New approach energizes agency

In the behavioral health field, it is commonly believed that the introduction of new, evidence-based treatment approaches into agency practice meets many challenges including excessive startup costs, staff turnover, difficulties in “fitting” the new treatment approach to the agency's target populations, and insufficient training of staff.

Jewish Family & Children's Service (JF&CS) of St. Louis has a success story to share regarding the planning and implementation of a Dialectical Behavior Therapy (DBT) program. Originally developed by Marsha Linehan, PhD, to treat consumers with borderline personality disorder, DBT has been shown to be beneficial in treating other high-risk clients as well. Dr. Linehan's research demonstrated that clients who participated in DBT experience a significant reduction in hospitalizations, self-injurious behavior, substance use, trauma-related symptoms, anxiety, and depression, along with an overall improvement in their quality of life.

DBT treatment principles combine cognitive behavioral therapy with eastern philosophical approaches, especially the mindfulness part of the treatment and skills training. A full DBT treatment program, to be considered evidence-based, must include the following:

• DBT skills training group: Classes to teach clients skills that help them cope with very painful experiences, improve their relationships, and focus on important priorities and their emotional ups and downs more effectively;

• DBT individual therapy: Psychotherapy to help the client apply skills learned in groups to their individual issues;

• DBT consultation team: Weekly meeting of DBT therapists that enables them to consult, train, and help each other to maintain the most effective balance (validation of the client along with challenging the client) in their therapeutic work; and

• DBT phone consultation: 24-hour coaching of the client in using and applying skills.

Other critical components of a DBT program include:

• Leveling/elimination of the traditional therapy hierarchy where the staff members are positioned as experts/superiors relative to the consumer;

• Staff who practice the same skills that are taught to the consumers;

• Creation of a specific treatment contract between the therapist and the consumer;

• Dialectical interventions (balancing of validation and challenging of the client); and

• Use of daily diary cards by consumers to reinforce their use of skills.

In early 2007, the JF&CS manager of clinical services set a goal of having the clinical services staff trained in Dialectical Behavior Therapy within 12 months. Initially, she thought that it would be necessary to bring in outside trainers, since none of the existing staff had experience with DBT. She planned to host a DBT workshop and invite enough community professionals to defray the expense of training our own staff.

However, following staff vacancies in August and December of 2007, our clinical services manager was fortunate to find and hire two well-qualified staff members who were in the midst of completing DBT training. In February 2008, the manager hired a third individual trained in DBT who had conducted DBT skills training groups for over four years in a previous position.

More about Dialectical Behavior Therapy

What is it? DBT is a form of cognitive behavioral therapy that incorporates elements of mindfulness from Eastern philosophies.

When may DBT be indicated? DBT is a proven intervention model for consumers who:

• Struggle with suicidal thoughts or attempts;

• Engage in self-harming behaviors;

• Have frequent hospitalizations; or

• Meet criteria for borderline personality disorder.

In what other circumstances may DBT be appropriate? DBT has been shown to be effective in treating eating and substance abuse disorders and may be a good alternative for consumers, regardless of diagnosis, who:

• Display impulsive behaviors;

• Require a more structured therapeutic approach to establish and maintain limits; and

• Have been in therapy for an extended period and appear “stuck.”

What training is required to use DBT? Behavioral Tech (https://www.behavioraltech.org), founded by DBT creator Marsha Linehan, PhD, offers training for interested clinicians that typically involves:

• Completing a basic two-day course and an intermediate two-day course which cover the DBT philosophy and the skills to be taught in the skills training groups;

• Participating in ongoing DBT consultation groups regularly to continue developing and practicing skills and interventions that are used in DBT work with individuals and groups; and

• Moving on to advanced training that typically involves modules geared to working with specific populations, such as adolescents.

In March 2008, our DBT program expanded in two ways as we launched a DBT skills training group for consumers and committed to training all clinical services staff through scheduled in-service programs. The in-service program introduced the skills taught to DBT participants in the four modules of the program:

• Core mindfulness,

• Distress tolerance,

• Emotion regulation, and

• Interpersonal effectiveness.

Soon, we realized that about two-thirds of our potential DBT clients were referred from a specialized, county-funded program for residents with incomes at or below the poverty level who lacked health insurance. We subsequently negotiated a group therapy rate with the steering committee for this program and, as a result, were able to significantly underwrite the costs of providing DBT to this group. Consumers with other payer sources included group insurance, Medicare, and Missouri Medicaid “carve out” programs. We found it easy to fill up DBT groups, usually consisting of a maximum of 13 to 15 consumers, and found that group attendance typically averaged 10 attendees.

Our DBT skills training group for adults was originally divided into the four modules-core mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness-with each module presented in eight to 10 group sessions. More recently, the consultation team at JF&CS modified the DBT module structure. Modules presenting distress tolerance, emotion regulation, and interpersonal effectiveness are each preceded by three sessions devoted to core mindfulness. This change aligned our group structure more closely to DBT research models and acknowledged the huge significance of core mindfulness to the entire practice of dialectical behavior skills.

With the support of our executive leadership and necessary budget-related approvals, we also reconceptualized the DBT training workshop idea into a workshop aimed at community professionals. Our first workshop, held in January 2009, brought in 35 professionals, reflecting increased interest in DBT as a therapeutic intervention among mental health professionals in St. Louis. Marketing and recruitment costs for the workshop were minimal since they relied primarily on electronic communications and networking by staff with members of local professional networks.

We continue to build on our DBT skills through a variety of opportunities:

• Opportunities for direct service staff with incomplete DBT training to join our DBT consultation team;

• Continued refinement of our DBT consultation team, including the adoption of more frequent meetings to match the latest DBT protocol;

• Advanced DBT training, provided by the Missouri Department of Mental Health (MDMH) in June 2009;

• Development of the DBT telephone consultation piece of the DBT protocol; and

• Ongoing contact with and between the MDMH's DBT consultant and our local DBT team to foster greater knowledge exchange and improve our local training capabilities.

A very positive result of the DBT consultation team has been our ability to provide greater support for staff working with consumers who present with the most challenging problems. The members of the DBT consultation team express a great deal of excitement about the ideas, knowledge, and hopefulness they receive from this aspect of DBT.

It is important to note that, after two years of operating the DBT Skills Training Groups, we have no problem maintaining full groups. In fact, because of the many outside referrals that have been attracted by our DBT program, our agency found itself with a wait list of consumers seeking DBT programs. So, we created a second adult DBT group in March. Currently, we are focused on raising additional funds to implement an adolescent DBT program with a target launch date of September.

Why did DBT work for JF&CS?

• We have clinical staff that were very interested in this model of treatment and willing to study, debate, and embrace the DBT treatment approach.

• We have a committed, enthusiastic clinician who championed the process, helped staff work through the initial challenges of the DBT approach, and who remains our “point person” for the program with our manager of clinical services.

• We had 100 percent support from senior executives and management, who recognized that our agency's consumers would have better outcomes, that our reputation would be enhanced, and that the revenues realized would more than cover the costs of DBT planning and startup.

Della Kinsolving Benham, MSW, is a licensed clinical social worker and manager of clinical services, and Shannon Harting, LCSW, is a clinical social worker at Jewish Family and Children's Service ( https://www.jfcs-stl.org) in St. Louis, Missouri. Behavioral Healthcare 2010 June;30(6):25-27