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.     

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.     

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

ABSTRACT

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

The 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.     

An evaluation of the effectiveness of Diploma-level training in cognitive behaviour therapy

Background

As part of the UK government’s initiative to Increase Access to Psychological Therapies (see http://www.iapt.nhs.uk/for full details of the IAPT programme) there has been an expansion in the provision of post-graduate Diploma training in cognitive behaviour therapy (CBT). Previous evaluations of such training programmes have yielded mixed results but have been limited by small sample sizes and/or limited assessment measures.

Aims

To evaluate the impact of a long-standing Diploma in CBT training programme on a variety of measures of CBT competence.

Method

Trainees’ levels of CBT skill are compared at the beginning and end of CBT training. The effect of therapist factors such as age, professional background and gender on the development of CBT competence is also examined.

Results

Results show that trainees demonstrate higher levels of CBT skills after completing the training than they did before, with the majority achieving pre-determined criteria for competence. Trainees’ gender was not related to their performance but trainees’ age showed a negative association with CBT skill (older trainees performed worse). Trainees’ professional background also had an impact on their level of CBT competence, with trainees who were clinical psychologists demonstrating the highest levels of competence across a range of measures.

Conclusions

CBT Diploma training leads to increases in the level of trainees’ CBT competence, with the majority achieving the levels demonstrated in research trials by the end of training. Thus, this training is likely to lead to improved outcomes for patients. Further research is needed to determine the most efficient ways of enhancing CBT skills.     

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.     

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

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

Considering boundaries when doing therapeutic work with people who are seeking asylum: a reflective case study

People who are seeking asylum often have lived experience of their personal boundaries and human rights being violated. For this reason, it is especially important that we consider the impact of boundaries in therapeutic work with this population. This paper explores work with a woman with a severe trauma history who was seeking asylum in England. Examples of perceived boundary crossings in the therapeutic relationship are examined. Considerations for other clinicians working with asylum seekers are discussed. These include: addressing socio-political factors; being sensitive to cultural differences; the importance of supervision and reflective practice; the personal impact of such work; and using critical thinking and warmth to manage boundaries rather than rigidly following rules.     

A randomized wait-list controlled pilot study of dialectical behaviour therapy guided self-help for binge eating disorder

This study examined the efficacy of guided self-help based on dialectical behaviour therapy (DBTgsh) for binge eating disorder (BED). Individuals (88.3% female; mean 42.8 years) were randomized to DBTgsh (n = 30) or wait-list (WL; n = 30). DBTgsh participants received an orientation, DBT manual, and six 20-min support calls over 13 weeks. All participants were assessed pre- and post-treatment using interview and self-report; also, DBTgsh participants were re-assessed six months post-treatment. At treatment end, DBTgsh participants reported significantly fewer past-month binge eating episodes than WL participants (6.0 versus 14.4) and significantly greater rates of abstinence from binge eating (40.0% versus 3.3%). At six-month follow-up, DBTgsh participants reported significantly improved quality of life and reduced ED psychopathology compared to baseline scores. In addition, most improvements in the DBTgsh group were maintained, although binge eating abstinence rates decreased to 30%. These preliminary positive findings indicate that DBTgsh may offer an effective, low-intensity treatment option for BED.     

Sustained efficacy of dialectical behaviour therapy for borderline personality disorder

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

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.     

Clients with borderline personality disorder: Exploring their experiences of dialectical behaviour therapy

This study explores clients’ experiences of Dialectical Behavioural Therapy (DBT). Five participants, all with a diagnosis of borderline personality disorder, were interviewed following a semi‐structured format about their experiences of an NHS regional DBT programme. The interviews were transcribed and analysed using Interpretative Phenomenological Analysis (IPA). Three superordinate themes were identified consisting of a number of sub themes: joining a DBT Programme (external and internal factors); experience of DBT (specific and non specific factors); and evaluation of DBT (change, evaluation and role of the past and future). The study provides an insight into clients’ experiences of DBT. The results are discussed in relation to clinical practice and future research.     

