Psychiatrist Dr Pauline Cole explains why government funding for Dialectical Behaviour Therapy is urgently needed

Marsha Linehan first developed Dialectical Behaviour Therapy (DBT) in the 1980s and 1990s. Original research was with people who had severe emotional dysregulation or self-harm behaviours, but it is now widely regarded as a trans-diagnostic treatment.

Psychiatrist Dr Pauline Cole

DBT is a multi-modal treatment underpinned by a biosocial theory of emotional difficulties, a set of guiding principles and the three key paradigms of acceptance, change and dialectics.

The model of therapy contains four key modes of treatment:

  • skills training group which has a key role to teach DBT skills
  • individual therapy, which has a key role for assessment of problem behaviours and individual assistance to apply skills in the real world
  • telephone coaching between sessions to allow someone to assist the person to apply skills when it counts
  • team consultation, which promotes adherence to the principles and practice of the treatment and provides support to therapists.

The consultation team mode is something above and beyond clinical supervision. It is using many brains to help resolve an individual’s difficulties. The emphasis on adherence minimises the risk of ineffective therapy.

The three paradigms of acceptance, change and dialectics each have various principles embedded within them.

The acceptance paradigm encourages both therapist and patient to engage in the present moment. Reality acceptance skills include the invitation to respond willingly and effectively to the situation at hand, even when we don’t like the situation that we are in. Acceptance allows us to tolerate the reality without staying miserable or doing things that make the situation worse. Acceptance IS NOT approval, liking, condoning, giving up, or resignation. It is a necessary precursor to change.

The change paradigm encourages clarity about the behaviours that are being targeted and assists with commitment to goals. Analysis of the function of maladaptive behaviours, maintaining persistence with effective actions over time and following skills instructions ‘to the letter’ are considered essential.

The dialectics paradigm assists with resolution of polarities including the seeming opposition between acceptance and change. It helps people get unstuck when conflicts arise, and it takes a systemic viewpoint that seeks to find the complex transactions that are at play in any given situation.

The troublesome thing is that very few people in WA are able to receive comprehensive DBT because those services are not available. Many therapists deliver DBT-inspired approaches, however, these are not the same as comprehensive DBT. Linehan states that if there is no consultation team, then it’s not DBT.

There are many people here in WA for whom quicker access to comprehensive DBT could turn unbearable suffering into tolerable pain.

A significant number of people who access something called ‘DBT’ are only receiving DBT skills training. Treatment ‘dismantling’ studies show that the skills group is vital, however, individual therapy and access to phone coaching is often needed for those people with complex difficult-to-treat disorders such as borderline personality disorder.

Everyone can gain from DBT-type skills. Some do benefit from only DBT skills training or solo individual therapy, but it is inaccurate to call it DBT. This sets people up to say that DBT has failed when in fact they haven’t actually received DBT. 

It is heartbreaking to hear people who gain from using DBT skills say, “I wish I had learnt these strategies earlier.” Thankfully there are researchers in the US taking DBT skills training into schools. The DBT in Schools developers lament the ‘Waiting to Fail’ scenario – where schools wait until someone develops extreme symptoms before intervening, which really doesn’t make sense. 

There are significant problems in WA that need urgent solutions. People with complex mental health conditions and atypical responding patterns are getting stuck in EDs and hospital beds. This is exactly the cohort that DBT was developed to treat. 

Funding more beds isn’t what is needed – that just helps people remain stuck in the cycle of suicidality and hospitalisation as a way of life.

We have people with potentially good prognoses languishing untreated or undertreated. There is a definite ‘postcode lottery’ for comprehensive DBT within the public sector. And, in those areas where a form of comprehensive DBT is available, we have people dying by suicide while on long waiting lists. 

Unfortunately, comprehensive DBT is not easy to establish in the private sector because Medicare and health fund rebates are inadequate to cover the necessary duration of service.

A government funded statewide DBT service is urgently needed to facilitate the delivery of this life-saving treatment in WA. 

ED: Dr Cole is a consultant psychiatrist specialising in DBT at the Marion Centre.