This feature by Pablo Gagliesi, MD of DBT Iberoamérica is Part 3 of 3 in a series about DBT in Iberoamérica. Here in part 3, Pablo reveals more about the processes of translating DBT books and some of the more recent developments in the DBT community in this region.
In part 1 of this blog, I shared a look at the overall landscape of culture and DBT in Iberoamérica. In part 2, I talked about the introduction of DBT to the region. Now, I will share more about the processes of translating DBT books and some of the more recent developments in the DBT community in this region.
The story about access to translations of Dr. Linehan’s work is like a television drama. Literally, for 17 countries to unanimously decide to translate some terms into a single Spanish was a monumental task. We chose a somewhat neutral Spanish like the one used in some soap operas.
The rights to Linehan’s work had been purchased by a Spanish publisher who had decided to do a “cognitive” translation of the skills book and had left the textbook untranslated because they felt it was not a good deal. However, the contract was stuck in one of those limbos that neither angels nor demons can access. The feeling of frustration was tremendous. Suddenly, a window opened in the problem solving. DBT Iberoamérica decided to create a publishing house in order to buy the rights. Books are not usually produced in our region. They are photocopied and sent as files. The economic precariousness makes copyright a discussion of the developed world. Here the situation is different.
The publishing business is an entelechy, something that should be but is not. We knew it would not be a business for anyone, if anything it would be a loss. We created Tres Olas (www.tresolasediciones.com), a publishing house that focuses on third generation therapies and has translated into Spanish the main works of DBT – so far 15 books by American and Latin American authors. On several occasions, Geraldine Rodriguez intervened on our behalf helping us with the intricate publishing world. Without her we would still be stuck in the system. That small publishing house has been in operation since 2018 and is a kind of small jewelry factory. We are proud of that cooperative work and of having gained the acceptance of the readers. The publishing house was awarded as the most innovative in mental health at book fairs.
In May 2018, Eugenia Olavide joined the project as Director of DBT Iberoamérica. Although she did not come from the field of mental health, she had an interest and love for what we were doing and contributed hugely with her invaluable skills at managing and developing projects. We organized the first Iberoamerican Congress of DBT in Buenos Aires, Argentina. Marsha Linehan participated in it, as well as André Ivanoff, Tony DuBose, Jill Rathus, and Randy Wolbert, among others. 1500 participants attended, and the congress was held in three languages: English, Spanish, and Portuguese. We repeated the experience in a virtual format in 2022. The second DBT Congress attracted a lot more participants.
Currently, we are giving DBT workshops for adolescents with Jill Rathus, DBT PE with Melanie Harned, DBT PTSD with Martin Bohus, DBT-C with Francheska Perepletchikova, DBT Systems with Julie Brown, DBT TEENS with Jill Rathus, DBT STEPS A with Dr. Mazza and Dr. Dexter-Mazza, and we have had as guests to our events outstanding DBT teachers such as Michaela Swales, Lars Mehlum, Cesare Mafei, and Azucena García Palacios, among others. There are DBT trainings for eating disorders, substance use disorders, and extensions of behavioral activation programs, mindfulness, RO DBT, FAP, and ACT. There are two teams of trainers, one in Spanish (DBT IBEROAMÉRICA) and one in Portuguese (DBT Brasil) associated with Behavioral Tech Institute.
This is the story of an achievement. But dissemination and implementation has shown the huge deficiencies in the region’s health system and the walls that enclose it. The idea of making the best available treatment accessible to those in need is a guiding light for the project, but also a constant challenge.
When we began implementing the first standard treatments with good adherence in 2004, the problem to be solved culturally was – as we later discovered – part of the solution. The vast majority of our clients lived with their families and/or were emotionally and financially dependent on them. When a family member brought the client identifying, parents, grandparents, aunts and uncles, siblings, and friends came to the consultation. Since then, “Sumar al Amor” was created, which is the most widespread psychoeducation and skills training program in the region. In Latin America, family members certainly need to be involved in some way. While the program has not been extensively researched due to lack of funding, we believe it was the first program in the world to emphasize the family context of the clients.