An exploration of the therapeutic process while using computerised cognitive behaviour therapy

Background: Modern technologies that offer an alternative to face‐to‐face therapy have gained ground in the NHS. Critics have argued that some of the important elements of the therapeutic change process necessarily require a human therapist. Yet, the traditional understanding of the change process in psychotherapy is challenged by evidence that some computerised cognitive behaviour therapy (cCBT) programs may be as effective as face‐to‐face therapy, suggesting that in certain cases the interaction between user and a cCBT product satisfies sufficient criteria for personal change without the need for actual human contact. Aim: This study used the cCBT package Blues Begone as a means of investigating the process by which a computer‐mediated program helped adults with mild depression help themselves. Method: Seven qualitative interviews were conducted with mildly depressed users who had completed Blues Begone in their own homes without any additional human help or support. Findings: Interpretive phenomenological analysis (IPA) was performed with four main themes emerging. These were: the meaningful relationship; shape from confusion; stimulation and empowerment. This study illustrates some of the ways that some depressed users make use of cCBT self help.     

Clinical supervision in cognitive behavior therapy improves therapists’ competence: a single-case experimental pilot study

ABSTRACT

Clinical supervision is a cornerstone in psychotherapists’ training but there are few empirical evaluations on the effects of supervision on therapists’ competencies. The aim of this study was therefore to evaluate the effects of standardized supervision on rater-assessed competency in Cognitive Behavior Therapy (CBT). Six therapists with basic training in CBT were provided with protocol-based clinical supervision in CBT in a single-case experimental multiple baseline design. The supervision focused on specific CBT competencies and used experiential learning methods such as role-play. Each therapist recorded weekly treatment sessions during phases without and with supervision. The therapists’ CBT competence was assessed by third-party raters using the Revised Cognitive Therapy Scale (CTS-R). Statistical analyses showed that the therapists’ CTS-R scores increased significantly during the phase with supervision with a mean item increase of M = 0.71 (range = 0.50–1.0) on the supervision focus areas. This is one of the first empirical studies that can confirm that supervision affect CBT competencies. The results also suggest that supervision can be manualized and that supervisees have a positive perception of more active training methods. Further studies are needed to replicate the results and to find ways to improve the impact of supervision.     

Cognitive behaviour therapy for common mental disorders in people with Multiple Sclerosis: A bench marking study

Background

Mental health problems such as depression and anxiety are common in Multiple Sclerosis (MS) and are often under treated.

Aims

This paper reports on the clinical effectiveness of a cognitive behaviour therapy service for common mental disorders in people with MS and compares it to previous randomised controlled trials (RCTs) of cognitive behaviour therapy (CBT) in this population.

Methods

49 patients were deemed appropriate for CBT and 29 accepted treatment. Assessments were completed at baseline and end of treatment and included the Hospital Anxiety & Depression Scale. Results in the form of a standardized effect of treatment were compared with five previous RCTs.

Results

The results from this clinical service indicated statistically significant outcomes with reductions in depression and anxiety. The uncontrolled effect size was large but inferior to those found in published RCTs.

Conclusions

Cognitive behaviour therapy is effective for people with MS in routine clinical practice. Possible limits on effectiveness include more liberal patient selection, lack of specificity in rating scales and heterogeneity of target problems. Given the high rates of distress in this population, routine psychological interventions within neurology services are justifiable. Future research should aim to maximise CBT in such settings.     

Towards case-specific applications of mindfulness-based cognitive-behavioural therapies: A mindfulness-based rational emotive behaviour therapy

Teasdale, Segal and Williams (2003 Teasdale, JD, Segal, ZV and Williams, JMG. 2003. Mindfulness training and problem formulation. Clinical Psychology: Science and Practice, 10: 157–160. [Crossref], [Web of Science ®] [Google Scholar]) present the combination of mindfulness and cognitive-behavioural therapy as “one of the most exciting and potentially productive avenues for future exploration.” (p. 160). In the same paper they also recommend moving beyond the current general-purpose, non-case-specific applications of mindfulness (p. 157). By integrating mindfulness interventions more closely with cognitive behavioural theories, clinicians should be in a better position to administer tailor-made mindfulness-based interventions in response to specific case formulations. This paper examines important similarities and differences between mindfulness and Rational-Emotive Behaviour Therapy (REBT), in view of integrating the two practices closely within a one-on-one counselling environment. The latter half of the paper then presents recommendations of how such integration might be achieved in practice. This is illustrated with examples of three new interventions that combine mindfulness with three specific types of cognitive dysfunction as per REBT.