Dialectical Behavior Therapy Eating Disorder Program Diary Card - PDF

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					Implementing Dialectical                                                                                          Focusing on
Behavior Therapy                                                                                                     Based
Charles R. Swenson, M.D.
William C. Torrey, M.D.
Kelly Koerner, Ph.D.

Dialectical behavior therapy (DBT) is a cognitive-behavioral approach                      Description of DBT
to treating borderline personality disorder. Early empirical results are                   Dialectical behavior therapy is a cog-
promising, although they are not sufficient to establish DBT as an evi-                    nitive-behavioral therapy for the
dence-based practice in community settings. Nevertheless, the treat-                       treatment of borderline personality
ment has been widely implemented by mental health authorities, pro-                        disorder in which an ongoing focus on
gram leaders, and clinicians. The authors describe DBT’s four stages of                    behavioral change is balanced with
treatment, the functional areas addressed, and the treatment modes                         acceptance, compassion, and valida-
used as well as the reasons for the appeal of DBT to practitioners. They                   tion of the consumer. DBT’s biosocial
review barriers encountered by those who have implemented the mod-                         theory holds that individuals with
el and present strategies that have been developed to overcome the bar-                    borderline personality disorder have
riers. (Psychiatric Services 53:171–178, 2002)                                             a pervasive deficit in their capacity to
                                                                                           regulate emotions. The deficit origi-
                                                                                           nates in and is maintained by an on-

        orderline personality disorder        ing the effort of caring for people who      going transaction between the indi-
        is a formidable public health         experience repeated suicidal crises          vidual’s emotional vulnerability and
        problem. The estimated preva-         and frequent hospitalizations and            the environment’s pervasive pattern
lence in the general population is 2 to       whose mood is highly reactive. Con-          of invalidating the individual. As de-
3 percent (1–3). Fifteen percent of           sumers with the disorder often lose          fined in this treatment approach, in-
persons seen in outpatient clinics and        hope and resign themselves to chron-         validation is a complex construct that
about 25 percent of psychiatric inpa-         ic illness and palliative care.              includes the indiscriminate rejection
tients have the disorder (4–6).                  Despite an extensive literature on        of the communication of private ex-
   People with borderline personality         the psychotherapeutic treatment of           periences, the punishment of emo-
disorder present special difficulties to      people with borderline personality           tional displays but with intermittent
public-sector providers. Up to 80 per-        disorder, few approaches are support-        reinforcement of emotional escala-
cent have a history of parasuicide (7–        ed by research. Dialectical behavior         tion, and the consistent communica-
12), up to 67 percent have comorbid           therapy (DBT) is the only psychoso-          tion that emotional problems are eas-
substance use disorders (13), and 8 to        cial treatment with demonstrated suc-        ier to solve than they really are. DBT’s
10 percent eventually commit suicide          cess in several controlled treatment         biosocial theory explicitly supports a
(14–19). Individuals with the disorder        trials and is thus a promising develop-      nonpejorative stance toward individ-
constitute up to 40 percent of fre-           ment. Since DBT was introduced, the          uals with borderline personality dis-
quent recidivists in psychiatric hospi-       demand for it has been steady. The           order, which helps correct a common
tals (20,21). When borderline person-         purpose of this article is to briefly de-    tendency to blame them for their
ality disorder co-occurs with other           scribe DBT, review and critique its re-      maladaptive behaviors.
