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.     

An Open Trial Examining Dialectical Behavior Therapy Skills and Behavioral Weight Loss for Adults With Emotional Eating and Overweight/Obesity

Third-wave cognitive behavioral interventions for weight loss have shown promise. However, sparse data exists on the use of dialectical behavior therapy for weight loss. Adapted dialectical behavior therapy skills programs may be especially well suited for adults who engage in emotional eating and are seeking weight loss. Dialectical behavior therapy is skills-based, shares theoretical links to emotional eating, and is effective in treating binge eating. The current study examined the feasibility, acceptability, and preliminary efficacy of Live FREE: FReedom from Emotional Eating, a 16-session group-based intervention. A total of 87 individuals expressed interest in the program, and 39 adults with overweight/obesity (BMI ≥25) and elevated self-reported emotional eating were enrolled. Live FREE targeted emotional eating in the initial sessions 1–9, and sessions 10–16 focused primarily on behavioral weight loss skills while continuing to reinforce emotion regulation training. Assessments were administered at baseline, posttreatment, and 6-month follow up. Enrolled participants were primarily female (97.4%) and Caucasian (91.7%). Treatment retention was strong with participants attending an average of 14.3 sessions and 89.7% of participants completing the intervention. On average, participants lost 3.00 kg at posttreatment, which was maintained at follow-up. Intent-to-treat analyses showed improvements in key outcome variables (self-reported emotional eating, BMI, emotion regulation) over the course of the intervention. Combining dialectical behavior therapy skills with conventional behavioral weight loss techniques may be an effective intervention for adults with overweight/obesity who report elevated emotional eating.     

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.     

Effectiveness of Dialectical Behavior Therapy for Treating Eating Disorders

This study evaluated the effectiveness of dialectical behavior therapy (DBT) for treating eating disorder episodes and co‐occurring depression symptoms among individuals diagnosed with eating disorders. Separate meta‐analytic procedures for between‐groups and single‐group studies were conducted and yielded large effect sizes, indicating that DBT may be efficacious for decreasing disordered episodes among women diagnosed with eating disorders; medium to large effect sizes were noted for treating depression symptoms. Implications for evidence‐supported practice and study limitations are discussed.     

Dialectical Behavior Therapy Techniques for Counseling Incarcerated Female Adolescents: A Case Illustration

Dialectical behavior therapy (DBT) may successfully address the needs of female juvenile offenders, but systemic barriers prohibit adherence to the full DBT protocol. The authors built a rationale for using select DBT techniques with female adolescent offenders and provided a case illustration.     

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.     

A Preliminary Examination of the Acceptability,Feasibility, and Effectiveness of a Telehealth Cognitive-Behavioral Therapy Group for Social Anxiety Disorder

In light of the growing interest in, and need for, the telehealth delivery of health care, additional research is needed on the acceptability and effectiveness of these types of interventions. This study examined the acceptability, feasibility, and preliminary effectiveness of an adapted telehealth-delivered group cognitive-behavioral therapy (CBT) intervention for adults with social anxiety disorder (SAD). This report describes the adaptation and subsequent implementation of an 8-week telehealth-delivered group treatment designed to reduce symptoms of SAD. Specific adaptations for delivering treatment during the COVID-19 pandemic and the subsequent enactment of social distancing measures are discussed. Posttreatment data indicated that the intervention was feasible to implement in an outpatient mental health clinic, acceptable to participants, and associated with reduction in symptoms of social anxiety, general anxiety, depression, and stress.     

产褥期抑郁症的高危因素及防治措施的分析

产褥期抑郁症是指产妇在产褥期内出现抑郁症状,是产褥期精神综合征中最常见的一种类型.国外报道发生率达30%,国内资料较少,防治措施亦少.通常在产后6周内发病,产后2周出现症状,表现为易激惹、恐怖、焦虑、沮丧等,有时还会陷入错乱或嗜睡状态.既往无精神病史,包括抑郁症在内的抑郁症史.现对我院2004年6月～2005年6月分娩产妇中随机抽取有随访条件的1824例产妇进行调查,有产后抑郁症状者达289例,发生率15.84%.     

