“The DBT program has changed my life. It has helped me to reduce destructive behaviors that had been ruining my life.” This was a comment from a satisfaction survey distributed to participants in the Washington County Mental Health Dialectical Behavior Therapy (DBT) program last summer. Another wrote that DBT is “the most powerful mental health program I have ever accessed in over 30 years of dealing with my severe, chronic mental illness. This program teaches life skills in a way no other even approaches.” So what on earth is DBT?
DBT is a treatment developed by Marsha Linehan in the early 1990s to treat borderline personality disorder (BPD). This condition is characterized by rapid mood swings, repetitive self-injury and interpersonal chaos. It has been notoriously difficult to treat. The term “borderline” was first used in 1938 to describe patients who tended to get worse in traditional treatment and it later became a catchall category to describe clinically difficult cases. Clinicians treating patients diagnosed with BPD often felt frustrated and overwhelmed; treatment was rarely helpful. Clients receiving traditional treatment often felt blamed for their symptoms or were labelled as “manipulative” or “attention-seeking” by clinicians. Linehan’s premise was that clients diagnosed with BPD have difficulty managing overwhelming emotions and that they engage in certain behaviors, including self-injury, chronic suicidality and substance abuse, to escape from painful emotions. In essence, she proposed that the very behaviors that were so difficult to reduce were actually functioning, in the short-term, to help clients avoid emotional pain. Linehan stressed maintaining a stance of non-judgmental acceptance and also an urgent focus on helping clients change self-destructive patterns; this is the core “dialectic” in DBT. By focusing on helping clients learn to tolerate and manage difficult emotions, they become more able to avoid problematic behaviors and interpersonal chaos. Research on her treatment model has consistently yielded good results both in terms of reducing crisis-related behaviors but also in retaining clients in treatment.
In addition to being a challenging disorder to treat, borderline personality also tends to require an inordinate amount of resources to treat it. Nationally, clients diagnosed with Borderline Personality Disorder utilize between 15 - 20% of inpatient hospital beds. In fiscal year 2013, 19% of all Community Support Program (CSP) psychiatric admissions in the State of Vermont were individuals diagnosed with BPD although individuals with this diagnosis comprised only 10.4% of the CSP population. Because many are admitted with suicidal intent, discharge can be challenging. DBT has been shown to reduce self-injury and hospitalization rates and, consequently, tends to reduce costs associated with inpatient hospitalization and medical treatment in the emergency room. Clients receiving DBT at WCMHS evidence a dramatic drop in hospital utilization as well as reductions in self-injurious behaviors over the course of treatment.
DBT has a long and rich history here at WCMHS. We were one of the very first community mental health centers to try to implement the model. Marsha Linehan visited us in the mid-nineties to provide consultation and we have provided DBT services according to her model ever since. The DBT team at WCMHS includes clinicians from a variety of programs including CSP, Adult Outpatient, Children’s and Emergency Services. Team members join the DBT team because they are drawn to the model and want to provide more effective treatment to their clients. The team currently provides services to about 40 individual clients across programs and we hope to begin an adolescent DBT program this year. Treatment involves both individual therapy and a weekly skills group to help clients learn better ways to manage intense emotions. Individual therapists take calls at home to provide skills coaching if clients need help applying new skills. Team members also sit on a consultation team designed to improve their own skills and to provide needed support.
Front row (Left to right): Abby Tobias, Hayden Cooley, Mona Karia, Tess Larina Back Row (left to right): Sue Swindell, Sarah Lawrence, Chris Andresen, Becky White, Kathy Perry, Danielle Seymour, Ilana Pecan, Laura Philipps Missing: Lisa Barr, Mary Thompson, Jenn Taylor
As the director of the DBT program, I am honored and privileged to watch so many individuals work so hard to change their lives. Many have courageously faced enormous obstacles along their journey. The payoff is that once clients are more able to effectively manage emotions, not only do problematic behaviors diminish but many clients begin to lead lives that bring them joy. Many became able to maintain employment and build lasting relationships. Linehan views DBT as a “life enhancing program rather than a suicide prevention program.” The satisfaction of being a witness to this is what keeps me coming back to work each day.
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