DBT Peer Connections

Building Hope, Community and Skillful Means

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Consultation Team Agreements for DBT Peer Support Specialists

1. DBT Consultation Team Member Agreements
Commitments that must be made before joining a DBT consultation team:

  1. Dialectical Agreement: (to follow a dialectical philosophy); We agree to accept a dialectical philosophy: There is no absolute truth (nor is truth relative). When caught between two conflicting opinions, we agree to look for the truth in both positions and to search for a synthesis by asking such questions as, “What is being left out?”
  2. Consultation to the Client Agreement: (to empower and not fragilize clients); We agree that the primary goal of this team is to improve our own skills as DBT peer mentors, and not serve as a go-between for clients to each other. We agree to not treat clients or each other as fragile. We agree to treat other team members with the belief that others can speak on their own behalf.
  3. Consistency Agreement: (to not insist on consistency, but accept diversity and change); Because change is a natural life occurrence, we agree to accept diversity and change as they naturally come about. This means that we do not have to agree with each other’s positions about how to respond to specific clients, nor do we have to tailor our own behavior to be consistent with everyone else’s.
  4. Observing Limits Agreement: we agree to observe our own limits. As peer mentors and team members, we agree to not judge or criticize other members for having different limits from our own (e.g.: too broad, too narrow, “just right”).
  5. Phenomenological Empathy Agreement: (to find empathic, non-pejorative interpretations of ours and others’ behaviors); All things being equal, we agree to search for non-pejorative or phenomenologically empathic interpretations of our client’s, our own, and other members’ behavior. We agree to assume we and our clients are trying our best, and want to improve. We agree to strive to see the world through our clients’ eyes and through one another’s eyes. We agree to practice a nonjudgmental stance with our clients and one another.
  6. Fallibility Agreement: (to admit to mistakes, humanness and to recognize and let go of defensiveness). We agree ahead of time that we are each fallible and make mistakes. We agree that we have probably either done whatever problematic things we’re being accused of, or some part of it, so that we can let go of assuming a defensive stance to prove our virtue or competence. Because we are fallible, it is agreed that we will inevitably violate all of these agreements, and when this is done, we will rely on each other to point out the polarity and move to a synthesis

2. DBT Consultation Team Orientation

Being a member of a DBT consultation team means assuming certain responsibilities, agreeing to interact in particular ways, and accepting certain foundational assumptions about one’s self as a DBT peer mentor, those served, and consultation teammates. An orientation and commitment process helps new members understand these expectations in advance so that they can make an informed choice about joining a DBT consultation team.

  A) DBT Consultation Team Functions as They Relate to Peer Support:
  1. DBT peer support is defined herein as a community of former, current, and/or future DBT clients who encourage, cheerlead, validate, and nurture each other as they work to build skillful means and improve their lives.
  2. DBT peer mentors provide leadership in the course of DBT peer support by sharing their DBT experience and skills knowledge NOT by overtly instructing their peers on how to solve their problems. Although a DBT peer mentor may be tempted to help alleviate a mentee’s distress by intervening in a problem, it is his or her job not to teach their mentee how to eliminate distress, but rather how to tolerate and move through it by using skillful means, otherwise referred to in DBT terms as the consultation to the client strategy.
  3. A consultation team is composed of members who apply dialectical behavior therapy (DBT) assumptions, principles, strategies, and skills, as defined by Marsha Linehan, the creator of DBT, to a population of people who are learning to use DBT skills to achieve their individual goals and improve health and wellness. The team generally meets once a week for 1.5-2 hours.
  4. Because consultation team members often work with persons who have extremely distressing lives, behaviors, and/or tend to make slow progress toward goals, the primary function of a DBT consultation team is to increase the motivation and capability of its members in order to minimize the risk of burn out and increase adherence to DBT.
  5. When joining a team, members agree to be responsible for the outcomes of ALL peers who interact with the team. It is not a minor responsibility to provide DBT peer support and to agree to be a full-fledged member of a DBT consultation team. Therefore, by extension, when a person a team member interacts with commits suicide, all team members will say “yes” when asked if they have ever had a person whom they provided support to commit suicide.
  • B) Definition of a DBT Peer mentor – A DBT peer mentor is someone who:
    1. Has gained control over the following DBT stage 1 targets:
      • a) Behaviors that are life-threatening and/or harmful to themselves or others
      • b) Behaviors that interfere with DBT (get in the way of learning/using skills, attending appointments, working with others, etc.)
    2. Has had a minimum of 1 month free from self-identified problem behaviors
    3. Has a certificate of completion of DBT skills training from one of the following :
      • a) a formal, face-to-face, therapist-led DBT skills training group
      • b) 1-on-1 DBT skills training sessions with a therapist
      • c) Through professional DBT skills training for therapists offered by Behavioral Tech
      • d) Through DBT Peer Connections Free E-course
    4. Is willing to share his or her story of recovery with others in order inspire hope in peers, educate the public and combat prevailing mental health stigma, and to advocate for the continued development of compassionate, evidence-based mental health treatments like DBT.

