The Use of “Bug-in-the-Eye” Live Supervision for Training in Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) has been shown effective for the treatment of borderline personality disorder (BPD) and other high-risk, suicidal, and diagnostically complex populations. However, little has been written about how to train therapists in DBT’s highly structured framework of target hierarchies, behavioral chain analyses, and stylistic strategies. This case study illustrates the utility of a live supervision method known as “bug-in-the-eye” (BITE) in training a novice DBT therapist. “Willow,” a 35-year-old Hispanic female with BPD, engaged in 6 months of comprehensive DBT that included 25 individual therapy sessions. BITE supervision was implemented in Sessions 12 through 17. Therapist adherence to DBT was assessed from Sessions 8 to 21. Client and therapist satisfaction with BITE was assessed after Session 21. Results indicate that therapist adherence to DBT increased following the implementation of BITE supervision. In addition, both therapist and client found BITE supervision to be acceptable and minimally intrusive, with the therapist reporting increased confidence in delivering DBT. Furthermore, results indicate that DBT was effective in reducing Willow’s suicidal ideation and self-harm urges, decreasing her feelings and displays of intense fear and jealousy, and increasing her independence. Recommendations for implementing live supervision into DBT training settings are provided.