Gold Award: Integrating Dialectical Behavioral Therapy Into a Community Mental Health Program

Over the past five years, a community mental health program in Manchester, New Hampshire, has effectively integrated dialectical behavioral therapy into its clinical case management model. The center has adapted this therapy, which was designed for treatment of parasuicidal clients with borderline personality disorder, to treat a variety of clients who are high utilizers of care. The result has been a dramatic reduction in service use and costs among a group of clients for whom past treatments showed little benefit.

The Mental Health Center of Greater Manchester is a comprehensive program serving a total population of 165,000 in the city of Manchester and seven surrounding towns. The center operates more than 30 programs in 14 facilities, with a staff of 356 and a budget of around $16 million. More than 5,000 clients receive services annually, including more than 2,000 persons with severe and persistent mental illnesses who are served in a state-funded community support program.

In the early 1990s it became apparent that despite the center's ongoing commitment of substantial energy and resources to the treatment of borderline personality disorder, clients with the disorder were experiencing little or no lasting impact. In fact, they often seemed to maladaptively use what was offered them in service of their symptoms. These clients were frequently in crisis and had high rates of use of costly acute care and crisis stabilization services. Short-term crisis remediation seemed the only consistent outcome.

Exploring other options, the center experienced some success with cognitive-behavioral therapy. As a result, in October 1993 the center invited Marsha Linehan, Ph.D., developer of dialectical behavioral therapy, to the agency as a consultant to train staff. More than 30 of the center's clinical staff attended her two-day workshop. Shortly thereafter, the center's executive committee asked the medical director of the community support program, Daniel Potenza, M.D., to form a committee to develop a model that would integrate dialectical behavioral therapy into the center's practice.

In December 1994 the center implemented a one-year pilot project. Two master's-level therapists, who had attended an intensive two-week training program with Dr. Linehan at her program site, ran the pilot group under the direction of Dr. Potenza. They screened and selected clients with borderline personality disorder for participation in the multicomponent dialectical behavioral therapy program. Data from the pilot program indicated dramatic clinical improvements among the 14 clients who had finished all four modules, and a total cost savings of nearly $375,000. Subsequent participants have shown the same positive outcomes.

Since 1995, with extensive direction from the assistant director of the community support program, Patricia Auciello, M.S., and a team leader from this program, Toni Paul, R.N.C., M.Ed., the center has applied the principles of dialectical behavioral therapy with other client groups, including borderline spectrum patients who are not parasuicidal and teens with borderline features. In addition, staff throughout the center who serve clients with borderline features have received training in the principles of dialectical behavioral therapy and apply its techniques prescriptively.

In recognition of its successful integration of the principles of dialectical behavioral therapy, which has resulted in improved treatment of seriously ill clients, the Mental Health Center of Greater Manchester was selected as one of the two 1998 winners of the Gold Achievement Award presented by the American Psychiatric Association. The center won this year's award in the category of small community-based programs. The winner of the award for a large, academically or institutionally sponsored program is described in a separate article on page 1341.

The Gold Achievement Awards, which each include a $5,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals Group, are presented each year to recognize outstanding programs for persons with mental illness and developmental disabilities. The 1998 awards were presented on October 2 during the opening session of the Institute on Psychiatric Services in Los Angeles.

The dialectical behavioral therapy program

Dialectical behavioral therapy is a modification of standard cognitive-behavioral techniques for the outpatient treatment of borderline personality disorder. Dr. Linehan describes persons with borderline personality disorder as reacting abnormally to emotional stimulation. They react more intensely to lower levels of stress than others and take longer to recover.

Dr. Linehan has attributed this characteristic to an innate biological tendency and to a childhood environment in which one's beliefs about oneself and one's environment are continually devalued and invalidated. These factors combine to create an adult who is uncertain of the truth of his or her own feelings and who vacillates in a way that makes it difficult to manage three dialectical dilemmas. First, persons with borderline personality disorder are alternately vulnerable to others and invalidating of themselves. Second, they experience "active passivity," or the tendency to approach problems passively and helplessly and actively seek a rescuer, or they exhibit "apparent competence," that is, they appear to be capable when internally things are falling apart. Finally, they are often in an intense and unrelenting crisis into which all persons around them are pulled, or they are isolated in inhibited grief.

Dialectical behavioral therapy is a structured method to engage clients in a behavioral change process by simultaneously accepting them as they are and providing them with tools they can use to change. The Mental Health Center of Greater Manchester has developed a program that consists of the basic components of dialectical behavioral therapy, which is centered on group skills training. Participants sign a 12-month contract and pledge to remain with the group for the duration of the year-long program. Those who drop out are eligible to receive only emergency services for the duration of the contract period. Staff seek to re-engage these clients using the strategies of orienting and committing described by Linehan.

Staff

The staff of the program consists of the psychiatrist-director, Dr. Potenza, a master's-level program supervisor, Ms. Auciello, and nine master's-level therapists—two with degrees in social work and seven with degrees in counseling. Two therapists also serve as team leaders.

Skills training

A didactic skills training group, co-led by two therapists, meets for two and a half hours each week. Group members use workbooks to complete four 12-week training modules. Each of the modules focuses on a different set of skills: core mindfulness, which involves paying attention to one's experience by observing, describing what is perceived, and focusing on one thing at a time; emotional regulation, in which participants learn to modulate dysregulation of painful emotions; distress tolerance, which is the capacity to accept oneself and one's situation without attempting to change them; and interpersonal effectiveness, which is the ability to initiate desired changes and maintain relationships and self-respect.