major disorders, such as affective ill-       search base, speculate on the reasons           At the beginning of treatment, the
ness and eating disorders, standard           for the appeal of DBT to practition-         consumer and the therapist collabo-
treatment approaches for the other            ers, identify barriers to implementing       ratively generate a prioritized list of
conditions are less effective (22–26).        DBT, and describe strategies for over-       specific behavioral targets for change,
Providers often have trouble sustain-         coming those barriers.                       which then guides the content of
                                                                                           therapy sessions. After gaining the
                                                                                           consumer’s commitment to the treat-
Dr. Swenson is associate clinical professor of psychiatry at the University of Massachu-   ment program, the therapist helps the
setts Medical School in Worcester. Dr. Torrey is associate professor of psychiatry at      consumer in stage 1 to establish be-
Dartmouth Medical School in Lebanon, New Hampshire. Dr. Koerner is president of the        havioral control and to master skills,
Behavioral Technology Transfer Group in Seattle. Address correspondence to Dr. Swen-       in stage 2 to resolve posttraumatic
son at 695 Kennedy Road, Leeds, Massachusetts 01053 (e-mail, crobert01@aol.com).           stress disorder, in stage 3 to address
PSYCHIATRIC SERVICES   o February 2002 Vol. 53 No. 2                                                                           171
issues of self-respect and individual       that compare the treatment with al-         up, those who received DBT report-
goals, and in stage 4 to increase the       ternative treatments or with no inter-      ed significantly fewer parasuicide
capacity for sustained joy. Each stage      vention (27). To date, five randomized      episodes, fewer episodes of medical
has its own prioritized list of targets.    clinical trials of DBT can be found in      treatment for parasucidal behavior,
For instance, in stage 1 the therapist      the literature—two of standard DBT,         fewer days of psychiatric hospitaliza-
tries to reduce life-threatening be-        one of an adaptation of DBT for             tion, and less anger than those in the
haviors, then behaviors that interfere      women with borderline personality           comparison group, and interviewers’
with therapy, and then behaviors that       disorder and substance use disorders,       ratings of their social adjustment and
interfere with quality of life. The final   one of an adaptation of DBT for wo-         employment performance were bet-
step in stage 1 is to help the consumer     men with bulimia nervosa, and one in        ter. They were also more likely to
increase the use of his or her skills.      which DBT-oriented treatment is com-        have stayed in treatment. One year
   The therapist works directly with        pared with client-centered treatment.       after treatment, those who had re-
the consumer to address problems               The original study by Linehan and        ceived DBT continued to have fewer
connected with his or her environ-          associates (28–30) was of women who         days of psychiatric hospitalization,
ment, or social-professional network,       met criteria for borderline personali-      better global adjustment, and better
rather than consulting with persons in      ty disorder and who had both a histo-       interviewer-rated social adjustment
the network about the consumer. The         ry of suicide attempts and a recent at-     and employment performance. How-
therapist uses a variety of techniques,     tempt. Some of the women received           ever, although DBT reduced parasui-
including behavioral chain analyses to      one year of standard comprehensive          cide more quickly, by 12 months after
understand behaviors targeted for           DBT. Women in the treatment-as-             treatment the women in the compar-
change, problem solving with cogni-                                                     ison group had a similarly lower rate
tive restructuring, exposure proce-                                                     of parasuicide.
dures, skills training, and contingency                                                    Koons and associates (31) replicat-
management. Progress in changing                                                        ed these findings at a Veterans Affairs
the targeted behaviors is monitored
                                                        Dialectical                     clinic by comparing a six-month course
daily by the consumer, who com-                                                         of standard comprehensive DBT with
pletes a diary card for review with the
                                                   behavior therapy                     treatment as usual. Treatment as usu-
therapist.                                                                              al was delivered by self-identified
   DBT’s comprehensive treatment
                                               is the only psychosocial                 cognitive-behavioral therapists. Par-
package orchestrates the delivery of                                                    ticipants were women veterans who
five essential functions through five
                                              treatment for borderline                  met criteria for borderline personali-
typical DBT treatment modes. First,                                                     ty disorder. Unlike the women in the
a weekly 2.25-hour skills training
                                              personality disorder with                 study by Linehan and her group,
group, which uses a DBT skills train-                                                   those in the VA sample were not re-
ing manual, helps enhance con-
                                                demonstrated success                    quired to have a history of parasuicide
sumers’ capabilities. Second, weekly                                                    or a recent suicide attempt. Thus the
individual psychotherapy—under
                                                 in several controlled                  VA sample was less parasuicidal and
some circumstances twice weekly—                                                        had a lower rate of previous hospital-
works to improve motivation for
                                                    treatment trials.                   ization. At the end of the six-month
treatment and behavioral change.                                                        treatment period, Koons and associ-
Third, consumers telephone their                                                        ates found that treatment retention
therapists between sessions for skills                                                  was good for both groups and that
coaching as a way to generalize the         usual condition were referred to sub-       those who received DBT experienced
skills to their natural environments.       stance abuse or mental health treat-        less suicidal ideation, depression,
Fourth, individual therapists and           ment programs in the community, or,         hopelessness, and anger than those in
group skills trainers meet in weekly        if they were receiving treatment            the comparison group.
