Gold Award: Integrating Dialectical Behavioral Therapy Into a Community Mental Health Program: The Mental Health Center of Greater Manchester, New Hampshire

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.

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.

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 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.

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.

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.

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.