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 This therapy could save lives from suicide — if more people could get it
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September 20, 2023 at 6:30 a.m. EDT
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5 min
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In the 1980s, when Anthony DuBose set out to become a psychologist, he was told never to work with people with borderline personality disorder because they had high rates of suicide and intense emotional distress. They were considered untreatable.

This is no longer the case. Today, an approach called dialectical behavior therapy (DBT) can help patients struggling with suicidal ideation, self-harming behavior, addiction and mood disorders. It has become the gold standard for treatment.


DuBose first used DBT to help hospitalized teens. He now teaches the treatment to other therapists worldwide, as vice president of Seattle-based Behavioral Tech, founded by Marsha Linehan, the woman who developed DBT and published the first treatment manuals in the 1990s.

DBT saves lives and is finally getting the attention it deserves. Still, too few Americans can get it. Nearly half the population doesn’t have access to a mental health professional. Fewer than a quarter of providers are certified to deliver DBT, DuBose estimates, and insurance rarely covers it. This needs to change.

The United States recorded its highest-ever number of suicides in 2022. For every person who dies this way, an estimated 115 others are affected. That means more than 5 million Americans felt the aftershock of suicide last year.

What does DBT involve? Patients receive both individual therapy and group training in skills such as mindfulness, setting boundaries and asking for help. Between sessions, when crises arise, they get phone coaching to use the skills to cope.

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Kate Woodsome on mental health

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They learn to accept painful emotions and situations and, at the same time, to change behaviors that prolong their suffering. The therapy is “dialectic” in that it helps patients become comfortable with this contradiction.

Studies indicate that to see a real benefit, adults need at least a year of DBT. Adolescents need six months. And the therapists? They have regular consultations with a team of DBT providers to troubleshoot challenging cases.

DBT doesn’t always work. More than 1 in 4 patients drops out. But long-term studies of hundreds of people worldwide suggest that it reduces suicide attempts in teens and adults. In one randomized trial, suicidal women receiving DBT were half as likely to attempt suicide as those receiving other forms of care. It is endorsed by the respected medical review group Cochrane.

DBT has been adopted in the United States by some counselors working in Veterans Affairs, schools, prisons, and public and private practice, as well as by some traditional Native American healers.

Patients, families, legislators, health-care providers and insurers must work toward a health system where more people who need this lifesaving care can get it.

I spoke with DuBose about the treatment and why it’s not widely available. Our conversation was abridged and edited for clarity. The video embedded below offer more insight into how DBT works.

Kate Woodsome: How do DBT therapists understand people considering suicide?

Anthony DuBose: The patient is trying to solve a problem of intense suffering. From their perspective, they see no other option. We must understand that suffering and help them find a different solution than death.

In the U.S., there are fewer than 500 therapists with formal certification in DBT. How accessible is this treatment?

If a patient can fund this service for themselves, they’re going to land on a wait list. If a person is on Medicaid, they could get this in a community mental health center, but it might be hard to get in. For people in the middle, it’s exceptionally difficult because of the length of the treatment.

Do insurers not consider DBT medically necessary?

It is often not covered by insurance because it mixes a group class with individual therapy. Insurance companies might cover the therapy and not the skills. Or there might be a 12- or 24-session limit. That’s not going to get people through a year of treatment. Truncated treatment might work, but we don’t have enough analysis yet.

But insurance companies have called me because they know an ad hoc agreement is cheaper than having a patient keep showing up at the emergency department.

Getting certified to practice DBT takes time, money and the support of a team of experts. What else stops providers from offering the therapy?

One of the biggest barriers to access is fear. Mental health professionals are concerned that if they treat a person who’s at risk for suicide, they’re going to be dealing with potential for lawsuits, it’s going to interfere in their personal life, and they’re not going to be able to handle it.

Let’s say I’ve got a 19-year-old who’s having physical altercations with his parents. I’ve taught him skills, we’ve got a plan, and now he’s home, and he’s ready to put his fist through the wall or hit his mother. He calls me, and I coach him through it. That patient probably learned more in that real-life moment than in months of therapy. But the idea that we’re available to patients between sessions is quite off-putting to a lot of therapists.

Does this affect therapists’ quality of life?

Not as much as you’d think. These kinds of calls don’t take that much time — they tend to be no more than six minutes, about two to three times each month.

Where do you see hope?

I’ve seen so many patients change their lives in positive ways. I also get hope from their families and people who treat patients. We work in teams, and it creates a powerful sense of community.

For further insight into DBT’s principles and process, watch more of the interview with Anthony DuBose:

How can we accept pain while changing the behavior that causes suffering? (Video: The Washington Post)

If you or someone you know needs help, visit 988lifeline.org or call or text the Suicide & Crisis Lifeline at 988. For current or former military service members, please call 988 and press 1.

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