key: cord-0058955-x95l478z
authors: Ellberger, Madelaine
title: Dialectical Behavior Therapy and the COVID-19 Pandemic: Building a Life Worth Living in the Face of an Unrelenting Crisis
date: 2020-09-29
journal: Shared Trauma, Shared Resilience During a Pandemic
DOI: 10.1007/978-3-030-61442-3_24
sha: 03a0c5e3b4413027e4301921baf8c7f8ae8d52f0
doc_id: 58955
cord_uid: x95l478z

The COVID-19 global pandemic has drastically altered the way in which the world operates and human beings interact. The COVID-19 pandemic has affected the bodies, finances, minds, and souls of every individual in more ways than one. People all over the world are feeling the impact of the increase of these stressors, with the psychological impact being potentially as great as the physical. Prior to the onset of this global pandemic, suicide was already considered a major public health problem (World Health Organization, Suicide. Retrieved from https://www.who.int/newsroom/fact-sheets/detail/suicide, 2018). This chapter will offer a reflection on the experience of providing dialectical behavior therapy (DBT) during the ongoing COVID-19 pandemic. An overview of DBT will be provided in order to highlight the impact of the pandemic on the provider, the patient, and implementation of the treatment itself. Obstacles and adaptations to treatment will be presented through the lens of the four components of DBT by way of narrative and clinical case examples.

"What on earth is going on and how are we going to make this work?". These were the words that repeatedly came to my mind beginning in March 2020 as news of the novel coronavirus, formally known as COVID-19, spread across the media as quickly as the virus itself spread throughout the globe. I, along with the rest of the world, watched as nation after nation swiftly entered into crisis mode and culminated in a screeching halt. In all areas of life, people swiftly did what they could to adapt their professional and personal lives to the new socially and physically distanced reality. This phenomenon, which is still persisting, shifting, and changing, is known among the psychiatric community as shared trauma (Tosone 2012) . Shared trauma is defined as the multidimensional response that mental health clinicians experience as a result of primary or secondary exposure to the same collective trauma as their patients (Tosone 2012) . While one can argue that the appearance of COVID-19 has left the entire world enmeshed together in an experience of collective trauma, this experience is particularly unique for mental health providers. As mental health clinicians, we immerse ourselves in the pain, joy, triumphs, and failures of other people's lives. However, with good training and supervision, we learn to separate ourselves from our patients' experience. It is rare that we find ourselves immersed in simultaneous trauma with our patients, and yet that is exactly what has occurred in the wake of the global pandemic. I, like my other clinician constitutes, observed with dread as we quickly were forced to accept that we must learn to practice and treat our patients through an Internet-linked webcam.

As a clinician practicing dialectical behavior therapy (DBT), I have spent many days and years staring directly at death and joining my patients on a journey toward navigating how and what it means to build a life worth living. DBT, written by Dr. Marsha Linehan (1993) , is an evidence-based treatment aimed directly at treating borderline personality disorder, chronic suicidality, self-injury, and extreme emotion dysregulation. The treatment provides a blueprint of skills for clinicians to help patients learn a new way of living, once described to me by a middle-aged patient as a new lease on life. From the start of the COVID-19 pandemic, I have leaned on DBT as a guide for myself both clinically and personally, just as I have helped my patients do so.

The COVID-19 pandemic has ravaged the bodies, finances, minds, and souls of every individual in more ways than one. The entire human population is feeling the impact of the increase in these stressors, with the psychological impact being potentially as great as the physical. Prior to the onset of this global pandemic, suicide was already considered a major public health problem (World Health Organization 2018) . According to the National Institute of Mental Health (2018), suicide is the 10th leading cause of death overall in the United States. It is important to note that the current pandemic did not cancel out all other health crises but rather is occurring alongside them. In reflecting on the experience of providing DBT in the age of COVID-19, I am reminded of a radical acceptance, a core strategy taught in the distress tolerance module in DBT skills training (1993) . Rejecting reality does not change it, and in order to change reality, you must first accept it. This chapter will offer a reflection on the experience of providing dialectical behavior therapy during the ongoing COVID-19 pandemic. In doing so, the chapter will provide an overview of DBT in order to highlight the impact of the pandemic on the provider, the patient, and implementation of the treatment itself. Obstacles and adaptations to treatment will be presented through the lens of the four components of DBT. Throughout the chapter, clinical case examples will be provided in italics to bring the discussion to life. Names, gender, and all other identifying information have been altered in order to maintain confidentiality.

