The Structure of DBT Programmes

Lesbian and Gay people (LGP) experience higher rates of mental health difficulties, including self-harm, suicidal behaviours, as well as inequalities in health care, than their heterosexual peers. Dialectical Behaviour Therapy (DBT) is an evidence-based treatment for self-harm and suicidal behaviours, though there is little research on LGP's experiences of DBT. This research aims to explore LGP's experiences of completing a full DBT programme. A qualitative design with semi-structured individual interviews was utilised. The results were analysed using Interpretative Phenomenological Analysis. Six lesbian and two gay adults, aged between 22 and 47 years, living in the United Kingdom took part. All participants had completed a full programme of DBT within the 2 years prior to the interview. Four superordinate themes emerged from the data: (1) The DBT journey; (2) Connections and Sense of Community during DBT; (3) Sexuality both visible and invisible in DBT and (4) A Gender, Sexuality and Relationship Diverse (GSRD) affirmative future for DBT. Several clinical implications are suggested to improve DBT for LGP, for example to consider having other LGP within DBT groups, to create a more GSRD-affirming DBT (changes to the DBT manual, DBT therapists, DBT programme and physical DBT space), to adapt DBT techniques to manage sexuality-related difficulties and to adopt a GSRD-centric framework. Overall, DBT appears to be beneficial for LGP.

Gender- and sexuality-minoritised (GSM) adolescents are at increased risk of self-harm and suicidal behaviours compared to their cisgender and heterosexual peers. This increased risk is thought to be explained in part by exposure to stigma and societal oppression. Dialectical Behaviour Therapy (DBT) is an evidence-based intervention for self-harm and suicidal behaviour that may have advantages for supporting GSM young people in distress. No study has yet sought to understand what GSM-associated difficulties may be important to consider in DBT for adolescents, or the experiences of GSM young people in a standard DBT programme. Therefore, this study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Qualitative interviews were conducted with 14 GSM young people in a comprehensive DBT programme and were analysed using Reflexive Thematic Analysis. The analysis was supported by two further GSM young people who had finished DBT. The findings were split into three overarching themes (Identity, Impact of Others, and Space for Sexual and Gender Identity in DBT), each with themes within. The identity-based theme included "identity confusion and acceptance"; the relationship-based themes included "cis-Heterosexism" and "community connectedness"; and the space within DBT themes included "negotiating focus and targeting in DBT" and "creating safety in DBT". Findings are discussed in relation to implications and recommendations for therapists working with GSM young people within and outside of DBT.

This chapter provides a description and review of the research evidence for the adaptation of dialectical behavior therapy (DBT) and emotion-focused therapies for eating disorders (EDs). First, the chapter briefly describes the standard DBT program as originally developed for women with borderline personality disorder (BPD) and the evidence for standard DBT with BPD. Second, the rationale for the adaptation of DBT for EDs is given and preliminary evidence for DBT and other emotion-focused treatments is described. Finally, the Stanford DBT program for EDs is outlined. Given the promise of alternative treatments for eating disorders, further development, adaptation, and testing of transdiagnostic emotion regulation treatments is warranted.

This nonrandomized, naturalistic study describes a modified outpatient dialectical behavior therapy (DBT) program for borderline personality disorder (BPD) in which some patients receive the comprehensive, empirically supported DBT package and others receive DBT skills group therapy with non-DBT individual therapy. Patients who completed one skills group cycle showed significant improvements in BPD, depression, and suicidal ideation as measured by the Personality Assessment Inventory. Fifty-one percent of patients dropped out of skills group, but patients with in-system individual therapy were significantly more likely to complete group therapy. Although causal conclusions cannot be drawn, this report demonstrates that a modified DBT program can be implemented successfully in settings in which a full DBT package for all patients may not be feasible and suggests that BPD patients receiving non-DBT individual therapy may benefit from DBT skills group.

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 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 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.

