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.     

Population growth and social structure of confined colonies of mongolian gerbils: Scent gland size and marking behaviour as indices of social status

Male gerbils have larger ventral scent glands, and they mark more than females. In both sexes, scent gland activity is dependent on gonadal hormones. Observations on colonies of gerbils, living in enclosures or cages, showed that both scent gland size and marking behaviour were related to social status. In colonies founded by a single pair, breeding was confined to the original female. The infertility of the daughters was due to failure of sexual maturation. As this was always associated with a lack of development of the scent glands, the functional state of the latter could be used as an index of fecundity. A change in social organization (eg removal of the parents) caused previously infertile females to conceive and was accompanied by development of the scent glands If there was competition for dominance, the scent glands of the losers regressed; at autopsy, their ovaries and uteri appeared to be nonfunctional. The founding father usually had a larger scent gland than his sons, but the inhibition of sexual function was not as severe as in the females. However, the father characteristically showed much more marking behaviow in a neutral territory than his sons. None of the fem ales-except the mother-showed appreciable marking, and her scores were much lower than those of the dominant male. Asymptotic populations were reached at about the same level in enclosures and cages, implicating an intrinsic capacity for control independent of the number of animals per unit of space but probably related to the natural size of a social group. Stabilization of numbers was achieved not only by reproductive inhibition of young females, but also by cessation of breeding by the founding mother and death of litters. Littermates raised in enclosures without their parents showed delayed sexual maturation accompanied by fighting which resulted in the formation of a hierarchy headed by a breeding female and a dominant (marking) male.     

Sex differences in aggressive behaviour in various strains of mice

Two nonalbino inbred (C57 BL/6 and C3H/He) and one albino strain (Swiss) of mice were compared for female aggression toward intruders: 1 in period of lactation, 2 in nonlactating state and (3) in nonlactating state but previously rubbed with urine of lactating females; and for male aggression toward familiar or unfamiliar opponents. The results showed that resident females of the C57 and Swiss strain vigorously attack lactating intruders introduced into their cages. This effect was mediated by urinary cues emitted by the latter mice. It was also shown that Swiss residents displayed aggression towards nonlactating females, irrespective of their strain. Groups of C57 residents reacted most aggressively towards Swiss females, less aggressively towards C3H intruders, but did not show any aggression towards their own nonlactating conspecifics. In contrast, none of the C3H resident female groups displayed aggression towards intruding females of any category or strain. The results also showed that the males of the three strains displayed little (Swiss and C3H) or no aggression (C57) towards familiar opponents, whereas they directed increased aggressive responses towards unfamiliar ones. Comparisons among the three strains of mice revealed that Swiss males were the most aggressive in either situation. On the other hand, the finding that C3H males showed aggressive responses suggested that male and female aggression are, in this strain, under separate genetic or hormonal control.     

Growth and social behavior of previously undernourished mice

Developing mice were growth-retarded by underfeeding of their mothers during lactation. Control mothers were well nourished throughout. All offspring were fed ad libitum from weaning till their behaviour was tested in adulthood. The undernourished mice had weight deficits at weaning of 49% compared with controls. Nevertheless, they showed partial catch-up growth thereafter, in that their absolute weight deficits decreased between weaning and adulthood. Social behaviour observations were made on pairs of mice of the same treatment group. Previously undernourished mice were slower to start attacking one another, spent more time near or in contact with one another and did less tail-rattling than their controls.     

The little puppet: working with autistic defences in mother-infant psychotherapy

This paper outlines a constellation around birth in our society that is related to advanced western medicine and the way that families move around the globe. It describes a brief therapy with a three-year-old child who was diagnosed as autistic, and a mother who resorted to 'heroic' defences against the anxiety of being unsupported in a strange country. The therapist undertook to process the catastrophic experiences of the birth as expressed in the child's play and transform the accompanying monstrous fantasies into human experiences and thoughts. By providing a maternal container for both mother and child, the therapist was able to dissolve the couple's negative enmeshment and help create a space in the mother's mind in which she could process her own feelings, and thereby process and understand the child's feelings and communications.     

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.     

Prefrontal brain activity predicts temporally extended decision-making behavior

Although functional neuroimaging studies of human decision-making processes are increasingly common, most of the research in this area has relied on passive tasks that generate little individual variability. Relatively little attention has been paid to the ability of brain activity to predict overt behavior. Using functional magnetic resonance imaging (fMRI), we investigated the neural mechanisms underlying behavior during a dynamic decision task that required subjects to select smaller, short-term monetary payoffs in order to receive larger, long-term gains. The number of trials over which the longterm gains accrued was manipulated experimentally (2 versus 12). Event-related neural activity in right lateral prefrontal cortex, a region associated with high-level cognitive processing, selectively predicted choice behavior in both conditions, whereas insular cortex responded to fluctuations in amount of reward but did not predict choice behavior. These results demonstrate the utility of a functional neuroimaging approach in behavioral psychology, showing that (a) highly circumscribed brain regions are capable of predicting complex choice behavior, and (b) fMRI has the ability to dissociate the contributions of different neural mechanisms to particular behavioral tasks.     

Cognitive-behavioural interventions in a patient with an anxiety disorder related to diabetes

This study extends the data on the efficacy of cognitive interventions for patients with chronic medical problems and describes the case of a 37-year-old woman with an anxiety disorder related to diabetes. The effects on panic frequency, use of safety behaviour and related beliefs were investigated after the introduction of two main cognitive-behavioral interventions. The results are consistent with predictions from the cognitive model of panic. This case demonstrates the usefulness of directly challenging the 'meaning' of the feared situation in order to produce clinically significant improvements in the management of physical disease.     

Cognitive behaviour therapy of acute stress disorder: a four-year follow-up

The aim of this study was to index the long-term benefits of early provision of cognitive behavior therapy to trauma survivors with acute stress disorder. Civilian trauma survivors (n = 80) with acute stress disorder were randomly allocated to either cognitive behavior therapy (CBT) or supportive counseling (SC) - 69 completed treatment, and 41 were assessed four years post-treatment for post-traumatic stress disorder (PTSD) with the Clinician Administered PTSD Scale. Two CBT patients (8%) and four SC patients (25%) met PTSD criteria at four-year follow-up. Patients who received CBT reported less intense PTSD symptoms, and particularly less frequent and less avoidance symptoms, than patients who received SC. These findings suggest that early provision of CBT in the initial month after trauma has long-term benefits for people who are at risk of developing PTSD.     

Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment

This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.