Brief Report
Development and Clinical Outcomes of a
Dialectical Behavior Therapy Clinic
Travis Lajoie, M.D.
Joshua Sonkiss, M.D.
Anne Rich, M.D.
Objective: The authors describe the rst 6 months of a dialec-
tical behavior therapy (DBT) clinic operated by trainees in a
general adult psychiatry residency program. The purpose of this
report is to provide a model for the creation and maintenance of
a formalized resident DBT clinic.
Methods: Residents participated in the DBT clinic, attended a
weekly combined lecture series and consultation group super-
vised by the clinic director, and completed a 20-hour online
Continuing Medical Education course in DBT skills training.
Results: Eight residents participated in the clinic, each carrying
one patient with Borderline Personality Disorder. The clinic did
not experience any major administrative problems during 6
months of operation.
Conclusion: A Resident DBT Clinic was successfully imple-
mented as an elective rotation in the adult psychiatry residency
training program at the University of Utah.
Academic Psychiatry 2011; 35:325327
Received December 22, 2009; revised April 30, May 26, 2010; accepted
May 27, 2010. From the Dept. of Psychiatry, University of Utah School
of Medicine, Salt Lake City, UT. Correspondence: Anne Rich, M.D;
Anne.Rich@hsc.utah.edu (e-mail).
Copyright 2011 Academic Psychiatry
Academic Psychiatry, 35:5, September-October 2011
B orderline Personality Disorder (BPD) is a severe and
persistent mental disorder, with a prevalence of ap-
proximately 4% in the community and as high as 20% in
clinical psychiatric populations (1). It is a condition char-
acterized by emotional dysregulation and behavioral dys-
control, with high rates of self-harm, poor quality of life,
and behaviors that interfere with therapy. An estimated
69% to 80% of individuals with BPD attempt suicide, and
10% complete suicide (10). BPD is associated with heavy
utilization of psychiatric services; medical complications;
involvement in divorce, libel, and childrearingrelated
lawsuits; violence, and sexual indiscretions (2). The public
health costs of this disorder are still unknown, but are
believed to be tremendous (3).
BPD is the only major psychiatric disorder for which
psychosocial interventions remain the primary treatment
(1). Outpatient Dialectical Behavior Therapy (DBT) is one
treatment supported by randomized, controlled studies
demonstrating superiority over treatment-as-usual for pa-
tients with BPD (4). DBT was evaluated initially in a 1991
randomized trial and follow-up and assessed subsequently
in eight published randomized, controlled trials across ve
separate research centers (4). The evidence from these
studies has consistently demonstrated reductions in sui-
cidal behavior, suicidal ideation, and frequency of inpa-
tient hospitalizations, along with improved treatment re-
tention (4 6).
Despite the proven effectiveness of DBT as a major
approach to the treatment of borderline personality disor-
der, there is lack of standing presence in the treatment of
BPD in most psychiatric training curricula. A literature
review of the PubMed database for resident DBT clinics
produced two articles, each of which described the dif-
culty of implementing DBT-based treatment in a training
environment and the need for greater exposure to DBT
http://ap.psychiatryonline.org 325
DIALECTICAL BEHAVIOR THERAPY CLINIC
training during residency to increase the likelihood of its
use upon graduation (3, 8).
In order to improve resident psychotherapy training in
DBT, psychiatry residents and clinical faculty at the Uni-
versity of Utah developed a DBT clinic that began oper-
ation in January 2009. The purpose of this report is to
describe an innovative model that may be used by other
residency programs for the creation and maintenance of a
formalized resident-run DBT clinic that incorporates both
academic and clinical teaching and provides needed clin-
ical services to high-risk patients with personality disor-
ders.
Method
Design
The University of Utah Resident DBT Clinic was de-
signed to adhere as closely as possible to the model de-
scribed in Linehans classic text, Cognitive-Behavior
Therapy of Borderline Personality Disorder (6). Skills-
training groups were designed around the four skill mod-
ules described in Linehans Skills Training Manual for
Treating Borderline Personality Disorder (7). The follow-
ing key principles were incorporated into our clinic:
Referrals were initially screened by a clinician trained
in DBT. Acceptable referrals met criteria for BPD.
No medications were prescribed in the clinic, as patients
received medications from other providers.
Patients who passed the initial screening were expected
to sign a 6-month treatment contract stipulating required
attendance at both individual therapy sessions and skills-
training sessions every week.
Patients agreed that all therapists and skills trainers
involved in the DBT clinic would be actively involved in
their treatment and would have access to their personal
health information.
Patients agreed that if they missed more than three
consecutive therapy and/or skills-training groups, DBT
would be terminated for the duration of their 6-month
contract, after which they could negotiate a new contract if
desired.
The DBT contract permitted patients to contact their
individual therapists for telephone consultation and skills-
coaching during and outside of normal clinic hours, with a
goal of 24-hour telephone coverage. There was no require-
ment of 24-hour telephone coverage, which differs from
the original Linehan model (6).