3. DBT Consultation Team Commitment Session for New Members

All new DBT team members should meet with the team leader, a team member, or, in some cases, the entire team, for a commitment session before they join the team. The strategies used in this meeting are identical to those used in commitment sessions with new clients in DBT, including, for example, orienting to DBT team, all of the commitment strategies, troubleshooting, etc.

  • A) assessing DBT Peer Mentor Readiness – Before joining a consultation team, prospective DBT peer mentors should answer the following questions.
    1. What are the names of the 4 DBT skills modules and do you know all the skills well enough to provide personal examples of their use?
    2. When you are distressed are you more likely to use skills or resort to problem behaviors?
    3. When an interpersonal conflict arises, are you able to regulate anger, urges to attack, blame, judge, or reject others effectively?
    4. Are you comfortable talking about your mental health problems with others?
    5. Are you willing to share your recovery story publicly?
    6. In your own words, explain what recovery means to you.
    7. What are some DBT skills that you do daily to maintain your gains in mental health recovery?
    8. What is the most important goal that you are working on right now?
    9. What may get in the way of you being an effective DBT peer mentor?
    10. What are signs that you need DBT peer support?
  • B) Commitment Session Tasks – The following items are reviewed during the commitment session with the emphasis on assuring that the potential new consultation team member understands:
    1. What a DBT consultation team is and how the team functions.
    2. What the obligations of team members are.
    3. The ramifications of each commitment that is made (i.e.; the upside and downside of each commitment).
    4. That participation in a DBT team must be voluntary, but that once a commitment is made, there will be every expectation that the member abides by the commitments made.

4. DBT Consultation Team Member Behavioral Agreements
DBT Peer mentors who agree to become full-fledged members of the consultation team agree to do the following:

  1. Be committed to demonstrating compassion, non-judgment, mindfulness and dialectical thinking in their actions
  2. Be engaged in team meetings and not be silent observers or focused only on their own work
  3. Treat the meeting as vital to the DBT process
  4. Avoid distractions and/or meeting cancellations
  5. Complete agreed upon homework
  6. Come to meetings prepared
  7. Be willing to give advice to team members with more DBT experience
  8. Assess problems before giving solutions
  9. Practice humility by admitting and learning from mistakes
  10. Be willing to undergo chain analyses for problem behaviors that cause mistakes
  11. Call out the “elephant in the room” and describe it in nonjudgmental detail
  12. Prepare for and repair after missing team meetings
  13. Speak up when concerned or frustrated by the team process
  14. Carry on and/or take brief time-limited breaks when feeling so burned out, frustrated, tired, overworked, under-appreciated, hopeless, that it is difficult to use interpersonal effectiveness skills

5. Roles during DBT Consultation Team Meetings
Members agree to assume any one of the following roles (as needed) at each meeting.

  • A) DBT Consultation Team Leader.
    1. In charge of making sure the consultation team sticks to the consultation agreements.
    2. Responsible for setting up the agenda and having the team stay mindful to time & agenda during the meeting
    3. Staying up-to-date with the latest research in DBT (and keeping the team aware of this research).
    4. Helping the team stay away from the “all-or-nothing thinking or behavior”
    5. Helping the team stay away from staff-splitting,
    6. Pointing out dialectical dilemmas when he/she notices it and moving the team towards synthesis.
    7. Although teams may have a member who is considered a leader based on DBT experience, the role of meeting leader is generally rotated.
  • B) Team Observer
    1. Is mindful of deviations from Team Agreements and other ineffective behaviors during the meeting.
    2. Brings the team’s attention to ineffective behaviors as they arise.
  • C) Note Taker – takes notes on the content of the meeting, including issues brought for consultation and advice given by the team.
  • D) Member – Actively participates in assessment of issues brought for consultation, including defining the problem behaviorally and helping to formulate solution strategies.
    1. Each member has an opportunity to bring up any problem he/she is having with a particular person during this meeting. The member should let the team leader know about this before the meeting so the team leader can add this to the agenda.
    2. Other members of the team may be allocated the responsibility of setting the agenda or maintaining mindfulness to the agenda. When this was done, it was done on a rotating basis between members of the group. This identified member who will be setting up the agenda and being in charge of having the team stay mindful to this agenda should be identified before the previous group has adjourned.

6. Structure of DBT Consultation Team Meetings
Meetings happen weekly and for at least 60 minutes – ideally for 90-120 minutes. Generally, meeting activities occur in this order:

  1. Mindfulness practice;
  2. Agenda Setting (an agenda template is available [here: DBT CT Agenda Signup.doc]);
  3. Case Consultation (based on hierarchy of targets and urgency rating);
  4. Teaching