consultation team meetings—consid-          when they entered the study, they              Linehan and colleagues (32) re-
ered mandatory in DBT—to enhance            were allowed to continue with indi-         ported on a randomized clinical trial
their therapeutic skills and to main-       vidual psychotherapy. They also re-         of an adaptation of DBT for women
tain or improve their motivation. Fi-       ceived case management as needed.           with a dual diagnosis of a substance
nally, DBT program directors struc-           After one year of treatment, wo-          use disorder and borderline personal-
ture the treatment environment, and         men who received DBT reported less          ity disorder. The adapted treatment
case managers help consumers struc-         anger and better global social adjust-      entailed four major modifications to
ture their environments.                    ment than those in the comparison           standard DBT: the addition of specif-
                                            group, and interviewers’ ratings of         ic targets relevant to drug use; a set of
Research findings                           their global adjustment were better.        attachment strategies intended to en-
The strongest level of evidence for a       The two approaches were equally ef-         hance patients’ connection to therapy
given treatment is the support of nu-       fective in producing clinically signifi-    and the treatment team; an optional,
merous randomized clinical trials,          cant improvement in depression. At          tapered drug-replacement program;
conducted by different investigators,       the six-month posttreatment follow-         and case management. Women in the
172                                                                           PSYCHIATRIC SERVICES   o February 2002 Vol. 53 No. 2
treatment-as-usual group received             that in client-centered therapy. In        apy is usually conducted by master’s-
multiple referrals for treatment in the       both approaches, six group sessions        level therapists whose experience
community. Both during treatment              that focused on significant interper-      varies. Although one study showed
and four months after treatment, the          sonal relationships were offered to        that people with different levels of
women who received DBT had sig-               participants. When treatment ended,        training can master the conceptual
nificantly less drug abuse than those         participants who received DBT-ori-         complexity of DBT, as measured by a
in the comparison group as measured           ented treatment had clinically signifi-    test (42), effectiveness studies of
by both structured interviews and uri-        cant reductions on measures of sui-        DBT delivered by typical outpatient
nalyses. In addition, the women who           cide and self-harm behaviors. They         therapists would provide consider-
received DBT were more likely to              also showed improvement on meas-           ably stronger evidence.
stay in treatment. However, no signif-        ures of suicidal ideation, were more
icant differences were found in the           likely to have remained in treatment,      The appeal of DBT
amount of medical or psychiatric in-          and had experienced fewer days of          Despite the lack of effectiveness trials
patient treatment received during the         psychiatric hospitalization. Those in      supporting the transfer of DBT to
course of treatment. Four months af-          DBT also showed greater improve-           routine community settings, mental
ter treatment, those in DBT showed            ment on measures of depression, im-        health authorities, program leaders,
significantly more gains in global and        pulsiveness, anger, and global psycho-     and practitioners have embraced
social adjustment and in state and            logical functioning.                       DBT with enthusiasm, and many have
trait anger.                                     In addition to these randomized         implemented programs. The fore-
   Safer and colleagues (33) conduct-         clinical trials, a number of other ex-     most factor contributing to the de-
ed a randomized controlled trial com-         periments and quasi-experiments add        mand for DBT appears to be the in-
paring outcomes for 31 women with             support to the use of standard and         tense need experienced by mental
bulimia nervosa who either received           modified versions of DBT (36–38).          health providers for a treatment that
20 weeks of individual DBT psy-                  The literature on DBT has recently      is clear, “do-able,” and effective.
