Dialectical behavior therapy group skills training in a community mental health setting: a pilot study

Effective and affordable therapies are needed for treating people with severe and persistent mental illness in a community mental health setting. In this pilot study, we evaluated the effectiveness of a modified dialectical behavior therapy (DBT) protocol for improving symptoms and functioning in a cohort of persons with severe and persistent mental illness. We provided six months of weekly DBT skills training in a group setting. Depression symptoms decreased significantly after treatment. There was a wide range of number of sessions attended, with a minority of the participants completing the full course of treatment. Increased attendance was correlated with improvements in depression symptoms, overall symptoms, quality of life, and community functioning. The study findings suggest that the group skills training component of DBT can be successfully implemented in a community mental health center and that further research to determine its efficacy in comparison to other treatments is warranted.     

Dialectical Behavior Therapy Group Skills Training in a Community Mental Health Setting: A Pilot Study

Abstract

Effective and affordable therapies are needed for treating people with severe and persistent mental illness in a community mental health setting. In this pilot study, we evaluated the effectiveness of a modified dialectical behavior therapy (DBT) protocol for improving symptoms and functioning in a cohort of persons with severe and persistent mental illness. We provided six months of weekly DBT skills training in a group setting. Depression symptoms decreased significantly after treatment. There was a wide range of number of sessions attended, with a minority of the participants completing the full course of treatment. Increased attendance was correlated with improvements in depression symptoms, overall symptoms, quality of life, and community functioning. The study findings suggest that the group skills training component of DBT can be successfully implemented in a community mental health center and that further research to determine its efficacy in comparison to other treatments is warranted.     

Dialectical Behavior Therapy Skills for Families of Individuals With Behavioral Disorders: Initial Feasibility and Outcomes

Family members of individuals with behavioral disorders are a valuable source of logistical and emotional support for patients. Family members may take on tremendous financial and/or psychological responsibility to care for their loved ones, which can result in poor psychological outcomes for the family and, in turn, impede the recovery of the patient. Dialectical Behavior Therapy (DBT) skills training is an effective treatment that has been utilized with numerous populations, including family members of individuals with behavioral problems, and has shown efficacy in improving various interpersonal outcomes; however, no study has examined feasibility and outcomes of delivering all four unabridged DBT skills modules to this population. Twenty participants attended weekly DBT skills classes for 6 months, where they acquired skills in mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. There were significant pre-post improvements for emotion dysregulation, stress reactivity, and various interpersonal outcomes; there were no significant changes in depression or anxiety. These results suggest that DBT skills may be effective at improving broad clinical domains in a sample of family members of individuals with behavioral problems. This research is the first step in demonstrating that DBT skills might benefit family members of patients with heterogeneous mental health problems and, therefore, fits in to the field’s growing interest in cost-effective transdiagnostic interventions.     

Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis

Dialectical Behavior Therapy (DBT) prioritizes suicidal behavior and other self-directed violence as the primary treatment targets, and has been demonstrated to reduce self-directed violence in clinical trials. This paper synthesizes findings from controlled trials that assessed self-directed violence and suicidality, including suicide attempts, non-suicidal self-injury (NSSI), suicidal ideation, and accessing psychiatric crisis services. Eighteen controlled trials of DBT were identified. Random effects meta-analyses demonstrated that DBT reduced self-directed violence (d = -.324, 95% CI = -.471 to -.176), and reduced frequency of psychiatric crisis services (d = -.379, 95% CI = -.581 to -.176). There was not a significant pooled effect of DBT with regard to suicidal ideation (d = -.229, 95% CI = -.473 to .016). Our findings may reflect the prioritization of behavior over thoughts within DBT, and offer implications for clinical practice and future research concerning the implementation of DBT for acute suicidality.     

Efficacy of dialectical behaviour therapy for adolescents

The current review provides a qualitative assessment of the efficacy of dialectical behaviour therapy (DBT) as adapted for adolescents. The aim was to assess the efficacy of DBT compared to usual methods in the treatment of adolescent mental health symptoms, inclusive of suicidal ideation and self‐harm. Computerised databases including Medline and PsycINFO were accessed and knowledgeable informants in the area of DBT were contacted. Inclusion criteria required the studies to be clinical trials on DBT provided to adolescents. Due to the requirements on research design only three studies were appropriate for review. The review focused on quality assessment of the current data, including investigation into the effects of selection bias, confounding variables, outcome measures and measurement errors. The data suggest that there is some evidence for DBT being effective in reducing symptoms of mental health, especially those consistent with borderline personality disorder. The resultant data, however, are of very poor quality, and as such the review addresses ways to improve the quality of research and offers suggestions for future research.     

