The Dialectics of Integrating DBT within a Multi-focal Treatment Program | The Retreat at Sheppard Pratt

The Dialectics of Integrating DBT within a Multi-focal Treatment Program

August 3, 2011 —

The Dialectics of Integrating DBT within a Multi-focal Treatment Program
Don Ross, MD, Medical Director, The Retreat at Sheppard Pratt

The Retreat at Sheppard Pratt was designed 10 years ago to address the needs of a varied group of patients who needed more intensive, expert treatment beyond what could be provided on traditional inpatient units or in the outpatient setting. The three anchors of the program were intensive psychotherapy (based on a psychodynamic understanding of each patient), expert biomedical evaluation and treatment, and a focus on wellness and the whole person (body/mind/spirit). This 3 pronged approach has been quite successful clinically, and over the past decade, the Retreat has grown from a 6 bed residential treatment unit to a 16 bed unit with an average length of stay of 35 days. After the first few years, we found those patients who struggled with emotional dysregulation benefited from learning mindfulness-based meditation and other skills that are well conceptualized and taught through Dialectical Behavior Therapy (DBT). Over time, we have increased the amount of time devoted to DBT (and expanded the expertise of our staff) to the point where DBT is now a 4th anchor in organizing our approach to treating our patients. We run 7 hours/week of DBT group therapy and DBT skills training for all patients and offer individual DBT consultations and treatment plans when indicated. DBT provides a set of principles which helps our nursing staff respond in a consistent manner to patients when they are in crisis. In turn, patients are more consistent in putting their newly developed skills into practice regarding their treatment issues.

DBT was originally designed as an evidence-based outpatient treatment for chronically suicidal patients with borderline personality disorder. Over time, it has proven to be effective for patients with trauma disorders, mood disorders, and addictions. DBT involves a combination of cognitive behavioral therapy techniques, Zen Buddhist approaches to acceptance and mindfulness, and an appreciation of a dialectical world view. We have found that many of these elements are helpful to the vast majority of our patients, from those with core borderline personality disorder to those with neurotic level personality issues that complicate Axis I disorders such as treatment-resistant depression, severe anxiety disorders, and addictions.

In the process of adapting DBT to our unit, we have found that certain inherent conflicts arose. A dialectical approach to resolving these conflicts areas has been very useful. A dialectical approach requires one to recognize that the “truth” often has two opposing sides, and that there is wisdom and utility in weathering the tension of disagreement while working towards a synthesis. We have found that understanding and embracing this dialectical process has been essential as we integrated DBT into the other components of our treatment program.

For example, we always have been a program sympathetic to the unique, individual needs of each patient. At times this has meant that patients who were too depressed to attend groups were treated in modified individual sessions until they were able to benefit from group work. The opposing “truth” was that some patients were inadvertently being reinforced for not attending groups and the additional individual attention was contributing to dependent regression and undermining the full therapeutic power of group cohesion.

As we increased our DBT group therapy offerings, we came up against this tension more directly. Eventually, we responded by offering individual tutorials focused on helping the patient attend group. Patients were reinforced with more individual attention from the DBT leaders as they attended group more regularly and could stay through more of the sessions. The individual time outside of group remained focused on maximizing their capacity to benefit from the group. The net result over time has been nearly 100% attendance at groups and a stronger group experience for everyone, with a clear focus for staff and patients for those times that a patient has needed individual help.

Another example of dialectical tension that emerged was the difference in focus between a psychodynamic approach to treatment and a DBT-based approach. A psychodynamic approach works with the “truth” that the past determines the present (and future), and to understand the past is to give power to the patient to change things going forward. A thorough exploration of how a patient came to be stuck in depression, addiction, or borderline behaviors can be useful or even essential. On the other hand, DBT appreciates the “truth” that a focus on the past can be an unproductive exercise, draining time and energy from actually changing problematic behaviors and attitudes. Regrets about the past and worries about the future are a major source of suffering. DBT emphasizes the value in staying with the present moment as one develops the skills to make a better future possible. Patients can get caught in the confusion of these differing approaches if therapists or nursing staff become rigid in their stances.

It has been important to keep open a dialog within the therapy staff that highlights these competing points of view. What has emerged is a more integrated role of understanding the past as one means of getting underneath entrenched patterns of thinking and acting so that they become accessible to change. Simultaneously, patients learn new skills of mindfulness and interpersonal effectiveness which allow them to put insights into action in their current day world. Often, making changes in behavior on a trial basis stirs up powerful feelings, which then allows for a more meaningful understanding of the past as it lives within the patient currently. For example, a depressed patient who confronted her husband’s lack of sexual interest in her was flooded with feelings and inner judgments about being a slut and unworthy of love. This brought up in a new way her experience of her mother’s critical view of her during adolescence, which could now be reevaluated and integrated into a new and healthier self concept.

We have seen how psychodynamics and DBT are complementary, especially in cases where previous efforts at treatment have failed. Whether the patient is working on past, present, or future, the therapist becomes a partner in the work and validates the patient’s experience, offering the necessary emotional support throughout.

Finally, integrating DBT into an already strong therapy program has highlighted the dialectics of effective leadership as a group attempts to change. On the Retreat, we have skilled and experienced psychodyamically-trained therapists who are committed to their work. Asking them to change their perspective in order to integrate a “new player” such as DBT presented a challenge. At the same time, our DBT coordinator is an equally talented and experienced therapist, who is committed to using DBT in its most effective form. Nursing staff, who provides the “holding environment” for the Retreat, has found DBT to be an effective organizing paradigm in their work with patients in the evenings, especially when they are processing distressing material. All of the therapy and nursing staff are dedicated to alleviating the suffering of our patients and creating the conditions for a better life.

Leading this integration has required me to create a structure for change and then use the talents and energies of the therapists to creatively fill the spaces created. For example, I took the position that all patients will have an immersion experience with DBT skills training in the course of a month stay on the Retreat. A more intensive DBT skills training program was developed in response to this, building upon the best of what had been an 8 week program. Diary cards are now required and used for keeping track of problem areas. Using this mechanism, we work with patients to see how their developing skills and a dialectical perspective can be helpful in addressing their identified problems. Homework is assigned and reviewed, with staff available for help in the evenings. Attendance at groups is expected and therapists are not to schedule individual appointments during group times. When a patient misses a group or a therapist takes a patient out of a group, this is addressed as a therapy interfering behavior that needs our full attention.

After some initial discussion and debate, I pushed forward these changes, even though not everyone was on board with them. I simultaneously created a variety of forums to encourage spirited dialog and learning from each other. We have a DBT consultation team, a staff reading and discussion group, a doctor’s meeting, a 2 hour staff meeting, and open “office hours” on the unit. In each of these forums, therapists and nursing staff discuss principles of DBT in the context of clinical situations and other perspectives on treatment. Our weekly staff meeting has shifted to include a focus on behavioral targets for each patient for that week. Through this approach, DBT has become integrated into the Retreat program and there is even more discussion among team members than before. This vitality is felt in the clinical work and in staff satisfaction with the work we are doing. The dialectical approach to change has proven to be useful for staff change as well as in helping our patients to change.