chotherapy sessions or were assigned          been reviewed (39,40) and critiqued           DBT is an integrative approach that
to a waiting list. The major modifica-        (41). The findings most common             resonates with the current zeitgeist in
tions to standard DBT included a              across studies suggest that DBT re-        mental health care. It weaves togeth-
shorter treatment period, specific tar-       duces severe dysfunctional behaviors       er neurobiology, cognitive science,
gets relevant to binge eating and pur-        that are targeted for intervention, in-    behaviorism, a focus on trauma, and
ging, and inclusion of systematic skills      creases treatment retention, and re-       spirituality (43), which is appealing to
training, with use of a manual, in in-        duces psychiatric hospitalization. Al-     practitioners of any of these orienta-
dividual psychotherapy sessions. The          though published follow-up data are        tions, who find in DBT an avenue to
manual-based DBT focused on train-            limited, the available data indicate       expand and integrate their areas of
ing in mindfulness, tolerance of dis-         that improvements may remain up to         expertise. In its emphasis on skills de-
tress, and skills to regulate emotions,       one year after treatment (29).             velopment, self-care, a nonpejorative
all of which were drawn from Line-               Overall, these published reports        attitude, a staged treatment leading
han’s skills training manual (34). Us-        show that DBT is a promising treat-        to full recovery, and consultation with
ing an intent-to-treat design, Safer          ment for a population in great need of     the consumer rather than consulta-
and colleagues found that the women           effective services. It should be noted     tion with those in the consumer’s en-
who received DBT experienced high-            that three of the five randomized con-     vironment about the consumer, DBT
ly significant decreases in binge-            trolled trials (31,33,35) and all three    is also compatible with the recovery
purge behavior compared with the              of the experimental and quasi-experi-      and consumer empowerment move-
women on the waiting list. None of the        mental studies (36–38) were conduct-       ments. The specific behavioral tar-
women who received DBT dropped                ed by investigators who were not as-       gets, staged treatment, ongoing docu-
out of treatment.                             sociated with Linehan’s group. Nev-        mentation of outcomes, and cost-ef-
   Turner (35) compared a DBT-ori-            ertheless, additional studies by differ-   fectiveness (44) make DBT attractive
ented treatment with client-centered          ent groups of investigators in a variety   to managed care companies.
treatment by using an intent-to-treat         of outpatient settings would deepen           DBT is simple and coherent enough
design with a racially diverse sample         our overall understanding of DBT           to be understood by new practitioners
of men and women in a community               and could answer specific questions        and sophisticated and complex enough
mental health clinic. The two treat-          about the transferability of the prac-     to appeal to experienced therapists.
ments were delivered by the same ex-          tice to typical public mental health       The skills and strategies offer con-
perienced therapists over one year.           outpatient settings.                       crete pragmatic help almost immedi-
The DBT-oriented treatment condi-                One question is about the level of      ately, yet the comprehensive model
tion modified standard DBT with               training required. DBT therapists in       and treatment stages provide a road
psychodynamic case conceptualiza-             the randomized clinical trials were        map for long-term, recovery-oriented
tion and incorporated skills training         described as having years of experi-       treatment. The implementation pro-
into individual DBT psychotherapy             ence conducting therapy, and most          gram takes clinicians through a grad-
sessions so that the number of hours          had doctoral-level training. However,      uated learning process that leads to
of clinical contact was equivalent to         in typical mental health settings, ther-   competence in DBT practice and ad-
PSYCHIATRIC SERVICES   o February 2002 Vol. 53 No. 2                                                                         173
herence to the model. Finally, DBT’s        fort and start-up. The promotion of         setback. With the high turnover rates
requirement that skills trainers and        DBT can also fail if expectations for       in many community mental health
individual clinicians form a consulta-      program fidelity are not clearly artic-     settings, staff recruiting and training
tion team provides a mechanism for          ulated and reinforced. Because no           is an ongoing process.
