Chapter 7 - Dialectical behavior therapy for individuals with substance use problems: theoretical adaptations and empirical evidence

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.

The promise of third-wave behavioral therapies in the treatment of substance use disorders

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.

Dialectical behavior therapy (DBT) is an empirically supported treatment for suicidal individuals. However, DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team, and little is known about which components are needed to achieve positive outcomes. To evaluate the importance of the skills training component of DBT by comparing skills training plus case management (DBT-S), DBT individual therapy plus activities group (DBT-I), and standard DBT which includes skills training and individual therapy. We performed a single-blind randomized clinical trial from April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up. Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a university-affiliated clinic and community settings by therapists or case managers. Outcomes were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would outperform DBT-S and DBT-I. The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was controlled across conditions, and all treatment providers used the DBT suicide risk assessment and management protocol. Frequency and severity of suicide attempts and NSSI episodes. All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and reasons for living. Compared with the DBT-I group, interventions that included skills training resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = -3.5 [P < .001]) and DBT-S (t94 = -2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]). A variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol are effective for reducing suicide attempts and NSSI episodes. Interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some areas. clinicaltrials.gov Identifier: NCT00183651.

Dialectical Behaviour Therapy (DBT) is an intensive and multi-modal intervention developed for individuals with multiple comorbidities and high-risk behaviours. During pandemic-related lockdowns, many DBT services transitioned to delivering treatment via telehealth, but some did not. The current study sought to explore the experience of DBT teams in Australia and New Zealand who did and did not transition to telehealth during the early stages of the COVID19 pandemic, as the majority of research on DBT via telehealth has originated from North America, and focussed on therapists who did make this transition. DBT team leaders in Australia and New Zealand completed a survey with open-ended questions about the barriers they encountered to delivering DBT via telehealth, and for those teams that implemented telehealth, the solutions to those barriers. Respondents were also asked about specific barriers encountered by Indigenous and Pacific people service users. Of the 73 team leaders who took part, 56 reported providing either individual therapy, skills training or both modalities via video-call during lockdown. Themes emerging from perceived barriers affecting just DBT providers included the assessment & management of emotions and high-risk behaviours, threats to privacy and information security posed by telehealth, logistical issues related to remote sessions, and the remote management of therapy-interfering behaviour. Themes emerging from perceived barriers affecting both providers and service users included disruptions to therapeutic alliance, lack of willingness, lack of technical knowledge, lack of private spaces to do DBT via telehealth, and lack of resources. The solutions most frequently cited were the provision of education and training for therapists and service users in the use of telehealth, and the provision of resources to access telehealth. These findings are relevant to clinical delivery of DBT, as well as planning and funding for DBT telehealth services.

Background Substance use and emotion regulation are common treatment targets in dialectical behaviour therapy (DBT) and they may be categorised as a life‐threatening behaviour, a treatment interfering behaviour, or a quality of life interfering behaviour. Research examining these constructs in DBT‐informed community mental health samples is limited. Aims This study examined substance use, difficulties in emotion regulation (DERS) and programme outcomes (attendance and graduation) among 55 adults from a DBT intensive outpatient programme within a community mental health centre in the United States. Results Our results revealed a statistically significant inverse relationship between substance use at programme entry and the DERS total scale ( Hyp‐ 1: r = −0.29, p &lt; 0.05). No statistically significant relationships were established between the remaining DERS subscales (all other p s &gt; 0.05). In addition, there were no statistically significant relationships between substance use with attendance ( Hyp‐2 : β = −2.17, p = −0.78) and graduation ( Hyp‐ 3: β = −0.55, p = 0.40). Discussion Substance use may regulate emotions as a maladaptive short‐term benefit with long‐term cost. When not influencing life‐threatening behaviours, substance use may be identified as a quality of life interfering behaviour as opposed to a therapy‐interfering behaviour. Conclusion This study provides preliminary evidence to suggest the importance of assessing substance use and emotion regulation to inform treatment targets.

