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.     

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.     

Einfluss des Behandlungssettings auf den Gesundungsverlauf

Even though managed care systems research emerged as an important field in psychotherapy research in the last years, studies examining the effects of its psychotherapeutic measures on outcome are still rare, especially in Germany. Little is known about the effectiveness of psychotherapy in different treatment settings, i. e. whether and how patients in outpatient psychotherapy differ from inpatients in respect to initial impairment status and pace of improvement. Two longitudinal data sets—inpatient (N=759) and outpatient (N=521)—were used to scrutinize these questions. Results yielded no differences between treatment settings as to patients’ initial impairment. A linear model adequately represented the mean course of improvement in inpatient psychotherapy. For outpatient psychotherapy, a bipartite linear model for treatment and for the follow-up period proved more appropriate. During 1 year, patients in both settings attained a similar amount of improvement. However, pace of in-treatment improvement was 10 times faster in the inpatient setting. Initial impairment substantially predicted the course of psychological improvement in both treatment settings.     

Teilstationäre Psychotherapie

Psychotherapeutic day clinics increasingly take over responsibility for the treatment of patients who cannot be cared for satisfactorily, respectively, at all in an inpatient setting. Psychotherapy in a day clinic setting is a treatment in its own right which has progressively established itself between inpatient and outpatient treatment. Empirically raised up to date data prove the efficacy and the efficiency of psychotherapeutic treatment in day clinics. Accordingly, the goal of the present study is to investigate the outcomes of psychotherapeutic treatment in a day clinic with a psychodynamic concept. Since 1996 the psychotherapeutic day clinic Basel empirically assesses the treatment course of all admitted patients. Patients and therapists fill in questionnaires upon admittance, two months into the course of treatment and upon discharge (SCL-90-R, PSKB-Se-R, OPD etc.) Our results indicate that significant improvements of symptoms as well as of socio-communicative competency can be achieved during treatment which remain stable even after discharge (first follow-up three months after discharge). Comparing outcome data of patients treated in full-time inpatient setting and of patients who undergo partial hospitalization we found that outcome was at least equivalent. Additionally we found that the diagnosis of a personality disorder influenced treatment results significantly in some symptom specific spheres.     

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.     

Dialectical Behavior Therapy for Adolescents: Theory, Treatment Adaptations, and Empirical Outcomes

Dialectical behavior therapy (DBT) was originally developed for chronically suicidal adults with borderline personality disorder (BPD) and emotion dysregulation. Randomized controlled trials (RCTs) indicate DBT is associated with improvements in problem behaviors, including suicide ideation and behavior, non-suicidal self-injury (NSSI), attrition, and hospitalization. Positive outcomes with adults have prompted researchers to adapt DBT for adolescents. Given this interest in DBT for adolescents, it is important to review the theoretical rationale and the evidence base for this treatment and its adaptations. A solid theoretical foundation allows for adequate evaluation of content, structural, and developmental adaptations and provides a framework for understanding which symptoms or behaviors are expected to improve with treatment and why. We first summarize the adult DBT literature, including theory, treatment structure and content, and outcome research. Then, we review theoretical underpinnings, adaptations, and outcomes of DBT for adolescents. DBT has been adapted for adolescents with various psychiatric disorders (i.e., BPD, mood disorders, externalizing disorders, eating disorders, trichotillomania) and problem behaviors (i.e., suicide ideation and behavior, NSSI) across several settings (i.e., outpatient, day program, inpatient, residential, correctional facility). The rationale for using DBT with these adolescents rests in the common underlying dysfunction in emotion regulation among the aforementioned disorders and problem behaviors. Thus, the theoretical underpinnings of DBT suggest that this treatment is likely to be beneficial for adolescents with a broad array of emotion regulation difficulties, particularly underregulation of emotion resulting in behavioral excess. Results from open and quasi-experimental adolescent studies are promising; however, RCTs are sorely needed.     

On the Boundary: Family Therapy in a Long-Term Inpatient Setting

This paper presents a paradigm of family therapy in a long-term inpatient setting. After reviewing literature commenting on the necessity of attending to the needs of families of inpatients, the essential functions of inpatient treatment are discussed and an approach to family therapy, related to and reflecting those functions, is developed. Four functions of inpatient family therapy are delineated: joining, support, intervention, and validation. What distinguishes these from similar functions in outpatient treatment is the family therapist's position on the hospital-family boundary.     

Group processes and process evaluations in a new treatment setting: inpatient group psychotherapy followed by internet-chat aftercare groups

Little is known about processes characterizing therapeutic Internet-chat groups, which offer a novel way of providing group therapy over distances. In this study group processes and group evaluations were examined in a treatment setting where face-to-face inpatient groups are followed by chat aftercare groups. For a sample of 121 patients who participated in both treatment modalities, group processes and group evaluations were modeled using hierarchical linear modeling. The group evaluations followed a consistent upward course from the beginning of therapy until the end of chat aftercare. For the process measures Activity and Emotional Reactivity, the initial scores at the beginning of the chat groups were lower than at the end of the inpatient treatment, but higher than at admission. During chat aftercare, Activity and Emotional Reactivity scores increased less than during the inpatient phase, but on average Activity and Emotional Reactivity were higher during Internet-chat aftercare. The predictive value of the acquaintance of the therapist from inpatient treatment and the course of group evaluations during inpatient treatment on the course of group evaluations during chat aftercare were examined.     