ongoing education, support, supervi-        validated fidelity measure for DBT             Operational barriers can arise as
sion, and renewal for practitioners.        programs has been formulated, men-          the program leader defines and struc-
                                            tal health authorities and program          tures the DBT program within the
Barriers to implementation                  leaders must rely on DBT experts to         agency. Some leaders, hoping to max-
Public mental health authorities, pro-      determine adherence. In several cas-        imize the impact of DBT, have made
gram leaders, practitioners and their       es, DBT teams have been funded but          the mistake of modifying DBT for
clinical supervisors, and consumers         then allowed to drift, resulting in such    nonstandard populations and con-
all play important roles and face dif-      extensive modifications that the treat-     texts before establishing a viable stan-
ferent barriers in implementing prac-       ment no longer resembled DBT.               dard program. In a radical departure
tices in the public sector (45).               Finally, implementation can fail if      from the general culture of a commu-
                                            mental health authorities cannot            nity mental health center, DBT prac-
Public mental health authorities            work out funding mechanisms to cov-         titioners deliberately refrain from
Public mental health authorities,           er ongoing costs. Some programs             consulting with other professionals
sometimes working through public-           have enthusiastically implemented all       who are working with the consumer
sector managed care companies,              five standard DBT treatment modes           unless it is absolutely necessary, and
powerfully influence the allocation of      only to discover that available benefit     instead coach the consumer to inter-
finite public dollars among the range       packages cannot easily be adjusted to       act skillfully with other treatment
of treatment options. To facilitate the     cover even the first year of costs. In      providers. Unless those providers, in-
implementation of DBT, these au-            particular, standard benefit packages       cluding psychiatrists, inpatient staff,
thorities must be aware of the prac-        fail to reimburse fully for a 2.25-hour     and emergency services staff, are ad-
tice, give it high priority, and then       group, for two group therapists, for        equately oriented by DBT practition-
support it through effective policies       telephone consultation outside week-        ers to this policy, they may come to
and financing. Several factors keep         ly individual therapy, and for atten-       regard the DBT program as noncol-
public mental health authorities from       dance at consultation team meetings.        laborative. Given the intensity of con-
learning about DBT and giving it pri-                                                   flicts that can arise about the care of
ority. Adults with borderline person-       Mental health program leaders               people with borderline personality
ality disorder do not have the backing      Mental health program leaders set           disorder, fault lines can consolidate to
of any powerful advocacy group, so          priorities for care, seek resources, and    the detriment of the treatment envi-
political pressure to provide disorder-     structure the operational details of        ronment as a whole. Finally, to argue
specific services is lacking. Pressures     practice. Given the challenge of tran-      for the ongoing support of the DBT
to invest in DBT typically arise from       sitioning current clinicians and vul-       program, leaders must demonstrate
clinicians and program leaders who          nerable consumers to a new team-ori-        the success of the program by track-
are disenchanted with current ap-           ented model, program leaders must           ing important outcomes over time,
proaches, and occasionally from man-        understand and clearly assign priority      such as rates of suicidal behavior or
aged care companies in search of            to DBT to avoid getting sidetracked         days of hospitalization.
more cost-effective treatments. Nev-        by crisis situations. The work of pro-
ertheless, some public mental health        gram leaders is slowed if they do not       Clinicians
authorities who appreciate the poten-       strongly believe that individuals with      Clinicians face barriers in becoming
tial benefits of DBT balk at giving pri-    borderline personality disorder are         effective DBT therapists. For many
ority to a practice whose effectiveness     truly suffering, want treatment, and        clinicians, the shift requires a dramat-
in typical community health care set-       can get better. Some program leaders        ic reworking of therapeutic belief, a
tings has yet to be firmly established.     show a premature readiness to modi-         significant role redefinition, and the
   For public mental health authori-        fy the treatment package in response        acquisition of new skills. For some,
ties who do give DBT high priority,         to financial, political, or philosophical   repeated and painful treatment fail-
further barriers arise in the process of    pressures, not appreciating that high-      ures with consumers who have bor-
guiding and funding the implementa-         fidelity programming may be more            derline personality disorder have led
tion. Promoting DBT successfully is         effective.                                  to pessimism and burnout. Compet-
not simply a matter of contracting for         Program leaders face staffing chal-      ing demands in a practitioner’s work
clinician training. Several states have     lenges. Recruiting and retaining staff      can interfere with the time and focus
found that when intensive training for      to work with high-risk consumers can        necessary to learn to practice DBT.
