DBT Agency Payment and Communication Policy

[exhaustedmama]

Hi, there.  My husband and I need some advice from other parents of adult children with BPD who have paid for DBT treatment programs.  Our DD24 has agreed to go to therapy.  In fact, she has wanted therapy for awhile, but that's another story...  Anyhow, we found an agency of psychiatric nurses who specialize in DBT.  Clients participate in an intake session plus 4-6 individual sessions ($150/ea) before beginning the first of three 8 week groups ($800 x 3).  During group clients are expected to continue to attend weekly or bi-weekly individual sessions ($150/ea).  All in all, approximately 6 months, approximately $7000.  If she does not cancel individual sessions within 24 hours, we will be charged the full cost of the session.  If she misses 3/8 group sessions, she will be kicked out without any refund of fees.  I don't know for sure what would happen if she doesn't do homework/participate appropriately.

Our daughter is very bright and talented, but has not yet demonstrated an ability to commit to anything, whether it be school or work or promises she's made.  She has had several jobs, quitting (often just not showing up anymore) or getting fired (because she stops trying, not because she's not capable), tried post-secondary school several times, dropping out or failing out each time.  She also lies extensively.  While living with us, for example, several times after being fired from a job or quitting a job, she has pretended to work, outright lying to our faces when we've confronted her, waking up, leaving the house, returning later, or making up obvious lies about why she didn't have to go into work, etc.  I cannot even tell you how many times this pattern has repeated itself. She now lives on her own and is about to start job number four since fall 2022. Without going into details, when I cosigned her lease, it was with promises made that she has not kept.  You all have loved ones with DBT - you know that I could go on about these concerns, but I'll spare you. Ha ha

The reason these details are relevant is because we asked the agency offering DBT for two things:  to know when her appointments have been scheduled and whether she has attended, and (this is where things get tougher) to know if she is attending and participating in the group.  DBT groups come with a commitment to homework and participation.  We have said clearly that we don't want to know anything about the content of the therapy, only that she is attending and participating, but this is the response we got from the agency: "With group participation, we...would be unable to provide those details as (we have) a "consult to patient" agreement.  This...means that treatment is geared to teach clients to engage directly with their support system in regards to progress...if a client is not engaging appropriately in treatment or is missing sessions the behaviour is addressed by the clinical team".

We feel caught between a rock and hard place.  We want to support our daughter's treatment, but with her history of not following through on things and blatantly lying to us, as well as breaking promises, the agency's stance seems unreasonable.  Our daughter will NOT be honest if she begins to miss group or slack off, and she will certainly not tell us if she gets kicked out of a group.

Any thoughts/ideas/opinions are welcomed.  I've requested a follow up call to discuss, and would like to know if we're being unreasonable.  If the agency doesn't budge what the heck do we do?

Our objective is to better understand the struggles our child faces and to learn the skills to improve our relationship and provide a supportive environment and also improve on our own emotional responses, attitudes and effectiveness as a family leaders

[InTheWilderness]

Exhaustedmama, I don’t think you’re being unreasonable, if that helps. It seems to me that your daughter could sign a release allowing for free communication. What strikes me as over the top is the cost of the program and harsh no refund policy. Maybe they assume their clients are self pay and that policy will help induce them to stay engaged with the program? I’m assuming you don’t have insurance. If she is not fully committed, I can see why you’d have reservations. And if you pour money into this now and she doesn’t engage, will you have the resources to try again when she’s actually ready?

I have been through something like this with my son, not DBT group, but 2 failed PHP programs and 1 failed IOP, which were 100% paid for by insurance. He has now given up on group. That is another risk, if she’s not ready, she might decide the problem is with group or DBT and not her. And then she’s done with group. Has she had success with any group program? If so, I think this is potentially a good sign.

Another thing, when my son missed his PHP and IOP group sessions, they called me. We’ve worked with two different programs and they each wanted that contact with me. I didn’t ask for it, although I appreciated that. Seemed to be their policy to contact family if patient doesn’t show. It’s one way to try to hold them accountable.

But what I’ve noticed with self-pay mental health practitioners/programs is the inflexibility, compared to programs and practitioners that accept insurance.

Final thought: some people aren’t ready for DBT when they join, but will pick up pieces here and there. (My son can tell me what he’s supposed to do in a crisis, the DBT skills he learned. He says they just don’t work for him.) So some people will cycle through DBT skills classes over a period of years. I don’t understand the punitive nature of their non participation policy. It seems to me that the nature of the disorder, BPD, is such that they will drop in and out of classes.

Final, final thought: a young adult DBT group we found (the only one in our area for young adults) is self pay and very expensive. When,my son asked if they had BPD folks in their DBT program, they said rarely. They aren’t set up for the vicissitudes or very accommodating of the BPD client. In that case, my son wasn’t interested. He wanted to connect with other folks with BPD, which he thought would help him stay engaged.

I hope this has helped.

[exhaustedmama]

Thanks so much for your response, InTheWilderness!  I had a lengthy chat with the director of the program, and I am feeling somewhat better.  I explained my daughter's history of "ghosting" jobs as well as other avoidance behaviours, and the subsequent lying that has occurred when she engages in this avoidance.  As a clinical team they will be aware of this pattern of hers and if she begins to demonstrate this behaviour they will share with her that they'll need to call me if she doesn't re-engage.  If she ghosts them, they will call me to confirm she's safe, so in that way I'll find out, as well.  Also, I can pay for each group in two instalments, so that if she quickly disengages/gets removed, I can forgo the second payment. I did feel hopeful after the conversation, as we talked about other aspects of the treatment (I've had my heart broken many times because I've allowed myself to feel hope, but so be it...).

We've decided to take the leap of faith and hope that our daughter uses this opportunity to do some heavy work. Currently, she is very open to counselling and appreciates the opportunity, but we absolutely know that could change if/when it becomes uncomfortable or someone angers her. 

So, fingers crossed...