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New approach energizes agency

June 1, 2010
by Della Kinsolving Benham, LCSW and Shannon Harting, LCSW
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Dialectical Behavior Therapy program builds reputation and referrals for St. Louis 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.

JF&CS staff includes (from left to right): simon koski, shannon harting, esther scharf, smadar shenhav, and peter walker
JF&CS staff includes (from left to right): Simon Koski, Shannon Harting, Esther Scharf, Smadar Shenhav, and Peter Walker

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 (http://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,

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