Does Adding the Dialectical Behavior Therapy Prolonged Exposure (DBT PE) Protocol for PTSD to DBT Improve Outcomes in Public Mental Health Settings? A Pilot Nonrandomized Effectiveness Trial With Benchmarking

The Dialectical Behavior Therapy Prolonged Exposure (DBT PE) protocol improves DBT’s effects on PTSD in research settings, but its effectiveness in community settings is largely unknown. This pilot nonrandomized controlled trial examined DBT with and without DBT PE in four public mental health agencies. Patients (N = 35, 12-56 years old, 80.0% female, 64.7% racial/ethnic minorities, 44.1% sexual minorities) had PTSD, were receiving DBT, and completed assessments every four months over one year. Sixteen patients (45.7%) initiated DBT PE, 19 (54.3%) did not, and dropout did not differ between groups (31.3% vs. 26.3%). The primary barrier to initiating DBT PE was clinician turnover (57.9% of non-initiators). After adjusting for confounds, DBT PE initiators (g = 1.1) and completers (g = 1.4) showed a greater reduction in PTSD than patients who received DBT only (g = 0.5; p’s < .05). Rates of reliable improvement in PTSD were 71.4% (DBT PE completers), 53.8% (DBT PE initiators), and 31.3% (DBT). Similar patterns were observed for posttraumatic cognitions, emotion dysregulation, general psychological distress, and limited activity days. There was no worsening of self-injurious behavior or crisis service use among patients who received DBT PE. Benchmarking analyses indicated comparable feasibility, acceptability, and safety, but a smaller magnitude of clinical change, than in efficacy studies. Results require replication in a randomized trial but suggest that DBT PE can be transported effectively to community settings.     

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.     

Barriers and facilitators affecting the sustainability of dialectical behaviour therapy programmes: A qualitative study of clinician perspectives

Dialectical behaviour therapy (DBT) is a psychological treatment developed for individuals experiencing chronic suicidality and high‐risk behaviours. Despite the substantial evidence supporting the effectiveness of DBT, many programmes have problems with its sustainability. The goals of the current qualitative study were to identify factors that impact the sustainability of DBT programmes within a publicly funded mental health system and identify factors that are particularly relevant for youth DBT programmes. Interviews with trained adult and youth DBT clinicians (N = 31) were conducted to explore their experiences providing DBT. Three major themes that emerged as barriers to the sustainability of DBT programmes included the following: systemic challenges, conflicts within the consultation teams and clinician burnout. Factors influencing the success of DBT programmes included the following: systemic support, clinician commitment and “buy in”, and team cohesion. Factors specific to providing DBT with youth (i.e. level of commitment, simplifying the language, and parental investment) and recommendations for sustainability for adults and youth programmes were also identified. Findings of this study provide valuable information on factors impacting DBT programmes within the unique context of a Canadian mental health service system, where community‐based services are publicly funded. These findings have clear clinical utility and can be used to generate solutions to clinicians' perceived barriers and to foster perceived facilitators within similar contexts.     

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.     

Implementing Skills for Psychological Recovery at a Psychology Training Clinic During COVID-19

The COVID-19 global pandemic has disrupted the routine provision of community mental health services, which is especially concerning given that emerging data suggest a rise in mental health concerns related to the COVID-19 crisis (Xiong et al., 2020). Thus, it seems imperative to provide trauma-informed services that are tailored to clients’ coping with the pandemic and can be effectively delivered via telehealth. The goals of these important services would be to mitigate current distress, help prevent the onset of long-term mental health problems, and facilitate client safety during a public health crisis. The present article provides an overview of adoption and telehealth implementation of the Skills for Psychological Recovery (SPR) secondary prevention program within a psychology training clinic. Initial clinical outcome data supported the program’s success in reducing mental health symptoms among individuals in psychological distress due to the COVID-19 crisis; however, the results were more striking for adults than for youths. The article concludes with recommendations for broader implementation and future directions for clinicians, supervisors, organizations, and researchers.     

