Your Experience with DBT in the community psychiatry

[Marasmus1]

I am curious about the experiences of community psychiatrists referring patients with BPD to therapists with DBT background.
As we are all aware, research has proven significant benefits of DBT in overall BPD symptomatology (Although drop out rates even in the well crafted research studies can go as high as 50%). In my outpatient practice, approximately 20% of my patients have diagnosis of BDP or BPD traits. I have been referring them to therapists in the community who market themselves as DBT therapists.

Now, based on my experience with my patients (my sample size is probably around 40 or so), I haven`t observed any significant change in their overall BPD symptoms even after a year of therapy. Maybe a couple of patients have made some significant progress but they were quite high functioning to begin with. Overall, my observation is that majority of my patients continue struggling significantly with interpersonal relationships, identity disturbance (ever changing interests, hobbies, friends, sexual partners, jobs etc..) and inner void (emptiness, boredom, unable to invest self into goals, values etc.)

I highly doubt any of these therapists performing the manualized version of DBT that M. Linehan tested empirically. However, working with most of these patients over a year and not seeing even small progress kind of burn me out. For seasoned and experienced psychiatrists in this forum;

1) Why is there such a discrepancy between the research validated therapy and my experience with this therapeutic modality in the community samples.
2) Are there any suggestions what I can do for these folks besides providing psycho-education and treating their co-morbidities? (which is a different ballgame as my experience is that unless there is some improvement in their BPD, the improvements in their comorbidities are quite temporary with frequent relapses)

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[smalltownpsych]

My experience has been that most therapists that say they do DBT know very little about it. Even those few of us that do know what we are doing struggle with how to implement Linehan’s DBT in the community since she utilizes a structured and intensive program with a treatment team and I am not sure who is going to pay for that. Give me six months to a year of groups and skills coaches and twice a week individual therapy and I’ll get the results.

 

[splik]

The key part of DBT is the skills group. Are you referring them to the groups? If they aren't doing the groups, they aren't doing DBT. while working with an individual skills therapist is also part of DBT it is secondary to the groups. You need to refer them to a program, not an individual therapist.

 

[Marasmus1]

The key part of DBT is the skills group. Are you referring them to the groups? If they aren't doing the groups, they aren't doing DBT. while working with an individual skills therapist is also part of DBT it is secondary to the groups. You need to refer them to a program, not an individual therapist.

Yes but only DBT groups in the town is 10 days partial hospitalization program. So 6 months to 12 months group skills is non existent. There are many ''DBT inspired'' individual therapists who take these clients.

 

[hamstergang]

I highly doubt any of these therapists performing the manualized version of DBT that M. Linehan tested empirically.

1) Why is there such a discrepancy between the research validated therapy and my experience with this therapeutic modality in the community samples.

I think you answered your own question.

 

[Marasmus1]

I think you answered your own question.

Well my second question though is what am I going to do with these patients? I am not able to help them with their core BPD symptoms

 

[splik]

Well I think you have answered your own question. DBT is not available to you. General Psychiatric Management for BPD is pretty reasonable for the masses who cannot access DBT. In terms of suicide attempts and self-harm, and reduction in hospitalizations, they are equivalent in efficacy. GPM assumes the pt is in weekly dynamically oriented therapy typically in a split treatment model with a separate psychopharmacologist.

 

[Sikrouf]

I ve reached the same conclusion regarding how important dbt could be for a huge portion of my inpatients so ive started doing a dbt skill training group myself a year ago (i m a very young psychiatrist with 3 years of experience, took me around 6 months to feel

I was doing the manualized version of linehan (both skill training and the 1983 one)

I ended up doing 3 sessions a week:
90 mins skill training for inpatients
90 mins skill training for outpatients low functioning (no stable relationship no job)
A session if 60 mins doing only exercice available for both groups

So patients were doing around 2.5 hours of dbt a week with me
Some of them also had a psychologist who was doing "some" dbt but in 2 years i didnt manage to make them read the damn books let alone apply them
I was also managing medication for some of them but didnt do much appart from deprescribing for most

Had around 12 patients total
It worked for everyone
It basically worked so well that i quickly started practicing it myself and it basically changed the way i am in ways i could not imagine
When i mean worked im talking real life functional improvement such as not coming back to the inpatient unit, went back to working full time and so on

I ve had 3 patients who attended to one or two sessions then left, otherwise no attrition

I m now leaving the public hospital and will try to continue in private practice

Long story short my experience with it was mind blowing, and thats with me not being the smartest guy in the room, with little to no experience
I can only imagine what happens with the full package and someone who knows what hes doing, but my patients and i will be long dead before they have acces to this

My advice ? same as always, when you want something done, do it yourself : P

 

[deleted1100659]

Closest legit DBT group is probably around >2 hours away. That is mainly why.

