The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial

Randomised controlled studies in research environments have demonstrated dialectical behaviour therapy (DBT) to be more efficacious than treatment as usual in reducing suicidal behaviour in patients with borderline personality disorder (BPD). Limited evidence exists for the effectiveness of DBT in the treatment of BPD within routine clinical settings. This study examines the clinical and cost effectiveness of providing DBT over treatment as usual in a routine Australian public mental health service. Forty-three adult patients with BPD were provided with outpatient DBT for six months with patient outcomes compared to those obtained from patients in a wait list group receiving treatment as usual (TAU) from the same service. After six months of treatment the DBT group showed significantly greater reductions in suicidal/non-suicidal self-injury, emergency department visits, psychiatric admissions and bed days. Self-report measures were administered to a reduced sample of patients. With this group, DBT patients demonstrated significantly improved depression, anxiety and general symptom severity scores compared to TAU at six months. Average treatment costs were significantly lower for those patients in DBT than those receiving TAU. Therapists who received intensive DBT training were shown to produce significantly greater improvements in patients’ suicidal and non-suicidal self-injury than therapists who received only 4 day basic training. Further clinical improvements were achieved in patients offered an additional six months of DBT. This study demonstrates that providing DBT to patients within routine public mental health settings can be both clinically effective and cost effective.     

A systematic review and meta-analysis of dropout rates from dialectical behaviour therapy in randomized controlled trials

ABSTRACT

Dropout is an important factor that may compromise the validity of findings from randomized controlled trials (RCTs) of dialectical behaviour therapy (DBT). We conducted a targeted meta-analytic review of dropout from RCTs of DBT, with the aims of (1) calculating average rates of dropout from DBT; (2) investigating factors that moderate dropout; (3) examining whether dropout rates from DBT differ to control interventions; (4) synthesising reasons for dropout. Forty RCTs of DBT met full inclusion criteria. The weighted mean dropout rate was 28.0% (95% CI = 23.6, 32.9). Dropout rates were not related to target disorder, dropout definition, delivery format, therapist experience, and therapist adherence. Unexpectedly, dropout rates were significantly higher in trials that offered telephone coaching and utilized a therapist consultation team. DBT dropout rates did not significantly differ to dropout rates from control interventions. Few trials reported reasons for dropout, and there was little consistency in the reported reasons. Findings suggest that over one in four patients drop out from DBT in RCTs. This review highlights the urgency for future trials to explicitly report detail pertaining to patient dropout, as this may assist in the development of strategies designed to prevent future dropouts in RCTs of DBT.     

The impact of dialectical behaviour therapy training on therapists in Singapore: A mixed-methods study

Background

While dialectical behaviour therapy (DBT) has much empirical support for treating borderline personality disorder (BPD) and other conditions, little research has examined the dissemination of DBT in Southeast Asia.

Aims

This study evaluated training outcomes following a 5-day intensive DBT training programme in a group of psychologists in Singapore, who were in the process of implementing DBT as part of the training's objectives.

Methodology

A mixed-methods design was employed. Fourteen psychologists from a public psychiatric hospital in Singapore were recruited. Seven self-selected into DBT training, and the remaining were matched controls who were not attending the training programme. The latter served as a nonrandomised control group. Prior to and 3 months after training, all participants completed measures of stigma towards BPD patients, burnout and therapeutic alliance. DBT training participants additionally attended a focus group discussion assessing their experiences and challenges implementing DBT in Singapore's context.

Findings

Quantitative analyses using mixed ANOVA showed that, compared with controls, DBT-trained participants demonstrated significantly greater increases in acceptance towards BPD patients. No between-group differences were found on changes in burnout or therapy alliance with patients. Analyses of qualitative data using thematic analysis revealed that DBT training impacted the way participants conceptualised and delivered therapy for BPD patients, and highlighted several challenges in implementing DBT in the local hospital context.

Conclusion

The findings demonstrate the potential of DBT training in improving clinicians' attitudes towards BPD patients and support a need for policymakers to prepare organisations for DBT implementation to ensure programme sustainability.     

