Description of an Intensive Dialectical Behavior Therapy Program for Multidiagnostic Clients With Eating Disorders

The authors describe an intensive outpatient dialectical behavior therapy (DBT) program for multidiagnostic clients with eating disorders who had not responded adequately to standard, empirically supported treatments for eating disorders. The program integrates DBT with empirically supported cognitive behavior therapy approaches that are well established for the treatment of eating disorders. Attention is given to inclusion and exclusion criteria, how the program differs from standard treatments for eating disorders, and the application of specific DBT treatment components for multidiagnostic clients with eating disorders.     

“You Didn’t Cause Racism,and You Have to Solve it Anyways”: Antiracist Adaptations to Dialectical Behavior Therapy for White Therapists

There are currently no published studies that investigate or discuss the cultural responsiveness of Dialectical Behavior Therapy (DBT) to the needs of Black/African-American clients. In addition, no published scholarly works offer guidance to therapists on how to practice antiracism within the context of delivering evidence-based treatment. Methods for developing a culturally responsive antiracist treatment are discussed within a dialectical framework and from the perspective of critical race psychology. We propose that an antiracist adaptation to DBT is needed to correct for context minimization errors in the DBT model that create an invisibility of racism. Recommendations are made for an additional DBT Therapist Agreement that encourages labeling and targeting therapist treatment-interfering racist behavior. An additional Therapist Consultation Agreement is also proposed to guide therapist antiracist advocacy and functional validation for Black/African-American clients. The DBT technology is used in conjunction with other multicultural theoretical models to recommend strategies for developing White DBT therapists’ antiracist competencies. Future directions for developing critical race psychological research are discussed.     

A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries

This paper describes the Common Elements Treatment Approach (CETA) for adults presenting with mood or anxiety problems developed specifically for use with lay counselors in low- and middle-income countries (LMIC). Details of the intervention development, training, supervision, and decision-making process are presented. Case vignettes are used as examples throughout. Preliminary findings are presented on counselor/supervisor performance and client outcomes from practice cases completed prior to randomized controlled trials (RCT) conducted at two sites for adult survivors of torture and/or systematic violence in (a) southern Iraq and (b) Thailand-Burma border.Data suggest that local supervisors and lay counselors with little prior mental health training or experience maintained fidelity to the model. The majority of pilot clients were retained in treatment, suggesting acceptability. Using the Reliable Change Index (RCI) for each individual we examined the number of clients above a minimal threshold (z > 1.96) for each outcome. In Iraq 100% of clients had RCIs above the threshold for depression and posttraumatic stress, and 81.8% for impaired function. In Thailand, 81.3% of clients had RCIs above minimum threshold for depression, 68.8% for posttraumatic stress, and 37.5% for impaired function.Implementation of CETA is discussed in relation to cultural issues within LMIC. These findings, combined with US-based evidence, suggest that a common elements approach warrants further development and testing as a means for addressing the treatment gap for mental health problems in LMIC.     

Modifying Dialectical Behavior Therapy for Deaf Individuals

Therapies that rely on written materials, information, or procedures involving familiarity with the dominant culture (e.g., colloquialisms, history) often pose barriers to people who use another language, have low English literacy, or are less familiar with the dominant culture. All this applies deaf individuals. One of the most well-validated mental health treatments for reducing suicidality in those diagnosed with borderline personality disorder is Dialectical Behavior Therapy (DBT; Koons et al., 2001; Linehan et al., 1999; Linehan et al., 2006; Linehan et al., 2002; Verheul et al., 2003). Unfortunately, its heavy reliance on written materials, prevalent use of metaphors, and other culture-bound characteristics make DBT inaccessible to the average deaf consumer. We describe the potential benefits that DBT could offer deaf clients, some of which are uniquely related to the life experiences and societal challenges faced by deaf people. Barriers to accessing standard DBT treatment and the materials used are described. Modifications of DBT materials and methods that we have found effective with deaf clients are detailed. It is concluded that DBT materials and methods can be successfully modified for use with this population. Available resources and additional benefits of employing DBT with deaf clients are noted.     