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.     

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.     

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.     

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 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.     

Konflikt- und Strukturachse der Operationalisierten Psychodynamischen Diagnostik des Kindes- und Jugendalters

This paper presents the advantages of a comprehensive Operationalized Psychodynamic Diagnostic in childhood and adolescence (OPD-CA) for subsequent treatment planning. Information about the conflict and structural axes as a function of age, gender, diagnosis and proposed form of treatment (outpatient/inpatient) was analyzed in a group of 116 patients. Independent from the diagnosis, a similar ranking in the importance of conflicts was found. Self-esteem conflicts were more prominent for inpatient children and adolescents and identity conflicts were more prevalent in children and adolescents who were at the start of outpatient therapy. Patients with an indication for inpatient treatment had a significantly lower level in all structural dimensions. This study analyzes the reasons for these findings.     

Short-Term Inpatient DBT Combined with Metacognitive Interventions for Personality Disorders: A Pilot Acceptability and Effectiveness Study

This study aims at evaluating the effectiveness of an intensive 1-month residential treatment course in an Italian psychiatric unit for patients meeting criteria for personality disorders (PD). This study involved 189 patients consecutively admitted to the unit and assessed at admission and discharge. The inpatient program was based on Dialectical Behavior Therapy (DBT) combined with Metacognitive interventions. Primary outcome was a reduction of general symptom severity (as measured by SCL-90-R). Secondary outcomes were reduction in depression (BDI), interpersonal problems (IIP-47). Other outcomes were impulsivity (BIS-11), aggressiveness (AQ), and dissociation (DES). We found a significant reduction in symptom severity, as well as in depression, interpersonal problems, dissociation, impulsivity and aggressiveness. The size of this benefit was predicted mostly by number of criteria met at SCID-II and intake scores mostly for impulsiveness and dissociation. In conclusion, intensive 1-month residential DBT combined with metacognitive interventions can be effective in treating patients with any PD presenting with severe global suffering, prominent self-harm and suicidal risk.

     

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.     

Alkoholabhängigkeit in der psychiatrischen Klinik

In Germany 2.4?% of the population suffer from alcohol dependency and 3.8?% of adults from alcohol abuse. Despite an extensive number of options available for addiction therapy only a minority of affected persons receive addiction-specific therapy. This results in a chronification of the disease and a reduction of approximately 15 years in life expectancy. Background knowledge of the foundations of alcohol addiction leads to a new understanding of the processual course of the disease as well as to new therapy interventions. Individualized treatment includes a combination of outpatient, partial inpatient or inpatient therapeutic measures and range from medical advice for reduction of alcohol consumption, to qualified withdrawal treatment up to pharmacological relapse prophylaxis and long-term weaning treatment. Under current therapeutic conditions abstinence quotas of 50-70?% over 1 year can be achieved. Treating physicians must have sufficient diagnostic certainty and furthermore must be in command of motivating discourse techniques, knowledge on the therapeutic options of outpatient and inpatient withdrawal treatment, pharmaceutical relapse prophylaxis and mediation in rehabilitation measures.     

Inpatient and outpatient psychiatric treatment: The effect of matching patients to appropriate level of treatment on psychiatric and medical-surgical hospital days

The effects of inpatient or outpatient treatment for psychiatric disorder on posttreatment hospital days were examined for 106 Health Maintenance Organization (HMO) patients who initially presented for inpatient treatment. Based on a complete mental status examination and the availability of appropriate treatment alternatives, 15% were admitted to inpatient and 85% were referred for intensive outpatient treatment. In the 12 months following treatment, (a) neither group had further psychiatric hospital days and (b) those treated on an outpatient basis had fewer medical-surgical hospital days. Number of medical-surgical hospital days was lower for patients who completed the full treatment plan. These results complemented experimental research regarding the clinical effectiveness of outpatient treatment alternatives.     

Rapid Cycling

Rapid cycling is not a distinct disorder, but is a particularly severe form of bipolar disease. One in six patients with bipolar disease seen by psychiatrists either as an outpatient or as an inpatient suffers from four or more episodes per year. If at least four episodes occur within one year, this high-frequency phase is called ?rapid cycling“ (RC). Treatment for bipolar disorder with RC usually includes trialling mood stabilizers, such as lithium, anticonvulsants, and modern antipsychotics.In four out of five RC patients, treatment improves disease progression; however, some patients exhibit RC for many years.Specific studies have raised the suspicion that administering antidepressive therapy could facilitate an unfavorable course of bipolar affective disorder. The present case demonstrates disease progression and treatment attempts in a patient with distinct RC progression.     

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.