Dialectical Behavior Therapy and the real deal: Multiple layers, multiple players

Dialectical Behavior Therapy is a very complex treatment- I think more so than the public realizes. Organizations that are adherently providing Dialectical Behavior Therapy services generally need to include individual psychotherapy, DBT skills groups, psychopharmacology consultation if needed, DBT consultation team meetings for the providers of DBT, and 24-hour on call pager availability. They should subscribe to assumptions about clients and therapists, be knowledgeable about research findings and publications, have a regular mindfulness practice, adhere to the 24-hour rule, and have a structured format for sessions which include diary cards, behavior chain analysis, and priority targets for treatment.  “Adherent” DBT treatment requires a pretty good grasp of not only the skills, but ways to teach and generalize skills to contexts outside of treatment based on functional analyses of behavior. DBT was originally designed to treat repeat suicide attempters. It has since been utilized to treat eating disorders, substance use, incarcerated populations, couples, families, older adults, adolescents, developmentally disabled clients, “difficult-to-treat” clients, and clients who don’t tend to benefit from “treatment as usual.” Because it has become so popular, clinicians have utilized DBT training to work with clients who are not so “severe”.  However, in general it is known for being a tough treatment for a tough population that involves tenacity for getting clients to change while at the same time maintaining compassionate acceptance.

DBT has been criticized because it is so complex- it is certainly difficult to implement and takes considerable effort and energy to maintain. DBT is generally practiced in settings in which there are multiple providers- popular settings include hospitals, VA programs, research clinics, day programs, community mental health centers, and prison systems. Private outpatient clinics that primarily provide adherent DBT exist, but seem to be less prevalent. DBT in many of these settings means getting treatment from trainees (they may not be licensed) – but treatment is more accessible as trainees cost less money.

Doing adherent DBT from a mental health and business perspective takes multiple players with multiple talents. If money isn’t coming from research grants or the business isn’t a non-profit, mental health clinicians have to be funded in some manner. In order for all the components of DBT to be in place, someone in the organization needs to attend to business, administration, and organizational matters. They need to make sure that the business is sustainable and profitable. Someone needs to be taking care of legal matters, such as employment law, hiring/firing of employees, considering mission statements and the direction of the organization, enhancing compliance with insurance company requirements (such as claim filing and tracking), and making sure that practice is ethical and HIPAA compliant. Like any business, someone needs to take care of marketing, referral sources, attracting clients, and providing good customer service. Due to the complexity of DBT, having a solid understanding of the treatment can take years, lots of good supervision, and a grasp of how to do not only individual psychotherapy- but group treatment and crisis coaching. It involves finding and supervising clinicians who are invested in doing the treatment, are willing to be available at all times by pager, are interested in taking on high risk clients, and who can sustain their own lifestyles in which they don’t get burned out or overwhelmed. In addition, if the clinic or program desires to have evidence of effective treatment, the clinic may have to employ someone with a research background to work on data collection and outcome measures. Like any person with strengths and weaknesses, it makes sense that having multiple players with multiple talents is needed for very complex and “adherent” DBT treatment- and that not all clinicians (or business administrators, or researchers) are created equal.

What I have to offer is unique because I have a strong background in group therapy and DBT and I love doing groups. My DBT training did not offer a strong background in groups, group therapy, group dynamics, and the general implications for structuring and maintaining groups. However, I was able to get this training in graduate school. Therefore, I have a stronger basis for offering DBT skills groups. What I love about DBT groups is that I can offer valuable content that can be flexibly adapted to the needs of my groups while giving my clients opportunities for shared experiences.