Dialectical Behavior Therapy: Helping to Manage Out-of-Control Emotions and Teach Life Skills

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The Dialectical Behavior Therapy (DBT) program is a comprehensive treatment incorporating behavior therapy, mindfulness practice, motivational interviewing, and cognitive behavioral therapy. This evidence-based practice, initially developed by Dr. Marsha Linehan, PhD, ABPP, is currently being implemented by a team at the Lourdes Center for Mental Health (LCMH).

DBT is meant to treat patients who have suicidal or self-injury behaviors, as well as therapy-interfering behaviors that may get in the way of being able to benefit from traditional mental health treatments. Nicole Babcock, LCSW-R, adult therapist on the team at LCMH, describes DBT as an “intensive therapy that balances acceptance and change while helping patients to achieve a life that feels worth living.” There are a number of interventions that are provided throughout the year long program including: individual therapy, group skills training, phone coaching, and a therapist consultation team.

“It’s about accepting people for who they are while at the same time asking them to change. Accepting people for who they are is critical to getting them to be able to move towards changing, that’s the difference with DBT,” says Heather Hubeny, LCSW, CEAP, the adolescent therapist on the team at LCMH.

Rather than trying to treat everything at once, DBT works with patients in stages. “It gives us a strategy and tools to be able to work with clients who come in with such complex problems that it can be hard to know where to start,” says Babcock. The first stage of DBT addresses life-interfering and therapy-interfering behaviors and quality of life. Only after tackling those problems is it possible to start working on the secondary stage which focuses on working through the patient’s trauma.

Evidence shows that patients involved with DBT have decreases in their use of crisis services, suicide attempts, non-suicidal self-injury, substance abuse, depression and anxiety symptoms, angry outbursts/aggression, and the use of psychotropic medications. It also shows an increase in their remission from PTSD, depression, anxiety & eating disorder symptoms, hopefulness, life satisfaction, and the ability to cope with negative emotions.

Though in the pilot stage, LCMH is already seeing the positive benefits of their work with patients enrolled in the DBT program. “We have many patients who have been in therapy for a very long period of time, who have gone through multiple therapists or multiple psychiatrists because their problems are so intense and can be so overwhelming to try to make progress with. To see those patients be able to have measurable success and getting feedback in terms of being able to feel better about themselves, recognize their own emotions and understand where they are coming from is huge,” shares Babcock.

LCMH has higher group retention rates in the DBT program compared to stand-alone groups. In fact, meeting others that are experiencing similar issues during the group skills training has been so meaningful to participants that LCMH is getting requests to continue the group beyond the program.

As well, almost without exception, patients are beginning to show improvement in a number of areas. Babcock shares, “we have quite a few group members who have had long-term self-injuring behaviors that have had various response rates but all of them have shown a very significant decrease in self-injuring behavior.”

Eligibility criteria for the DBT program includes level 1, highest risk behaviors such as recent suicide attempts, suicidal statements, non-suicidal self-injury, serious therapy-interfering behaviors, incarcerations, police involvements, serious addictions and eating disorders (though people with addictions/eating disorders are required to be in concurrent treatment for addictions issues at the same time). After submitting a referral packet, patients at LCMH go through a full mental health assessment to determine the appropriate diagnosis. At that point patients are also assessed for the DBT program.

Patients make a significant commitment when they enter the DBT program. “I can’t say enough about the work that our patients have put it in,” Babcock remarks. Patients complete daily diary cards, homework for group and individual therapy and must also travel to LCMH twice a week for treatment which, with the population enrolled, can be a huge barrier in itself.

There are a number of strategies in place to ensure that patients are ready to make the commitment to the DBT program. A standard four session orientation & commitment phase is implemented at the start of the program. During this phase clinicians use strategies such as playing devil’s advocate as well as identifying long term goals that would make the patient’s life worth living. They then tie those tasks directly to the work they will be doing through DBT to help the patient understand the importance of completing them. “It’s working backwards from the goal to get those steps in place and then reminding that person that each task is going to get them one step forward towards their goal,” Hubeny says.

“When you’re working with people who have long histories of trauma, typically most of these people have PTSD diagnosis or some sort of trauma in their past, the ability to develop a trusting relationship is key to being able to make progress,” shares Hubeny. DBT applies a concept called “radical genuineness” to help achieve that connection. Babcock describes it as “this idea that it’s not a hierarchical interaction with the patient, it’s that you’re both on the same team working towards the same goals and you are being real with the patient.”

One example of radical genuineness is a patient asking a personal question of their therapist. In a traditional setting a therapist might inquire why the patient is asking the question. When using radical genuineness, if there is not a good reason not to answer the question, the therapist answers it honestly or they express that they are not comfortable answering it and give their reasoning. “Many times the people who have these types of problems [that lead them to DBT] have had a number of people in their lives who have not been straight with them, who have been afraid of their reactions if they told them the truth. We address things directly because that’s what’s most effective,” Babcock says.

DBT is positively affecting those enrolled in the program and their families, as well as the therapists implementing the program. A parent of a patient in the DBT therapy program comments, “My child has stopped & actually used DBT skills in situations. I feel my child is much less angry.” An adult participant echoes this sentiment, “I have started being more aware of triggers for my depression, anxiety, etc. and have been developing some skills that help in both working around and dealing with scenarios head on.”

“It’s a great privilege to be able to do this kind of therapy because it allows us to really see change happening, in the moment. That has been the greatest difference I have seen as a clinician,” says Hubeny.

Because the program is very intensive to provide between the labor, resources and training necessary, not every clinic in the area is able to provide this service. The team it LCMH is currently the only one in the area using a comprehensive DBT program. “I really credit Lourdes and Dr. Lavin, in particular, for spearheading getting this project off the ground because it is something really needed in this community and it’s something that none of the other clinics in this area are able to provide at this level,” says Babcock. This is a critical service that isn’t available to patients anywhere else within a one-hour drive of Binghamton. Tuition for the team of four clinicians to complete a 2-phase, intensive training in DBT was covered by Care Compass Network.

The staff at LCMH is incredibly grateful to CCN for providing funding for the training. Funding is the biggest barrier for implementing DBT. The current reimbursement structure for insurance does not allow for the program to remain fiscally sustainable without outside funding or compromising the structure of the program. According to Babcock, Medicaid drastically decreases the rate of reimbursement for clinics after a set number of sessions, generally 30. During their enrollment in the DBT program patients not only make weekly individual visits but also come for weekly group skills training. This could mean more than 100 visits a year, and under the current reimbursement structure, not all are fully reimbursed. This significantly decreases the financial sustainability of a highly effective treatment. “We are already prioritizing the treatment needs of our patients over the rate of reimbursement as we look to balance the competing priorities in offering this much needed service to patients in our area. In addition, the current reimbursement rate, even at full value, is not sufficient to cover the complexity of service that is provided through DBT, and is not differentiated from treatment as usual,” Babcock says. “We do have real hope that there can be meaningful changes at the state level that will make DBT not only more sustainable within our clinic, but also more accessible through clinics across the state,” says Babcock.