Dialectical behavior therapy (DBT) was first created by Marsha Linehan (1993) as a cognitive behavioral treatment to reduce suicidal behaviors as a result of emotion dysregulation in individuals diagnosed with borderline personality disorder (BPD). The combination of interpersonal difficulties, the complexity of presentation with other comorbid issues, and high-risk behaviors often exhibited by individuals with BPD has led many mental health clinicians to label individuals diagnosed with BPD as untreatable patients (Fava and Ellberger 2020) . A large body of evidence exists to substantiate DBT as a successful treatment for individuals who meet criteria for BPD. Randomized controlled trials with adults diagnosed with BPD indicate that compared to psychotherapy by clinicians not trained in DBT (referred to as "treatment as usual"), standard DBT significantly reduces suicidality, self-harm, hospital admissions, emergency room visits, anger outbursts, and hopelessness (Feigenbaum et al. 2012; Linehan et al. 1991 Linehan et al. , 1993 Verheul et al. 2003) . This finding has been validated with adult populations being treated in outpatient clinics, on inpatient units, and in forensic institutions. According to the Cochrane Collaboration Review, DBT is the only treatment adequately supported by data to be deemed an effective, empirically supported treatment modality for BPD (Stoffers-Winterling et al. 2012) . DBT has also been identified as a primary or supplementary treatment modality for individuals with substance disorders (Lee et al. 2015; Pennay et al. 2011) , eating disorders (Harned et al. 2008) , and posttraumatic stress disorder (Harned et al. 2014 ).

Linehan has provided a solution to this problem in the psychiatric community in the form of DBT, an empirically validated, comprehensive, and effective mode of treatment for BPD. DBT is comprised of four main facets: individual therapy, group skills training, phone coaching, and consultation team (Linehan 1993) . At its most basic core, DBT is a treatment of emotions. Through a dialectical synthesis balancing acceptance and change strategies, patients learn how to both accept and manage their big emotions in order to gain more competence and sense of control over their life. As a DBT practitioner of several years, I will describe each of these facets using my own clinical experience to create a more robust picture of the way in which DBT works.

In considering the breakdown of the different components of DBT, I think about individual DBT as the place in which the patient and the therapist take a fine-tooth comb to the patient's experiences. The goal of individual therapy is to increase awareness of ineffective behavioral response patterns and create goals targeting changes in these areas in order to establish a more secure and rewarding life. In individual therapy, time is spent helping patients apply and generalize skills learned in group to specific areas of their life. At the same time, a part of the session time is also spent observing and processing the transactions between the therapist and the patient as a way to address patterns of behavior in vivo. These two components are crucial to the success of treatment, as in DBT we believe that without the mindfulness of what is pulling at us in the moment, we cannot begin to do something differently. Through the use of various interventions such as diary cards, behavior chain analysis, validation, and irreverence, the patient learns and practices slowing down their cognitive process enough to begin to understand the function of his or her behavior.

DBT clinicians are required to maintain the basic assumptions of the treatment, which call for a nonjudgmental and radically genuine way in communicating with the patient (Linehan 1993) . There is a broad base of literature that maintains that one of the greatest predictors of therapeutic success, regardless of disorder or treat-ment modality, is the relationship between the provider and patient (Choi-Kain et al. 2017; Flückiger et al. 2012; Woolcott Jr 1985) . Patients engaging in DBT have often endured prior relationships in treatment and in their lives in which they may have experienced rejection as a result of their pathology. The only way in which to help such patients believe that change is possible is through a trusting and caring therapeutic relationship.

