This feature by Emily Cooney, PhD, Carla Walton, PhD, Mike Batcheler, and Kirsten Davis, DClinPsy, is Part 1 of 2 in a series about DBT in Australia and New Zealand. In this first part, Emily, Carla, Mike, and Kirsten share the journey so far. DBT is a worldwide community, and we are excited to shine a light on how DBT has developed in different regions and countries.
Mā ngā huruhuru ka rere te manu
A Māori Whakataukī (proverb): It is the feathers that enable the bird to fly
As two nations separated by a 2000km (1250 mile) ocean, Australia and New Zealand (or Aotearoa: the indigenous name for New Zealand) are sometimes collectively referred to as ‘Australasia.’ It’s a big region, stretching almost 6000km (3750 miles) from Perth, by the shores of the Indian Ocean, to the eastern reaches of Aotearoa’s South Pacific islands. There are large mountains, enormous deserts, big cities and Middle Earth. So how to establish, disseminate, and provide DBT over such large, dispersed, and culturally-diverse countries?
In the mid-1990s when DBT was taking hold in the USA, a travelling English psychiatrist named Nick Argyle was invited to a basketball game by Charlie Swenson where the after-match discussion left Nick very interested in this new treatment. He brought that enthusiasm to Aotearoa and, in 1998, helped launch Aotearoa’s first DBT ‘programme’ (yes, that’s how we spell it). In 2000, in Auckland (Aotearoa’s biggest city), a Behavioral Tech intensive training followed, provided by the legendary Cindy Sanderson, Kelly Koerner, and Amy Wagner. This was a gamechanger for Aotearoa and included clinicians from Newcastle and Sydney, Australia. Seeds were now sown across fertile lands.
Growing any service is not easy. One challenge was how to keep training and supporting clinicians in a complex treatment when located half a world away from quality US trainers. And, back then, there was no internet! In Aotearoa, healthcare is largely provided through government-funded public services. In 2005, a government-funded workforce initiative was able to form an alliance between a small group of local clinicians and Behavioral Tech. In 2006, Emily Cooney joined this group when she returned to Aotearoa from her post-doctoral fellowship in Seattle, where she also served as a research therapist on two of Dr Linehan’s trials. Blessed with the enduring support of Behavioral Tech, a local training company DBTNZ (dbtnz.co.nz) was formed that continues to contribute to workforce training in Aotearoa today.
Through perseverance, DBT is now an almost-regular part of much of Aotearoa’s public mental health service delivery (where indicated) for adults and many adolescents. Also, more recently, there is DBT provided in some child protection services and those for survivors of sexual assault. A barrier remains in access to phone/generalization in many public mental health services, with only some services providing this. Another challenge has been to get high-fidelity DBT into Aotearoa’s private practice healthcare settings which tend to be small and less structured. Of note, Kirsten Davis (a DBTNZ, DBT Training Australia, and BTECH trainer) and others are now developing comprehensive private-practice DBT. Kirsten is also developing the provision and evaluation of DBT skills training for youth in primary mental healthcare settings. DBT is now provided across a wider range of services and we can confidently say that many people in Aotearoa have found benefit from the treatment. Read Part 2 of this blog to find out how our clinicians and researchers are working to extend this further.
Australia has its own history and cultures. As far as we know, the team of clinicians from Newcastle and Sydney (noted above) were the first Intensively trained team to provide Comprehensive DBT in Australia. This group published a randomized controlled trial confirming the value of their work (Carter, Willcox, Lewin et al., 2010). Following on, there have been a number of Behavioral Tech Intensive trainings in Australia led by such stellar trainers as Jennifer Sayrs, Kate Comtois, Linda Dimeff, Tony DuBose, and Alan Fruzzetti. This has contributed to a significant but still modest number of DBT services across many parts of urban Australia. Rural services have been harder to reach (see Part 2 of this blog). In addition to the DBT programs within public mental health, Australian private health funding models may have contributed to a larger number of ‘DBT-informed’ or partial implementations within the context of partial hospitalisation and intensive outpatient (day hospital) programs.
Until recently, training of clinicians in DBT in Australia has been less linked to Behavioral Tech or other training providers associated with the treatment developer. Concern about this has recently led to the establishment of DBT Training Australia (DBT TA; www.dbttrainingaustralia.au), an International Affiliate of Behavioral Tech. DBT TA’s mission is to provide training and consultation to advance the high-fidelity implementation of DBT in Australia – to raise the bar.