Trajectories and Processes of Symptom Change Over Time in Dialectical Behavior Therapy for Borderline Personality Disorder

Despite ample evidence for Dialectical Behavior Therapy (DBT) as an effective treatment for borderline personality disorder (BPD), close examination of the trajectory of change in BPD symptoms over the course of DBT is lacking. There also remain questions regarding the directionality of changes in different domains of BPD symptoms, such as improvements in dysfunctional behaviors and thoughts/feelings. In order to provide more fine-grained information about the treatment process in DBT, the current study aimed to (a) examine the trajectories of change of BPD-associated negative thoughts/feelings and behaviors, and positive behaviors, and (b) test the temporal relationship between changes in negative behaviors and thoughts/feelings. The study involved 55 adult clients attending a 6-month outpatient DBT program for BPD who completed assessments of BPD symptoms every four sessions. Growth curve models suggested that clients experienced a faster rate of decrease in negative behaviors during the initial phase of treatment, whereas steady rates of improvement were found for negative thoughts/feelings and positive behaviors, respectively, throughout treatment. Further, a random-intercept cross-lagged panel model found that the within-person fluctuations in negative behaviors preceded the within-person changes in negative thoughts/feelings at a subsequent time point during the later phase of treatment, whereas within-person fluctuations in thoughts/feelings were followed by changes in negative behaviors at the beginning and end of the treatment. These results highlighted the complexity of patterns and processes of change in BPD symptomatology during the course of DBT.     

COMPARISON OF STAFF TRAINING STRATEGIES TO PROMOTE GENERALIZED TEACHING SKILLS

Two studies compared the effectiveness of different strategies for promoting generalization of staff skills in teaching self-care routines to clients with developmental disabilities. In Study 1, 9 direct-care staff members of group homes were trained sequentially through four conditions: (a) the provision of written instructions, (b) performance-based training using a single client program exemplar and simulated clients (single case training), (c) performance-based training using actual developmentally delayed clients as trainees (common stimuli training), and (d) performance-based training using multiple client program exemplars with simulated clients (general case training). The results indicated that staff members did not reach all generalization criteria until general case training was provided. Because staff members had been trained sequentially through several conditions in Study 1, a second study controlled for potential sequence effects. In Study 2, 7 staff members were trained using only the general case strategy after baseline. All staff members reached generalization criteria with only general case training, replicating the findings of Study 1. Together, the two studies demonstrated that the general case training strategy was more effective at promoting generalized training effects across clients, settings, and client programs than other commonly used staff training approaches.     

Phone coaching in Dialectical Behavior Therapy: frequency and relationship to client variables

Telephone coaching is a treatment mode in Dialectical Behavior Therapy (DBT) that is designed to help clients generalize skills, prevent suicidal behaviors, and repair therapeutic ruptures. To date, phone coaching has received scant empirical investigation. The aims of this study were to (1) describe patterns in frequency of telephone calls and text messaging in DBT and (2) investigate whether demographic factors, baseline severity, suicidal behaviors, and therapeutic alliance are associated with phone and text frequency. Participants were 51 adults (35 treatment completers) with borderline personality disorder (BPD) in a six-month comprehensive DBT treatment program. Phone coaching frequency was documented by therapist weekly session notes. The average number of contacts per month was 2.55 (SD = 4.49). Four of the 35 treatment completers comprised 56% of the contacts. Having a recent history of suicidal behaviors, degree of severity at baseline, or the strength of the therapeutic alliance was not associated with phone coaching use. However, lower income was significantly associated with a higher frequency of phone coaching use. These preliminary results can help clinicians and administrators make informed decisions on how to better provide phone coaching and clarify the degree of effort involved in providing this service to clients with BPD.     

A Cross-cultural Analysis of Avoidance (Relative to Approach) Personal Goals

The results from this research supported our primary hypothesis that the adoption of avoidance (relative to approach) personal goals varies as a function of individualism-collectivism (across representations of this distinction). Interdependent self-construals were positively related and independent self-construals were negatively related to adoption of avoidance goals (Study 1), Asian Americans adopted more avoidance goals than non-Asian Americans (Study 2), and persons from South Korea and Russia adopted more avoidance goals than those in the United States (Studies 3 and 4, respectively). Studies 3 and 4 investigated and found support for our secondary hypothesis that avoidance personal goals are a negative predictor of subjective well-being in individualistic (the United States), but not collectivistic (South Korea and Russia), countries. The findings are discussed in terms of other approach-avoidance constructs and motivational processes.     

Implementation of DBT-Informed Therapy at a Rural University Training Clinic: A Case Study

University training clinics offer state-of-the-art treatment opportunities for clients, particularly for underserved and underinsured client populations. Little has been published regarding the implementation of Dialectical Behavior Therapy (DBT) in settings such as a university training clinic, which may face challenges in utilizing such a comprehensive treatment. This single-case study describes the application of a DBT-informed treatment with a female BPD client, highlighting how the modifications made can ease implementation in a rural university training clinic. Data collected from DBT diary cards document minimal time demands required for the use of between session-coaching, along with clinically meaningful changes in suicidality and misery ratings, and effective DBT skill use. A discussion of the unique components and contributions of this case to informing potential DBT modifications within university clinics are presented.     