clinicians was arranged before mental       be difficult, particularly before the          DBT is a behavioral therapy that
health program leaders had had a            team has developed a track record of        involves active and directive work to
chance to prepare for DBT adminis-          providing adequate support to thera-        analyze and change target behaviors
tratively, the clinicians’ lack of orien-   pists. Even when a team is staffed and      through cognitive restructuring, skills
tation, preparation, and commitment         going well, losing a trained, skilled       training, exposure procedures, and
has seriously impeded the training ef-      staff member can be a demoralizing          contingency management. Access to
174                                                                           PSYCHIATRIC SERVICES   o February 2002 Vol. 53 No. 2
training in these component proto-            focus on immediate behavioral              tion. Twenty-five people responded
cols is limited during both profession-       change to be jarring. For these con-       to our survey. Participants included
al and postgraduate training. Difficul-       sumers, the DBT therapist’s emphasis       mental health authorities, program
ty obtaining DBT supervision can in-          on behavioral assessment, behavioral       leaders, clinicians, consumers, and
terfere with on-the-job learning. Psy-        change, self-monitoring of target be-      DBT trainers and consultants. We
chodynamically trained clinicians are         haviors, skills training, and homework     also reviewed published descriptions
sometimes concerned that what they            assignments can seem superficial or        of strategies for implementing DBT
see as the root causes of the problems        off the mark. Even when consumers          in several settings, including inpatient
are being neglected. Those trained to         understand the general goals and log-      settings (49,50), a partial hospital
see borderline personality disorder as        ic of DBT, they sometimes cannot           (51), a community mental health cen-
a manifestation of poorly integrated          link that logic with their own prob-       ter (52), and a forensic setting (53).
aggression are likely to see DBT ther-        lems to see how the treatment could
apy as relatively blind to aggression         help them.                                 Public mental health authorities
and its vicissitudes, and therapists             DBT requires a considerable com-        Public mental health authorities con-
trained to be concerned about thera-          mitment from the consumer. To enter        sidering whether to invest in DBT
peutic neutrality may have trouble of-        DBT, most consumers must termi-            need a primer on the nature and
fering the extensive teaching and             nate treatment with their current cli-     scope of the problem of caring for in-
strategic self-disclosure required in         nician or clinical team, to whom they      dividuals with borderline personality
DBT. Some therapists object to                are often very attached. Shifting alle-    disorder, a clear description of DBT, a
DBT’s staged approach to posttrau-            giances to DBT team members who            summary of the research on out-
matic stress disorder, in which the           are trained to avoid reinforcing crisis    comes for consumers in DBT, tips on
systematic processing of memories             behavior can be difficult for con-         implementing DBT, an estimate of
and affects is attempted only after sta-      sumers when these same behaviors           the nature and costs of a DBT train-
bility and safety have been estab-            may have been reinforced for years         ing sequence that would result in
lished, although this staged approach         by the case managers, residential out-     functioning DBT programs, a tool
is normative in current trauma treat-         reach workers, inpatient staff, and        that can be used to measure program
ment models (46–48).                          emergency services personnel who           fidelity, and a list of other public men-
   To practice DBT, therapists must           have cared for them. The time com-         tal health authorities that have under-
do things that many are not accus-            mitment—a session and a lengthy            taken implementation and that can
tomed to doing, such as following a           skills group each week for a minimum       provide consultation.
