Clinicians experience high levels of distress when caring for patients with complex needs. Team members may not know how to support one another. If unaddressed, burnout and disengagement may develop. Traditional clinician wellness programs often task individuals to seek support outside of their professional roles and teams.1 However, such programs fail to leverage team members as valuable sources of support. We propose that clinicians would benefit from skill-building within teams to manage emotions, build mindfulness, tolerate distress, and communicate validation of varying team member perspectives. While these skills may be unfamiliar to clinicians, there is a rich history and evidence base to draw from Dialectical Behavioral Therapy (DBT). In this article, we briefly describe DBT and share lessons from our early experiences in implementing a DBT-informed care team within the Comprehensive Care Program at the University of Chicago.
Developed by psychologist Marsha Linehan in 1993, DBT has demonstrated efficacy in treating borderline personality disorder, with applications to a variety of other mental health conditions.2 The goal of DBT is to develop a life worth living through organizing behavior around a set of commitments, instead of feelings, urges, and thoughts. DBT seeks synthesis between the dialectical principles of change and acceptance, with the goal of enhancing patients’ and team members’ motivation, capability, and skills. In addition to patient-facing components of treatment (individual therapy, group skills training, phone coaching), a core component of DBT is the consultation team that provides a regular forum for clinicians to support one another and manage the high stress and potential burnout of treating clients with high behavioral health needs, including suicidality.3
DBT’s intentional commitment to clinician well-being through embedding consultation teams within its core structure presents a radical and exciting model for health care settings; yet, guidance on implementation is currently lacking. Over the past two years, our Comprehensive Care Program at the University of Chicago adapted these DBT principles into our weekly Complex Care Rounds. The Comprehensive Care Program is a primary care program that is focused on patients at increased risk of hospitalization, and which features primary care and interprofessional team continuity across both inpatient and outpatient settings.4 Our Complex Care Rounds (CCR) were modeled after DBT consultation groups, designed as twice weekly, 45-minute sessions attended by an interprofessional team, including social workers, community health workers, administrators, physicians, students, and AmeriCorps volunteers. The overall goal of CCR is to facilitate team communication and enhance clinician motivation and efficacy while formulating complex needs interventions. Each month, core attendees take turns serving as facilitator and process monitor. Each meeting begins with the process monitor reviewing and reaffirming the commitment of all team members to abide by the team’s consultation agreements, which are a set of shared assumptions built from DBT principles (see table).5 By their nature, assumptions cannot be proven, and yet each team member agrees to operate as if they are true when joining the consultation group, thus reducing the team’s distraction and struggle to get to certainty. Following consultation agreement review, the facilitator triages cases for discussion based on a patient/clinician needs hierarchy, with 1-3 cases discussed at each meeting. During the case consultations, team members consider both the needs of clinician and patient when providing validation, sharing perspectives, and suggesting resources. The process monitor reviews the group processes at the end of each meeting, flagging the team if an agreement is not observed during the session.
We present the following three early lessons from implementation:
Lesson 1: Transforming a traditional medical team to a DBT-informed care team requires a shift in the group’s assumptions, focus, approach to care, and group processes.5 A core assumption of DBT is that team members and relationships between team members and patients need support. Thus, the focus of the group’s work shifts from patients alone to patients, team members and team culture. The dialectic of acceptance and change is emphasized in the approach to both the care of patients as well as the work of team members. Team members work together not only to share information and coordinate patient care, but also to intentionally reflect on group process, with openness to mistakes and shared vulnerability. Our team observed that the shift toward a DBT approach takes time and practice, with more rapid assimilation of newer members when these members are integrated into an established team.
Lesson 2: Shared consultation agreements (or shared assumptions) are foundational to guiding consultation team discussions and team culture. These agreements aim to foster an inclusive team culture with a “both/and” perspective, promote behaviorally specific language, encourage team members to observe personal and professional limits, and acknowledge that mistakes are universal (see table). We noticed that over time the agreements became a shared language among team members and are frequently referenced to remind ourselves and each other to search for synthesis among differing perspectives and to promote team communication.
Lesson 3: Embedding structural elements that promote a DBT approach can help operationalize the cultural transition to a DBT-informed care team. We developed a patient/clinician needs hierarchy, with an accompanying 4-point scale, to prompt team members presenting cases to rank both the patient’s need level (1 = needs interfering with health and/or life; 4 = resource needs that could improve valued living) and one’s own personal level of need/distress (1 = high level of distress impacting care provided; 4 = team member perspectives would add value). Cases are prioritized for discussion based on a mean of the patient and clinician need levels. The needs hierarchy helped introduce and invite new members to communicate their own needs and provided a consistent approach to prioritizing case discussions.
In summary, DBT principles provided a compelling roadmap and model for integrating clinician well-being within the structure of our healthcare team. If you are interested in incorporating DBT principles into your personal and team practice, consider the following suggestions for next steps you can take to get started: 1) Highlight both clinician’s and patient’s needs during case discussions by introducing the case hierarchy of patient/clinician needs or encouraging team members to regularly share how a case has affected their well-being; and 2) Model use of consultation agreements when discussing patient care as a team by using behaviorally specific language when describing the actions of patients and acknowledging that all team members, including ourselves, make mistakes.