The HoST programme: A pilot evaluation of modified dialectical behaviour therapy with female offenders diagnosed with borderline personality disorder

The Holloway skills therapy programme (HoST) at Her Majesty’s Prison and Young Offenders’ Institution Holloway is provided to women who, because of problematic behaviour associated with borderline personality disorder, are often excluded from treatment in prison and in the community. HoST addresses issues of offending behaviour, self-harm, suicidality and indiscipline, through a modified evidence-based treatment modality, dialectical behaviour therapy (DBT), which is a form of cognitive behaviour psychotherapy. This paper will outline the possibility of a modified DBT approach to working with female offenders in the prison setting. A pilot evaluation of female prisoners who received the treatment is also presented through a range of quantitative measures. In turn, positive outcomes with regard to reduction in time spent on the assessment and care in custody teamwork process, reduction in adjudications and improved overall mental health are presented. These findings are discussed along with the implications for clinical practice in the prison setting. The need for future structured research is also discussed.     

A Cultural Adaptation of Dialectical Behavior Therapy in Nepal

Growing evidence exists on the potential for adapting evidence-based interventions for low- and-middle-income countries (LMIC). One opportunity that has received limited attention is the adaptation of psychotherapies developed in high-income countries (HIC) based on principles from LMIC cultural groups. Dialectical behavior therapy (DBT) is one such treatment with significant potential for acceptability in South Asian settings with high suicide rates. We describe a tri-phasic approach to adapt DBT in Nepal that consists of qualitative interviews with major Nepali mental health stakeholders (Study 1), an adaptation workshop with 15 Nepali counselors (Study 2), and a small-scale treatment pilot with eligible clients in one rural district (Study 3). Due to low literacy levels, distinct conceptualizations of mind and body, and program adherence barriers, numerous adaptations were required. DBT concepts attributable to Asian belief systems were least comprehensible to clients. However, the 82% program completion rate suggests utility of a structured, skills-based treatment. This adaptation process informs future research regarding the effectiveness of culturally adapted DBT in South Asia.     

Telehealth for Dialectical Behavioral Therapy: A Commentary on the Experience of a Rapid Transition to Virtual Delivery of DBT

Telehealth has been rapidly adopted to provide continuity of delivery of mental health services in light of COVID-19. However, the remote implementation of intensive treatments like dialectical behavioral therapy (DBT) has been vastly understudied. The aim of the current commentary is to describe potential obstacles, propose solutions, and discuss advantages of transitioning from traditional in-person to a virtual delivery format for full model DBT. We speak to these points at multiple levels of relevance to clinical scientists and practitioners: (1) considerations about the virtual delivery format, (2) considerations for the virtual delivery of DBT specifically, and (3) person-level considerations (e.g., client, clinician). We illustrate the commentary using examples of obstacles encountered and solutions identified during our DBT team’s rapid transition to telehealth in response to COVID-19-related shut-downs and discuss considerations for the extension of telehealth delivery of DBT going forward. We are hopeful that the rapid transition to telehealth delivery of mental health services in response to COVID-19 serves as a call to action for clinicians to adapt and leverage technology to deliver DBT on a broader scale to improve patient health outcomes.     

Responding to the Crisis in Children's Mental Health: Potential Roles for the Counseling Profession

Mental health concerns pose a substantial threat to the immediate and future health of children and their functioning at home, at school, and in the community. Research indicates that 1 in 5 children has a diagnosable mental or addictive disorder and 1 in 10 has a serious emotional disturbance. This review considers emerging trends, national initiatives, and the roles of related professions in responding to the crisis in children's mental health. Recommendations are offered for counseling practice, training, leadership, and research.     

Affirmative Dialectical Behavior Therapy Skills Training With Sexual Minority Veterans