Efficacy of Telehealth Treatments for Posttraumatic Stress-Related Symptoms: A Meta-Analysis

This meta-analysis summarizes the findings of outcome research on the degree to which telehealth treatments reduce posttraumatic stress disorder (PTSD)-related symptoms. In a search of the literature, 13 studies were identified for inclusion in the meta-analysis and were coded for relevant variables. A total of 725 participants were included. Results indicate that telehealth treatments are associated with significant pre- to postreduction in PTSD symptoms (d = 0.99, 95% confidence interval [CI]: 0.87–1.11, p < .001), and result in superior treatment effects relative to a wait-list comparison condition (d = 1.01, 95% CI: 0.76–1.26, p < .001). However, no significant findings were obtained for telehealth intervention relative to a supportive counseling telehealth comparison condition (d = 0.11, 95% CI: ? 0.38 to 0.60, p = .67), and telehealth intervention produced an inferior outcome relative to a face-to-face intervention (d = ? 0.68, 95% CI: ? 0.39 to ? 0.98, p < .001). Findings for depression symptom severity outcome were generally consistent with those for PTSD outcome. Telehealth interventions produced a significant within-group effect size (d = 0.98, 95% CI: 0.86 to 1.10, p < .001) and superior effect relative to wait-list comparison condition (d = 0.80, 95% CI: 0.56–1.05, p < .001). Relative to face-to-face interventions, telehealth treatments produced comparable depression outcome effects (d = 0.13, 95% CI: ? 0.55 to 0.28, p = .53). Taken together, these findings support the use of telehealth treatments for individuals with PTSD-related symptoms.     

Dialectical Behavior Therapy With Prolonged Exposure for Adolescents: Rationale and Review of the Research

Among adolescents, interpersonal trauma has been associated with severe post-traumatic stress disorder (PTSD) and impairments across multiple domains of functioning (e.g., Derosa, Amaya-Jackson & Layne, 2013; Ford, Courtois, Steele, van der Hart, & Nijenhuis, 2005; van der Kolk, 2005). Such difficulties can include high-risk behaviors such as active suicidality (Middlebrooks & Audage, 2008) and nonsuicidal self-injurious behavior (NSSI; Hu, Taylor, Li, & Glauert, 2017). While there have been many advances in the treatment of trauma, treatment dropout for adolescents seeking trauma-informed treatment is predicted by diagnostic comorbidity and complexity (Sprang et al., 2013), as well as the number of traumatic events endorsed (Wamser-Nanney & Steinzor, 2016). Many traumatized adolescents with high-risk behaviors are referred to Dialectical Behavior Therapy (DBT-A). However, DBT-A does not yet include a specific, evidence-based protocol for treating PTSD, without which treatment gains may not be sustained for traumatized adolescents (Harned, Korslund, & Linehan, 2014). While Prolonged Exposure (PE) is indicated as the gold-standard treatment for PTSD and has proven effective for adolescents (PE-A; Foa, McLean, Capaldi, & Rosenfield, 2013), it has not yet been validated with adolescents who are actively suicidal. However, PE has successfully been integrated within DBT for adults with co-occurring Borderline Personality Disorder and PTSD (e.g., DBT-PE; Harned et al., 2014). Based upon this model, the current paper proposes the integration of DBT-A and PE-A to treat adolescents with interpersonal trauma who also present with high-risk behaviors. The paper discusses anticipated complications related to adapting this model for adolescents and provides direction for future research.     

Preliminary Evidence for the Effectiveness of Dialectical Behavior Therapy for Adolescents

This meta‐analysis evaluated the effectiveness of dialectical behavior therapy for adolescents in reducing symptoms of depression, anxiety, self‐injury, and suicide risk. Twelve between‐group studies (N = 834) were chosen that met the inclusion criteria. Results revealed small‐to‐medium Hedges's g effect sizes for all 4 symptoms compared with control and alternative treatment groups. However, the small number of effect sizes available for each analysis limited the generalizability of the findings. Implications and suggestions for future research are discussed.     

A Pilot Implementation-Effectiveness Trial of a Single-Session Telehealth Workshop and Smartphone-Based Cognitive Behavioral Intervention for Managing Emotions Among College Students

The number of college students who need mental health treatment outpaces the resources available to counseling centers to provide these needed services, presenting a need for low-cost, scalable interventions for college populations. We conducted a pilot implementation-effectiveness trial of a scalable treatment package that consisted of a single (telehealth) workshop plus a companion app that provided ecological momentary intervention. Participants (n = 177) received a workshop provided by counseling center staff and trainees. We were interested in (1) engagement with the app, (2) acceptability of the treatment package, and (3) initial effectiveness of the treatment package. Regarding engagement with the app, we found that participants preferred two reminder prompts per day and identified two key breakpoints when engagement declined significantly: at day 15, when just over half of the sample practiced a skill on the app at least once during the day and at day 41, when just over one third of people practiced a skill on the app each day. Regarding acceptability of the treatment package, students generally reported positive attitudes about the single-session workshop and app, but also noted that the content and assessments in the app needed to be more dynamic to improve how engaging it is. Regarding effectiveness, we found that about 75% of the sample experienced a significant reduction in negative affect from pre- to post-ecological momentary intervention. Moreover, there were significant pre- to post-study decreases in experiential avoidance and symptoms of anxiety and depression and increases in self-efficacy for managing negative emotions. The results of this study are promising in terms of providing initial support for this novel treatment package and provide useful information for researchers planning to develop and test similar interventions.     