treatment manual, giving homework,            of one year—can be daunting to con-           In an example of a successful pro-
reviewing a consumer’s self-ratings of        sumers, especially if their lives have     cess, one of the authors (CRS), acting
behaviors, and serving as the coordi-         been too chaotic to make long-term         as director of training for DBT and as
nator of the consumer’s treatment             planning possible in the past. The ex-     regional medical director in the
team. The active role of DBT thera-           plicit commitment to change behav-         Massachusetts Department of Men-
pists, which includes teaching skills         iors can frighten consumers who can-       tal Health, provided consultation to
groups, encouraging and coaching              not envision a life without self-harm      the Massachusetts Behavioral Health
consumers in the use of skills, and           or suicidal preoccupation. Finally, the    Partnership (MBHP), the statewide
taking crisis calls, is new to many cli-      prospect of entering a treatment that      managed care company for behav-
nicians. For DBT to work, therapists          explicitly identifies the goal of devel-   ioral health in the public sector, on
must also learn to rely on the consul-        oping a life worth living can set off      the development of DBT resources
tation team for advice, balance, and          consumers’ fears that with improve-        for public-sector consumers. MBHP
support rather than trusting only their       ment will come the loss of supports        clinical managers reviewed the re-
own judgment or the help of a one-            that are in place because of their se-     search and clinical literature in ad-
on-one supervisor.                            vere behavioral problems.                  vance of an orientation meeting in
                                                                                         November 1997. At the meeting, spe-
Consumers                                     Strategies for implementation              cial attention was paid to research
Common barriers that consumers                Although many factors favor the im-        outcomes, qualifications of DBT prac-
must overcome include changing                plementation of DBT, powerful barri-       titioners, and guidelines for determin-
their expectations of what constitutes        ers limit its widespread high-fidelity     ing the fidelity of a DBT program.
treatment, arranging their lives to fa-       implementation. Over more than a              MBHP then defined an enhanced
cilitate DBT treatment, and manag-            decade, those involved in the dissemi-     benefit package that would support
ing the emotions prompted by enter-           nation of DBT have developed a num-        standard DBT for consumers with
ing yet another form of therapy after         ber of strategies to overcome these        borderline personality disorder. To
repeated treatment failures. Having           barriers. The strategies described be-     receive the benefit, DBT programs
learned in previous treatment that            low were derived from the authors’         and clinicians had to meet credential-
change will come about through pro-           observations and from the responses        ing criteria and report outcome data
cessing memories of trauma or                 to a questionnaire that we developed       for each consumer every 90 days. By
through gaining psychodynamic in-             to administer to people who have           September 2000, 14 MBHP-creden-
sights, some consumers find DBT’s             been involved in DBT implementa-           tialed DBT programs had been im-
PSYCHIATRIC SERVICES   o February 2002 Vol. 53 No. 2                                                                          175
plemented in the state. At regular in-    therefore be prioritized, protected,        the knowledge and skills they need to
tervals, MBHP officials have interact-    and strengthened in each program.           implement DBT. Typically clinicians
ed with authorities in the Depart-        One state is considering raising the        are first introduced to DBT in grand
ment of Mental Health to adjust and       salaries of clinicians who stay with the    rounds, seminars, and professional
refine the benefit package for maxi-      agency for more than two years after        literature or on Web sites. They can
mum usefulness.                           intensive DBT training. Because             then learn it in sufficient depth to de-
  State mental health authorities in      some degree of clinician turnover is        liver the therapy from treatment
Connecticut, New Hampshire, and           unavoidable, program leaders should         manuals (26,34) and videotapes (55–
Vermont have insisted that agencies       organize focused and effective train-       57) for self-guided study. Clinicians
wanting to implement DBT form             ing materials that can be used repeat-      can also attend standardized one- and
planning teams of clinicians and ad-      edly. Many programs have developed          two-day introductory workshops that
ministrators before entering intensive    videotaped introductions to their           are designed to teach DBT and to
DBT training. The resulting high lev-     DBT program, have sponsored annu-           shift attitudes toward consumers with
el of preparation and commitment          al DBT seminars for any interested          borderline personality disorder in a
has ensured enthusiastic and well-or-     staff, have sent practitioners to DBT       compassionate direction. For clini-
ganized statewide dissemination.          update meetings, and have incorpo-          cians without training in behavioral
                                          rated updated training materials and        principles and protocols, behavioral
Mental health program leaders             exercises in the weekly consultation        treatment manuals for self-guided
Like public mental health authorities,    team meetings.                              study and continuing education work-
program leaders who are considering                                                   shops are also available. Specialty
DBT need a general introduction to                                                    workshops focus on DBT skills train-
the practice, along with details about                                                ing and DBT as adapted for sub-
structuring the model in an agency,                                                   stance abusers and adolescents. Op-
including the optimal use of training                 Numerous                        portunities to update skills and
funds and judicious selection of DBT                                                  knowledge and to learn how to imple-
team members. Expert DBT consult-                   public mental                     ment modifications in DBT, such as
ants can be hired to orient program                                                   those for substance abusers, can be
leaders to DBT, addressing biases             health programs have                    found at regional advanced two-day
about the consumer population, cog-                                                   workshops and at the annual meeting
nitive-behavioral treatments, and fea-      implemented dialectical                   of the International Society for the
sibility of implementation. One state                                                 Improvement and Teaching of DBT,
organized a day-long DBT workshop         behavior therapy and have                   where research presentations, sym-
focused on the needs of administra-                                                   posia, and poster presentations keep
tors. A regional mental health author-       developed strategies to                  practitioners up-to-date.