Culture and social support: who seeks it and why?

Are Asians and Asian Americans more or less likely to seek social support for dealing with stress than European Americans? On the one hand, the collectivist orientation of Asian countries might favor the sharing of stressful problems; on the other hand, efforts to maintain group harmony might discourage such efforts. In 2 studies, Koreans (Study 1) and Asians and Asian Americans in the United States (Study 2) reported using social support less for coping with stress than European Americans. Study 3 examined potential explanations for these effects and revealed that relationship concerns accounted for the cultural differences in use of support seeking. Discussion centers on the potential benefits and liabilities of seeking social support.     

Dialectical Behavior Therapy for Managing Interpersonal Relationships

Dialectical Behavior Therapy (DBT) is a treatment designed for individuals having borderline personality disorder (BPD), patients having binge eating disorder, co-morbid substance dependence and BPD, and depressed older adults. This paper aims to explore the use of DBT and to ascertain the status of DBT education in treating difficulties in handling interpersonal relationships among clients seeking counseling and psychotherapy. The skills training mode can be employed for teaching skills to solve relationship problems. Validation and acceptance strategies can lessen rejection sensitivity and negative feelings that make interpersonal situations chaotic. Black and white thinking can be resolved by finding a middle path through acceptance and change. This paper suggests the possible utility of DBT for enhancing psychological well-being in clients.     

Making Lemonade out of Lemons: Dialectical Behavior Therapy via Telehealth During a Pandemic

The COVID-19 pandemic has created a burden on healthcare systems and increased demand for mental healthcare at a time when in-person services are limited. Many programs offering dialectical behavior therapy (DBT) for complex clients have pivoted to telehealth in order to increase access to critical mental healthcare. There is, however, limited research on the provision of telehealth treatment for clients with complex psychopathology more broadly, or the telehealth implementation of DBT more specifically. The aim of this study was to examine the use of telehealth services and related clinician attitudes and experiences in the context of DBT. We examined the degree of telehealth platform adoption among DBT clinicians, as well as changes in stress and self-care strategies. A supplemental aim was to gather clinicians’ recommendations for providing DBT via telehealth. Participants included N = 99 DBT practitioners (79.8% female; 20.2% male). Qualitative and quantitative methods were used for data analysis. Findings show that telehealth DBT has been widely adopted among DBT clinicians, and that clinicians’ attitudes to telehealth DBT are cautiously optimistic. Participants described three main areas of stress associated with DBT via telehealth provision, as well as lost and novel self-care strategies.     

The Ethics of Ethics Reviews in Global Health Research: Case Studies Applying a New Paradigm

With increasing calls for global health research there is growing concern regarding the ethical challenges encountered by researchers from high-income countries (HICs) working in low or middle-income countries (LMICs). There is a dearth of literature on how to address these challenges in practice. In this article, we conduct a critical analysis of three case studies of research conducted in LMICs. We apply emerging ethical guidelines and principles specific to global health research and offer practical strategies that researchers ought to consider. We present case studies in which Canadian health professional students conducted a health promotion project in a community in Honduras; a research capacity-building program in South Africa, in which Canadian students also worked alongside LMIC partners; and a community-university partnered research capacity-building program in which Ecuadorean graduate students, some working alongside Canadian students, conducted community-based health research projects in Ecuadorean communities. We examine each case, identifying ethical issues that emerged and how new ethical paradigms being promoted could be concretely applied. We conclude that research ethics boards should focus not only on protecting individual integrity and human dignity in health studies but also on beneficence and non-maleficence at the community level, explicitly considering social justice issues and local capacity-building imperatives. We conclude that researchers from HICs interested in global health research must work with LMIC partners to implement collaborative processes for assuring ethical research that respects local knowledge, cultural factors, the social determination of health, community participation and partnership, and making social accountability a paramount concern.     

Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial

Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Within the last few years, several adaptations to specific settings have been developed. This study aims to evaluate a three-month DBT inpatient treatment program. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment (i.e. four weeks after discharge for the DBT group). Pre-post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson's criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features. Stability of the recovery after one month following discharge, however, was not evaluated and requires further study.     

