NOTE: The opinions expressed by this trainer do not necessarily reflect the opinions of the US Department of Health and Human Services, The Public Health Service, the Indian Health Service, or the trainer’s affiliated institutions.
Providing DBT within the Indian Health Service
The Indian Health Service (IHS), a component of the U.S. Department of Health and Human Services, operates two Youth Residential Treatment Centers (YRTC) in the Phoenix Area of the IHS. Desert Visions, located in Arizona on the Gila River Reservation, was established in 1994, and Nevada Skies, located on the Pyramid Lake Paiute Reservation in Nevada, was established in 2009.
Both facilities now enjoy significant support from the tribal governments, not only in the Southwest, but throughout the nation. Six years ago, Dr. Joel Beckstead, Clinical Director of both YRTC sites, and other members of the executive team embarked on a listening tour with the purpose of understanding how the facilities were meeting the needs of the American Indian adolescents and how the tribal partnerships might be further enhanced. During these visits in Arizona, Tribal leadership and Tribal health care providers voiced their frustration with the frequency in which adolescents were unsuccessfully discharged and did not complete the program. The Tribal Leaders questioned the efficacy of the treatment centers.
In addition to Tribal concerns, Dr. Beckstead also found that facility staff were increasingly discouraged and were experiencing burn-out because of the high acuity level of the adolescents who were admitted to the program. The high acuity was due to patients that were admitted with both substance abuse and behavioral health diagnoses.
Tribal concerns, the need for sustaining staff, and the multiplicity of treatment regimens resulted in Leadership seeking a therapeutic modality that would address these priorities. In consultation with executive leadership at Desert Visions/Nevada Skies, it was determined that Dialectical Behavior Therapy (DBT) would meet these three critical priorities.
Almost simultaneously, as Dr. Beckstead and the executive team were addressing these Tribal concerns, Congress was responding to testimony from Tribal leaders, the Indian Health Service, and public health experts concerning the alarming incidence of suicide attempts (some successful) and the prevalence of methamphetamine use in their communities. In 2009, Congress appropriated funding to support pilot projects using or adapting evidenced-based or practiced-based treatment, as well as projects developing promising practices. This allowed Tribal and IHS programs to address suicide or methamphetamine use, and in some cases, both issues.
At the request of Executive Leadership, Dr. Beckstead contacted the Behavioral Health Services Branch at the IHS Headquarters and was encouraged to apply for a new grant program, titled “the Methamphetamine and Suicide Prevention Initiative (MSPI).” Desert Visions was chosen to receive an MSPI grant to provide the funding necessary for the implementation of DBT.
In April, 2010, Desert Visions began the process of providing intensive training to counselors and staff in learning and implementing DBT. MSPI funds were used to send counselors to workshops, conferences, and training in the basics of DBT implementation. Eight providers were able to attend a two-week intensive training and had the opportunity to work with Dr. Marsha Linehan, the developer of DBT and a professor at the University of Washington. She provided invaluable feedback and direction regarding the implementation of DBT at both facilities. Over the past six years, this grant has resulted in a well-trained staff equipped to meet the demands of the adolescents, to fulfill the expectations of Tribal partners, and to begin to increase staff job-satisfaction.
Researching the Effectiveness of DBT with Native American Youth
In order to track the success of the implementation of this treatment modality, Dr. Beckstead implemented the use of the Youth Outcome Questionnaire (YOQ), an empirically validated tool. This instrument has been used in multiple behavioral health settings, both outpatient and inpatient. The primary purpose of the instrument is to track adolescents’ progress in treatment. Additionally, the data from the YOQ is used by the clinical staff, in collaboration with the clients and their families, to modify treatment plans in order to address areas where the clients are experiencing stress to meet their individual treatment goals.
In November, 2013, a three-year program/statistical review of the YOQ data of 229 patients who had been enrolled in treatment at Desert Visions from 2010-2013 was conducted. The analysis of the outcome data showed that of the 229 patients admitted into the center that had received DBT treatment, 201 met the criteria for clinically significant change, i.e., “recovered” or “reliable change” or “improved” and ten (10) met criteria for no change. No patients deteriorated during this time. Eighteen (18) patients had only one YOQ score and were not included in the analysis. These results far exceeded the YRTC leadership’s expectations. The results of this program review were published in the journal Addictive Behaviors in July 2015.
The Growth of DBT within Systems Treating Native Americans
In Indian Country, the good news spread fast. Desert Visions/Nevada Skies began to receive requests from Tribal Behavioral Health Programs to provide additional information about DBT. In addition, the Executive Leadership began to develop a plan to share the program with Tribal partners. Aftercare providers in Tribal communities expressed interest in learning about DBT and a desire reinforce the tools the adolescents had learned to help them remain sober and continue to make effective choices. In February of 2011, Desert Visions provided a four-day training in DBT to over 100 mental health professionals providing services to American Indian/Alaskan Native adults and adolescents.
In February and August of 2013, Desert Visions served as a training center by providing interested Tribal and IHS stakeholders the opportunity to complete a two-week intensive course in Dialectical Behavior Therapy in order to support treatment efforts in the aftercare setting. Behavioral health providers from six unique tribes participated in additional trainings at Desert Visions. Additionally, behavioral health providers from Phoenix Indian Medical Center (PIMC), the largest medical center in the Indian Health Service, attended previous training and subsequently completed a two-week intensive. Behavioral Health Services at PIMC now offers a DBT skills training group for adolescents.
Desert Visions and Nevada Skies represents an example of an implementation strategy that could serve as a template for implementation of DBT at other Tribal and IHS programs in the future.
If you would like to hear more about the work that Dr. Beckstead’s team is doing at Desert Visions and Nevada Skies, you may be interested in a 1.5 hour webinar recording of Dr. Beckstead speaking about his experiences and research with using DBT to treat American-Indian and Alaska-Native youth.
Joel Beckstead, PhD, ABPP, graduated from Brigham Young University with a PhD in clinical psychology in 2002. He is board certified in clinical psychology from the American Board of Professional Psychology. Upon graduating from Brigham Young University, he served for 4 years in the United States Army from 2001-2005 and deployed to the Pentagon in 2001 shortly after 9/11 to provide support to the service men and women stationed there. After completing his service in the Army, he accepted a job with Immigration and Custom’s Enforcement as the Arizona Mental Health Consultant. In July of 2009 he was hired as the Clinical Director of Desert Visions Youth Wellness Center in Sacaton, Arizona.