT—in particular, a comprehensive program—also means that clients must commit their time to treatment. At minimum, they must commit to 1 hr of individual therapy and 2 hr of group skills training each week, setting aside 2 separate days to come into the Clinic. In addition, they are expected to complete therapy homework and call for phone coaching when needed. In Willow’s case, transportation barriers at times interfered with her committing her time to DBT. Willow relied on her husband to drive her to and from sessions. If he ran late, she arrived at her individual or group session late. Throughout treatment, the therapist and Willow discussed ways to ensure timely arrival to sessions.
Comprehensive DBT can also be an expensive endeavor for clients. Nearly half of individuals with BPD are currently unemployed, and up to 45% receive disability benefits (Sansone & Sansone, 2012). Many clients with limited financial resources find it difficult to afford treatment. At the time of treatment, Willow had been unemployed for several years and received mental health disability benefits. She and her husband lived with her parents to reduce housing costs. Willow benefitted from receiving low-cost treatment at a training clinic like the one referred to here; however, as discussed in the section below, finding such a clinic—or one that accepts insurance—can prove difficult.
10 Follow-Up
After terminating treatment at the Clinic, Willow received supportive counseling from her previous therapist at her primary care doctor’s office approximately once every other week while she remained on the wait list for the comprehensive DBT program at her regional hospital. Two months after treatment termination, she began her new DBT program. Three months after treatment termination, she returned to the Clinic for a follow-up assessment.
During this assessment, Willow reported maintained improvements in her psychiatric symptoms and overall quality of life; however, it must be noted that these improvements may have been influenced by her engagement in her new DBT program after termination from the Clinic. She scored a 10 on the BDI-II, indicating mild levels of depression, and 80 on the DERS, indicating significant improvements in emotion regulation. Furthermore, she reported no self-harm or suicide attempts since terminating treatment. In addition, she reported continuing with her independence exposures such that she was now confidently driving alone and experimenting with new hobbies. Most notably, she reported turning her passion for creative writing and literature into something productive. She had written several short stories and entered them into local fiction contests, increasing her self-confidence and mastery.
11 Treatment Implications of the Case
DBT has received ample support of its efficacy for individuals like Willow, that is, individuals who meet criteria for BPD, and have a history of suicidal behaviors and a number of comorbid psychological problems (Katz & Cox, 2002; Linehan et al. 1991; Linehan et al., 2006; Linehan et al., 1993; Lynch et al. 2007). Thus, it is not much of a surprise that Willow showed benefits from this treatment. What is noteworthy about this case is the use of live supervision, in the form of BITE, to increase the therapist’s adherence to DBT over the course of Willow’s treatment. It is possible that other trainees’ use of DBT can be similarly improved via BITE.
DBT is a complex treatment to deliver for a novice therapist. Within any session, the therapist is reviewing the diary card, determining how to use the information from the diary card and the target hierarchy to structure the session, making quick decisions about when to conduct a chain analysis and what skill to teach when, trying to balance validation and change, and keeping in mind other stylistic strategies that keep the session moving. And all the while, the therapist is keeping in mind her formulation of the case, which informs many of the above decisions. Furthermore, the therapist is also trying to be mindful in the session and keep tabs on time. Given the complexity of DBT as a treatment for novice therapists to deliver, any intervention that enhances the therapist’s acquisition of knowledge or clinical skill should be considered. Carmel et al. (2015) found that trainees receiving BITE supervision developed superior case formulations of their DBT clients than trainees receiving SAU, suggesting that BITE had an effect on increasing trainees’ learning of DBT theory and implementation. This case example adds evidence that BITE supervision may also improve novice therapists’ adherence to the treatment model during therapy sessions. The promising effects of BITE on increasing trainees’ abilities to conceptualize and deliver DBT should be noted when considering supervision options within a training clinic.
Other methods have been found effective in increasing therapists’ knowledge of DBT strategies. In fact, recent studies have shown that traditional training models, including reading a training manual or participating in online- or instructor-led trainings, may be effective in increasing therapists’ knowledge of DBT treatment strategies (Dimeff et al., 2015). However, the same study found that increased knowledge of DBT, through studying a manual or attending training, does not necessarily increase therapists’ self-reported DBT proficiency (Dimeff et al., 2015). An advantage of BITE is that live supervision provides therapists with immediate feedback about their strengths and weaknesses in a session, thereby increasing their own self-assessment and providing a sense of efficacy in sessions. Willow’s therapist found the supervisor’s immediate feedback reassuring to know that an expert was on hand to guide her and her client in the right direction. She noted that the supervisor’s presence led to her making therapeutic decisions quickly, allowed her to practice many of the stylistic strategies, and helped her get unstuck when necessary. Thus, BITE increased the therapist’s confidence in delivering DBT. Furthermore, the therapist noted that while she thought beforehand that BITE might negatively impact the therapeutic relationship, both she and Willow quickly adapted to its use in session and there was no notable strain.
12 Recommendations to Clinicians and Students
This case indicates that live supervision, in the form of BITE, can be integrated into DBT treatment with few complications. BITE was tolerated well by both client and therapist, and the changes in the therapist’s adherence scores indicate that it may have been effective in promoting adherence to DBT. Although there are some challenges to implementing BITE, namely in terms of scheduling at a time that works for three individuals, there are many potential benefits that override these challenges. Since DBT is a complex treatment designed to treat a complex client population, it is imperative that we work to improve the quality of the training that is provided to students of this modality, as well as the quality of the treatment that is received by individuals experiencing a great deal of suffering. Thus, we recommend the following:
Live supervision should be implemented into DBT training settings. Live supervision can be used with novice DBT student therapists at the start of their training to provide more directive and immediate feedback to the learning clinician. It can also be used as needed to assist student therapists in implementing a particular DBT intervention or in working through a challenging period of treatment. Live supervision can be tailored to the needs of the training clinic and the needs of the students in terms of frequency and when live supervision falls in the course of treatment and training. Live supervision can function in DBT training clinics as a way for supervisors to monitor student therapist progress and can also serve as in-vivo guidance for student therapists when they are “stuck” in treatment.
Data should be collected on effectiveness of BITE in such settings. Gathering data from other therapists, patients, and supervisors implementing BITE will give a more robust picture of the acceptability and feasibility of live supervision. Other areas of interest and future directions in research might include gathering data on how BITE affects patient outcomes, therapist self-efficacy, or the use of certain DBT therapist strategies.
Larger research trials should be conducted to evaluate the efficacy of BITE supervision compared with other training models for individuals learning dialectical behavior therapy.
Footnotes
Acknowledgements
We would like to acknowledge the therapists and clients at Dialectical Behavior Therapy Clinic at Rutgers University (DBT-RU) for supporting this line of research.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This therapy client was a part of a larger study funded by the American Foundation for Suicide Prevention (AFSP; Grant SRG-0-126-11).