Over the last decade, the US has experienced a significant increase in mental health symptomology and suicidality among children and adolescents, with the COVID-19 pandemic contributing to an even greater increase.
In 2021, the surgeon general deemed mental health concerns in children and adolescents a “national crisis,” and in 2022, data revealed suicide as the second leading cause of death for youth ages 10 to 14 and the third leading cause of death for youth, ages 15 to 19 (CDC). Children and adolescents from historically marginalized backgrounds are at a higher risk of developing mental health concerns due to social determinants of inequity (Murthy, 2022), which include those of low socioeconomic status, ethnic/racial minorities, and LGBTQ+ populations.
Although 2023 data from the Centers for Disease Control and Prevention revealed a slight decrease in mental health concerns and suicidality among youth, the need for increased mental health screening and accessibility to behavioral health services remains high.
While additional resources are needed for identifying youth who may be experiencing mental health symptoms or stress from adverse childhood experiences (ACEs), research shows increased screening does not automatically lead to commensurate rates of service utilization for these individuals. A cross-sectional study published in 2021 revealed that among a sample of 11,896 children, ages 2 to 17, whose screening results showed high distress symptoms and/or a high rate of ACEs, their rates of “no clinical contact” following screening ranged from 40% to 67% (Finkelhor, Turner, LaSelva, 2021). Similar to the existing analysis on treatment utilization, researchers determined access to behavioral health services appears to be a contributing factor to the lack of treatment follow-through. This highlights the need to focus on increasing access to effective, evidence-based therapies.
Implementing Dialectical Behavior Therapy
Given the increase in suicidality, depression, and other mental health diagnoses over the last decade, it is imperative clinicians providing mental health support are educated in the most effective evidence-based therapies (EBTs). Dialectical behavior therapy (DBT) is a cognitive behavioral therapy designed to treat individuals with a wide range of mental health conditions and emotional dysregulation challenges. Numerous randomized control trials (RCTs) and meta-analyses have found DBT to be the most effective evidence-based therapy for treating suicidality and self-injury for adults and adolescents and effective for other symptom presentations significantly impacted by emotional dysregulation (Hernandez-Bustamante et al., 2024 & Kothgassner et al., 2021). DBT is one of Devereux’s most widely used EBT and is implemented in a variety of treatment settings across the country, including residential treatment facilities, outpatient programs, and acute hospital settings.
While traditional treatment-oriented models of care focus on symptoms and their presentations, DBT emphasizes reducing feelings of hopelessness and revisits the concept of an individual’s “life worth living goal,” which is the vision of creating a life that is no longer compatible with the idea of suicide or other high target behaviors. The “life worth living goal” looks at living a life of balance (Linehan, 1993, p. 124).
DBT combines cognitive and behavioral interventions, mindfulness skills, and acceptance and change strategies to teach individuals effective ways to cope with emotional dysregulation and move away from ineffective coping methods, such as suicidal thoughts and behaviors, self-injury, substance use, and other impulsive actions. An effective DBT program requires clinicians to be trained in the principles, skills, and interventions of DBT. Clinicians are not required to be certified in DBT to provide DBT treatment. However, it is recommended they have foundational or intensive DBT training to ensure high-fidelity treatment. A comprehensive DBT program requires four main components of DBT, including (Linehan, 1993):
- Weekly group skills training
- Weekly Individual therapy
- Skills coaching (outside of scheduled sessions)
- A clinician consultation team
Challenges With Accessibility, Sustainability
Although EBTs are the gold standard for mental health treatments, many community-based health centers and treatment facilities face challenges in implementing high-fidelity, sustainable, evidence-based therapies, such as DBT (King, J.C. et al., 2018). When examining research regarding the sustainability of DBT implementation in healthcare settings, studies reveal the most common barriers are related to financing, resources (e.g., time commitment), clinician turnover, and administrative support (King et al., 2018; Quetsch et al., 2020).
In addition to the barriers listed above, insurance coverage for DBT therapy can be difficult to obtain because DBT involves many different components of therapy, some of which are not funded or are underfunded by insurance companies, particularly Medicaid (e.g., phone coaching, skills training for families, consultation teams). This is critical since treatment programs that primarily treat marginalized populations are more likely to be funded through Medicaid versus private insurance. While this is an understudied area of research specific to DBT, mental health disparity analysis reveals youth with public health insurance have less access to mental health services in general (James et al., 2015). A study assessing DBT youth treatment outcomes with private insurance compared to public/public eligible insurance holders reveals lower rates of treatment completion for youth without private insurance (James et al., 2015). While reasons for the lower rates of completion are multifaceted, this shows the reality of the challenges marginalized youth face when seeking and receiving mental health treatment.
Given these factors, it is unsurprising that despite strong evidence of the effectiveness of DBT, service providers and families that use Medicaid often find it difficult to locate comprehensive DBT therapy in their demographic area, particularly when seeking community providers that accept Medicaid funding. DBT listservs and websites often highlight challenges with insurance coverage and locating comprehensive programs and well-trained clinicians in community health centers. These same listservs and websites often report it is much easier to find comprehensive DBT services in group practices and private facilities that only accept private insurance or out-of-pocket payers. This reveals the barriers marginalized groups face in accessing the most effective treatments for some of the most prevalent mental health concerns in our society.
