Broad strokes or fine points: Are dialectical behavior therapy modules associated with general or domain-specific changes?

The present study investigated the effectiveness of dialectical behavioral therapy (DBT) and the effect of improvement in DBT skills on clinical outcomes. Participants included 57 adults who attended a community mental health service and underwent one of two modes of DBT. Twenty-six adults had been diagnosed with borderline personality disorder (BPD) and participated in comprehensive DBT (DBT-C; including group skills training, individual therapy, and phone coaching). Thirty-one adults had BPD traits and participated in DBT skills training (DBT-S; group skills training only). In the present study, the DBT skills examined were mindfulness, emotion regulation, and interpersonal effectiveness; the clinical outcomes examined were borderline symptoms, psychological distress, and quality of life. Six 2 × 2 analysis of covariances indicated significant improvements in psychological distress, quality of life, mindfulness, and interpersonal effectiveness (but not borderline symptoms and emotion regulation), over a 6-month period. Mode of delivery of DBT did not impact on the improvement in DBT skills and clinical outcomes over the 6-month period. Hierarchical multiple regression results indicated that improvement in DBT skills (mindfulness, emotion regulation, and interpersonal effectiveness) were associated with reductions in borderline symptoms and psychological distress, with emotion regulation the only skill uniquely associated with improvements in clinical outcomes. The results of the present study support the effectiveness of DBT and the specific role of emotion regulation for favorable clinical outcomes over a 6-month period, independent of the mode of delivery of DBT.

BackgroundDialectical behavior therapy (DBT) is a first‐line treatment for the prevention of suicide. Zhong‐Yong thinking could be viewed as a Chinese way of dialectical thinking, has long been a culturally dictating thinking style in China. To enhance cultural adaptability, we integrated Zhong‐Yong thinking into DBT group skills training and examined its efficacy in suicidal prevention compared with a supportive group therapy and a wait‐list group in high‐risk suicidal Chinese college students.MethodsA total of 97 suicidal participants were randomized to either Zhong‐Yong thinking based DBT group skills training (DBTZYT, n = 33), or supportive group therapy (SGT; n = 32), or wait‐list group (WL; n = 32). DBTZYT was a 12‐week program based on Zhong‐Yong thinking instead of dialectical thinking, coaching participants mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Supportive group therapy was a 12‐week program aiming at improving interpersonal effectiveness and emotion regulation skills. Outcome measures were assessed at pre‐ and post‐treatment and 6‐month follow‐up.ResultsAt post‐treatment measures, the levels of suicidal ideation, hopelessness, psychache symptoms, and general psychopathology had significantly decreased in both intervention groups; at the 6‐month follow‐up measures, the intervention effects were better maintained in the DBTZYT group rather than in the SGT group. Specifically, DBTZYT was more effective in relieving participants’ long‐term obsessive‐compulsive, anxiety, hostility, phobic, psychotic, and additional symptoms.ConclusionsZhong‐Yong thinking not only could integrate with DBT skills training in Chinese young adult population, but also has special strength in enhancing DBT’s efficacy.

Subthreshold binge-eating disorder (BED) symptoms can lead to additive physical and psychological health challenges and may put youth at risk for developing BED during the early adulthood. We examined the implementation of a condensed dialectical behavior therapy (DBT) skills intervention for subthreshold binge-eating behaviors in adolescents. Fifteen 14-18years old participated in a 10-week DBT skills group, which experientially introduced mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills in the context of emotionally driven overeating behaviors. Adolescents and caregivers completed measures of emotional eating and binge-eating behaviors at baseline and post-intervention, including the Eating Disorder Examination Questionnaire and Emotional Eating Scale for Children and Adolescents. Eleven participants were retained at 3-month follow-up. Descriptive statistics were compared at all three time points. Results suggested a reduction in emotional eating and binge-eating behaviors based on youth self-report and caregiver report. Acceptability ratings of the treatment were high among participants completing the intervention. Using DBT skills to target emotionally driven overeating behaviors in youth may be useful in the treatment of subthreshold BED behaviors and potentially deter future development of full-criteria BED. Level IV, uncontrolled pilot trial.

Objective: To examine the feasibility and initial efficacy of 2 abbreviated dialectical behavior therapy (DBT) skills training groups: emotion regulation skills only and emotion regulation with mindfulness skills. Participants: Participants were 24 undergraduates (aged 18–29) with significant emotion dysregulation who participated between February and May of 2010, 2011, and 2012. Methods: Participants participated in 2-hour weekly group sessions for 8 weeks and completed outcome measures at baseline, midtreatment, posttreatment, and 4-week follow-up. Results: Participants in both conditions made significant gains, with large effect sizes, across measures of emotion regulation, affect, skills use, and functioning. There were no differences between the 2 groups, suggesting no additive benefit of mindfulness skills. Conclusions: This pilot study provides support for the acceptability and efficacy of abbreviated DBT skills training in colleges, given significant improvements, positive feedback, and low attrition. Impediments to feasibility included recruitment difficulties, particularly due to scheduling constraints.