This study describes naturalistic 3-month follow-up after discharge from a 5-day partial hospitalization dialectical behavior therapy (DBT) program for women diagnosed with borderline personality disorder (BPD). We also examined individual BPD criteria as predictors of treatment response. Fifty women diagnosed with BPD were consecutively recruited from a partial hospital DBT program, 47 of whom (94%) completed all assessments including baseline (prior to discharge) and 3-months post-discharge assessments. Most continued with some combination of individual psychotherapy and pharmacotherapy, and all had the option of continuing with weekly DBT skills classes. Baseline scores were compared to 3-month scores using paired two-tailed non-parametric (sign) tests. Regression analyses were conducted to identify predictors of outcome. Depression, hopelessness, anger expression, dissociation, and general psychopathology scores significantly decreased over the 3-month follow-up interval, although scores on several measures remained in the clinical range. Those who endorsed emptiness, impulsivity, and relationship disturbance demonstrated improvement on a number of outcomes, while those who endorsed identity disturbance and fear of abandonment had less improvement on some outcomes. These findings illustrate (1) that improvement occurred over a 3-month interval on a number of measures in patients receiving treatment as usual following discharge from a partial hospitalization program, and (2) that BPD is a complex, heterogeneous disorder for which there is no single pathognomonic criterion, so that each criterion should be considered individually in determining its potential effect on treatment outcomes.

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).

Previous studies about the effectiveness of Dialectical Behaviour Therapy for the treatment of Borderline Personality Disorder have had promising results. However, no previous studies have examined its effectiveness when delivered in low secure inpatient services for women. To evaluate clinical outcomes during and after a 1-year period of admission within a low secure unit for women offering a Dialectical Behaviour Therapy programme. A naturalistic, within subjects study of clinical data collected as part of routine practice was conducted. Participants were 18 consecutively admitted women who met the diagnostic criteria for Borderline Personality Disorder and had completed at least 1 year of treatment. Measures covered: risk behaviours; self-reported symptoms of Borderline Personality Disorder, and current mood and symptom experience; staff reports of clinical problems, needs and social functioning. Scores were compared between admission and at 6 months and 1 year. There was a statistically significant improvement on all 13 measures over the year's treatment. Most improvement was demonstrated between admission and 6 months. Engagement in1-year's treatment was associated with significant reduction in risk behaviours and both staff-rated and self-rated outcome measures. Some significant questions remain about which elements of the programme are most effective but the results are encouraging.

DR BURNS: Ms J is a 44-year-old woman with a history of borderline personality disorder. She lives alone and currently works full-time as a residential counselor in the mental health field. She purchases Medicaid-type insurance through Common Health in Massachusetts. She initially came to see Dr M in July 2000 because she was unhappy with her previous primary care physician. Ms J has an extensive psychiatric and comorbid medical history. She first had contact with a mental health care professional at the age of 22 after moving away from home and starting her first job. The transition precipitated extreme anxiety, and Ms J lost her sense of self-direction. She became extremely dependent on others and feared abandonment. When other changes and personal losses occurred, Ms J reacted with intense emotional instability, marked by depression and intermittent anger. She has had numerous, prolonged hospitalizations for depression, suicidal ideation, and suicidal behavior with multiple drug overdoses and selfinjury. These factors led to the diagnosis of borderline personality disorder. Additionally, Ms J has many medical problems that have necessitated additional hospitalizations, surgery, and orthopedic interventions. Some physicians have questioned whether these medical problems had a psychological component to them. Ms J has been in outpatient treatment with various health care providers since about 1978. She has had multiple psychiatric and medical inpatient hospitalizations. Over the years she also has participated in day treatment programs, residential treatment, and a supportive housing program that helps individuals access housing and live independently. Ms J has participated in several dialectical behavior therapy (DBT) skills training groups. Her medical history is significant for arthritis following a motor vehicle collision, chronic back pain, seizure disorder, sleep apnea for which she receives continuous positive airway pressure, nocturnal myoclonus, migraine headaches, hyperlipidemia, and gastroesophageal reflux disease. Ms J has a history of asthma and psychogenic laryngospasm that required tracheostomy placement for 4 months in 1999. She had a hysterectomy in 1996. She cannot tolerate hormone replacement therapy due to worsening depression. Despite this history, Ms J has made tremendous strides in the past 4 years. Five years ago, she was hospitalized for 265 days in 1 year; however, during 2001 she was hospitalized for only 4 days. In the past, she has taken lamotrigine, nortriptyline, desipramine, imipramine, fluoxetine, sertraline, paroxetine, citalopram, nefazodone, venlafaxine, tranylcypromine, isocarboxazid, phenelzine, quetiapine, olanzapine, risperidone, and lithium. Her current psychiatric medications are sustained-release bupropion, 150 mg/d; topiramate, 100 mg twice daily; and amitriptyline, 10 mg at bedtime. She is no longer taking clonazepam after 20 years of use. Her medical regimen includes albuterol, fexofenadine, fluticasone, omeprazole, montelukast, carbamazepine, tramadol, zolmitriptan, verapamil, and rofecoxib. Both she and the nurse specialist who provides her medications are now comfortable with her having a 1-month supply of medications, along with refills. Ms J attributes her improvement to a good working relationship with her current therapist, a clinical social worker, and a DBT program. She has a close relationship with her parents and all but one of her sisters. She also has established close and supportive friendships. There is no family history of mental illness in firstdegree relatives. Her parents are in their 70s. She does not smoke or drink alcohol. She reports being allergic to penicillin, erythromycin, phenytoin, acetaminophen/ oxycodone hydrochloride, sertraline, tetracycline, intravenous pyelogram dye, novocaine, haloperidol, sulfacontaining medications, and diazepam. Ms J wonders what her future will bring, whether she can maintain her progress, and what could help her be successful in the long run.

