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1 Contents of This Packet 1) Overview letter 2) Dialectical Behavior Therapy (DBT) Clinic flyer 3) Diagnostic criteria for borderline personality disorder 4) Guidelines and agreements for participating in DBT skills training groups at UMMC 5) Example handouts provided for skills and topics covered in the DBT skills groups a. Mindfulness b. Emotion Regulation c. Distress Tolerance d. Interpersonal Effectiveness 6) Treatment history information form and Release of Information forms 7) Crisis Prevention Planning Sheet 8) Crisis Prevention Plan PLEASE NOTE: Items 6-8 above require your attention. Please complete these forms and bring them with you to your Initial Evaluation appointment.

2 University of Mississippi Medical Center 2500 North State Street, Jackson, Mississippi Telephone This packet of materials offers a general overview of the focus and structure of the skills groups. A few of the pages represent actual handouts used in the group. Others include the guidelines and expectations for participating in the skills group, an information sheet for the client and therapist to complete that will function as a Crisis Prevention Plan, and the DSM-IV diagnostic criteria for Borderline Personality Disorder. As an introduction The general goal of the Dialectical Behavior Therapy skills group is to help members learn and refine skills in changing behavioral patterns associated with problems in living, specifically those causing misery and distress. Emotion regulation, distress tolerance, selfawareness, mindfulness, and interpersonal effectiveness are the areas of focus in the Dialectical Behavior Therapy Skills Training Group. Please be very clear that the DBT group is not a psychotherapy group in the usual sense. The group format is most similar to an experiential seminar its task is to educate the participants in a subject that is both informational and experiential. The group is structured and focused on skills training. Members are expected to commit to: o Regular attendance o Completion of written and behavioral homework assignment o Willingness to review their homework in the group discussion. Learning and using the skills taught in the group is best accomplished when the individual therapist is active in supporting the client s skills practice. Although some effort is made to integrate into everyday life the new behaviors taught in skills training, the lack of time and the complexity of achieving such an integration requires that each participant s individual therapist be actively engaged in helping the client apply the skills. In other words, the individual therapist is the day-to-day coach for the client. All potential members must complete a 2-hour Initial Evaluation with one of the DBT Therapists or Group Leaders. Tasks to complete in the assessment are multiple, including, but not limited to the following: o Identification of current goals and targets in individual therapy o Symptom history and treatment history o Assessment of moods, emotions, symptoms, and current difficulties, including impulsive behaviors o Signing of Release of Information forms allowing the UMC DBT Clinic therapists to contact current and previous inpatient and outpatient treatment providers.

3 If you are scheduled for an Initial Evaluation, please familiarize yourself with this information packet. To allow for the most efficient use of time in our meeting together, please find and complete the form in this packet that requests names, addresses, and telephone numbers of your current and recent treatment team members and programs. Also, please be sure to bring this entire packet with you to your appointment. New members are invited into groups as space allows. All members are registered in the Department of Psychiatry at UMC. Check-in occurs before group, requiring that members arrive early enough to complete check-in activities without being late for the group. After reviewing the enclosed material, please call me with any questions you may have about the Skills Groups or the DBT Clinic in general. Sincerely, Kim L. Gratz, Ph. D. Associate Professor Director, DBT Clinic Director, Personality Disorders Research Department of Psychiatry and Human Behavior University of Mississippi Medical Center Phone: (601) Fax: (601)

4 Dialectical Behavior Therapy (DBT) Clinic The University Physicians' DBT Clinic specializes in providing state-of-the-art individual and group treatment for borderline personality disorder, trauma-related difficulties, and addictive and impulsive behaviors, including deliberate self-harm and substance use. Treatment begins with a comprehensive diagnostic evaluation that takes into account current and past difficulties, as well as previous treatments. Tailored, individualized treatment plans are developed on the basis of this evaluation and in collaboration with the clients and referring treatment providers. Treatment in this clinic may be comprised solely of individual DBT, or a combined package of individual and group DBT. The DBT clinic also provides DBT skills groups as a compliment to ongoing therapy provided by other clinicians or treatment centers. Progress is systematically assessed throughout treatment. Kim L. Gratz, Ph.D., Director Dr. Gratz received her Ph.D. in Clinical Psychology from the University of Massachusetts Boston. She completed her clinical internship at McLean Hospital/Harvard Medical School, followed by a postdoctoral clinical research fellowship within the Center for the Treatment of Borderline Personality Disorder at McLean Hospital. Dr. Gratz specializes in the treatment of deliberate self-harm and borderline personality. Matthew T. Tull, Ph.D. Dr. Tull received his Ph.D. in Clinical Psychology from the University of Massachusetts Boston, after completing his clinical internship at the Boston VA Healthcare System. He specializes in the treatment of substance use and anxiety disorders, with expertise in PTSD. CONTACT US AT