Primary to the model, DBT also includes a group skills training component. When explaining the treatment to a new patient, I like to call skills group the "bread and butter" of DBT. Skills training group is where patients learn replacement behaviors in order to reduce and extinguish engaging in dangerous or impulsive behaviors in the context of emotion dysregulation. From a behavioral perspective, the concept of replacement behaviors is important. It allows people to practice a new way of being, rather than just expecting people to be different or feel different without instruction. In fact, learning and practicing skills builds a sense of mastery over the self and the internal experience and is considered by Linehan and those of us who practice DBT to be a significant component in recovery from borderline personality symptoms (Linehan 1993) .

Within the adult DBT model, there are four modules of skills, each of which correspond to the problem behaviors that bring folks into DBT (Linehan 1993) . These modules are mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. In my own experience, I would argue that the entire treatment model is couched in mindfulness. That is to say that one can't opt in their awareness to "do something different" if they aren't aware of what exactly is pulling at them and what else they could do to get what they need. That is what mindfulness provides, in my opinion -choices. Distress tolerance is the crisis management module. In this module, patients learn how to delay urges and decrease impulsivity by mindfully turning their awareness onto other stimuli (Linehan 1993 ). This module is particularly important in building behavioral control over suicidal and self-injurious urges, as well as other target behaviors (Linehan 1993) . The rationale for this module is simple and founded in basic learning principles: the less one reinforces a thought or behavior, the less likely it is to remain present and will eventually become extinct. Emotion regulation skills are what I like to call "life worth living skills." These skills help patients become more effective problem-solvers of their emotions, learn to create and break down reasonable goals, and behaviorally activate (Linehan 1993) . They literally help someone begin to live a life that looks like that which he or she may describe as desirable. Lastly, interpersonal effectiveness skills help people bring more balance into their relationships in order to maintain positive relationships and create effective boundaries. This set of skills is particularly helpful in helping patients tolerate and reduce ineffective behavior in the context of fears of abandonment or rejection (Linehan 1993 ).

By definition, phone coaching is the opportunity for DBT patients to engage in brief, out-of-session communication with their individual therapist in times of extreme emotion dysregulation and crisis. The main goal of phone coaching is skills generalization (Linehan 1993) . Particularly at the beginning of treatment, it is helpful for patients to reach out to their therapist in a time of crisis in order to utilize a skill in their environment in the moment, rather than engage in an ineffective behavior out of habitual patterns of responding. However, based on my clinical experience, I might argue that an equally valuable secondary effect of phone coaching is building and reinforcing the relationship between the patient and therapist. I have found that simply the knowledge that I am available to patients outside of session, in my "real life," helps the patient feel held even in the context of behavioral treatment. Out-of-session contact can also be used to make repairs between the patient and therapist or to share good news. We bring ourselves, our personalities, and our emotions into treatment in order to reinforce to patients that this relationship, even if it is therapeutic, is real.

The final component of DBT is the weekly consultation team meeting. The purpose of the consultation team is to ensure that each clinician is providing the best care possible with each patient. Each week, my DBT team meets for 3 h to discuss aspects of cases each clinician might be struggling with or have questions about. The team provides the clinician with valuable feedback from multiple perspectives on how to best help the patient. The consultation team upholds the primary tenant of the dialectical thinking, in that there is no one correct way of seeing a situation and solving a problem and no one absolute truth. The consultation team serves as "therapy for the therapist," providing validation and support in problem-solving to help the clinicians deal with their own therapy-interfering behaviors, emotions, thoughts, or burnout. DBT is not a treatment that should be done in isolation, as that stands in complete opposite of the notion of dialectical thinking. DBT clinicians deal primarily and consistently with very complex issues such as suicidality, self-harm, and trauma. Just as the therapist is on a journey with the patient, so, too, is the consultation team on a journey with the therapist.