ity in another state offered a day-long                                                  However, the most inclusive train-
introduction to DBT for program                 overcome barriers                     ing format is the ten-day intensive
leaders and practitioners that includ-                                                DBT workshop for practitioners and
ed a series of presentations by estab-                 to its use.                    program leaders, which is designed to
lished DBT program leaders from                                                       get DBT programs up and running.
agencies in other parts of the state.                                                 In one statewide intervention, some
The format allowed the administra-                                                    evidence suggested that this format
tors who were unfamiliar with DBT                                                     helps frontline clinicians master
to have detailed discussions about                                                    DBT’s knowledge base (42).
feasibility and implementation strate-      To evaluate the success of their             The process starts in a pretraining
gies with experienced program lead-       DBT program, leaders must collect           commitment phase during which
ers. Some program leaders have            information about consumer out-             teams apply and are selected and dur-
joined practitioners in attending         comes and program fidelity. For the         ing which role induction takes place.
DBT’s standard 10-day intensive           former, a one-page DBT outcome as-          Teams are accepted only if a success-
training workshops, where they have       sessment form is available that pro-        ful DBT implementation seems pos-
formed collaborative bonds with oth-      vides a compact format for the moni-        sible. Solo practitioners are not ac-
ers in their agency while receiving       toring of all relevant outcomes (54).       cepted into the training. Trainers
consultation about program design         For the latter, a program adherence         serve as consultants to applicants for
tailored to their agency and about        measure has been developed and pi-          intensive training, sometimes sug-
their case presentations.                 lot tested and is now undergoing fur-       gesting preparation work before the
   Program leaders need to have           ther development.                           training. All participants are expected
strategies for retaining skilled DBT                                                  to commit to attending all ten days
clinicians. The DBT consultation          Clinicians                                  and to have read Linehan’s manuals
team is the mechanism within the          A variety of strategies have been de-       before the training begins.
treatment model that addresses de-        veloped to help clinicians change              The training itself includes team
moralization and burnout and should       their therapeutic beliefs and acquire       exercises and consultations that ad-
176                                                                         PSYCHIATRIC SERVICES   o February 2002 Vol. 53 No. 2
dress existing team problems, en-             second in priority only to targeting       oped strategies to overcome them.
hance team cohesion, and reduce               suicidal behaviors.                        The lessons learned from disseminat-
some potential barriers to implemen-             The first stage of treatment in DBT     ing DBT may be helpful to others
tation. During the initial five days—         is the precommitment stage, during         who are promoting the implementa-
part 1—the treatment is taught                which the consumer and the therapist       tion of other practices. o
through didactic methods, experien-           collaboratively identify the con-
tial exercises, role playing, and video-      sumer’s goals and convert those goals      Acknowledgments
taped DBT sessions. The training              into a prioritized list of behaviors to    Work on this paper was supported by the
team highlights DBT principles and            target. They also consider and agree       West Family Foundation through the
strategies in the management of the           on methods by which DBT will help          West Institute at Dartmouth and by West
                                                                                         Central Behavioral Health in Lebanon,
workshop. After part 1, there is a six-       achieve the goals. They specifically       New Hampshire. The authors thank Kim
month interval during which teams             discuss factors that may interfere with    Mueser, Ph.D., for his helpful comments.
and individuals practice the treat-           the consumer’s participation. Some
ment in extensive homework assign-            myths about cognitive-behavioral           References
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