Clients with borderline personality disorder: Exploring their experiences of dialectical behaviour therapy

This study explores clients’ experiences of Dialectical Behavioural Therapy (DBT). Five participants, all with a diagnosis of borderline personality disorder, were interviewed following a semi‐structured format about their experiences of an NHS regional DBT programme. The interviews were transcribed and analysed using Interpretative Phenomenological Analysis (IPA). Three superordinate themes were identified consisting of a number of sub themes: joining a DBT Programme (external and internal factors); experience of DBT (specific and non specific factors); and evaluation of DBT (change, evaluation and role of the past and future). The study provides an insight into clients’ experiences of DBT. The results are discussed in relation to clinical practice and future research.     

Integrated Group Psychotherapy Program [IGGP] for Multi-Diagnosed Clients

This article describes a group therapy–centered program geared toward the treatment of individuals with co-occurring disorders, including addictive disorders, borderline personality disorder and other mental health issues which involve difficulties with emotion regulation. Group therapy plays a vital role in their recovery. Over 18 years, the author has developed a treatment model that offers an integrative approach to group therapy and individual treatment encompassing psychodynamic and other empirically based therapies, especially dialectical behavior therapy (DBT). Its value lies in its therapeutic effectiveness with hard to reach clients, in its practice-based evidence, its team-building and management approach, its training component and its capacity for replication.     

Dialectical Behavior Therapy Adapted for the Vocational Rehabilitation of Significantly Disabled Mentally Ill Adults

Twelve vocational rehabilitation clients with severe mental illness received a comprehensive adaptation of dialectical behavior therapy (DBT) delivered in a group format. Treatment consisted of 2 hours of standard DBT skills training per week and 90 minutes of diary card review, chain analysis, and behavioral rehearsal. Participants were selected based on previous failure to obtain or maintain employment. The participants had a mean of 3 psychiatric diagnoses each, and all participants met criteria for a personality disorder, with 58.3% having a diagnosis of borderline personality disorder. There were 4 dropouts and 8 treatment completers. The treatment completers improved significantly and maintained their improvements (at 6-month follow-up) in depression, hopelessness, and the experience of anger. In addition, the completers improved significantly from pretreatment to 6 months follow-up on anger expression, control of anger expression, work role satisfaction, and on number of hours worked weekly.     

Dialectical Behavior Therapy and Motivational Interviewing: Conceptual Convergence,Compatibility, and Strategies for Integration

Dialectical behavior therapy (DBT) and motivational interviewing (MI) are two widely used and efficacious psychosocial interventions. An immense and growing number of studies examine DBT, MI, or adaptations of these approaches across diverse treatment contexts and across various clinical populations. Because DBT and MI are in high demand, it is probable that trainees and established practitioners will encounter one or both treatments over the course of their careers. Although MI and DBT initially evolved in distinct contexts for different populations, these approaches share a number of common fundamental principles. Each provides distinct and complementary strategies for enhancing clients’ motivation and ability to change. For some, an integrative or sequenced application of MI and DBT may enhance client care. The present article highlights areas of divergence, convergence, and opportunities for integration, and offers practical tips for applying DBT and MI in conjunction.     

Assertive community treatment for frequent users of psychiatric hospitals in a large city: A controlled study

Evaluated a large-city adaptation of the assertive community treatment (ACT) model (Stein & Test, 1980). Outcomes were examined after 1 year for 82 clients, averaging over 17 lifetime psychiatric hospitalizations, randomly assigned either to ACT or to a drop-in (DI) center. After 1 year, 76% of the ACT clients and only 7% of DI clients were involved in the respective programs. The ACT team averaged 2 home and community visits per week to each client. ACT clients averaged significantly fewer state hospital admissions and state hospital days than did DI clients. ACT clients reported greater satisfaction with program services, fewer contacts with the police, and less difficulty with practical problems associated with psychiatric readmission. More ACT clients were known to have stable community housing. Annual per-client treatment costs for ACT were estimated to be $1,500 less than for DI.     

Principles of Skills Assessment in Dialectical Behavior Therapy

Since its inception, increasing clients’ capabilities in experiencing and managing emotions, interpersonal relationships, and crises has been central to both the theory and practice of Dialectical Behavior Therapy (DBT; Linehan, 1993a, Linehan, 1993b, Linehan, 2015a, Linehan, 2015b). Enabling clients to learn new skills, and to effectively implement them to change behavior, requires both capability and motivation on the part of skills trainers and individual therapists alike. The most effective DBT practitioners precisely assess at each stage of skills acquisition, strengthening, and generalization to determine how well their clients perform new skills. They assess what barriers are preventing effective skills use, in order to implement a focused endeavour to overcome any obstacles. This paper reviews principles of skills assessment within each treatment modality and provides therapists with checklists for identifying problems, and case vignettes illustrating helpful therapeutic strategies.