Could DBT really solve crisis pregnancies?

One of the treatments Fine Gael TD Lucinda Creighton suggested this week that could be used to treat women who are pregnant and feeling suicidal is "dialectical behaviour therapy" or DBT.

This relatively new form of therapy is a development of cognitive behaviour therapy (CBT) and is used in some parts of the State to treat personality disorders or phobias, or for those who have a history of self-harming.

Ms Creighton's suggestion that DBT may be suitable for pregnant women feeling suicidal drew a strong response from Dr Anthony McCarthy, perinatal psychiatrist at The National Maternity Hospital at Holles Street, who said he was amazed at the number of politicians and obstetricians who seemed to hold vast understanding of suicide, pregnancy and the risks "as if they understand these issues and can then come up with proposals".

Specifically, in relation to DBT, he said he was surprised at the suggestion that it should be written into legislation when “most people have never heard of it”.

Dr McCarthy also said that suggesting such a therapy hinted that society’s “views of women” were related to emotional instability because dialectical behaviour therapy was specific for those with an emotionally unstable personality disorder.

So what exactly is dialectical behaviour therapy? How does it differ from the better-known cognitive behaviour therapy and when is it appropriate as a treatment?

Dr Brendan Kelly, who is senior lecturer in psychiatry and consultant psychiatrist at the department of adult psychiatry, University College Dublin, explained the main differences between CBT and DBT.

Therapy differences
"Cognitive behaviour therapy is about your cognition, such as your thoughts and your behaviours. It helps, for example, in dealing with catastrophising, as well as magnification and minimisation, and teaches us how we can learn ways to deal with these things.

“It is about training your mind, and has its roots ultimately in lots of Buddhist meditation practices. For some who have, say, depression, CBT can be helpful. For those who have severe depression, sometimes their mental state is such they can’t engage in this initially and anti-depressant medication can be helpful in getting them to a place where they can start problem solving.

“For mild depression, CBT is the treatment of choice.”

Often with CBT, the therapist will try to understand the sequence of events or thoughts that might lead up to, for example, a panic attack and then the therapy involves learning to interrupt that pattern.

The form of therapy Deputy Creighton suggested, which is DBT, is a development of CBT.

“What DBT does is it takes the CBT approach and applies it to situations where a person’s emotions are running haywire,” said Dr Kelly. “DBT is often focused on the self-harm element of behaviour and in making people aware of what is going on in their minds and realising that labelling these mood fluctuations is often enough to make us change them.”

History of self-harm
One person who has undergone DBT therapy is 30-year-old Deborah* from Cork. She has had mental health issues since she was 14 years old, and has a history of self-harming.

Over the years, she has tried a range of treatments and therapies. “I was suffering from depression and at my wit’s end,” she said.

“I was being medicated and hospitalised and not getting anywhere. My psychiatrist recommended DBT and it has been invaluable. It is more straightforward and black and white, and gave me coping skills to help me break down the problem bit by bit. The programme lasted a year and included one-to-one and group therapy, as well as phone coaching.”

Deborah said DBT could, in her opinion, be used to treat suicidal pregnant women, and that anyone with mental health issues may potentially benefit from it. "My most recent diagnosis was borderline personality disorder. It is very similar to bi-polar where it is a mood disorder. I had a lot of anger and it led to me self-harming. DBT has given me back my life."

Government plan
Daniel Flynn, who is principal psychology manager and leader for the DBT programme in Cork run by the HSE since 2010, said that DBT was being provided as part of the Government's Vision For Change plan in relation to the mental health services.

He outlined the current availability of DBT in Ireland. "CBT would be the gold standard for depression and anxiety disorders and there is evidence to say it is very effective for all of those issues," he said.

“When we look at things such as borderline personality disorders, this is where DBT comes into the fray.

"The Government's Vision for Change plan says that people who self-harm should have access to DBT. What we have around the country is pockets of expertise in DBT.

“This year, we have put in proposals to look at a more co-ordinated national roll-out of DBT services. We got funding to train 16 teams across the country and that is being done in a targeted way.”

In relation to using DBT as a treatment for suicidal pregnant women, Mr Flynn said that as DBT was a relatively new area of therapy, not enough evidence was available to support that view.

“When talking about suicide, we need to differentiate between what is a long-standing difficulty that someone has in relation to their emotional system, as opposed to someone who finds themselves in a situation where they are in an acute stress such as a crisis pregnancy.

“DBT was designed for people with chronic and enduring mental health difficulties as opposed to acute problems. That is not to say that some DBT programmes can equally be applied to other issues, but there isn’t evidence-based research to show how it impacts on suicidal pregnant women.

“It is not the treatment of choice for those women. It takes up to 12 months to deliver a typical stage-one DBT programme, so that would also make it unsuitable,” he said.

Whatever about the suitability in certain cases, John Walsh, also from Cork, said his son engaged with DBT treatment following a marriage break-up, and Mr Walsh's family believe the therapy saved his son's life.

“Eventually, we got him to talk and he got involved with the DBT programme in Cork. Our son would be dead today if it wasn’t for DBT,” Mr Walsh said.

Not only did his son avail of the therapy, but the whole family engaged in the programme and it has led to significant positive life changes. “It opened our eyes, changed our behaviours and made us question our actions,” Mr Walsh said.

“My son is back to us the way he was and it has given him the life skills to deal with things that arise now which he didn’t have before.”

There are cautions, however. Eoin Stephens is a CBT practitioner and President of PCI College, and says that while CBT is appropriate as a treatment for many mental health issues, it does not impact on all.

“CBT has certainly shown itself to be the most efficient therapeutic approach to date in dealing with certain mental health problems, but not with all such problems,” Stephens says. “It has a high level of success with mild and moderate depression, but not so much with very severe depression. It also has a high success rate with certain anxiety disorders, such as panic disorder, but only where there are few added complicating factors, such as another mental health problem or an addiction.” In relation to severe depression, Stephens notes that this is one of the areas where other approaches, such as DBT or Schema Therapy, may have a better success rate, but that these treatments do tend to be long-term approaches.

In private practice, Stephens estimates that CBT sessions can cost anywhere from €60 to €120 for a one-hour session and that the relative affordability of CBT is certainly a factor in helping to make it popular. The length and success of a course of therapy depends on several factors, including the nature of the problems, the financial resources of the clients, and the willingness of the client to work on themselves between sessions. “CBT is still one of the best approaches,” Stephens says, “but it is not necessarily outstandingly better than some other well-established approaches.”