5 Diagnostic Criteria for Borderline Personality A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance: markedly and persistently unstable self-images or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) 5. Recurrent suicidal behavior, threats, or self-injury 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours or rarely more than a few days) 7. Chronic feeling of emptiness 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. Transient, stress-related paranoid ideation or severe dissociative symptoms

6 Guidelines and Agreements for Participating in Dialectical Behavior Therapy Skills Training Group At University of Mississippi Medical Center 1. Each client must be in ongoing individual therapy. 2. Clients are not to come to sessions under the influence of drugs or alcohol. 3. Clients are not to discuss past (even if immediate) self-harm or suicidal behavior with other clients outside of sessions. In addition, discussion of symptom behavior in session will be conducted with respect for the limits of others in the room. 4. Clients who call each other for help when feeling symptomatic must be willing to accept help from the person called. 5. Information obtained during sessions, as well as names of clients must remain confidential. 6. Clients who are going to be late or miss a session should call Dr. Gratz ( ) ahead of time. 7. Clients who miss a group session should make arrangements from a peer to learn of the homework assigned for the next meeting. 8. While friendships are not actively discouraged, group members are responsible for refraining from peer involvement that interferes with commitment to learn and practice skills. 9. Sexual partners may not be in Skills Group together. 10. Clients must have a written crisis prevention plan, co-signed by their individual therapist and supplied to Dr. Gratz prior to starting the group.

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11 Treatment History Information Form As noted in the material in the general overview section of this packet, an Initial Evaluation appointment includes the completion of a number of forms. The Release of Information forms are important documents in which the potential DBT client gives consent for current health care providers to exchange clinically relevant information with the Intake Clinician, DBT Therapist, and/or the Skills Group Leader(s). If the client has worked with other providers, either in individual therapy or in other forms of treatment (inpatient, partial or day treatment, other group programs, medications, etc.), discharge summaries and/or contact with particular members of the past treatment teams are requested as well. To assist in making our Initial Evaluation meeting as productive as possible, please bring with you the name, address, telephone and fax numbers for the following people or programs: 1. You current therapist s name: Phone: Fax: Address: 2. Current pharmacotherapist s name (if different from therapist): Phone: Fax: Address: 3. Your case manager s name: (if different from above): Phone: Fax: Address: 4. Previous therapist s name, if working with current therapist for less than 2 years: Phone: Fax: Address: 5. Day Treatment or Partial Hospital Programs you have attended in the past 5 years: Name: Address: Phone: Fax: 6. Inpatient Programs you have attended in the past 5 years: Name of program(s): Address(s): Phone(s): 7. Please use the back of this page to list the contact information for anyone else or any other program you think we should contact. Thank you. Please bring these papers with you to your Initial Evaluation appointment.

12 Authorization for Release of Health Information The University of Mississippi Medical Center (UMMC) 2500 North State Street, Jackson, MS Forms that are not complete will not be accepted by UMMC If UMMC is releasing your health information, please provide the name and address of the person or class of persons to whom UMMC may release the health information: 16) Date by which the information is needed: _ 17) A description of the health information to be released. Describe the health information to be released (i.e. physician notes, x-rays, operation records, account information). Please be SPECIFIC. Unless otherwise indicated, permission to release the information expires in six (6) months from the date it is signed. The information released could potentially be released again by the person receiving it. You have the right to take your permission to release information away at any time. If you do so, it does not affect the information that has already been released. If you give permission for another facility or person, other than UMMC, to release your health information and you wish to take your permission away, you must contact that facility or person to withdraw your permission. If you are requesting UMMC to release your health information and you wish to take your permission away, a written notice, which has been signed and dated by the patient whose health information was to be released, should be sent to UMMC at the following address: UMMC, Attention: Office of Compliance, 2500 North State Street, Jackson, MS The notice should have the following information on it: (1) the patient's name; (2) a description of the health information that UMMC had permission to release; (3) the name or other specific identification of the person(s), or class of persons, that UMMC was going to send the information to; and (4) the date that the permission was signed. UMMC will not refuse to treat you if you do not sign this form. I have carefully read and understand the above, and do herein expressly and voluntarily authorize the disclosure of the above information about, or medical records of, my condition, including any and all alcohol and/or drug treatment records to those persons or agencies listed above. 18) Signature of Patient or Personal Representative (Form must be completed before signing) Form # 1862 Rev. 2/08

13 Crisis Prevention Planning Sheet for Participating in DBT Skills Group in the DBT Clinic at University of Mississippi Medical Center Name: Home phone: Home address: Date: Work Phone: Work address: Referring therapist: Phone: Address: Current individual therapist: Phone: day/evening Pager: Pharmacotherapist: Phone: day/evening Pager: Emergency contact: CRISIS PREVENTION PLAN: (Please identify the plan agreed upon by client and individual therapist as to how the client will manage feelings of distress, impulsivity, or self/other injury. Please be advised that the DBT group leader is not available to be active in a crisis plan.)

14 CRISIS PREVENTION PLAN If I feel as though I am at risk for harming myself, I will take the following actions: Patient Signature Therapist Signature Date Date

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