Client Case Study: Nystrom & Associates

Today, we are featuring a Q&A with one of our clients, Nystrom & Associates, to shed light on Nystrom's journey with DBT and Behavioral Tech Institute, as well as the value DBT has brought to their program. Their responses may be helpful to those who are considering DBT.

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Tell us more about your treatment setting. We are a large multi-state outpatient mental health provider. Our comprehensive DBT programming is embedded into our outpatient services as an IOP – Intensive Outpatient Program. In addition, our agency provides many other mental health services that allow for collaboration and patient care. Services include psychiatry, case management, SUD, dietitians, in-home care for children/adults, adult day treatment, and mother/baby programming. We deliver standard adult DBT, DBT SUD, and DBT for clients who are differently abled. DBT-A, adolescent/multifamily groups along with DBT-C, children/multifamily groups are also at many of our sites. Currently, we have DBT in Minnesota only. Our agency has recently expanded into Wisconsin, Iowa and North Dakota. Our goal, in the near future, is to expand our DBT services into some of those regions. How many DBT patients does Nystrom serve? We serve approximately 700 clients a year between pretreatment, stage 1 and stage 2, across 15 sites. What is your primary client population? We serve a diverse clientele of adults, children, adolescents, and families in the Twin Cities metro area and in many of Minnesota’s smaller cities and rural communities. Most funding sources are through national and state programs such as Medicaid and Medicare, with a small number utilizing private insurances. Since we are DBT certified by the state of Minnesota through DHS, our program requires that clients meet the DHS definition of medical necessity for DBT.  Clients must either have BPD or have multiple diagnoses with severe emotion dysregulation for whom other less intensive treatments have not worked effectively. As a side note, Minnesota was the first state to have a DBT state certification that is tied to higher reimbursement rates for DBT clinicians who provide DBT treatment to fidelity. How has DBT impacted your patients? Some sentiments we have received at the end of treatment from clients:

• Adult - “I would be dead if it were not for this program. This is the only treatment that has worked. Who knew you could have strong emotions and use skills to stay effective?”
• Teen - “I couldn’t stop self-harming on my own or keep any friends. My family didn’t know what to do. After DBT, I stopped self-harming, can keep friends, and talk to my parents.”
• Parent - “Before we started DBT, we didn’t know what to do and were making the situation worse. We thought it was their problem and wanted them fixed. We learned how to deal with our own emotions, validate feelings, and find a middle path. We have a family that can be together now. Thank you!”

How many people are on your team(s) across all sites? We have 15 teams across Minnesota that range in size from 3-13 people. Across our teams, at any given time, we have 80-85 clinicians. Our DBT Team Leads are individually-certified by the Linehan Board of Certification (LBC) or are in the process of becoming certified. Our original and largest team is program-certified with the LBC. How has DBT impacted your team(s)? It is very common for clinicians who transition to DBT to say that being trained in and providing this treatment has been life-changing both professionally and personally. Many describe it as the most effective treatment they have delivered and that it impacts how they parent, partner, and live their lives. Our clinicians describe being on a DBT consult team as supportive, skill sharpening, and skill equipping to do the hard work of treating clients with life-threatening behaviors. What steps did you take before you started training to make the decision? I, Sarah, was intensively trained in 2007/2008 with Randy Wolbert and Suzanne Witterholt. I was part of the launch team for our DBT program in 2006. We read the Linehan text and skills manual together and met weekly for discussion and initial consultation. Sometimes we were a week ahead of the clients and were flying a bit more by the seat of our pants than I was comfortable with! I knew I needed more expertise to provide the treatment to fidelity. I knew our clients deserved that level of excellence. Our organization was very supportive and sent a small group of us to that first training. It was, and still is, one of the most significant and impactful training experiences I have ever had. The quality of the training was as good as, or frankly way better than, anything I had experienced in graduate school. I came away truly changed. If you were advising another program considering DBT, what steps would you recommend they take? Lessons learned? We would recommend that teams begin on a solid foundation of excellent training. We require all our clinicians to be DBT foundationally trained within the first 6-12 months of their hire and all our team leaders to pursue LBC certification. We prioritize investing in and providing significant resources into training and ongoing supervision for all our DBT clinicians. It was crucial to educate our administration early and often as to the things that make DBT unique, the data to support its efficacy, and the reason why it often needs more resources and support than other programs. Our administration has been supportive from the beginning and are involved at every level. Our founder and CEO, and one of our most active VPs, attended a foundational training years ago. They got a taste for both the ins and outs of the treatment and also joined us in a passion for the clients we serve. We have made sure to include all subsequent key leaders in our community so that this passion and commitment to excellence and fidelity remains at our core. And finally, we have had wonderful DBT mentors from early on, and that has made a significant difference. A shout out to our mentors Bev Long, Randy Wolbert, Ronda Reitz and Suzanne Witterholt. I would advise any new DBT program to have a DBT champion and mentor to help with support and expertise. What steps have you taken to onboard nonclinical staff to assist in your DBT program? We communicate regularly with our non-clinical staff to educate and cast vision for our DBT program. We attend staff meetings, administrative meetings, and the like to collaborate. Many of our staff, such as our front desk staff, billing staff, and administrative staff, are interested in the treatment and want to know more. We have taught some of the DBT skills to non-clinical staff in various settings to use in their work. For example, we taught interpersonal effectiveness skills to the billing and collections staff. It has been a big hit for years and has created a sense of community and shared vision. In which ways have you engaged or worked with Behavioral Tech Institute? We have worked with BTECH for many years and are big fans! We have attended numerous DBT training courses: DBT Foundational Training, DBT Intensive Training, Intensive Training in the DBT Prolonged Exposure Protocol for PTSD, Adapting your DBT program for Substance Use Disorder, Advanced Intensive, DBT Skills Training, and Mindfulness and Reality Acceptance for Personal and Professional Practice. We have also co-hosted a number of BTECH training courses, on-site and online, for our community and beyond. These training courses are always well attended and highly rated. We have benefited from the collaboration and expert consultation between BTECH and our state DHS. Donna Pattie, one of our Team Leads, now works as a BTECH Trainer and consultant in the broader DBT community and in-house. Her training and connection with BTECH have enriched our program in countless ways. Learn more about DBT training with Behavioral Tech Institute here!