Somewhat for this reason, people are beginning to know their rights to receive appropriate and compassionate treatment, to behave as conscious users or consumers. The access to information generated by the Internet revolution has received a lot of criticism, but we must also recognize that we have never had free access to so much. People ask questions to the internet, and the internet – mistakes and successes – has democratized knowledge. It is enough to put a list of behavioral problems on the web to find a diagnosis, a treatment, a discussion, or a testimony. Testimonials on networks and socialization have changed the world of the clients, helping them to feel less alone and more understood.
Families have suffered for decades from being singled out by professionals as the “cause” of all ills; this model has isolated and paralyzed them. Today, many of them have been able to overcome the barrier of blame, sometimes despite the persistence of certain traditions in mental health, to ask for more specific help. The notable change in the day-to-day clinic is that the questions are changing. Now they are not interested in “why is this happening?” – perhaps they know that we don’t know so clearly or that we tend to have theories that rebuke them. Now they more assertively and pragmatically ask “What can I do about this?”
DBT has undoubtedly been part of this profound shift from a paternalistic health care system to a treatment that gives control and power back to the clients and their families. Clients with Borderline Personality Disorder (BPD), along with their families and significant others, have suffered and still suffer from arduous problems in receiving treatment that works.
In 2022, the Iberoamerican Society of DBT associated with the WDBTA was also formed. It is a very diverse organization with participation of colleagues from the region that is forming with periodic events.
In 2023, we can say that DBT is the fastest expanding treatment in the territory with hundreds of trainings and countless colleagues. The networks have been flooded in these last two years by DBT consumers and providers with much perseverance.
Despite the good news, the region still faces some challenges, which we describe below:
- The speed of dissemination of evidence-based treatment is extremely slow. There are still not enough therapists and equipment to assist people who require it.
- Access to the literature is very limited. On the one hand there is a zealous care of intellectual property that is deserved, but on the other hand, moving the publishing business model from the north (where it works) to the south of the world (where it is not a business that works) is complicated. It is complicated for personal and business interests that there is no important value in the sale of a book, a paper, a publication that exceeds the transformative power of dissemination: That is, you may not make any money from this book, but you will be able to offer the treatment, and the trainings and you will be recognized. The open versus closed access discussion is already outdated and is crippling dissemination. In the territory where I live, not even a self-help best seller is a big deal. I compose a song that Spotify plays, but ultimately the profit is in the shows I perform. Who explains to authors and publishers that we are on another planet economically speaking? The publication of the first DBT book in Spanish by a group of colleagues was an impressive example. It had not yet reached the bookstores and a free unauthorized online version was already offered that same afternoon. For this very reason, we must reinvent access to the bibliography if we want access to the trainings so that there is access to the treatments.
- We must increase the availability of bibliographic material in other languages of the territory. As much as 60 million Latin Americans speak native languages and 10 million Spaniards speak other Iberian languages. This is a laborious and costly project, but a pending debt.
- The absence of research and statistics in the territory. This is the result of the lack of coordination of an organization that brings together researchers and funds.
- Although there is a growing number of therapists trained in DBT, we still cannot be sure that these treatments are adherent. This is somewhat due to the fact that there are no reinforcers for this to happen (certifications), there is an oversupply of courses of different qualities, and there is no regulatory body.
- Teams and therapists do not have much cohesion and collaboration among themselves. Partly because of the competitiveness in a relatively small field.
- The cost of training is high by regional standards.
- The cost of standard treatment is high for the region’s parameters.
- It has not yet been possible to involve health policy makers (states, heads of government, hospital directors) in a stable and consistent manner.
- We still need to modernize and adapt treatments and training to new technologies; therapists and trainers are lagging behind the advances in this regard with a slow incorporation of the process.
This is my region: One with many challenges, still very inspiring! We accept challenges wholeheartedly.
Interested to learn more in DBT development around the world? Read here for this blog from Vinícius Guimarães Dornelles on the history of DBT in Brazil.
Pablo Gagliesi, MD, graduated from the Catholic University of Cordoba and University of Buenos Aires. He is a specialist in Psychiatry at the National University of Buenos Aires, and graduated in Psychoanalytic, Systemic, and Cognitive-Behavioral psychotherapy. Dr. Gagliesi is DBT-LBC certified and certified in EMDR. He is the first official Trainer for Behavioral Tech in Latin America. Read his full bio here.
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