Around the world, suicide ideation, attempts, and deaths pose a major public and mental health challenge for patients (and their loved ones). Accordingly, there is a clear need for effective clinical treatments that reliably reduce suicidal thoughts and behaviors. In this article, we review the Collaborative Assessment and Management of Suicidality (CAMS) and Dialectical Behavior Therapy (DBT), two clinical treatments that rise to the highest levels of empirical rigor. Both CAMS and DBT are now supported by randomized controlled trials (RCTs), with independent replications, and meta-analyses. There are also supportive data related to training clinical providers to use CAMS and DBT with adherence. RCTs that investigate the use of both interventions within clinical trial research designs and the increasing use of these complementary approaches within routine clinical practice are discussed. Future directions for research and clinical use of CAMS and DBT are explored as means to effectively treat suicidal risk.

Dialectical Behaviour Therapy (DBT) contains a weekly consultation team meeting that provides DBT to DBT therapists. While adherence to the treatment manual has been measured in individual therapy and skills training classes, this is the first study measuring adherence in consultation team meetings. The authors hypothesized that 1) it is feasible to apply the DBT-Adherence Coding Scale (DBT ACS) and DBT Adherence Checklist for Individual sessions (DBT AC-I) to evaluate DBT model adherence of consultation teams and 2) that provision of a brief intervention focusing on shaping model adherent behavior would move consultation team processes closer to adherent DBT. DBT adherence rating by a calibrated DBT adherence rater suggests that adapted versions of the DBT ACS and DBT AC-I can be applied to measure model adherence of DBT consultation teams. Implementing a non-concurrent multiple-baseline single-subject case design, this study illustrates that some behaviors in consultation team meetings were more adherent than others after the intervention.

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.

Introduction: In the treatment of borderline personality disorder (BPD), there is empirical support for both dialectical behavior therapy (DBT) and schema therapy (ST); these treatments have never been compared directly. This study examines whether either of them is more effective than the other in treating patients with BPD. Methods: In this randomized, parallel-group, rater-blind clinical trial, outpatients aged between 18 and 65 years with a primary diagnosis of BPD were recruited in a tertiary outpatient treatment center (Lübeck, Germany). Participants were randomized to DBT or ST with one individual and one group session per week over 1.5 years. The primary outcome was the BPD symptom severity assessed with the mean score of the Borderline Personality Disorder Severity Index at 1-year naturalistic follow-up. Results: Between November 26, 2014, and December 14, 2018, we enrolled 164 patients (mean age = 33.7 [SD = 10.61] years). Of these, 81 (49.4%) were treated with ST and 83 (50.6%) with DBT, overall, 130 (79.3%) were female. Intention-to-treat analysis with generalized linear mixed models did not show a significant difference at 1-year naturalistic follow-up between DBT and ST for the BPDSI total score (mean difference 3.32 [95% CI: –0.58–7.22], p = 0.094, d = −24 [–0.69; 0.20]) with lower scores for DBT. Pre-to-follow-up effect sizes were large in both groups (DBT: d = 2.45 [1.88–3.02], ST: d = 1.78 [1.26–2.29]). Conclusion: Patients in both treatment groups showed substantial improvements indicating that even severely affected patients with BPD and various comorbid disorders can be treated successfully with DBT and ST. An additional non-inferiority trial is needed to show if both treatments are equally effective. The trial was retrospectively registered on the German Clinical Trials Register, DRKS00011534 without protocol changes.

Dialectical Behavior Therapy (DBT) has been proven to be successful for reducing symptoms related to Borderline Personality Disorder [1,2] . However, because of the gap that exists between mental health and substance abuse treatment approaches, little research has been done to show the effects of DBT approaches on addictive thinking and behaviors. In addition, only recently have researchers begun applying DBT interventions with a teenage population [3]. Using selfreport methods, the authors examine the use of a modified DBT approach with 13 participants from ages 14-26, exploring the effects of a DBT group modality on symptoms commonly found in individuals with substance use disorders (SUDs). Preliminary findings resulted in an overall mean score of 3.24 for 14 items corresponding to SUD symptomology, suggesting that DBT interventions helped to reduce: a) Self-destructive behaviors and a propensity for relapse b) Identity disturbances and low self esteem c) Relationship conflict and social skills difficulties and d) Dichotomous thinking and emotion dysregulation. Future studies are needed using larger sample sizes, informant reports, and a sample of individuals with a primary diagnosis of SUDs, to gain confidence in these findings.

