Assessment of Parents,Couples, and Families in Dialectical Behavior Therapy

Family intervention in Dialectical Behavior Therapy (DBT) is a core part of multiple required functions of DBT, providing opportunities for skill training (including relationship-specific skills that are not covered in individual DBT), skill generalization, and direct intervention into the social and family environment. In order to intervene with parents, partners and other family members efficiently and effectively, therapists must first conduct a careful assessment. The core relationship transaction of emotion vulnerability/dysregulation and inaccurate expression leading to invalidating responses (and vice versa) is highlighted, as are the treatment targets in DBT with families, which inform assessment targets. Then, two core assessment procedures are explored, with clinical examples: (a) conducting “double chain” analyses, demonstrating how one person’s social or relationship responses affect the other’s emotional arousal (and vice versa); and (b) direct behavior observation of family interactions, which allow treatment targets to be identified efficiently. These two assessment strategies may also be combined. Implications for family interventions are discussed.     

Dialectical behavior therapy--family skills training

Over the past three decades, family interventions have become important components of treatment for a number of psychiatric disorders. To date, however, there has been no family treatment designed specifically for borderline personality disorder patients and their relatives. This article describes one short-term family intervention called Dialectical Behavior Therapy-Family Skills Training. Based on Linehan's Dialectical Behavior Therapy (DBT), borderline patients' behavioral patterns are thought to result from a lifelong transaction between emotional vulnerability and invalidating features of the social and familial environment. Individual DBT focuses on reducing individual emotion dysregulation and vulnerability and enhancing individual stability. The complementary family interventions proposed in this article aim to: 1) provide all family members an understanding of borderline behavioral patterns in a clear, nonjudgmental way; 2) enhance the contributions of all family members to a mutually validating environment; and 3) address all family members' emotion regulation and interpersonal skills deficits.     

Affirmative Dialectical Behavior Therapy Skills Training With Sexual Minority Veterans

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

Dialectical Behavior Therapy: An Emotion-Focused Treatment for Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment for borderline personality disorder (BPD) that is based on the theory that emotion dysregulation is the core feature of BPD. This article focuses on aspects of DBT theory and techniques that specifically address emotion. The dialectical and biosocial theories that underlie DBT are reviewed with an emphasis on how each relates to emotional experiencing in BPD. Selected treatment strategies that address emotion dysregulation and their hypothesized mechanisms of change are also described. Relevant research findings are incorporated throughout to provide an empirical foundation for the DBT theories and strategies that are discussed.     

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.     

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.     

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.     

Application of a CBPR Framework to Inform a Multi-level Tobacco Cessation Intervention in Public Housing Neighborhoods

African American women in urban, high poverty neighborhoods have high rates of smoking, difficulties with quitting, and disproportionate tobacco-related health disparities. Prior research utilizing conventional "outsider driven" interventions targeted to individuals has failed to show effective cessation outcomes. This paper describes the application of a community-based participatory research (CBPR) framework to inform a culturally situated, ecological based, multi-level tobacco cessation intervention in public housing neighborhoods. The CBPR framework encompasses problem identification, planning and feasibility/pilot testing, implementation, evaluation, and dissemination. There have been multiple partners in this process including public housing residents, housing authority administrators, community health workers, tenant associations, and academic investigators. The advisory process has evolved from an initial small steering group to our current institutional community advisory boards. Our decade-long CBPR journey produced design innovations, promising preliminary outcomes, and a full-scaled implementation study in two states. Challenges include sustaining engagement with evolving study partners, maintaining equity and power in the partnerships, and long-term sustainability of the intervention. Implications include applicability of the framework with other CBPR partnerships, especially scaling up evolutionary grassroots involvement to multi-regional partnerships.     

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.

     

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.     

Assessment-Driven Case Formulation and Treatment Planning in Dialectical Behavior Therapy: Using Principles to Guide Effective Treatment

Dialectical Behavior Therapy (DBT) is a complex cognitive-behavioral treatment designed for a population with multiple problematic and high-risk behaviors. As with any behavioral treatment, the role of assessment in DBT is critical. Although there is a significant body of research supporting the efficacy of DBT, there is a relative dearth of practical and principle-based information that help therapists formulate cases and treatment from a DBT perspective. In this article, we provide a step-by-step guide for creating an assessment-driven DBT case formulation and treatment plan. We focus on identifying stage of treatment, determining goals, developing the target hierarchy, assessing and treating the primary target behavior, and tracking outcomes. We highlight the few rules that inform DBT assesssment and practice, note and correct several common misconceptions, and demonstrate how the use of thorough assessment can result in a more nuanced case formulation and treatment plan.     

Dialectical Behavior Therapy for Managing Interpersonal Relationships

Dialectical Behavior Therapy (DBT) is a treatment designed for individuals having borderline personality disorder (BPD), patients having binge eating disorder, co-morbid substance dependence and BPD, and depressed older adults. This paper aims to explore the use of DBT and to ascertain the status of DBT education in treating difficulties in handling interpersonal relationships among clients seeking counseling and psychotherapy. The skills training mode can be employed for teaching skills to solve relationship problems. Validation and acceptance strategies can lessen rejection sensitivity and negative feelings that make interpersonal situations chaotic. Black and white thinking can be resolved by finding a middle path through acceptance and change. This paper suggests the possible utility of DBT for enhancing psychological well-being in clients.     

