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.     

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.     

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.     

Lessons Learned Conducting Dialectical Behavior Therapy via Telehealth in the Age of COVID-19

Given the severity and suicide risk of patients typically treated by Dialectical Behavior Therapy (DBT) and the absence of guidelines regarding delivery of DBT via telehealth, it is crucial that the DBT treatment community gather and rapidly disseminate information about effective strategies for delivering DBT via telehealth. The current study surveyed DBT providers (N = 200) to understand challenges and lessons learned as they transitioned to conducting DBT via telehealth during the COVID-19 pandemic. Open-ended responses to challenges and lessons-learned were coded. Most frequently noted challenges were Therapy-Interfering Behaviors and elements related to the provision of Individual Therapy and Skills Training Group. The majority of providers offered advice for implementing group skills training, avoiding or overcoming therapist burnout, and emphasized continued adherence to treatment principles, even in the context of this new treatment modality. Overall, this qualitative study marks a starting point on identifying best practices delivering DBT via telehealth for which it is anticipated that clinical recommendations in this area will evolve, informed by clinician, researcher, and consumer input.     

Essential anxiety: COVID-19 in analytic practice

This paper explores the impact of the COVID-19 pandemic on my relationship with analysands and my inner world. I reflect on the role of the archetypal Self during times of existential anxiety that may lead to an experience of ‘essential anxiety’. This term refers to a meeting by a fearful ego with an inward recognition of the Self, when faced with threat. The efforts to curb the spread of the pandemic changed our ways of life, while the virus itself threatened our existence in debilitating or outright destructive ways. But what also came into view, in sessions of analysis and supervision, was the creative instinct, and a celebration of life. The soul-to-soul relationship, and the connection with images of the archetypal Self, made the experience of existential anxiety at times an essential experience that facilitated psychological growth. I discuss some advantages of on-line Jungian analysis where, despite distance and partial view, the body still serves as container to hold important psychological material, conferring a sense of wholeness for analyst and analysand. The COVID-19 crisis is terrible and terrifying but it also provides an opportunity for self-regulation and individuation.     

A Functional Approach to the Assessment and Treatment of Non-Suicidal Self-Injury in Veterans: A Dialectical Behavior Therapy–Informed Perspective

Given that non-suicidal self-injury (NSSI) is related to increased odds of suicidal ideation and suicide attempts, treating NSSI in veterans is a key treatment priority to help reduce suicide risk and increase quality of life. Treating NSSI can be difficult for clinicians and training in addressing NSSI can enhance therapist empathy and decrease negative attitudes. The current paper describes prevalence of and risk factors for NSSI in veterans and presents a Dialectical Behavior Therapy (DBT)-informed approach for arriving at a functional understanding of NSSI in order to inform assessment and treatment. This DBT-informed approach is demonstrated with two case examples of veteran clients. While in many circumstances treatment of NSSI may be most effective in the context of full model DBT (i.e., individual therapy, group skills training, phone coaching, and therapist consultation team), many aspects of the functional approach discussed herein are not specific to DBT and could therefore be integrated into behavioral analyses and case formulations conducted within non-DBT therapeutic approaches.     

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.     

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.     

虚拟团队共享式领导的双刃剑效应研究：基于调适性结构理论的视角

虚拟团队因新兴技术驱动而成为组织管理的潮流, 尤其全球疫情的爆发使得远程办公备受关注。共享式领导是与虚拟团队高度匹配的领导模式, 但现今学界对虚拟团队共享式领导作用机制的研究比较匮乏, 且集中在正面效应和团队层次, 忽略了共享式领导可能存在的负面效应及对个体层次的影响。研究基于调适性结构理论, 提出虚拟团队共享式领导有助于团队及个体内部动机和效能感的提升, 同时也会加剧团队内社会惰化现象和关系冲突水平, 引发员工的工作负荷和工作焦虑感, 进而对团队绩效和个体绩效产生双刃剑效应, 同时, 团队虚拟性、任务复杂性和任务重要性在其中起到调节作用。研究模型系统打开了虚拟团队共享式领导的影响机制黑箱, 为组织如何在虚拟情境下领导团队、提升绩效提供借鉴。     

A Dialectical Behavior Therapy Skills Group Case Study on Mothers With Severe Emotion Dysregulation

Parenting is an emotionally demanding endeavor, which can be particularly challenging for parents who struggle with psychopathology and lack the regulation skills to manage their own emotional lability. Although dialectical behavior therapy (DBT) is an effective treatment that directly targets emotion dysregulation, little is known about whether DBT might also improve parenting behaviors. A DBT skills group was employed to examine whether DBT skills are utilized by mothers in their parenting and whether skill use improves parenting. Four mothers with severe emotion dysregulation who met diagnostic criteria for at least one Axis I disorder were part of a case study, in which they completed a DBT skills group for mothers, and two of the mothers participated in an in-depth exit interview regarding their use of DBT skills in their parenting. The mothers reported substantial changes in their parenting during the exit interview and modest improvements were found for parenting in pre- to posttreatment parenting assessments. This paper describes the various parenting contexts in which DBT skills were used and discusses maternal emotion regulation as a potential pathway from DBT skills to improved parenting.     

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.     

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.     

Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder

A central component of Dialectical Behavior Therapy (DBT) is the teaching of specific behavioral skills with the aim of helping individuals with Borderline Personality Disorder (BPD) replace maladaptive behaviors with skillful behavior. Although existing evidence indirectly supports this proposed mechanism of action, no study to date has directly tested it. Therefore, we examined the skills use of 108 women with BPD participating in one of three randomized control trials throughout one year of treatment and four months of follow-up. Using a hierarchical linear modeling approach we found that although all participants reported using some DBT skills before treatment started, participants treated with DBT reported using three times more skills at the end of treatment than participants treated with a control treatment. Significant mediation effects also indicated that DBT skills use fully mediated the decrease in suicide attempts and depression and the increase in control of anger over time. DBT skills use also partially mediated the decrease of nonsuicidal self-injury over time. Anger suppression and expression were not mediated. This study is the first to clearly support the skills deficit model for BPD by indicating that increasing skills use is a mechanism of change for suicidal behavior, depression, and anger control.     

Decision-bound theory and the influence of familiarity

In this article, we derive a nonparametric prediction from decision-bound theory (DBT). The crucial aspect that is tested is whether or not familiarity of a stimulus affects response time in categorization. We show that, for our design, DBT, extended with some reasonable and testable assumptions, predicts no familiarity effect. Our prediction is nonparametric in that, rather than fit a specific instantiation of general DBT, we posit only some general assumptions of this theory and derive the prediction from these assumptions. It is found that familiarity did have a strong impact on response time for at least half of our participants. We suggest that DBT is in itself incomplete and should be extended to account for the full range of available data.     

Excessive Worrying as a Central Feature of Anxiety during the First COVID-19 Lockdown-Phase in Belgium: Insights from a Network Approach

Since the WHO declared the COVID-19 pandemic on March 11, 2020, the novel coronavirus, SARS-CoV-2, has profoundly impacted public health and the economy worldwide. But there are not the only ones to be hit. The COVID-19 pandemic has also substantially altered mental health, with anxiety symptoms being one of the most frequently reported problems. Especially, the number of people reporting anxiety symptoms increased significantly during the first lockdown-phase compared to similar data collected before the pandemic. Yet, most of these studies relied on a unitary approach to anxiety, wherein its different constitutive features (i.e., symptoms) were tallied into one sum-score, thus ignoring any possibility of interactions between them. Therefore, in this study, we seek to map the associations between the core features of anxiety during the first weeks of the first Belgian COVID-19 lockdown-phase (n = 2,829). To do so, we implemented, in a preregistered fashion, two distinct computational network approaches: a Gaussian graphical model and a Bayesian network modelling approach to estimate a directed acyclic graph. Despite their varying assumptions, constraints, and computational methods to determine nodes (i.e., the variables) and edges (i.e., the relations between them), both approaches pointed to excessive worrying as a node playing an especially influential role in the network system of the anxiety features. Altogether, our findings offer novel data-driven clues for the ongoing field’s larger quest to examine, and eventually alleviate, the mental health consequences of the COVID-19 pandemic.     

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.     

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.     

Behind the (Virtual) Mirror: Online Live Supervision in Couple and Family Therapy

Online therapy and supervision, a rapidly rising practice in couple and family therapy, has been the subject of a growing body of literature. From its early days, family therapy training has included live supervision, which has typically been conducted by a supervisor and a team of trainees situated on the other side of a one-way mirror. With the outbreak of the COVID-19 global pandemic, we—the staff of supervisors at the Barcai Institute in Tel Aviv, Israel—were compelled to find solutions to continue meeting with clients and to provide supervision for family therapy trainees. To this end, we have shifted our live supervision courses (“practicums”) to the virtual arena, adapting the popular application “Zoom” into what we call “PractiZoom.” Based on over 100 PractiZoom sessions conducted between March and May 2020, involving 14 supervisors and 28 therapists-in-training and their clients, the article reflects on this pioneering online practicum for the online live supervision of therapists with geographically distributed participants. In this article, we outline our operational methods and adaptations for conducting live behind-the-mirror supervision online. Following a short theoretical background, we outline the process of online live supervision, discuss our reflections and those of our trainees on the challenges and possibilities it poses, and offer a number of preliminary conclusions and recommendations.     

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.     

Goal disruption during COVID-19: Reimagining goals during a global pandemic

The COVID-19 pandemic has been a major source of professional and personal disruption and has had both direct and downstream consequences on almost every aspect of peoples' lives, including their personal goal pursuits. In the face of unexpected hardships and obstacles, people have had to find new paths to goal achievement. In the present work, we examined whether difficulty adjusting goal pursuit during the global disruption of the COVID-19 pandemic is related to negative affective, cognitive, and behavioral goal-related outcomes. Across two studies, we found that people who had more difficulty adjusting their goal pursuit during the pandemic experienced more negative feelings toward their goals, were less satisfied with the status of their goals, and were less likely to actually achieve their goals. Moreover, individual differences in planning tendencies, need for predictability, general adaptability, and perceived pandemic disruption were related to more difficulty adjusting goal pursuit. This work demonstrates the importance of flexibility in the face of setbacks and obstacles, especially during times of disruption and uncertainty.