Dialectical behavior therapy adapted for suicidal adolescents

We report a quasi-experimental investigation of an adaptation of Dialectical Behavior Therapy (DBT) with a group of suicidal adolescents with borderline personality features. The DBT group (n = 29) received 12 weeks of twice weekly therapy consisting of individual therapy and a multifamily skills training group. The treatment as usual (TAU) group (n = 82) received 12 weeks of twice weekly supportive-psychodynamic individual therapy plus weekly family therapy. Despite more severe pre-treatment symptomatology in the DBT group, at post-treatment this group had significantly fewer psychiatric hospitalizations during treatment, and a significantly higher rate of treatment completion than the TAU group. There were no significant differences in the number of suicide attempts made during treatment. Examining pre-post change within the DBT group, there were significant reductions in suicidal ideation, general psychiatric symptoms, and symptoms of borderline personality. DBT appears to be a promising treatment for suicidal adolescents with borderline personality characteristics.     

Treating PTSD in suicidal and self-injuring women with borderline personality disorder: development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure Protocol

This study focused on the development and pilot testing of a protocol based on Prolonged Exposure (PE) that can be added to Dialectical Behavior Therapy (DBT) to treat PTSD in suicidal and self-injuring individuals with borderline personality disorder (BPD). Women with BPD, PTSD, and recent and/or imminent serious intentional self-injury (n = 13) received one year of DBT with the DBT PE Protocol, plus three months of follow-up assessment. The treatment was associated with significant reductions in PTSD, with the majority of patients no longer meeting criteria for PTSD at post-treatment (71.4% of DBT PE Protocol completers, 60.0% of the intent-to-treat sample). A minority of patients (27.3%) engaged in intentional self-injury during the study. Improvements were also found for suicidal ideation, dissociation, trauma-related guilt cognitions, shame, anxiety, depression, and social adjustment. There was no evidence that the DBT PE Protocol led to exacerbations of intentional self-injury urges or behaviors, PTSD, treatment dropout, or crisis service use. Overall, the results indicate that this integrated BPD and PTSD treatment is feasible to implement within one year of treatment, highly acceptable to patients and therapists, safe to administer, and shows promise as an effective intervention for PTSD in this complex and high-risk patient population.     

Sustained efficacy of dialectical behaviour therapy for borderline personality disorder

Dialectical Behaviour Therapy (DBT) is considered one of the most promising treatments for borderline personality disorder (BPD). Recently, we reported significantly positive effects of 12 months DBT on parasuicidal behaviour and impulsivity in a mixed group of female BPD patients with and without substance abuse. Fifty-eight women with BPD were randomly assigned to either 52 weeks of DBT or treatment as usual (TAU). Follow-up assessment took place at 78 weeks, i.e., 6 months after discontinuation of DBT. Participants were clinical referrals from addiction treatment and psychiatric services. Outcome measures included parasuicidal behaviour, impulsivity and substance abuse. Six months after treatment discontinuation, the benefits of DBT over TAU in terms of lower levels of parasuicidal and impulsive behaviours, and in alcohol use, sustained. No differences between the treatment conditions were found for drug abuse. In conclusion, DBT seems to have a sustained effect on some of the core symptoms of BPD and on alcohol problems in a mixed population of female borderline patients with and without substance abuse problems.     

Skills Practice in Dialectical Behavior Therapy for Suicidal Women Meeting Criteria for Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is an evidence-based practice for borderline personality disorder (BPD) and suicidal behavior that has been replicated with a variety of populations. Patients’ practice of behavioral skills taught in the group skills training component of DBT may be partly responsible for the positive treatment outcomes according to the skills deficit model of BPD that underlies DBT. This study was designed to examine the type and frequency of skills practiced by DBT patients. Participants were 49 women, who met criteria for BPD and current and chronic suicidal behavior, receiving 1 year of standard DBT as part of a clinical trial. Skills were recorded on the daily diary cards completed by participants each week and reviewed by their individual therapists. Results indicated that the majority of participants reported practicing skills most days throughout treatment. Crisis survival and mindfulness skills were practiced most frequently in our sample. Hierarchical linear modeling demonstrated that skills practice increased as a function of time in therapy. Directions for future research are discussed.     

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.     

Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy

Premature termination from group psychotherapy continues to be a serious problem in the treatment of patients with borderline personality disorder (BPD). Qualitative research is regarded as an important means to shed light upon the complex dynamics leading to dropout. We conducted an interview study with patients having a diagnosis of BPD (n = 8) who dropped out from long-term group psychotherapy as a continuation therapy following intensive day treatment. The group therapists for these patients were interviewed as well (n = 12). The findings suggest the operation of many processes that contribute to dropout. Most significant appeared to be experiences of separation and loss of the day hospital that were not worked through and a failure of the group to regulate and contain the patients' affects. To integrate patients at risk of premature termination it seems necessary to pay attention to the strong negative emotions that they experience in the group. A higher treatment intensity than weekly group sessions may help to promote more beneficial group processes.     