I am a senior staff clinician at a private DBT outpatient therapy center in the New York metro area. We are considered one of the longest standing and largest DBT teams in the county, with the founders of my practice trained by Linehan herself. In early March, as the severity of the spread of COVID-19 increased in the United States, our team decided to begin working remotely via a HIPAA-compliant video platform. Suddenly, my team members and I went from seeing each other and working collaboratively for 10-12 h a day, to working in solitude, often haphazardly, in whatever room with a door we could find in our respective homes. Our patients went from the ritual of driving to our office twice weekly for individual session and skills group to having to face themselves alone over a video camera in order to receive treatment. True to the treatment itself, therapists and patients alike had to engage in a shared and collaborative experience of acceptance and change in order to maintain the continuity and quality of care that has saved and continues to save so many lives. It remains a testament to the strength and resilience of my patients, the solidarity and steadfastness of my team, and the brilliance and timelessness of this treatment modality that we have, and continue, to achieve the aforementioned goal of helping people build a life worth living in the face of what Linehan (1993) might call an unrelenting crisis. The remainder of this chapter will highlight the ways in which the pandemic climate has impacted clinicians and patients throughout the four facets of the treatment.

I never signed up to sit in front of a computer screen for what feels like endless hours. The art of psychotherapy is punctuated by the connection formed between two human beings, therapist and patient, in the service of a shared goal, healing. One of the greatest professional adjustments I have had to face during the pandemic is the experience of providing treatment, particularly individual therapy, over video conferencing. There is a notable, though difficult to operationalize, difference in the experience of connecting to a patient in person versus via teletherapy. Since the beginning of the transition, I find myself physically and emotionally exhausted after sessions because of the sheer amount of effort that is required to obtain what feels like the closest thing to an in-person session.

The identification and repair of therapy-interfering behaviors, and integral component of relationship-building and movement in DBT, has expanded to include online behaviors that get in the way of effectively engaging in session. It is important to state that in DBT we focus on therapy-interfering behaviors engaged in by both the patient and the clinician. This is a nod to the core assumption that therapists are not infallible and we make mistakes. This allows us to utilize our own ineffective behaviors to model and normalize to patients the process of problem-solving and effective interpersonal communication when issues arise. Teletherapy provides many opportunities for therapy-interfering behaviors on "both sides of the couch," as I like to say. Issues such as texting or using the phone during session, browsing the Internet/social media, and just general difficulty maintaining attention for 45 min on video are some of the most common behaviors that both myself and my patients have engaged in. Across the board my patients have reported having difficulty feeling connected to treatment at different times, regardless of whether they started treatment during the pandemic and have only experienced teletherapy or have been seeing me for many years and have established strong rapport. Many patients with borderline personality disorder struggle with fear of abandonment and feelings of emptiness (American Psychiatric Association 2013). The sometimes disjointed and sometimes distracted experience of individual therapy over Zoom has created circumstances in which patients' fears of abandonment or feelings of emptiness are sometimes activated and become part of the problem-solving of therapyinterfering behaviors.

Avery is a young adult patient and DBT graduate whom I have been treating on and off for 3 years, beginning when she was in high school. While at college Avery would seek treatment from a local provider as she attended school out of state and come back to see me over the various break periods. At the start of the pandemic, Avery's campus closed down, and she was forced to return home for the remainder of the semester. Upon returning home, Avery began seeing me again for weekly individual sessions. Initially, sessions focused on the goal of adjusting to living back at home with family, maintaining social engagement in a socially distanced climate, and creating a structure so that depressive symptoms would not worsen. Avery would come to session every week on time; however, after about 6 weeks or so, Avery seemed to have adjusted well to being home and began to have less and less to say in session. This has been a previously identified therapy-interfering behavior in the past with Avery, the function of which was identified as a fear of ending treatment and sadness around losing the relationship. As I became aware of this iteration of the behavior, I planned on addressing it directly in session with the goal of helping Avery to create a plan for temporary termination in the service of her learning how to assess her needs, effectively say goodbye, and tolerate feelings of sadness and emptiness.