Devereux’s Commitment to Providing DBT
Since 2018, Devereux Advanced Behavioral Health has invested significant resources in the implementation, sustainability, and fidelity of DBT for its child-serving residential and outpatient programs focused on treating emotional and behavioral disorders. Devereux has collaborated with Treatment Implementation Collaborative, LLC (TIC), which provides quarterly consultation and training for behavioral health clinicians. In total, Devereux has invested in more than 150 hours of external DBT-specific training for clinicians and staff (approximately 30 hours/year) since 2020 and developed internal foundational trainings, in collaboration with TIC, for clinicians and staff. This training has allowed staff to obtain up to 30 hours of free continuing education credits per year. The organization also partners with an internal national consultant who supports DBT implementation across teams, as well as a national Fidelity Advisory Committee that consists of national and center clinical and operations representatives who oversee national implementation goals and fidelity of the model. These internal supports ensure Devereux provides multiple levels of leadership and administrative support for the implementation of DBT across its centers.
Devereux’s training and support efforts have allowed the organization to provide comprehensive DBT services to more than 500 youth, the majority of whom are Medicaid recipients, with an additional 100-plus youth who have received DBT skills training as a supplement to other evidence-based treatment. Over the last two years, Devereux has experienced an increase in the number of individuals receiving DBT services on an annual basis.
Strategies for Sustainability, Achieving High Fidelity
To minimize barriers to sustainable, high-fidelity implementation, Devereux has developed a comprehensive system to evaluate and monitor the integrity of its DBT programs. This system includes coaching and feedback, monthly integrity monitoring of the four core modalities of DBT, and innovative dashboards for tracking integrity. This process ensures the provision of high-fidelity services for all youth who receive DBT therapy, recognizing this may be their only opportunity to access the comprehensive model and benefit from its effectiveness.
Devereux has made additional accommodations to the delivery of the model to increase access for a larger number of marginalized individuals and families by offering opportunities to engage in DBT through telehealth. Offering telehealth services has allowed individuals and caregivers to increase their engagement with the treatment model when transportation and parental schedules might have otherwise impeded participation. Devereux remains committed to offering comprehensive DBT and is dedicated to delivering these services with high fidelity to ensure all youth, regardless of their background or socioeconomic means, can receive evidence-based therapy that has a long-lasting, positive impact on their mental health.
About Devereux Advanced Behavioral Health
Devereux Advanced Behavioral Health is one of the nation’s largest nonprofit organizations that provides services, insight, and leadership in the evolving field of behavioral healthcare. Founded in 1912 by special education pioneer Helena Devereux, the organization operates a comprehensive network of clinical, therapeutic, educational, and employment programs and services that positively impact the lives of thousands of children, adults – and their families – every year. Focused on clinical advances emerging from a new understanding of the brain, its unique approach combines evidence-based interventions with compassionate family engagement. Devereux is a recognized partner for families, schools, and communities, serving many in the areas of autism, intellectual and developmental disabilities, specialty mental health, education, and child welfare. For more than a century, Devereux Advanced Behavioral Health has been guided by a simple and enduring mission: To change lives by unlocking and nurturing human potential for people living with emotional, behavioral, or cognitive differences. Learn more: www.devereux.org.
Crystal Taylor-Dietz, PsyD, is National Director of Behavioral Health Services of Devereux Advanced Behavioral Health.
References
Finkelhor D, Turner H, LaSelva D. Receipt of Behavioral Health Services Among US Children and Youth With Adverse Childhood Experiences or Mental Health Symptoms. JAMA Netw Open. 2021;4(3):e211435. doi:10.1001/jamanetworkopen.2021.1435
Hernandez-Bustamante M, Cjuno J, Hernández RM, Ponce-Meza JC. Efficacy of Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder: A Systematic Review of Randomized Controlled Trials. Iran J Psychiatry. 2024 Jan;19(1):119-129. doi: 10.18502/ijps.v19i1.14347. PMID: 38420274; PMCID: PMC10896753
James S, Freeman KR, Mayo D, Riggs ML, Morgan JP, Schaepper MA, Montgomery SB. Does Insurance Matter? Implementing Dialectical Behavior Therapy with Two Groups of Youth Engaged in Deliberate Self-harm. Adm Policy Ment Health. 2015 Jul;42(4):449-61. doi: 10.1007/s10488-014-0588-7. PMID: 25199812; PMCID: PMC4362888
King, J.C., Hibbs, R., Saville, C.W.N. et al. The survivability of dialectical behaviour therapy programmes: a mixed methods analysis of barriers and facilitators to implementation within UK healthcare settings. BMC Psychiatry 18, 302 (2018). https://doi.org/10.1186/s12888-018-1876-7
Kothgassner OD, Goreis A, Robinson K, Huscsava MM, Schmahl C, Plener PL. Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: a systematic review and meta-analysis. Psychol Med. 2021 May;51(7):1057-1067. doi:10.1017/S0033291721001355. Epub 2021 Apr 20. PMID: 33875025; PMCID: PMC8188531
Lee, P., Lang, J. M., Vanderploeg, J. J., & Marshall, T. (2021). Evidence-Based Treatments in Community Mental Health Settings: Use and Congruence With Children’s Primary Diagnosis and Comorbidity. Research on Child and Adolescent Psychopathology, 1-14
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Publications
Murthy VH. The Mental Health of Minority and Marginalized Young People: An Opportunity for Action. Public Health Reports®. 2022;137(4):613-616. doi:10.1177/00333549221102390
Quetsch, L.B., Herschell, A.D., Kogan, J.N. et al. Community-based behavioral health administrator perspectives on sustainability of Dialectical Behavior Therapy: a qualitative evaluation. bord personal disord emot dysregul 7, 5 (2020). https://doi.org/10.1186/s40479-020-0120-5
Syversen AM, Schønning V, Fjellheim GS, Elgen I, Wergeland GJ. Evaluation of dialectical behavior therapy for adolescents in routine clinical practice: a pre-post study. BMC Psychiatry. 2024 Jun 14;24(1):447. doi: 10.1186/s12888-024-05876-z. PMID: 38877441; PMCID: PMC11177375