Changes in personality in pre‐ and post‐dialectical behaviour therapy borderline personality disorder groups: A question of self‐control

Dialectical behaviour therapy (DBT) is an evidence‐based therapy for people with borderline personality disorder (BPD). Past research has identified behavioural changes indicating improved functioning for people who undergo DBT. To date, however, there has been little research investigating the underlying mechanism of change. The present study utilised a between‐subjects design and self‐report questionnaires of Self‐Control and the five factor model of personality and drew participants from a metropolitan DBT program. We found that pre‐treatment participants were significantly lower on Self‐Control, Agreeableness and Conscientiousness when compared to both the post‐treatment assessment and the norms for each questionnaire. Neuroticism was significantly higher both before and after treatment when compared to the norms. These findings suggest that Self‐Control may play a role in both the presentation of this disorder and the effect of DBT. High levels of Neuroticism lend weight to the Linehan biosocial model of BPD development.     

Predictors of response and drop-out during intensive dialectical behavior therapy

The purpose of this study was to examine the effectiveness, and predictors of response and drop-out during a four-week course of intensive dialectical behavior therapy (I-DBT) in 447 outpatients suffering from borderline personality disorder (BPD), over a 10-year period. Assessments included a diagnostic interview, the International Personality Disorder Examination Screening Questionnaire, the Beck Depression Inventory, and the Beck Hopelessness Scale. Among these participants, 103 started a second course of treatment. In agreement with previous reports, I-DBT was effective in reducing levels of depression and hopelessness with a trend of increasing effectiveness over the study period. High schizoid scores and low narcissistic score predicted poor response. Treatment completion rate was high, and low education predicted dropout. A discussion on the usefulness of a second course of treatment should be held with patients and staff as it was not effective in reducing depression and hopelessness.     

Negotiating for Improved Reimbursement for Dialectical Behavior Therapy: A Successful Project

Dialectical Behavior Therapy (DBT) is an evidence-based treatment for borderline personality disorder that has been widely disseminated to many outpatient treatment settings. Many practitioners depend on third-party payers to fund treatment delivery. DBT requires additional clinical services not often included in outpatient therapy, including a weekly skills group led by 2 clinicians, and the requirement for clinicians to attend weekly consultation team and provide intersession contact for coaching. Standard outpatient insurance rates for individual and group sessions do not provide adequate reimbursement for the additional services of DBT. This paper describes how 2 DBT team leaders collaborated to obtain improved reimbursement for their programs. The 2 teams met with insurers, educated them about DBT, and showed outcomes from their programs to achieve large increases in reimbursement rates. The paper includes client outcome data from both programs.     

Dialectical behavior therapy for the treatment of anger and aggressive behavior: A review

ObjectiveThe management of anger and aggression is a public safety issue. Dialectical behavior therapy (DBT) is a promising treatment for reducing anger and violent behavior. This mode of therapy addresses maladaptive behavior by teaching emotion regulation, distress tolerance, interpersonal effectiveness, core mindfulness, and self-management skills.MethodsThis paper reviewed DBT treatment for anger and aggressive or violent behavior. The literature search included articles from 1998 to September 2013. A total of 21 peer-reviewed articles studying the effects of DBT on anger and aggressive behavior were reviewed.ResultsAdaptations or modifications were made to standard DBT to accommodate the specific needs of the variety of populations across studies. Nine studies attempted to understand the efficacy of DBT for anger and aggressive behavior while twelve studies measured the efficacy of DBT within the context of a BPD diagnosis. There are nine randomized controlled trials (RCT) assessing DBT to reduce anger and aggressive behavior.ConclusionResearch has shown that there are potentially clinically significant results when using DBT to treat anger and aggression in various samples. Findings from this review suggest that treatments, even when modified show a positive impact on the reduction of anger and aggressive behaviors.     

Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting

This study evaluates the effectiveness of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in an unselected, comorbid population seeking 3-month inpatient treatment. We studied 50 consecutively admitted individuals (44 women, six men) with BPD as defined by DSM-IV at three time points (at admission, at discharge, and at the 15-month follow-up). For the clinical diagnoses, we used the Structured Clinical Interview for DSM-IV (SCID) and compared the frequencies of comorbid axis I and axis II disorders at admission and at the 15-month follow-up. Overall, participants showed a high degree of comorbidity. Psychopathology was significantly reduced at post-treatment and at follow-up. Effect sizes for outcome measures were within the range of those of previous studies. Our findings support the notion that the results of the DBT efficacy research can be generalized to an inpatient setting and to patients with BPD disorder with high comorbidity.     