During our Zoom session, I followed my plan and discussed what I saw going on in session and discussed problem-solving in what I thought was both a validating and yet firm manner. After session, I received an angry message from Avery outlining the ways in which I had failed as a provider, most notably highlighting observations of teletherapy-specific therapy-interfering behavior such as the sound of the mouse clicking or my eyes seemingly moving across the screen. While this was predominantly an emotional reaction to feeling abandoned by my suggestion that she may be ready to take a break from treatment, I had to acknowledge that dialectally speaking, there was some validity to her feedback, albeit the severity of the identified behavior may not have been accurate. In the moments of long silence or shrugs on Zoom, I had often found myself pulled to glancing down at my phone or briefly scrolling through an email. Both their truth and my truth were occurring side by

Avery's side, apologized for my ineffective behavior, and processed the emotions and thoughts fueling her email. Avery, in turn, was able to effectively express her sadness, feelings of shame as a result of a perceived abandonment, and anxiety about losing the relationship. Collaboratively, we problem-solved a way in which to both preserve the relationship and yet still take a pause from treatment. As a result, we created a plan that involved several DBT skills used for coping and a scheduled number of sessions we would maintain before taking a break from treatment. In addition, we directly outlined how to assess the need to return to treatment and how to utilize session time effectively.

There are striking differences between in-person group pre-pandemic and video conference group necessary during the pandemic. Aside from the face value importance of the role that skills group plays in the overall structure of the treatment, there are several secondary benefits that patients receive from engaging in skills group. Group can be considered a multilevel group, with participants at varying points of the first year of their treatment. Based on my observations from spending years leading DBT skills groups, this multilevel experience provides so many benefits for patients. It allows veteran members to display mastery over skills and model positive outcomes of engaging in the treatment through sharing their experiences over time in treatment. For newer members, participating in group with longer-standing patients provides concrete, real-life examples that this treatment does work and things actually can get better. Skills group in its design is inherently validating for the DBT patient, as it brings together a group of people all struggling with different and yet similar problems, with the goal of learning how to manage big emotions in a world where they have often felt othered. During in-person groups, members enter one by one, have the opportunity to say hello to each other and catch up in a friendly way before starting, and often continue to share in a casual manner during the 10-minute break that occurs during every group. While many DBT patients have struggled tremendously with interpersonal relationships and loneliness, the group provides the opportunity to experience a sense of belongingness in an effective manner.

The experience of Zoom group creates a barrier to the experience of community that is created during in-person groups. Patients can't really have side conversations with one another when everyone can hear every part of a conversation, and only one person's audio can be heard at the same time. Although there is still a break, it now involves each member muting themselves and turning off their video so they can take some time off the screen in order to account for the sheer fatigue that occurs from attending a 90-minute video session. Similar therapy-interfering behaviors that occur during individual therapy occur during group as well. In-person group leaders would address therapy-interfering behavior by speaking privately with the patient either before or after group. Over video, it has become much harder to effectively manage therapy-interfering behaviors in group and address them in an effective and non-shaming way. In addition, I find that there are more technological issues such as a participant's Zoom freezing in the middle of their example or someone being unable to access the link. These technological difficulties are particularly disruptive, especially because I have very little control over preventing them and solving them.