Individual therapy

Participants in the program also meet for one hour each week with an assigned therapist or case manager. Targeted at these sessions are particular problematic behaviors or events from the past week, which are explored in detail—describing the chain of events leading up to them, discussing alternative solutions, and examining what kept the client from using more adaptive solutions. Both between and during sessions, the therapist actively teaches and reinforces adaptive behaviors, especially as they occur within the context of the therapeutic relationship. The emphasis is on teaching clients how to manage emotional trauma rather than reducing or taking them out of crises.

Telephone consultation

Telephone contact, as needed, between the client and the therapist is a standard part of dialectical behavioral therapy. During these contacts, the client and therapist discuss how the client can apply recently learned skills and problem-solving techniques to upsetting events that occur between sessions.

Pharmacological intervention

To benefit from dialectical behavioral therapy, clients must be able to connect with the year-long process and participate in the groups. Dr. Potenza and the medical staff have developed a medication protocol to alleviate symptoms that interfere with therapy and that enhance participation. Positive symptoms of borderline personality disorder include affective instability and impulsivity. Typical and atypical neuroleptics are used to address mood disruption, and selective serotonin reuptake inhibitors seem to lessen impulsivity. Negative symptoms present as an inability to concentrate, which is not a good pharmacological target, psychosis, and dissociation. Some clients receive neuroleptics for psychosis, and atypical neuroleptics seem to provide better symptom control. Lorazepam is used to treat acute dissociation, and typical neuroleptics appear to lessen the frequency of episodes of chronic dissociation, especially among clients who self-mutilate.

Ancillary services

If appropriate, clients may gain access to ancillary services such as strategic case management, vocational services, benefits counseling and advocacy, community integration, and tutoring. Some clients are provided audiotaped modules to enhance skill development.

Funding sources and outcomes

The expanded program is funded at about $520,000 a year. More than $380,000 comes from third-party payers such as Medicaid and private insurance. The center has been able to sell the program as a package to managed care organizations, and those contracts supply nearly $60,000. The state provides about $85,000.

Data for the first 14 clients to complete their 12-month contract indicate dramatic and positive changes in the use of services compared with the year before program entry. The patients had a 77 percent decrease in hospital days, from 479 to 85 days. Use of partial hospital days decreased 76 percent, from 173 to 42 days, and a 56 percent decrease in crisis bed days was noted, from 170 to 73 days. Face-to-face contacts with emergency services were cut by 80 percent, from 61 to 12 days. Due to the nature of the program, the number of scheduled outpatient visits tripled for the 14 patients, from 438 days in the year before the program to 1,387 days during the program.

Although the cost of these clients' outpatient visits increased from $49,000 to $141,000, hospital costs for them decreased from $453,000 to $83,000. Total treatment costs were cut by more than half, from $645,000 in the year before program entry to $273,000 during the program.

Another significant outcome for the 14 clients was in vocational status. During the program, eight clients were employed, up from two in the year before the program.

Related programs

It became apparent early in the development of the program that a screening device was necessary to select appropriate patients for dialectical behavioral therapy. Thomas Fox, M.D., chief medical officer at the center, in collaboration with colleagues from other treatment facilities, developed both a self-administered questionnaire for patients and a structured interview to be used by staff in inpatient medical and psychiatric facilities or by outpatient behavioral health providers and primary care physicians. The instruments are used selectively with patients who are high utilizers of acute care and who have done poorly in terms of clinical outcomes and satisfaction.

In 1997 program staff identified the need for a weekly transition group for clients to enter at the conclusion of their 12-month contract. The group was implemented to reinforce skills and refine their application. Clients may remain in the transition group for one year. Clients also continue in individual therapy, and sessions are gradually reduced in frequency. The goal is to achieve independence from the system of care.

A less structured version of the program—called dialectical behavioral therapy "lite"—has been developed for borderline-spectrum clients who are not parasuicidal but who exhibit behavioral and emotional dysregulation. This program has proven particularly useful for clients with affective disorders and posttraumatic stress disorder.

A dialectical behavioral therapy program for adolescents who display traits that are consistent with a diagnosis of borderline personality disorder has also been implemented. A child psychiatrist and two master's-level child therapists run the program, which is an abbreviated 16-week course followed by a 16-week transition group.

Two treatment teams in the center's state-funded community support program for clients with serious and persistent mental illnesses have received training in dialectical behavioral therapy and apply its techniques prescriptively. They have found a cognitive-behavioral approach to be useful with many clients. Some of their clients with borderline features participate selectively in the skills training groups.

The center has implemented a self-help group for program graduates to maintain their skills and to reinforce the learned cognitive-behavioral approaches to self-directed symptom management. Graduate leaders run the group with mentoring support from program staff.

Conclusions

The effectiveness of dialectical behavioral therapy has drawn the interest of clinicians throughout the mental health center. Since the program's inception, staff have conducted numerous training and development sessions for other personnel. Currently, they conduct a monthly study group on the clinically integrated approach to dialectical behavioral therapy, which is attended by an average of 12 people. The program also receives numerous inquiries from other mental health providers seeking to improve care for this difficult-to-treat patient group.

The Mental Health Center of Greater Manchester has succeeded in the systemwide integration of a new clinical approach that has been proven effective by numerous studies. By giving staff clinicians new skills and tools, the center has enabled them to greatly improve the lives of clients in their care.

For more information, contact Thomas S. Fox, M.D., Chief Medical Officer, Mental Health Center of Greater Manchester, 401 Cypress Street, Manchester, New Hampshire 03103; phone, 603-668-4111; fax, 603-669-1131; e-mail, [email protected].