Efficacy of Dialectical Behavior Therapy for Adolescents in a Partial Hospitalization Program

This study evaluated dialectical behavior therapy for adolescents (DBT‐A) vs. treatment as usual within a 6‐week partial hospitalization program. The 103 adolescent participants (mean age = 15.27 years) were predominantly girls (n = 63, 61%) with a variety of primary mental health diagnoses. Results indicated that DBT‐A was superior for decreasing symptoms of depression and interpersonal sensitivity, but no statistically significant difference was detected for anxiety or hostility. Implications for treating youth with transdiagnostic identities are discussed.     

Differential Effectiveness of Behavioral Parent-Training and Cognitive-Behavioral Therapy for Antisocial Youth: A Meta-Analysis

Extended the findings from previous meta-analytic work by comparing the effectiveness of behavioral parent-training (BPT) and cognitive-behavioral therapy (CBT) for youth with antisocial behavior problems. Youth demographic variables were also examined as potential moderators of the effectiveness of these 2 types of interventions. Thirty BPT studies and 41 CBT studies met inclusion criteria for this meta-analysis. The weighted mean effect size (ES) for all interventions was 0.40. Youth age was found to moderate the outcome of the 2 interventions, with BPT having a stronger effect for preschool and school-aged youth and CBT having a stronger effect for adolescents. The results also indicate that there may be systematic differences in the outcomes associated with BPT and CBT when the setting of the intervention is considered, suggesting the need to carefully consider the effect of setting in future research. This study also highlights the need for outcome research dealing with more diverse populations and the better classification of research participants on different developmental trajectories of antisocial behavior.     

The Efficacy of Behavioral Couples Therapy and Emotionally Focused Therapy for Couple Distress

Twenty treatment outcome studies, 13 of which evaluated behavioral couples therapy (BCT) and seven of which evaluated emotionally focused therapy (EFT) were reviewed, leading to the following conclusions. BCT leads to short and long-term gains for moderate to severe couple distress. In the long term BCT probably leads to no better outcomes than its constituent components—behavioral exchange training and communication and problem solving skills training. Addition of a cognitive therapy component to BCT or the use of a variety of treatment formats does not improve the efficacy of BCT. Integrative couples therapy and insight-oriented marital therapy may be more effective than BCT, but studies supporting this conclusion require replication. EFT leads to short and long-term gains for mild to moderate couple distress. Addition of a cognitive therapy component to EFT does not enhance its efficacy. EFT may be more effective than problem solving therapy and less effective than integrated systemic therapy, but the two studies supporting this conclusion require replication.Michael Byrne, PhD, is a Clinical Psychologist, Midland Health Board, Ireland; Alan Carr, PhD, is Director of the Clinical Psychology Training Programme, Department of Psychology, Arts Building, University College Dublin, Belfield, Dublin 4, Ireland (alan.carr@ucd.ie). Marie Clark, PhD, is Lecturer, Department of Psychology, University of Surrey, United Kingdom.     

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.     

The Importance of Theory in Cognitive Behavior Therapy: A Perspective of Contextual Behavioral Science

For the past 30 years, generations of scholars of cognitive behavior therapy (CBT) have expressed concern that clinical practice has abandoned the close links with theory that characterized the earliest days of the field. There is also a widespread assumption that a greater working knowledge of theory will lead to better clinical outcomes, although there is currently very little hard evidence to support this claim. We suggest that the rise of so-called “third generation” models of CBT over the past decade, along with the dissemination of statistical innovations among psychotherapy researchers, have given new life to this old issue. We argue that theory likely does matter to clinical outcomes, and we outline the future research that would be needed to address this conjecture.     

Stopping the Nonadherence Cycle: The Clinical and Theoretical Basis for Dialectical Behavior Therapy Adapted for Adolescents With Chronic Medical Illness (DBT-CMI)

Most adolescents with chronic illness do not adhere to their regimen. A novel transdiagnostic adaptation of dialectical behavior therapy (dialectical behavior therapy for chronic medical conditions; DBT-CMI) is presented to improve medical adherence in adolescents. The authors describe the approach of DBT-CMI and the model’s conceptualization of nonadherence, with specific focus on the core concepts of non-adherence across illness in adolescence.DBT-CMI has been piloted in two disease groups with preliminary benefit. DBT-CMI lends itself theoretically as a transdiagnostic approach due to specific skills that target core concepts of nonadherence in adolescence. Future research is warranted on the applicability of DBT-CMI across other pediatric medical conditions to replicate findings and examine long-term outcomes.