Due to the needs of our center, I began running a new skills group time slot in late November of 2019, prior to the COVID-19 outbreak. Generally speaking, running a new group tends to be more challenging because you are literally starting from scratch, with all members starting from zero in terms of skills group experience. With the onset of the pandemic only a couple of months after the start of group, just as the group was barely beginning to get its groove, we transitioned to teletherapy, and the group went virtual. Within the first few weeks, my group members dwindled from six to four, as several patients couldn't tolerate the experience of teletherapy. With an already somewhat lower energy group, the loss of two voices left me feeling like I had to work harder to make up for the challenges faced in virtual group. My usual teaching and engagement strategies did not seem to land in the same manner in teletherapy, and I noticed people engaging in other activities or even getting up and leaving the screen during non-break times, a distraction that did not occur in all of my years of leading in-person skills groups. I would do my best to find innovative ways to engage participants; however, the management of therapy-interfering behaviors felt like they were getting in the way. I tried many different behavior management strategies, such as irreverence, whole group contingencies, and reinforcing online group rules several times, none of which have seemed to maintain change.

homework examples and have seen this person provide feedback to other group members in a friendly and appropriate manner. While group has probably been one of the most continuously challenging aspects of providing DBT during the pandemic, I am hopeful that the natural flow of treatment will take its course, with new members being added over time. This might provide my current group members the opportunity to take on a veteran role and engage more, as I have seen happen so many times during in-person groups.

I have always had fairly broad limits with my phone coaching rules. However, I decided that in the wake of the pandemic, I would adjust my limits to reflect the ongoing crisis nature of the pandemic environment. While for many years I had made myself available for coaching calls between the hours of 7 AM and 1 AM every day, I decided to, for the first time ever, expand these limits to provide coaching 24 h, 7 days a week. I offered these new hours not only to my patients but also extended that to different doctors working the warzone of the hospitals to share with their colleagues in need of intervention. In my years practicing DBT, my friends and family have become accustomed to my "give me one second, I'm getting a patient call," as a dart away from the bar, dinner table, movie theater seat, or out of bed. The experience of working from home and particularly being quarantined for several months during the peak of infection in New York initially left me feeling like I had no break from or escape in my work. I would go from seeing patients for 12 h in my tiny little makeshift home office to transitioning onto the couch only to get a coaching call or text asking for help. I had nowhere to dart away to.

In addition, the extreme hospital overload in the initial months of the pandemic created a very uniquely complex dilemma surrounding patients at imminent risk for suicide. While the function of phone coaching is to help patients effectively manage a crisis in the moment through skill use, there are times in which the patient is not willing or able to maintain safety and needs to be hospitalized. Additionally, there have been times I have received calls from patients after making an attempt in which they needed to seek immediate medical treatment. These occurrences, though somewhat infrequent, are not uncommon among DBT clinicians, and I, myself, have had my fair share of them. However, COVID-19 threw a wrench in my otherwise welloiled machine that was the process of hospitalizing a patient. Especially in the first few months of the pandemic outbreak, I have had to ask myself at each and every suicidal crisis call questions like "Is this person's risk truly great enough to chance exposing them to COVID?", "Are psychiatric units even operating? Would this bed be better used to treat a dying COVID patient?", and "What will happen if the hospital is at capacity and the patient gets turned away?". Ultimately, if someone's life is imminently in danger, I have and always will send them to the hospital, as I don't take gambles with people's lives. That being said, COVID-19 has forced me to reevaluate my own risk assessment process and has created situations in which I must handle crises much more intensively than I would were hospitalization not to become another causality of the pandemic.

Lorena is an adult DBT patient who has not yet completed her first 6 months of treatment. Lorena has a significant developmental trauma history and meets criteria for borderline personality disorder. She has been chronically and acutely suicidal for several years in the wake of a number of significant interpersonal losses among family members and friends. Lorena thinks constantly about dying, has written suicide letters many times over the years, keeps several box cutters in different places throughout their house in order to have them available at any time, and engages in cutting as self-injury in order to practice and prepare herself for the act of suicide by cutting and bleeding out. In addition, at the beginning Lorena shared with me a few specific potential suicide dates she had planned in the upcoming months. One of these dates has come and gone since the start of the pandemic. 