7. DBT Consultation Team Meeting Check List

  • A) The Team designated:
    1. A Team Leader (TL)
    2. An Observer
    3. A Note Taker (NT)
    4. The TL led a mindfulness practice
    5. The TL read one of the Consultation Team Agreements
    6. The NT read the notes from last team meeting
    7. The TL Identified a Dyad of the Week to discuss
    8. The TL checked if anyone was going out of town
    9. The Team identified back-up coverage
    10. No peer mentor expressed plans to go out of town
  • B) The TL asked for updates to the emergency contact sheet
  • C) The TL checked if anyone had clients with:
    1. Life-Threatening Behavior (including imminent risk)
    2. Therapy Interfering Behavior (including approaching 4 misses)
    3. Serious Quality of Life Interfering Behavior
  • D) The TL checked if any peer mentors were engaging in:
    1. Unethical, severely irresponsible behavior
    2. Team interfering behavior
    3. Therapy Interfering Behavior
  • E) The TL checked if any peer mentors were approaching burnout
  • F) The TL rang the bell to end the meeting

8. General Consultation Team Process

  • A) the team discussions focused on primarily PEER MENTOR behavior vs. client
  • B) highlighting, targeting, and problem-solving conducted with easy manner
  • C) a strong position was expressed about a clinical or related issue
    1.  Someone on the team brought up an opposing issue
    2.  The dialectic or tension was highlighted
    3.  The team worked to achieve synthesis
  • D) The team meeting involved a balance of acceptance and change-based styles

9. DBT Consultation Team Member Task Examples

  • A) Meeting Leader Tasks (same as mindfulness leader):
    1. Develops agenda with team members
    2. Determines the order of the agenda
    3. Manages time
    4. Reads one of the Dialectical Agreements
  • B) Observer Tasks (leader from previous week) observes and rings bell lightly when:
    1. A dialectic is unresolved
    2. Anyone (client or peer mentor) is treated as fragile (is an elephant in the room?)
    3. A judgmental/non-compassionate comment is made
    4. Defensiveness arises, forgetting that we are all fallible
    5. Non-mindfulness, doing two things at once appears
    6. Solutions given before the problem is assessed
    7. Treatment recommendations/comments violate DBT principles
    8. Consultant-to-the-team/DBT team leader intervening, doing rather than teaching
  • C) Note Taker Tasks (next up as meeting leader):
    1. Distributes and/or sends notification of agenda to members (if developed prior to meeting)
    2. Peer mentor-client dyads discussed
    3. Problems brought up
    4. Advice given
    5. Topics unaddressed due to time
    6. Issues/agreements for follow-up at next meeting
  • D) Consultation Member Tasks:
    1. Participate, remembering that peer mentors always have something to say, i.e.: staying silent throughout an entire consultation meeting is not participating
    2. Consult with members who want consultation:
      • a) Get agreement on problem presented and get it defined behaviorally (client behavior is problem; peer mentor behavior is problem; peer mentor wants to summarize and get validation/cheerleading/sympathy
      • b) Assess problem behaviorally:
        1. Look for reinforcers
        2. Look for aversive consequences
        3. Look for inadequate or inappropriate stimulus control
        4. Consider skills deficits
        5. Ask about secondary targets that might be contributing
      • c) Suggest strategies based on assessment/formulation
      • d) Check if more help is needed
        1. Give feedback to and coach team members who fall out of DBT in their therapy or during the meeting
        2. Highlight “elephants in the room” and topic avoidance when they arise
        3. Listen to and validate (when appropriate) members who wish to share or process experiences with clients or other team members.

10. Behaviors Observed During Consultation Team Meetings:

  • A) A peer mentor was doing 2 things at once (i.e.: reading and listening, talking on the telephone, chatting out of turn with other members)
    1.     The Observer range the bell
    2.     The behavior was highlighted and blocked by the team
  • B) A peer mentor was treated as fragile. An obvious issue came up that needed to be targeted (i.e.: defensiveness, judgmental talking, lateness) that was not highlighted or discussed by the team. Or, feedback clearly was needed, but was not provided.
    1.     The Observer range the bell
    2.     The behavior was highlighted
    3.     The team discussed the avoided issue or provided the needed feedback
  • C) A peer mentor displayed defensiveness in response to feedback
    1.      The Observer range the bell
    2.      The behavior was highlighted
    3.      The peer mentor was asked to rephrase the statement
  • D) A peer mentor offered solutions before the problem was defined
    1.      The Observer range the bell
    2.      The behavior was highlighted
    3.      The problem was clarified
  • E) A peer mentor engaged in self-invalidation (denigrating self, judgmental toward self, presenting as incompetent)
    1.      The Observer range the bell
    2.      The behavior was highlighted
    3.      The peer mentor was asked to rephrase the invalidating statement
  • F) A peer mentor spoke in a judgmental or derogatory manner about his or her peers
    1.      The Observer range the bell
    2.      The behavior was highlighted
    3.      The peer mentor was asked to rephrase the judgmental statement
  • G) A peer mentor was late for the meeting
    1.      The behavior was highlighted
    2.      A chain analysis was conducted
    3.      Solutions were agreed upon
    4.      A commitment to implement a solution was elicited
  • H) A peer mentor was obviously unprepared
    1.      The behavior was highlighted
    2.      A chain analysis was conducted
    3.      Solutions were agreed upon
    4.      A commitment to implement a solution was elicited
  • I) A peer mentor did not speak during the meeting
    1.      The behavior was highlighted
    2.      A chain analysis was conducted
    3.      Solutions were agreed upon
    4.      A commitment to implement a solution was elicited