An existing body of research demonstrates the efficacy of Dialectical Behavior Therapy (DBT) Skills in reducing a range of psychiatric symptomatology in the United States, although the relevance of DBT Skills in low- and middle-income countries in the Global South has been understudied. Focusing on India, a middle-income country, in this qualitative study, we explored the relevance of DBT Skills for emerging adults-typically individuals aged 18-29 years-using focus groups with counseling psychology graduate students. Students (N = 22, 90% women) participated in initial focus groups where DBT Skills were outlined and were asked whether these skills would be relevant for emerging adults in India, and what adaptations may be needed. Then, students received a virtual four-week DBT Skills training program in which they learned extensively about DBT Skills and subsequently participated in focus groups to discuss the relevance of those skills for emerging adults in India. Incorporating the adaptations they recommended, students then facilitated DBT Skills groups with emerging adults in India for eight weeks and then participated in focus groups to discuss the relevance of the skills. Thematic analysis was used to analyze the data from the three sets of focus groups. Twelve themes were identified and organized into three separate domains: (a) views about optimal interventions; (b) relevance of DBT Skills; and (c) sociocultural adaptations to DBT Skills. Overall, findings suggest relevance of DBT Skills for emerging adults in India with specific adaptations to emotion regulation, and more broadly to all modules by integrating collectivistic values and local cultural norms.

We assessed the effect of DBT skills utilization on features of borderline personality disorder as measured by the Personality Assessment Inventory-Borderline Features Scale (PAI-BOR). Participants were outpatients (N = 27) enrolled in a dialectical behavior therapy (DBT) program in a university-affiliated community mental health clinic. Diary cards were collected each week to track self-reported skills use. At the beginning of each new skills training module, patients completed another PAI-BOR. Univariate and multilevel analyses indicated significant improvement on the total PAI-BOR score and on several PAI-BOR subscale scores. Results also revealed that overall DBT skills use increased significantly over time, as did individual skills related to mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Multilevel modeling results indicated that overall skills use showed a significant effect on PAI-BOR total scores, Affective Instability scores, Identity Problems scores, and Negative Relationships scores, even after controlling for initial levels of distress and diary card compliance.

Do All Roads Lead to Rome? New Findings on Borderline Personality Disorder

The Royal Melbourne Hospital provides inpatient, outpatient and day patient treatment to over 130 patients within the NorthWestern catchment area of Victoria each year. The RMH Eating Disorders Unit is the largest public inpatient service Room: State-wide offering 8 inpatient beds, with an average length of stay of 36 days. The severity, chronicity and complexity of emerging presentations has resulted in a greater demand for inpatient beds, exhausted wait lists, and placed further need and demand on outpatient and transitional support. The Dialectical Behavioural Therapy (DBT) group for Eating Disorders was developed and introduced to the Unit in mid-2011 as a means to provide support, treatment and relapse prevention to those patients who presented with borderline personality disorder (BPD) features and/or often required multiple admissions. The DBT group is a skills-based closed group, which runs for 2.5 hours weekly for 15 weeks. The group focuses on psycho-education of eating disorders, mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. Each cohort is evaluated using pre-test and post-test measures as well as weekly participation feedback. The outcome measures to date have shown that the DBT outpatient group has been effective in reducing BPD features and impulsive behaviours; created positive shifts in mood, unhelpful thought patterns and schemas; reduced stress and anxiety; and attributed to lower readmission rates. This abstract was presented in the Adult Treatment and Services stream of the 2013 ANZAED Conference. Published: 14 November 2013

The last three decades have witnessed significant advances in psychotherapy. Numerous scholarly articles and books have been devoted to pertinent topics in the field, making it difficult for the practicing clinician to keep up with this rapidly growing area. The purpose of this article is to provide some guidelines on how to evaluate the empirical literature in psychotherapy and then to explore three key areas: evidence-based psychotherapies for patients with psychiatric disorders, individual variables that predict differential outcome to treatment, and the therapeutic alliance. Finally, two case examples will be presented to illustrate how knowledge of the empirical literature can facilitate an evidence-based approach to the daily practice of psychotherapy in general psychiatry.

In this study, key informant interviews were conducted with 13 administrators from nine community-based mental health agencies implementing dialectical behavior therapy in order to assess their perspectives on implementation. Four major themes were identified. They include opinions about dialectical behavior therapy and its fit with existing practices, resource concerns (for example, reimbursement issues, time commitment, and staff training), staff selection for training and staff turnover, and ongoing client referrals. Understanding agency administrators' unique perspectives and addressing their concerns is critical to treatment implementation given administrators' role in determining whether and how a treatment will be implemented. Better understanding of the fit between dialectical behavior therapy and existing service structures, the impact of staff turnover on implementation, and the resources required for implementation are all needed to ensure successful implementation and sustainability.