Dialectical Behavior Therapy in the Treatment of Abusive Behavior

Summary

Research suggests that a subset of men who abuse their partners have characteristics associated with borderline personality disorder (BPD). Dialectical Behavior Therapy (DBT) has shown promise as a treatment for BPD, and thus may be useful for these men. This paper describes how DBT principles might be applied to address the problem of partner abuse, including discussion of why one might expect DBT to be a helpful treatment model for this population, and how implementation of the model might be designed.     

Preschool competency in context: an investigation of the unique contribution of child competencies to early academic success

The present concurrent study combined developmental and ecological considerations to examine the unique contribution of multiple preschool competencies to an indicator of early academic success. Participants included 195 Head Start children from 32 classrooms representative of a large, urban Head Start program. Dimensional (variable-centered) analyses revealed 3 distinct classroom competency dimensions (i.e., General Classroom Competencies, Specific Approaches to Learning, and Interpersonal Classroom Behavioral Problems). The first 2 of these dimensions were found to be uniquely associated with early academic success. Findings from typological (person-centered) analyses supported the dimensional findings. Typological analyses revealed 7 profiles of classroom competency distinguished by high scores on the dimensions of General Competencies and Approaches to Learning, and these profiles were found to relate differentially to the indicator of early academic success.     

“You Didn’t Cause Racism,and You Have to Solve it Anyways”: Antiracist Adaptations to Dialectical Behavior Therapy for White Therapists

There are currently no published studies that investigate or discuss the cultural responsiveness of Dialectical Behavior Therapy (DBT) to the needs of Black/African-American clients. In addition, no published scholarly works offer guidance to therapists on how to practice antiracism within the context of delivering evidence-based treatment. Methods for developing a culturally responsive antiracist treatment are discussed within a dialectical framework and from the perspective of critical race psychology. We propose that an antiracist adaptation to DBT is needed to correct for context minimization errors in the DBT model that create an invisibility of racism. Recommendations are made for an additional DBT Therapist Agreement that encourages labeling and targeting therapist treatment-interfering racist behavior. An additional Therapist Consultation Agreement is also proposed to guide therapist antiracist advocacy and functional validation for Black/African-American clients. The DBT technology is used in conjunction with other multicultural theoretical models to recommend strategies for developing White DBT therapists’ antiracist competencies. Future directions for developing critical race psychological research are discussed.     

The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder

The working alliance between therapist and patient is an important component of effective interventions for borderline personality disorder (BPD). The current study examines whether client personality affects the development of the working alliance during the treatment of BPD, and whether this influences treatment effectiveness. Data was based on 87 patients with BPD who were participants in a randomized controlled trial comparing Dialectical Behavior Therapy (DBT) and general psychiatric management. Higher levels of trait Agreeableness were associated with steeper increases in working alliance throughout treatment, but only in the DBT condition. Increases in working alliance were in turn associated with better clinical outcomes. Mediation models revealed a significant indirect path from Agreeableness to better clinical outcomes, mediated through larger improvements in working alliance over time. These results highlight the role that patient personality can play during the therapeutic process, with a specific focus on the importance of Agreeableness for alliance development.     

EARLY HEAD START FAMILIES’ EXPERIENCES WITH STRESS: UNDERSTANDING VARIATIONS WITHIN A HIGH‐RISK,LOW‐INCOME SAMPLE

The federal Early Head Start program provides a relevant context to examine families’ experiences with stress since participants qualify on the basis of poverty and risk. Building on previous research that has shown variations in demographic and economic risks even among qualifying families, we examined possible variations in families’ perceptions of stress. Family, parent, and child data were collected to measure stressors and risk across a variety of domains in families’ everyday lives, primarily from self‐report measures, but also including assay results from child cortisol samples. A cluster analysis was employed to examine potential differences among groups of Early Head Start families. Results showed that there were three distinct subgroups of families, with some families perceiving that they experienced very high levels of stress while others perceived much lower levels of stress despite also experiencing poverty and heightened risk. These findings have important implications in that they provide an initial step toward distinguishing differences in low‐income families’ experiences with stress, thereby informing interventions focused on promoting responsive caregiving as a possible mechanism to buffer the effects of family and social stressors on young children.     

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.     

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

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

Dialectical Behavior Therapy and Motivational Interviewing: Conceptual Convergence,Compatibility, and Strategies for Integration

Dialectical behavior therapy (DBT) and motivational interviewing (MI) are two widely used and efficacious psychosocial interventions. An immense and growing number of studies examine DBT, MI, or adaptations of these approaches across diverse treatment contexts and across various clinical populations. Because DBT and MI are in high demand, it is probable that trainees and established practitioners will encounter one or both treatments over the course of their careers. Although MI and DBT initially evolved in distinct contexts for different populations, these approaches share a number of common fundamental principles. Each provides distinct and complementary strategies for enhancing clients’ motivation and ability to change. For some, an integrative or sequenced application of MI and DBT may enhance client care. The present article highlights areas of divergence, convergence, and opportunities for integration, and offers practical tips for applying DBT and MI in conjunction.