Purpose There is a dearth of literature examining the paraprofessional substance use disorder counselors (SUDCs) and their responsiveness to evidence-based substance use disorder (SUD) training. This study examined pre- and post-training knowledge related to three established SUD interventions – Screening, Brief Intervention, and Referral to Treatment (SBIRT), Mindfulness Oriented Recovery Enhancement (MORE), and Dialectical Behavior Therapy (DBT). Materials and Methods Undergraduate students enrolled in a SUDC training program (N = 63) participated in brief, evidence-based workshops and completed structured pre- and posttest surveys evaluating knowledge related to workshop content. Paired sample t-tests were estimated with 1000 bootstrapped samples to examine changes in knowledge from pre- to posttest and Hedges’ g and common language (CL) effect sizes were calculated. Results Results showed a statistically significant increase from pre- to posttest in participants’ overall knowledge scores across all three evidence-based interventions. The largest effects on knowledge were noted for the DBT workshop. Discussion The results of this study suggest that brief workshops on evidence-based SUD interventions such as SBIRT, MORE, and DBT present a promising avenue for undergraduate students in a SUDC training program to acquire knowledge essential for practicing as paraprofessional SUDCs. Conclusion There is currently an insufficient number of SUDCs to meet SUD treatment needs across the United States. Substantial growth in SUDC workforce needs is also projected by 2030. Well-trained paraprofessional SUDCs can provide one approach to expanding access to SUD treatment in coming years.

Third-generation therapies (TGTs) have been shown to be effective in the treatment of substance use behaviors in college-aged adolescents. These therapies are based on acceptance, mindfulness and psychological flexibility, which enable young people to change their Psychoactive Substance Use (PSU)-related behaviours, develop coping skills to manage difficult emotions and thoughts, reduce experiential avoidance and maintain long-term abstinence. To explore the implementation and potential benefits of third-generation therapies, Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT) and Mindfulness, for the treatment of PSU in college youth. This review includes articles within a 5-year window. A scoping, observational and retrospective review was conducted using the PRISMA method in SCOPUS, PUBMED and Web of Science. eight studies were found, six based on mindfulness, one on dialectical behaviour therapy and one on acceptance and commitment therapy. The results of the studies are promising and emerging for the intervention of the problem. The interventions used show evidence of reducing PSU and other mental health problems such as anxiety, depression and post-traumatic stress. In addition, they allowed patients to increase their well-being and mindfulness.

BackgroundSeveral quantitative studies support the effectiveness of the Dialectical Behavior Therapy (DBT) psychosocial skills training group component for adolescents with impulse-control disorder and/or emotional dysregulation. However, qualitative research to assess this psychotherapeutic tool in the adolescent population is sparse. This study aims to examine the subjective experience of adolescents with behavioral issues who have completed DBT skills training group, as well as using this experience to extract hypotheses regarding its usefulness which can then be verified at a later time by means of quantitative instruments.MethodsWe developed a qualitative study by using focus groups with adolescents (N = 20) whose diagnosis includes symptoms such as behavior disorder, impulse-control disorder and/or emotional dysregulation, and good informants, who have completed DBT skills training. Three focus groups were created.ResultsThe subjective experience of adolescents who have completed a DBT skills training group is collected in four main categories: experience of illness, motivation for therapy, experience of therapy and results of the therapy.ConclusionsAdolescents with behavioral problems assess their participation in the DBT skills training group positively, even recommending its usefulness to healthy population. Beyond learning skills, they emphasize the intrapsychic changes (as improvement in reflective activity) that they objectify after the group experience.

Patients with borderline personality disorder (BPD) have a 10% lifetime risk of death by suicide.1 Therefore, prevention of self-harm is an important target for treatment in this population. A recent...