Tuesday, 24 January 2017

To DBT or not to DBT? That was the question...

This was the intriguing title of one of the key presentations at the recent Powys Research, Therapies and Health Sciences Conference: Inspiration and Innovation to Drive Patient Centred Care. I attended the conference last November and subsequently wrote How is telehealth working in Mid Wales? The day was packed full of inspiring talks and workshops on all aspects of innovative health work and research going on in the county – do go this year if it’s on again and you get chance.

Anyway, Dr Kathryn Walters, Consultant Clinical Psychologist and Dr David Pyle, Associate Specialist Psychiatrist, told us all about a relatively new service that has been developed in South Powys, to deliver Dialectical Behaviour Therapy (DBT) for the first time in the county. They were joined by Richard, who has been through the programme in Powys and was able to tell us what it was like for him.

Dr Kathryn Walters
First things first. What exactly is DBT? Over to Kathryn and David: 

“DBT is a cognitive behavioural treatment that was originally developed in the United States to treat chronically suicidal individuals diagnosed with borderline personality disorder and is now recognised as the gold standard psychological treatment for clients with this diagnosis. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance dependence, depression, post traumatic stress disorder and eating disorders.” 

Apparently 20% of mental health inpatients have been diagnosed with BPD/ Emotionally Unstable Personality Disorder.

And so this is my next question: what is borderline personality disorder? 

We’re not very keen on psychiatric labels on this blog, but this one is used routinely by the mental health services in the UK, including here in Powys. Kathryn referred to the DSM V definition (the Diagnostic and Statistical Manual of the American Psychiatric Association) which is extremely detailed. There is a good description on the mental health charity Mind’s website, where people have also posted about what it feels like for them: “having BPD is like the emotional version of being a burn victim. Everything in the world hurts more than it seems to for everyone else and any 'thick skin' you are supposed to have just isn't there”. First thing on a Monday morning and probably most people would meet the criteria for BPD… but for those where difficulties continue and go on to become very extreme, and when people self harm often or attempt suicide, then they are very likely to come into contact with mental health services.

Kathryn explained more about the biosocial theory of BPD – that some people are born experiencing emotions more acutely, and have difficulties managing their emotions. This could be reinforced by the responses of family, friends and services, and ultimately it can be very difficult to change behaviours.

So, why DBT? Dialectics is about balancing opposites: balancing acceptance and change. It incorporates elements of mindfulness and radical acceptance, and helps people to accept the world as it is rather than battle against it. In other parts of the UK it had already been shown to be successful as a kind of “mental health gym” to improve the lives of people with a BPD diagnosis. A study in South West Wales where DBT is provided by Hywel Dda Health Board highlighted that financial savings could also be achieved. So, three years ago, in recognition of the fact that there was at that time no DBT service available to Powys residents, a bid was submitted to charitable funds to train six multi-disciplinary members of staff in order to set up a DBT service in South Powys.

Dr Kathryn Walters leads this team, which comprises Psychologists, Community Psychiatric Nurses (CPNs), an Occupational Therapist (OT) and a Psychiatrist. If, following assessment, someone is referred for a course of DBT they will join a rolling programme and be offered individual and group therapy, skills training, and phone consultations. (People in secondary mental health care with a care co-ordinator and a diagnosis of BPD can be referred. Care co-ordinators generally make referrals for DBT assessment). Feedback from people who have received DBT indicates that there is a general trend of improvement in people understanding and managing their difficulties better, and most are greatly satisfied with the programme.

Richard was in one of the first cohorts receiving DBT in Powys and spoke very favourably of his experience on the programme. Prior to joining he described his life as very difficult: “meds, meds, and more meds”, and not much support. It was rare for him to think through his thoughts – they were automatic and he would react to them. He was experiencing difficulties with his personal life to the extent that he self-harmed a lot. But this all changed once he started the 14 month DBT course. At first Richard felt that the programme went completely over his head. However, he committed himself to DBT and to the group, and he bonded quickly with fellow participants. It was reassuring to be with others who knew how he was feeling so that he didn’t have to explain all the time.

A third of the way through the DBT programme Richard had an experience which really changed his life. Everything suddenly became clear, and he felt changes within himself. He started to discuss his thoughts. By the end of the course he felt that he was a completely different person from when he had started. It is now 2 years since Richard completed the DBT programme, and he has not tried to self-harm or “do anything crazy” since. In fact, he is now into the third year of running his own business, has a good relationship with his partner, and a new baby.

Kathryn explained that people are encouraged to meet up as a “graduate group” once they have finished the course. There is also an open door for participants to get back in touch if that is what they want. The team stay in contact with annual Christmas cards. Meanwhile, demand for the South Powys DBT service has grown and there is currently a waiting list of 20 clients and three further members of staff have been trained to join the team.

So, in conclusion, it looks like the answer to the original question was definitely: “To DBT”. Which is perhaps not surprising, as much has been written online about the positive effects of DBT, such as: “DBT is not just a form of psychological therapy but a life-programme which patients use, initially to prevent serious self-harm or suicide and ultimately to build fruitful, satisfying lives”.

Do you have any experience of DBT? Whether you have or not, let us know what you think in the comments box below.


  1. I find it very hard to read this knowing how shockingly bad the MH service is for other "clients". :(

    1. Hi Anonymous

      Thanks for your comment and I really appreciate where you are coming from as I know many people have to wait a long time in Powys for talking therapies and we have posted blogs about the issues in the past. However, in terms of balance, it seems important to let people know of the good work that is going on out there too.

      If you would like to get in touch with us about specific issues or gaps in service then we can follow these up in our team with the relevant service provider. You can call us on 01597 822191 or email mentalhealth@pavo.org.uk and we look forward to hearing from you.


  2. Oh I have been in touch. I've attended your events. I've provided feedback. Nothing is ever done. Not even a response. It's not just the wait either. I would expect that if I am asked to wait 3 years, that it will at least be *worth* the wait. It isn't. I at least expected that having an assessment would mean I was triaged to an appropriate therapy with the right person. I wasn't. The only mechanism to find the right person is to join the back of the queue and try again. But what's the point when the therapy isn't the right therapy?

    1. Hi Anononymous

      We are very sorry if this meant a PAVO (Powys Association of Voluntary Organisations) event about our work. If you are happy to contact us by email we can carry on a more detailed correspondence about the event you mean, we can check our paperwork and work out what happened and take steps to make sure that doesn't happen in future.

      If your experiences are to do with the mental health services, including psychology, we can forward your general comments on to the right person but we need to know where in Powys you are, as some services have been delivered by another Health Board. If you are happy for this we could also forward your contact details so that they can reply directly to you. Alternatively if you let us know where you live, in broad terms rather than anything identifying, we can let you know the right person to approach.