Dialectical Behavior Therapy (DBT) is an evidence-based treatment effective for the stabilization and treatment of individuals suffering from pervasive emotion dysregulation, interpersonal dysregulation, behavioral dysregulation, and chronic suicidality who over-utilize inpatient and outpatient mental health services.¹ DBT has been shown to be effective in treating Major Depressive Disorder, eating disorders, and Posttraumatic Stress Disorder.^2-5 Jackupcak and colleagues⁶ recommend that mental health providers seek out specialized training, such as DBT, specific to the treatment of high-risk patients. Given the Veteran’s Affairs (VA) top clinical priority of suicide prevention, DBT is an evidence-based treatment that would be in line with this clinical focus and has, additionally, been shown to significantly reduce VA mental health service utilization and associated costs.⁷

In the VA system, there are currently 38 comprehensive DBT Programs (DBT Sharepoint, accessed 9/1/20) and the numbers continue to rise. At the Washington DC VAMC (DCVAMC), providers noted the need for DBT Services and an initiative was spearheaded by Dr. Lea Didion to introduce and grow a comprehensive DBT Clinical Service. Dr. Didion and other providers began an informal DBT Consultation Team (DBT-CT) in March 2018 after implementing DBT Skills Only Groups in their respective clinics. Regular consultations with other DBT Programs in the country led the DBT-CT to reach out to Dr. Laura Meyers at the Orlando VAMC who has created a nationwide initiative to bring two VA providers who have both received DBT-specific training to a VA for a 3-day training with the first two days available to any provider interested in learning more about DBT and the third day specific to the DBT-CT in order to assist with the creation of a comprehensive DBT Service. This initiative also provides for one year of weekly consultation by one of the trainers to the DBT-CT as they launch their service. The feedback received about the DBT Training was overwhelmingly positive: “DBT training was helpful in order to be able to incorporate these powerful tools into the daily therapy work I do with Veterans” – Anonymous and “The training allowed me to develop a foundational knowledge of DBT. It has supported my work with veterans with PTSD specifically practicing and implementing distress tolerance and mindfulness skills. The training also created a community of providers where I know I can go to for consultation and/or sharing clinical successes.” – Dr. Opsahl.

At the DCVAMC, Dr. Didion applied for a VISN 5 MIRECC Recovery Seed Grant and launched the comprehensive DBT Clinical Service at the DCVAMC. The DBT-CT began with five licensed psychologists and two postdoctoral fellows and has grown since that time. Currently the DCVAMC DBT-CT is comprised of seven psychologists and multiple trainees. Unique to the DCVAMC the DBT Service is not clinic-bound and Veterans from across the hospital are eligible for enrollment provided they have a suspected full diagnosis of Borderline Personality Disorder (BPD) and two or more incidents of either self-harm, suicide behaviors, or hospitalizations in the past year. The first Veterans were enrolled in October 2019 and the impact of this service has been significant. The DBT-CT has received approximately 51 referrals/consults and of those, 22 Veterans (43%) have either been enrolled or are pending enrollment. Of the 16 Veterans who have been enrolled in comprehensive DBT, two were hospitalized during the course of their treatment and two engaged in a suicide behavior, which is not atypical given the level of risk and emotional dysregulation experienced within this population. What is noteworthy is that of the Veterans who have completed DBT there have been no hospitalizations required nor suicide behavior reports. This is especially relevant given that, due to the COVID-19 pandemic, the comprehensive DBT Service has moved to 100% telehealth services.