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This blog was co-authored by Sarah M. Gross, MSW, LICSW and Donna Pattie, MSW, LICSW. Sarah M. Gross, MSW, LICSW - Executive DBT Program Director Sarah M. Gross, MSW, LICSW is a Linehan Board Certified DBT therapist who serves as the Executive Director of the DBT Program of Nystrom and Associates (NAL). Sarah helped begin the DBT program at NAL and has provided DBT services since 2006. Sarah currently oversees 15 DBT teams and provides supervision, consultation and leadership for the DBT program. Sarah has had extensive training including advanced training with Marsha Linehan, DBT treatment developer, and Melanie Harned, DBT PE treatment developer in addition to intensive trainings by other DBT experts. As a clinician Sarah works with adults, adolescents, and parents using the DBT treatment modality. In addition to her work with Nystrom, Sarah participates in several DBT consortiums and leadership groups to help advance the use of DBT as an evidence-based treatment. Prior to working for the Nystrom and Associates DBT program, Sarah worked as an in-home family therapist, school social worker, community coordinator in services for the homeless, and in the mental health triage unit for county mental health services. Sarah has over 25 years of experience in the social work and mental health fields. She received her Bachelor of Arts degree from Macalester College in Psychology and Environmental Studies. She received her Master of Arts degree in Social Work from the University of Minnesota. Donna Pattie, MSW, LICSW - DBT Trainer and Consultant Donna Pattie, MSW, LICSW is a Linehan Board Certified DBT therapist who is the DBT Team Lead in New Brighton, MN and the DBT Trainer and Consultant for 15 DBT outpatient teams within Nystrom & Associates, LTD. Donna supervises team members and interns and has delivered DBT in both the Adult and Adolescent/Family programs since 2011. She has trained intensively with Melanie Harned in DBT PE for clients with PTSD, has delivered DBT PE since 2015, and supervises Nystrom clinicians across MN in the delivery of DBT PE monthly. In addition to her work with Nystrom, Donna is contracted as a DBT Trainer and Consultant with Behavioral Tech in delivering DBT Foundational Trainings, DBT Intensive Trainings, and DBT Skills Trainings. Prior to working in MN, Donna delivered CBT in an outpatient private practice in North Easton, MA and was the Team Lead of the VA Medical Center’s Post Traumatic Stress Disorder Clinical Team in Brockton, MA. Her work at the VA began with the Substance Use Disorder Inpatient Detoxification and Rehabilitation programs. Donna brings over 30 years of experience in the clinical field and has a passion for fidelity to DBT treatment and for training both new and experienced clinicians in the field. She received her Master’s degree in clinical social work from Simmons College School of Social Work in Boston, MA.   Disclaimer: The Behavioral Tech Institute blog is designed to facilitate the sharing of ideas, experiences, and insights related to Dialectical Behavior Therapy (DBT). The content and views expressed in the articles, comments, and linked resources are those of the individual authors and do not necessarily reflect the views, policies, or positions of Behavioral Tech Institute or staff. Content is provided for information and discussion purposes only and is not intended as professional advice. Contributors to the Behavioral Tech Institute blog are independent, and their participation does not represent an endorsement by Behavioral Tech Institute.