BPD, either they hate you or love you. Or both. I had one today who complains about me everytime yet she still makes f/u appts with me every time. Some of my BPD im able to give medication to help ease the sx and they're thankful for that and very receptive. Others just never get better no matter what you do. I think thats just psychiatry. Some people you cant help.

 

[calvnandhobbs68]

I mean I don't think real deal DBT is available to most people. I don't consider myself any kind of DBT expert but I think one of the criticisms of the original DBT program is that it's heavily resource intensive and part of the "improvement" is really just the heavy amount of support the patients are getting (real DBT you essentially have a treatment team with a clinician on call 24hrs a day to field crisis phone calls for "phone coaching"....so yeah you're gonna reduce ER visits, hospitalization and self harming). @smalltownpsych put it pretty well.

 

[FlowRate]

I had the opportunity during residency training to work in a longer-term DBT PHP program for 6 months with therapists and psychiatrists who trained under Linehan. So I've seen how "full course" DBT looks. But that was in a very highly funded CMHC setting for a select group of pts with particularly severe BPD.

The organization I'm in now has a not super useful "DBT lite" group and another "full DBT" group that is perpetually booked and impossible to get patients into. I have seen similar issues in other organizations, as well. As with everyone else here, just not enough community availability of appropriate group treatment. Surprising in the sense that paying for individual therapists for a bunch of patients seems way more expensive than groups would be. (Although let's be honest that usually individual thx is baseline so group is in addition.)

 

[Ironspy]

The only DBT programs available where I am are at the state hospital and a local cash only program that costs ~$150k/year with a one year minimum commitment.

 

[Stagg737]

Well my second question though is what am I going to do with these patients? I am not able to help them with their core BPD symptoms

DBT isn't the only effective therapy for BPD. Find someone who is skilled in TFC, IPT and/or MBT and refer there. Of course, none of this will get better if your patients aren't willing/able to apply those concepts and make changes to malignant social situations.

 

[Candidate2017]

It basically worked so well that i quickly started practicing it myself and it basically changed the way i am in ways i could not imagine
When i mean worked im talking real life functional improvement such as not coming back to the inpatient unit, went back to working full time and so on

I initially read these 2 sentences to mean DBT'ing yourself improved your life to where you realized you needed to quit the inpatient unit to work full time for yourself (rather than patients getting back to work and never being hospitalized again).

I m now leaving the public hospital and will try to continue in private practice

In any event, all's well that ends well.

 

[hallowmann]

Yes but only DBT groups in the town is 10 days partial hospitalization program. So 6 months to 12 months group skills is non existent. There are many ''DBT inspired'' individual therapists who take these clients.

We have a DBT skills program that is about 44-50 hrs altogether across 4-6 mos, and people do have quite good results. It does require them to put the work in and it probably loses 25-30% in the first few weeks. The remaining people actually do have positive improvement. The problem with doing the individualized DBT in my experience has been that without the structure and building on prior skills, you spend half the time with the backtracking and relearning. It needs to be structured.

 

[Salpingo]

Now, based on my experience with my patients (my sample size is probably around 40 or so), I haven`t observed any significant change in their overall BPD symptoms even after a year of therapy. Maybe a couple of patients have made some significant progress but they were quite high functioning to begin with. Overall, my observation is that majority of my patients continue struggling significantly with interpersonal relationships, identity disturbance (ever changing interests, hobbies, friends, sexual partners, jobs etc..) and inner void (emptiness, boredom, unable to invest self into goals, values etc.)

It's been awhile since I looked at the literature, but the evidence for DBT in BPD usually relates to the number of emergency room presentations and incidence of self-injurious/suicidal behavior. I'm not aware of any evidence that it reduces identity diffusion or improves long term relationships.