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Adult Inpatient Treatment at Four Winds

 

The adult inpatient program at Four Winds Hospital uses Dialectical Behavioral Therapy as its primary treatment model. DBT is an evidence-based form of Cognitive Behavioral Therapy that integrates traditional CBT with dialectical philosophy and Eastern mindfulness practice. While originally developed to treat patients with Borderline Personality Disorder, DBT has been adapted to treat many forms of emotional distress. Four Winds takes a multidisciplinary approach in helping patients to learn DBT and to this end all therapy and nursing staff have been trained in the model. They function as coaches to aid patients in applying the skills learned in group settings to real-life situations. Those staff members who provide therapeutic ancillary services, such as our art program, have also received DBT training and have integrated DBT strategies and skills into these activities. Although a big focus of our inpatient treatment is skills groups, a number of our therapists have also been trained in providing individual and family DBT therapy. They have learned how to conceptualize a case from a DBT perspective and use this to develop treatment plans and strategies. 

Daily DBT Groups
The program provides daily DBT groups during which patients are taught DBT skills. The four DBT skills modules are mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. We teach these mindfulness skills in order to help patients better control behaviors that can lead to hospitalization and to help patients observe and describe their thoughts, feelings, and reactions non-judgmentally, so they can better attend to the present moment. They receive coaching on distress tolerance skills to provide alternatives to destructive behaviors until the painful moment passes. In addition, they are introduced to principles of emotion regulation to enhance their emotional resilience and fortitude. Finally, they learn about ways to improve their interpersonal effectiveness. Patients return to their outpatient providers with a Relapse Prevention Plan – an analysis of the chain of events and related behaviors that may lead to relapse or another hospitalization. To help break this chain, the plan includes skills and alternate behaviors the patient can utilize to avoid relapse and re-hospitalization.

Acute Care Facility
Since Four Winds is an acute-care facility the length of stay for patients is short so we have been judicious in choosing which skills to teach. The major focus is on helping patients develop skills that they can use in difficult situations. A key strategy used in DBT is that of Behavioral Chain Analysis (BCA). This strategy is used in a number of ways, but especially when a patient has been struggling or has not been able to control a serious problem behavior. These problem behaviors – such as self-harm, aggression toward others, dangerous risk-taking, drug abuse, binge eating, and self-starvation – seldom happen out of the blue. The patient is asked to look at the actions and emotions leading up to their incident and is coached to see how the negative consequences of one action can become the trigger for a second action with more serious consequences, creating a chain of increasingly negative events and choices. The patient completes a Behavioral Chain Analysis to form a timeline beginning from when they became emotionally vulnerable through every choice leading up to the problem behavior. The patient then processes the completed BCA with a staff person to get ideas about the most effective ways to prevent serious problem behaviors in the future. 

The use of DBT strategies in the adult inpatient program at Four Winds has been very effective in providing treatment. The underpinning of DBT theory is the recognition that everyone is doing the best they can in the moment, and they can learn to do better with the skills they acquire in therapy. This nonjudgmental approach to treatment creates an atmosphere of respect for our patients and colleagues that allows the treatment to be more successful.

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