In order to promote the DBT Service and enhance referrals to the service, a number of training and outreach presentations have been held. Dr. Didion presented on DBT and BPD at the annual Mental Health Summit in 2019, Dr. Didion and Dr. Chiriboga presented at the Mental Health Grand Rounds at the DCVAMC on using the Biosocial Model to enhance engagement in DBT, and Drs. Didion (DCVMAC), Grossman (Baltimore VAMC), and Phalen (Baltimore VAMC) co-presented a webinar on DBT Implementation and Initial Outcomes at the Baltimore and DC VA Medical Centers for the VA National Mental Health Recovery & Wellness Webinar Series in September 2020. Perhaps most excitingly, in September 2020 the DCVAMC DBT-CT hosted a 100% virtual Introduction to DBT training and invited all providers from VISN 5 to apply. This 1-day training was the first VISN 5-wide training offered for DBT and 35 participants attended with representation from all VAs in the VISN. It is part of the DCVAMC’s commitment to furthering the understanding and application of DBT in order to help treat Veterans who are struggling with high-risk behaviors and emotional dysregulation. It is the hope of the DCVAMC DBT-CT to offer this training on an annual basis, as it was recorded and to include both live and recorded training. This training was highly regarded, and anonymous survey results include the following comments: “This was an absolutely amazing training. I found each aspect incredibly helpful. Thank you for sharing the experience and expertise.” “All of the presenters were extremely knowledgeable about the DBT topics they were covering. I learned a lot about potential skills that can be applied to people through the DBT model. Overall, very informative.” “This was a well-prepared and organized program. I enjoyed the instruction and opportunities to participate in the more interactive portions… The content was good and I appreciated the visual aids as well.” The most common request for future presentations was to have additional training offered for providers who are at different levels of familiarity and skill with DBT.

Other future directions include expanding the DBT Clinical Service with the hopes of an appointed DBT Coordinator with dedicated time to run and expand DBT offerings. It is the hope of the current DBT Coordinator, Dr. Didion, to act as an informal consultant to other VAs who are hoping to create a DBT Service about the lessons learned for implementation. Additionally, while telehealth has presented unique challenges to the delivery of DBT it has also reduced barriers to accessing care; with numerous Veterans indicating that they are engaging in treatment because it is being offered via telehealth. In fact, telehealth has been so positive, the DCVAMC is considering offering a telehealth DBT group on an ongoing basis.

For more information about this program contact Dr. Lea Didion: Lea.DidionMattice@va.gov.

Are you interested in learning more about the Small Grants Program for Recovery offered through the VISN 5 MIRECC? Please visit the Small Grants Program for Recovery webpage!

A note from the editor: The DBT program outlined by Dr. Didion was featured in a recent VA National Wellness & Recovery Webinar. If you are interested in signing up to receive announcements about upcoming webinars, please Subscribe to the VISN 5 MIRECC Resources (be sure to include Webinar Announcements when you subscribe!)

References

1. DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical behavior therapy is effective for the treatment of suicidal behavior: A meta-analysis. Behavior therapy, 50(1), 60-72.
2. Valentine, S.E., Bankoff, S.M., Poulin, R.M., Reidler, E.B. and Pantalone, D.W. (2015), The Use of Dialectical Behavior Therapy Skills Training as Stand‐Alone Treatment: A Systematic Review of the Treatment Outcome Literature. J. Clin. Psychol., 71: 1-20. https://doi.org/10.1002/jclp.22114
3. Hill, D. M., Craighead, L. W., & Safer, D. L. (2011). Appetite‐focused dialectical behavior therapy for the treatment of binge eating with purging: A preliminary trial. International Journal of Eating Disorders, 44(3), 249-261.
4. Rizvi, S. L., & Steffel, L. M. (2014). A pilot study of 2 brief forms of dialectical behavior therapy skills training for emotion dysregulation in college students. Journal of American College Health, 62(6), 434-439.
5. Bohus M, Dyer A. S, Priebe K, Krüger A, Kleindienst N, Schmahl C, et al. (2013) DBT for PTSD after childhood sexual abuse in patients with and without borderline personality disorder: A randomized controlled study. Psychotherapy & Psychosomatics. 82:221–233.
6. Jakupcak, M. & Varra, E. (2011). Treating Iraq and Afghanistan War Veterans With PTSD Who Are at High Risk for Suicide. Cognitive and Behavioral Practice, 18, 85-97. 10.1016/j.cbpra.2009.08.007.
7. Meyers, L.L, Landes, S.J., Thuras, P. (November 2014). Veterans' Service Utilization and Associated Costs Following Participation in Dialectical Behavior Therapy: A Preliminary Investigation, Military Medicine, 179(11), 1368–1373. https://doi.org/10.7205/MILMED-D-14-00248