Patients who engaged in self-harming behavior were not
permitted to contact their individual therapist by phone or
326 http://ap.psychiatryonline.org
in person for 24 hours after the self-harm behavior oc-
curred. Patients could contact other members of the DBT
team during this time period, as described by Linehan in
her model (6).
DBT therapists and skills-group leaders met weekly for
consultation group.
Implementation
The DBT clinic was integrated into the existing resident
psychotherapy clinic. Participation in the DBT clinic was
strictly voluntary for residents. The clinic utilized existing
administrative infrastructure in the resident psychotherapy
clinic. Because existing facilities and administrative re-
sources were utilized, no additional administrative ex-
penses were incurred. No departmental funding was re-
quested or provided. DBT Clinic patients were required to
pay the same nominal fee charged to all resident clinic
patients for each individual therapy session. No additional
fee was charged for the weekly skills-group meetings.
Senior residents at the University of Utah are required to
carry a minimum number of psychotherapy patients, and
the proposal was worded such that DBT patients would
count toward the required total caseload in the resident
clinic. Also, the clinic required two residents to lead the
DBT skills-group for 75 minutes per week. For skills-
group leaders, the proposal stipulated that the skills-group
would count as one patient in their required caseload.
Supervision and Training
Residents who participated in the DBT clinic were re-
sponsible for obtaining 1 hour of one-on-one supervision
per month from a faculty member for each patient. Also,
they were required to attend a weekly combined lecture
series and consultation group supervised by the clinic di-
rector. Furthermore, DBT clinic participants were ex-
pected to purchase and read Linehans Cognitive-Behavior
Therapy of Borderline Personality Disorder (6) and Skills
Training Manual for Treating Borderline Personality Dis-
order (7). All of the original participants in the resident
DBT clinic completed a 20-hour online CME course of-
fered by Behavioral Tech, LLC (9). Residents who at-
tended the 6-month lecture series, completed the online
CME course, completed 6 months of therapy with a pa-
tient, and passed a nal written exam administered by the
clinic director received a letter of certication as a DBT
therapist. To evaluate the DBT curriculum, residents took
a pre-test before beginning the course and a post-test at the
completion.
Academic Psychiatry, 35:5, September-October 2011

Results
Eight residents participated as individual therapists
and/or skills-group leaders during the rst 6 months of the
clinic. Each individual therapist was assigned one DBT
patient. Residents post-test scores signicantly improved
from pre-test scores. The average score on the pre-test was
3/20, or 15% correct, whereas, on the post-test, the scores
had improved to 19/20, or 95%.
The clinic did not experience any major administrative
problems during the rst 6 months of operation. Some
staff members initially expressed concerns about the po-
tential for undue burden on administrative staff, but these
burdens never materialized. Obtaining ongoing funding
for online DBT skills-training and certication, however,
remains a challenge.
Discussion
This Brief Report was designed to outline the creation
and implementation of a resident DBT clinic within an
existing residency curriculum to improve the educational
quality and application of DBT among psychiatric train-
ees. Psychiatric trainees completed pre-tests and post-tests
to evaluate the DBT curriculum. The resident DBT clinic
was also established to provide an innovative model for
improving and implementing DBT training in other psy-
chiatric residency programs.
The resident DBT clinic at the University of Utah was
successfully implemented into an existing residency train-
ing curriculum by: 1) utilizing the physical space and
administrative staff of a designated resident psychotherapy
clinic to minimize additional costs; 2) taking advantage of
a Medical Scholars grant to afford the fees associated
with the online skills training through Behavioral Tech,
LLC; 3) offering the seminar during non-didactic and pre-
clinic hours, to minimize interference with required clin-
ical duties; and 4) limiting this psychotherapy elective to
postgraduate Year 3 and 4 psychiatry trainees, who were
familiar with the standard operations of the resident psy-
chotherapy clinic. These steps enabled a time-intensive
and manualized therapy such as DBT to be incorporated
with minimal disruption into a standing psychiatric cur-
riculum.
The resident DBT clinic appeared to be successful in
improving the educational quality and application of DBT
Academic Psychiatry, 35:5, September-October 2011
LAJOIE ET AL.
in an adult psychiatry residency program. All eight psy-
chiatric trainees completed the 6-month lecture series and
online skills-training through Behavioral Tech, LLC, and
all passed the post-seminar evaluation. The combined av-
erage post-test scores were signicantly higher than the
combined averaged pre-test scores, suggesting that both
the lecture series and online training were effective edu-
cational tools in improving resident knowledge in DBT. A
letter of certication in DBT was also granted to each
psychiatric trainee who participated in this elective rota-
tion.
In conclusion, a resident DBT clinic has been success-
fully developed and implemented as an elective rotation in
the adult psychiatry residency training program at the Uni-
versity of Utah. Further sources of potential funding are
being explored to replace the Medical Scholars grant that
covered the costs of the online skills-training. Clinical
outcome data are also being collected to analyze psychi-
atric trainees efcacy in treating individuals with BPD
with manualized DBT.
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