to Emergency Helpline (22)The client was provided with an emergency helpline telephone number that is available 24 hours a day.Positive feedback was provided as the client promised to utilize the emergency helpline telephone number rather than engaging in any self-harm behaviors.The client has not used the emergency helpline telephone system in place of engaging in self-harm behaviors and was reminded about this useful resource.
23 Provide Therapist Contact Information (23)The client was provided with the therapist's telephone number for phone coaching of skills learned in therapy.The client was provided with clear instructions for proper use of phone contact, including establishing limits.The client used the provided telephone number and was appropriate in his/her/their use.The client used the provided telephone number but was inappropriate in his/her/their use and was redirected in this area.The client has not used the provided telephone number and was reminded of its usefulness.
24 Elicit Contact Contract (24)An agreement was elicited from the client that he/she/they will initiate contact with the therapist or an emergency helpline if the suicidal urge becomes strong and before any self-injurious behavior is enacted.The client completed “No Self-Harm Contract” in the Adult Psychotherapy Homework Planner (Jongsma).The client was reinforced as he/she/they promised to terminate self-mutilation behavior and to contact emergency personnel if urges for such behavior arise.The client has followed through on the non-self-harm contract by contacting emergency service personnel rather than enacting any suicidal gestures or self-mutilating behavior; he/she/they were reinforced for this healthy use of support.The client's potential for suicide was consistently assessed despite the suicide prevention contract.
25 Teach Distress Tolerance Skills (25)The client was taught about how to apply DBT distress tolerance skills and chain analysis.The client was reinforced for using distress tolerance skills and chain analysis to identify and intervene to reduce self-harm and suicidal behaviors.The client struggled to understand distress tolerance skills and chain analysis and was provided with remedial information.
26 Assign Self-Monitoring Homework (26)The client was assigned self-monitoring homework (e.g. DBT Diary Card) to help guide in-session chain analysis and problem solving.The client completed self-monitoring homework, and this was reviewed.The client did not complete self-monitoring homework and was redirected to do so.
27 Resolve Therapy-Interfering Behaviors (27)The client's pattern of therapy-interfering behavior (e.g. missing appointments, lateness, noncompliance, abruptly leaving therapy) was consistently monitored.The client was confronted for his/her/their therapy-interfering behaviors.The clinician took appropriate responsibility for the clinician's own therapy-interfering behaviors.Therapy-interfering behaviors were problem-solved.
28 Use Strategies to Manage Maladaptive Behaviors, Thoughts, and Feelings (28)Validation, dialectical strategies, and cognitive-behavioral strategies were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings.Therapeutic techniques as described in Dialectical Behavior Therapy in Clinical Practice (Dimeff and Koerner) were used to help the client manage his/her/their symptoms.Validation was consistently used to help the client manage, reduce, and stabilize mal- adaptive behaviors, thoughts, and feelings.Dialectical strategies, such as metaphor or devil's advocacy, were used to help the client manage, reduce, or stabilize maladaptive behaviors, biases, and feelings.Cognitive-behavioral strategies, such as cost-benefit analysis, chain analysis, and problem solving, were used to help the client manage, reduce, or stabilize his/her/their maladaptive behaviors, biases, and feelings.It was noted that the client has decreased maladaptive behaviors, maladaptive thought patterns, and maladaptive feelings.
29 Conduct Skills Training (29)Group skills training was used to teach responses to identified personal vulnerabilities and skill deficits.Individual skills training was used to teach the client responses to identified behavioral personal vulnerabilities and skill deficits.The client was taught assertiveness for use in abusive relationships.The client was taught cognitive strategies for identifying and controlling financial, sexual, and other impulsivity.The client has participated in skills training for specific behavioral problems, and the benefit of this treatment was reviewed.The client has not participated in group skills training and was redirected to do so.
30 Teach Skills for Regular Use (30)Behavioral strategies were taught to the client via instruction, modeling, and advising.Role-playing and exposure exercises were used to strengthen the client's use of behavioral strategies.The client was provided with regular homework assignments to help incorporate the behavioral strategies into his/her/their everyday life.The client was reinforced for his/her/their regular use and understanding of behavioral strategies.The client has struggled to understand the behavioral strategies and was provided with remedial information in this area.
31 Conduct Trauma Work (31)As the client's adaptive behavior patterns have been evident, work on posttraumatic sequela was initiated.The client was assisted in using his/her/their new adaptive behavior patterns and emotional regulation skills to reduce denial and increase insight into the effects of previous trauma.The client was helped to reduce maladaptive emotional and/or behavioral responses to trauma-related stimuli through the regular use of adaptive behavioral patterns and emotional skills.The client was assisted in tolerating the distress of remembering and accepting the facts of previous trauma and in reducing self-blame.The client has been noted to be successful in using his/her/their adaptive behavioral patterns and emotional regulation skills in managing the effects of previous trauma.The client has become more emotionally disregulated due to the trauma work and was redirected to use behavioral and emotional regulation skills.
32 Explore Schema and Self-Talk (32)The client was assisted in exploring how his/her/their schema and self-talk mediate his/her/their trauma-related and other fears.The client's distorted schema and self-talk were reviewed.The client was reinforced for his/her/their insight into his/her/their self-talk and schema that support his/her/their trauma-related and other fears.The client struggled to develop insight into his/her/their own self-talk and schema and was gently offered examples of these concepts.
33 Assign Exercises on Self-Talk (33)The client was assigned homework exercises in which he/she/they identify fearful self-talk and create reality-based alternatives.The client was assigned the homework exercise “Journal and Replace Self-Defeating Thoughts” from the Adult Psychotherapy Homework Planner (Jongsma).The client was directed to complete the “Daily Record of Dysfunctional Thoughts” from Cognitive-Behavioral Therapy of Depression (Beck et al.).The client's replacement of fearful self-talk with reality-based alternatives was critiqued.The client was reinforced for his/her/their successes at replacing fearful self-talk with reality-based alternatives.
34 Reinforce Positive Self-Talk (34)The client was reinforced for implementing positive, realistic self-talk that enhances self-confidence and increases adaptive action.The client noted several instances from his/her/their daily life that reflected the implementation of positive self-talk, and these successful experiences were reinforced.
35 Develop Hierarchy of Triggers (35)The client was directed to develop a hierarchy of feared and avoided trauma-related stimuli.The client was helped to list many of the feared and avoided trauma-related stimuli.The client was assisted in developing a hierarchy of feared and avoided trauma-related stimuli.The client's journaling was used to assist in developing a hierarchy of feared and avoided trauma-related stimuli.
36 Direct Imaginal Exposure (36)Imaginal exposure was directed by having the client describe a chosen traumatic experience at an increasing, but client-chosen, level of detail.Cognitive restructuring techniques were integrated and repeated until the associated anxiety regarding childhood trauma was reduced and stabilized.The session was recorded and provided to the client to listen to between sessions.“Share the Painful Memory” from the Adult Psychotherapy Homework Planner (Jongsma) was assigned to help direct the client's imaginal exposure.Techniques from Dialectical Behavior Therapy in Clinical Practice (Linehan, Dimeff, and Koerner) were used to direct the client's imaginal exposure.The client's progress was reviewed, reinforced, and problem-solved.
37 Assign Homework on Exposure (37)The client was assigned homework exercises to perform exposure to feared stimuli and record his/her/their experience.The client was directed to listen to the taped exposure session to consolidate his/her/their skills for exposure to feared stimuli.The client was assigned situational exposures