Dialectical Behavior Therapy for Suicidal Self-Harming Youth: Emotion Regulation, Mechanisms, and Mediators

This article explores the efficacy of dialectical behavior therapy (DBT) for young people aging out of the Department of Children and Families system. The project was conducted with participants at a residential program for “transitional youth” who have serious emotional disturbance and emerging mental illness (N = 15). The research method combined a posttest-only comparison group design, with pretest-posttest observations for the DBT group. The research question explored the efficacy of DBT for this population, and used a mixed-method approach combining both quantitative and qualitative data collection. All participants received individual therapy, with 24/7 wraparound residential services. The DBT intervention consisted of an additional two hours of weekly skills-training groups. The mean length of exposure to the DBT intervention was 12.4 months. The quantitative measures included the Modified Global Assessment of Functioning Scale, and the Purposeful Productive Activity and Quality of Life Scale. The qualitative portion of the study involved semi-structured interviews and focus groups.Members of the DBT group improved from pretest to posttest, and when judged against the comparison group improvement was in terms of global functioning, social relationships, and productive use of time or “intentionality,” but not in terms of vocational functioning. The qualitative data suggest that DBT group members used the groups to work on specific interpersonal relationship, emotion regulation, and distress tolerance skills, as well as to get feedback and support from others in the group. The potential implications of these findings for clinical practice may be to suggest DBT as a promising, evidence-based intervention for this vulnerable and heretofore underserved population.

BackgroundStep-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential DBT plus 6 months of outpatient DBT. The program was specifically developed for people suffering from severe borderline personality disorder (BPD). The present study examines the effectiveness and cost-effectiveness of step-down DBT compared to 12 months of regular, outpatient DBT.MethodsEighty-four participants reporting high levels of BPD-symptoms (mean age 26 years, 95% female) were randomly assigned to step-down versus standard DBT. Measurements were conducted at baseline and after 3, 6, 9 and 12 months. The Lifetime Parasuicide Count and BPD Severity Index (BPDSI) were used to assess suicidal behaviour, non-suicidal self-injury (NSSI) and borderline severity. Costs per Quality Adjusted Life Year (QALY) were calculated using data from the EQ-5D-3L and the Treatment Inventory Cost in Psychiatric Patients (TIC-P).ResultsIn step-down DBT, 95% of patients started the program, compared to 45% of patients in outpatient DBT. The probability of suicidal behaviour did not change significantly over 12 months. The probability of NSSI decreased significantly in step-down DBT, but not in outpatient DBT. BPDSI decreased significantly in both groups, with the improvement leveling off at the end of treatment. While step-down DBT was more effective in increasing quality of life, it also cost significantly more. The extra costs per gained QALY exceeded the €80,000 threshold that is considered acceptable for severely ill patients in the Netherlands.ConclusionsA pragmatic randomized controlled trial in the Netherlands showed that 9 months of step-down DBT is an effective treatment for people suffering from severe levels of BPD. However, step-down DBT is not more effective than 12 months of outpatient DBT, nor is it more cost-effective. These findings should be considered tentative because of high noncompliance with the treatment assignment in outpatient DBT. Furthermore, the long-term effectiveness of step-down DBT, and moderators of treatment response, remain to be evaluated.Trial registrationwww.clinicaltrials.govNCT01904227. Registered 22 July 2013 (retrospectively registered).

Borderline Behavior in Adolescence: An Adjective in Search of a Treatment

For women with borderline personality disorder (BPD) mindfulness may provide a significant avenue for change and lead to an improved sense of well-being. In the current study, we examined the predictors of emotional well-being as well as the relationship between mindfulness and healthcare utilization. We employed a correlational design assessing 165 women diagnosed with BPD who were engaged in dialectical behavior therapy (DBT) and learning mindfulness skills. The participants ranged in age from 18 to 68 years and were solicited from five DBT treatment programs in five different states. Using the Five Facet Mindfulness Questionnaire, the Medical Outcomes Study measure of emotional and physical well-being, and the Multidimensional Scale of Perceived Social Support, we examined two hypotheses. The first hypothesis stated that emotional well-being would be predicted by mindfulness, social support, general physical health, and physical functioning with mindfulness as the strongest predictor of emotional well-being. As anticipated, mindfulness was the strongest predictor of emotional well-being followed by social support. The second hypothesis that mindfulness would be associated with healthcare utilization, specifically the number of prescription medications and the number of medically related office visits in the past 3 months was only partially supported. Women who reported greater incorporation of the mindfulness skills they learned in DBT reported less frequent healthcare usage; however mindfulness was unrelated to prescription medication use. The findings support the importance of the core skills of mindfulness taught as a primary component of DBT for women with BPD.