Linehan Board of DBT certification and accreditation is slowly taking hold. A small number of clinicians in Aotearoa and Australia have met this standard but, as yet, no programmes have been accredited. Again, barriers include distance from models and mentors. The motivation is also different, in that meeting private-insurance standards is not mandated in our public healthcare environments. Individuals tend to pursue accreditation for their own professional development and credentials. One positive factor in Aotearoa is that Emily Cooney and Mike Batcheler have both been trained in the UW DBT Adherence Coding Scale and bring this perspective to their training and consultation work.
In summary, for many years DBT has been growing in both Australia and Aotearoa and we continue to work towards growing stronger and doing better. Challenges have included location, geography, size, and cultural diversity. One constant question has been how to utilise this treatment for our people in our lands, when it was primarily developed from a North American perspective. We may claim the principles of behaviourism and Zen are universal and yet, across cultures, there are differences in how they may be relevant to the suffering our clients experience. Public healthcare providers in Australia and Aotearoa have a responsibility to provide services that are relevant and responsive to their indigenous communities and rural communities. Much of this challenge remains. Read here for the second part of this blog to find out what we are doing about it.
Emily Cooney, PhD, is a clinical psychologist, a senior lecturer at Otago University in Wellington, New Zealand, and an assistant professor adjunct at the Yale School of Medicine. Emily is a trainer for Behavioral Tech and DBT Training Australia and a Director and trainer for DBT New Zealand. She has been active in researching, providing and training in DBT since the early 2000s.
Carla Walton, PhD, is a clinical psychologist and Service Director of the Centre for Psychotherapy, a specialist service for Borderline Personality Disorder and Eating Disorders within Hunter New England Mental Health Service in Australia. For the past 15 years she has been involved in research and treatment provision to persons with Borderline Personality Disorder in both public and private sectors in Australia. She is a trainer for Behavioral Tech and a director and trainer for DBT Training Australia.
Mike Batcheler is a clinical psychologist who primarily provides all modes of DBT in New Zealand’s longest established DBT programme in a public mental health clinic. He is a trainer for Behavioral Tech and a director and trainer for DBT New Zealand and DBT Training Australia.
Kirsten Davis (DClinPsy) is a clinical psychologist and CEO of The Psychology Group, an organization which among other interventions provides comprehensive DBT, as well as DBT skills groups for youth seeking primary mental healthcare. She is a trainer for Behavioral Tech and a director and trainer for DBT New Zealand and DBT Training Australia.
Carter, G. L., Willcox, C. H., Lewin, T. J., Conrad, A. M., & Bendit, N. (2010). Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder. The Australian and New Zealand journal of psychiatry, 44(2), 162–173.
Cooney, E. B., Davis, K., Thompson, P., Wharewera-Mika, J., & Stewart, J. (2010). Feasibility of Evaluating DBT for self-harming adolescents: a small randomised controlled trial. Auckland, N.Z.: Te Pou o Te Whakaaro Nui: The National Centre of Mental Health Research and Workforce Development.
Cooney, E. B., Mooney, N., & Ryan, P. (2016). Dialectical Behavior Therapy skills training for men with problems related to anger. Poster presented at the Annual Strategic Planning Meeting for DBT, Seattle, WA.
Cooney, E. B., Walton, C. J., & Gonzalez, S. (2022). Getting DBT online down under: The experience of Australian and New Zealand Dialectical Behaviour Therapy programmes during the Covid-19 pandemic. Plos One, 17(10), e0275636.
Pasieczny, N., & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial. Behaviour Research and Therapy, 49(1), 4-10.
Walton, C. J., Bendit, N., Baker, A. L., Carter, G. L., & Lewin, T. J. (2020). A randomised trial of dialectical behaviour therapy and the conversational model for the treatment of borderline personality disorder with recent suicidal and/or non-suicidal self-injury: An effectiveness study in an Australian public mental health service. Australian & New Zealand Journal of Psychiatry, 54(10), 1020-1034.
Walton, C. J., Gonzalez, S., Cooney, E. B., Leigh, L., & Szwec, S. (2023). Engagement over telehealth: comparing attendance between dialectical behaviour therapy delivered face-to-face and via telehealth for programs in Australia and New Zealand during the Covid-19 pandemic. Borderline personality disorder and emotion dysregulation, 10(1), 16.