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.     

The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder

The working alliance between therapist and patient is an important component of effective interventions for borderline personality disorder (BPD). The current study examines whether client personality affects the development of the working alliance during the treatment of BPD, and whether this influences treatment effectiveness. Data was based on 87 patients with BPD who were participants in a randomized controlled trial comparing Dialectical Behavior Therapy (DBT) and general psychiatric management. Higher levels of trait Agreeableness were associated with steeper increases in working alliance throughout treatment, but only in the DBT condition. Increases in working alliance were in turn associated with better clinical outcomes. Mediation models revealed a significant indirect path from Agreeableness to better clinical outcomes, mediated through larger improvements in working alliance over time. These results highlight the role that patient personality can play during the therapeutic process, with a specific focus on the importance of Agreeableness for alliance development.     

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.     

The Initial Efficacy of Stand-Alone DBT Skills Training for Treating Impulsivity Among Individuals With Alcohol and Other Substance Use Disorders

Impulsivity is considered a core feature of substance use disorders (SUDs), including personological (i.e., negative urgency, positive urgency, lack of premeditation) and neuropsychological (i.e., cognitive and motor disinhibition, impulsive choice) dimensions. Dialectical Behavior Therapy Skills Training (DBT-ST) as a stand-alone treatment is an effective intervention for alcohol use disorder (AUD) and other SUDs. However, there are no studies that have investigated changes in impulsivity levels during a DBT-ST program, especially testing the therapeutic effects of DBT skills. Twenty-nine patients with AUD and other SUDs were admitted to a 3-month DBT-ST program. Self-report (i.e., UPPS-P) and computerized neuropsychological (i.e., Attentional Network test; Go/No-Go task; Iowa Gambling Task) measures of impulsivity were administered at the beginning and end of the DBT-ST. Distress tolerance (DTS), mindfulness (MAAS, FFMQ) and emotion regulation (DERS) were also assessed pre- and post-intervention. The study included two age- and gender-matched control groups: (a) untreated patients with SUDs (N = 29); (b) healthy controls (HCs) (N = 29). Twenty-four (82.7%) patients concluded the DBT-ST program. Emotion-based forms of impulsivity significantly improved during the program. At the end of treatment, impulsivity levels were significantly lower than those of untreated patients with SUDs and they were not significantly different from HCs. Cognitive disinhibition significantly decreased during the treatment. The improvement in impulsivity was explained by pre- posttreatment changes in distress tolerance, mindfulness and emotion regulation. Motor disinhibition did not improve during the treatment. These findings supported the initial efficacy of the DBT-ST program for addressing different features of impulsivity among individuals with AUD and other SUDs. Future follow-up studies should demonstrate the role of impulsivity domains in long-term relapse prevention.     

An open clinical trial of cognitive therapy for borderline personality disorder

Although borderline personality disorder (BPD) is a major public health concern, psychotherapeutic trials have been limited. The present uncontrolled clinical trial examines whether cognitive therapy for BPD is associated with significant improvement on measures of psychopathology. A total of 32 patients with BPD, who also reported suicide ideation or who engaged in self-injury behavior, received weekly cognitive therapy sessions over a 1-year period as described by Layden et al. (1993). The results revealed significant and clinically important decreases on measures of suicide ideation, hopelessness, depression, number of borderline symptoms and dysfunctional beliefs at termination and 18-month assessment interviews. Implications for further research with this difficult-to-treat patient population are discussed.     

Dialectical Behavior Group Therapy is Feasible and Reduces Emotional Dysfunction in Multiple Sclerosis

We examined whether dialectical behavior therapy (DBT) was feasible and effective in multiple sclerosis (MS). A convenience sample of 20 patients with anxiety or depression symptoms received either DBT (n = 10) or standard medical care (n = 10). The DBT protocol was found to be feasible in the MS population studied (e.g., good retention and acceptability). For the DBT group, significant improvements were demonstrated in self-rated and clinician-rated depressive symptoms, clinician-rated anxiety symptoms, self-rated general psychopathology symptoms, and quality of life. In contrast, the standard medical care group retained for exploratory purposes showed no significant improvements. This pilot work provides preliminary support for the utility of DBT in MS, but further work is needed to clarify this benefit using a large, randomized controlled approach.