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.
- West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. Nov 5 2016;388(10057):2272-2281. doi:10.1016/S0140-6736(16)31279-X.
- Linehan M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press; 1993.
- Walsh C, Ryan P, Flynn D. Exploring dialectical behaviour therapy clinicians’ experiences of team consultation meetings. Borderline Personal Disord Emot Dysregul. 2018;5:3. doi:10.1186/s40479-018-0080-1.
- Meltzer DO, Ruhnke GW. Redesigning care for patients at increased hospitalization risk: The Comprehensive Care Physician model. Health Aff (Millwood). May 2014;33(5):770-7. doi:10.1377/hlthaff.2014.0072.
- Sayrs J, Linehan M. DBT Teams: Development and Practice. New York: Guilford Press; 2019.
Clinical Practice, Hospital-based Medicine, Leadership, Administration, & Career Planning, Medical Education, SGIM, Wellness
Ms. Gier (email@example.com) is a licensed clinical social worker in the Comprehensive Care Program (CCP), Section of Hospital Medicine, University of Chicago. Ms. Maurer (firstname.lastname@example.org) is a rising first-year medical student at Rush University. Dr. Tang (email@example.com) is an assistant professor in the Comprehensive Care Program (CCP), Section of Hospital Medicine, University of Chicago.