Minority stress theory posits that unique stressors create an invalidating environment, which places sexual minority individuals at increased risk for psychiatric morbidity. Sexual minority veterans’ experience of minority stressors results in elevated levels of emotion dysregulation, anxiety, depression, and suicidality. Clinical interventions designed to address minority stress and treat emotional dysregulation and related disorders among sexual minority veterans are warranted. Professional guidelines recommend the adaptation of evidence-based treatments to address the unique features of sexual minority and veteran mental health. Dialectical Behavior Therapy (DBT) is a treatment for emotion dysregulation and related problems that addresses an invalidating environment, which is an appropriate framework for sexual minorities. The current research adapts the Emotion Regulation module of DBT Skills Training. This adaptation highlights minority stress as part of the invalidating environment and adds new teaching points to address the unique features of sexual minority mental health to create Affirmative DBT Skills Training. Six sexual minority veterans completed Affirmative DBT Skills Training meeting on a weekly basis for 10 consecutive weeks. Before and after treatment, participants completed measures of emotion regulation, anxiety, and depression as well as assessments of minority stress processes. Affirmative DBT Skills Training was well received in this sample. Results suggest that the intervention was effective in decreasing emotion dysregulation and symptoms of depression. These findings suggest Affirmative DBT Skills Training is a promising treatment, although more research is warranted, particularly given the small sample size and lack of a control group.     

Adapted group-based dialectical behaviour therapy for binge eating in a practicing clinic: clinical outcomes and attrition

Research evidence has been accumulating for the efficacy of dialectical behaviour therapy (DBT) for binge eating. However, support for its effectiveness and transportability beyond efficacy trials is lacking. The current study evaluated the feasibility of group-based DBT for binge eating within the context of an operating community clinic. Women ages 24-49 (M?=?39.60, SD?=?9.53) with either subthreshold and full-threshold binge eating disorder or bulimia nervosa formed the group and comprised the sample (n?=?5 treatment completers). Positive outcomes included significant improvement in both binge eating and secondary outcomes with the Eating Disorder Inventory subscales of Bulimia, Ineffectiveness, Perfectionism and Interpersonal Distrust. Attrition was elevated compared with previous efficacy trials, suggesting the need for increased attention to how to improve retention within routine practice settings. Given our limited sample size, these findings are viewed as promising but preliminary.     

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.     

Dialectical Behavior Therapy: Does It Bring About Improvements in Affect Regulation in Individuals with Eating Disorders?

The current investigation sought to determine whether a standard outpatient dose of dialectical behavior therapy (DBT) skills training (2 h per week) coupled with standard CBT treatment would be sufficient to produce changes in affect regulation over the course of day hospitalization treatment. In an uncontrolled pre-post treatment design, 65 women diagnosed with anorexia nervosa or bulimia nervosa were assessed at the beginning of treatment and at the end of treatment on affect regulation. Findings indicated that participants demonstrated a significant improvement in their ability to regulate affect, suggesting that weekly DBT treatment may play an important role in producing changes in affect regulation. Secondary analyses on eating disorder outcomes revealed a significant increase in weight gain as well as a significant reduction in restriction, bingeing, purging and eating disordered cognitions. Findings are discussed in the context of clinical and treatment implications for those with severe eating disorders.     

Dissociation predicts poor response to Dialectial Behavioral Therapy in female patients with Borderline Personality Disorder

A substantial proportion of Borderline Personality Disorder (BPD) patients respond by a marked decrease of psychopathology when treated with Dialectical Behavioral Therapy (DBT). To further enhance the rate of DBT-response, it is useful to identify characteristics related to unsatisfactory response. As DBT relies on emotional learning, we explored whether dissociation-which is known to interfere with learning- predicts poor response to DBT. Fifty-seven Borderline Personality Disorder (BPD) patients (DSM-IV) were prospectively observed during a three-month inpatient DBT program. Pre-post improvements in general psychopathology (SCL-90-R) were predicted from baseline scores of the Dissociative Experiences Scale (DES) by regression models accounting for baseline psychopathology. High DES-scores were related to poor pre-post improvement (β = -0.017 ± 0.006, p = 0.008). The data yielded no evidence that some facets of dissociation are more important in predicting DBT-response than others. The results suggest that dissociation in borderline-patients should be closely monitored and targeted during DBT. At this stage, research on treatment of dissociation (e.g., specific skills training) is warranted.     

Dialectical behavior therapy: current status, recent developments, and future directions

Dialectical behavior therapy (DBT) was developed as a treatment for parasuicidal women with borderline personality disorder and has been adapted for several other populations. This article describes standard DBT and several adaptations of it and reviews outcome studies with borderline patients in outpatient, inpatient, and crisis intervention settings, borderline patients with substance use disorders, suicidal adolescents, patients with eating disorders, inmates in correctional settings, depressed elders, and adults with attention-deficit/hyperactivity disorder. This treatment outcome review is followed by discussion of predictors of change in DBT, possible mechanisms of change, and current developments in theory, practice, and research.