Among all of the professional and practice adjustments I have had to make in the wake of the pandemic, the change in the consultation team experience has been the most significant. The consultation team is the heart and soul of every DBT practice, and there is nothing more special than my team. In between the heaviness that sometimes comes with treating our patients, the ability to socialize, debrief, or distract with my team members in the office has given me the support and comradery to be the expert DBT therapist I have learned to be. The milieu in my office is second to none, and it is sorely missed. Although my team and I all have one another's cell phone numbers and are available to each other at any moment in time, the special experience of the DBT team milieu is lost in the abyss of the Internet. My colleagues and I are no longer able to walk into each other's offices to get brief "hallway consultation" for a difficult situation. We no longer eat lunch together every week during our 3-hour consultation team meeting. The loss of interaction is, in my opinion, tangible.

The value of consultation team model is an often overlooked facet of the treatment; however, in the wake of the drastic restrictions placed on all of us during COVID-19, its place and purpose in the treatment have become impossible to replace. Simply put, DBT clinicians were not meant to practice alone. The consultation team is present not only to maintain the highest standard of care for patients, but, most notably, it also exists so that we can reduce the inevitable experience of burnout that comes with pouring your heart and soul into treating a group of patients whom are judged by the psychiatric community as "the most difficult patients to treat." Team meeting via video conference has significantly diluted the ability to mitigate burnout, sometimes actually adding to the burden that spending hours of Zoom places on all of our well-being.

Prior to has changed my team meeting experience, and for basically the first time ever, I find myself drifting away to social media or text messages when I usually listen mindfully, share gratefully, and support collaboratively. This is a shared experience among our team, and in true DBT fashion, we have spoken explicitly about this shift in the service of validating one another, problem-solving what we can, and collectively accepting what we must do about the reality of our current needs as clinicians and human beings. We lean on the treatment, which dictates that we lean on each other, as a way to move from shared trauma to shared resilience (Nuttman-Shwartz 2014).

As a final vignette, I will share a story about my team from our second week of quarantine. About 10 minutes before our team meeting was scheduled to begin, I received a call from a colleague and close friend of mine, frantically reporting that a very significant person in their life had died fairly suddenly from what was believed to be complications from COVID-19. On a personal level, I felt devastated for my friend and teammate. On a professional level, I knew I had to mobilize and help this person solve the immediate work-related issues that arose as a result of the crisis. I told my friend to inform the partners of our practice via text message of what occurred and swiftly drafted a text for this person to send to our bosses. In addition, I got a list of patients that would need coverage in the coming days while my friend grieved this loss from a distance. I provided that list to my bosses so they could figure out whom would cover each patient, because that's just what we do for each other. My bosses somberly shared the news with us before our mindfulness practice, and I know my colleague was flooded with concerned messages, cards, and fruit platters from our team both collectively and individually. We as a team reached out to my colleague's patients to inform them of coverage, managed any additional risk that came our way, and mindfully experienced the array of emotions that came with this experience. This is the value of the DBT team, and while things have drastically changed and continue to do so, the spirit of the DBT consultation must be maintained as a constant.

DBT asks both providers and patients to be willing to find a synthesis between acceptance and change. In DBT we are often looking at our patients' lives, our treatment, and ourselves and asking the question "what do we need to change and what do we need to accept in order to move forward?". The COVID-19 pandemic has called on the entire world to practice this dialectic in order to keep moving in the face of the uncertainty of the pandemic. This is true from on a global level all the way down to an individual treatment level. As DBT clinicians, the charge of adapting DBT to both maintain adherence to the model and adjust to the obstacles in the pandemic environment has, as I like to say, provided therapists with many opportunities to practice using skills. One of Marsha Linehan's most famous dialectical assumptions states that each and every person is doing the best they can at any given moment and at the same time can try harder and do better (Linehan 1993) . We as DBT therapists have been and will continue to do the best we can in any given moment to meet the needs of our patients and the treatment during this global pandemic. And, at the same time, we must continue to pause, reflect, problem-solve, and adapt as the world continues to shift and change with COVID-19.

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