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.

Bipolar disorder and borderline personality disorder commonly co-occur. Each disorder is associated with substantial morbidity and mortality, which are worsened by co-occurrence of the disorders. Emotional dysregulation, suicidality, and disrupted circadian rhythm are key aspects of psychopathology associated with both conditions. A novel psychotherapy combining elements of two evidence-based treatments (i.e., dialectical behavior therapy [DBT] for borderline personality disorder and social rhythm therapy [SRT] for bipolar disorder) is described. Unlike either treatment alone, the new therapy, called dialectical behavior and social rhythm therapy (DBSRT), targets all three disease-relevant processes and therefore may represent a promising new approach to treatment for individuals with these two conditions. DBSRT may also have utility for individuals with overlapping characteristics of bipolar disorder and borderline personality disorder or for those whose illness manifestation includes a mix of bipolar and borderline personality disorder traits. Strategies associated with DBSRT are described, and a brief case vignette illustrates its application.

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

This paper presents two studies conducted to develop and evaluate a new pragmatic measure of therapist adherence to Dialectical Behavior Therapy (DBT): the DBT Adherence Checklist for Individual Therapy (DBT AC-I). Study 1 used item response analysis to select items from the gold standard DBT Adherence Coding Scale (DBT ACS) using archival data from 1271 DBT sessions. Items were then iteratively refined based on feedback from 33 target end-users to ensure relevance, usability, and understandability. Study 2 examined the psychometric properties of the DBT AC-I as a therapist self-report and observer-rated measure in 100 sessions from 50 therapist-client dyads, while also evaluating predictors of therapist accuracy in self-rated adherence. When used as a therapist self-report measure, concordance between therapist and observer ratings was at least moderate (AC1 ≥ 0.41) for all DBT AC-I items but overall concordance (ICC = 0.09) as well as convergent (r = 0.05) and criterion validity (AUC = 0.54) with the DBT ACS were poor. Higher therapist accuracy was predicted by greater DBT knowledge and adherence as well as more severe client suicidal ideation. When used by trained observers, the DBT AC-I had excellent interrater reliability (ICC = 0.93), convergent validity (r = 0.90), and criterion validity (AUC = 0.94). While therapists’ self-rated adherence on the DBT AC-I should not be assumed to reflect their actual adherence, some therapists may self-rate accurately. The DBT AC-I offers an effective and relatively efficient method of evaluating adherence to DBT when used by trained observers.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10488-023-01274-x.