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1 Dialectical Behaviour Therapy: Development and Distinctive Features |
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3 | (20) |
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Key messages for clinicians |
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DBT is an integrative treatment, synthesizing behavioural theory, principles of Zen practice, and dialectics |
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DBT was developed in an endeavour to solve the problem of chronic suicidality presenting in clients with a borderline personality disorder diagnosis |
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DBT was the first treatment to demonstrate clinical efficacy with this Client group |
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Since the publication of the treatment manuals, OBT has been adopted and adapted for clients in a range of settings and with different clinical presentations and diagnoses |
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SECTION II THEORETICAL UNDERPINNINGS OF DBT |
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2 Understanding the Bio in the Biosocial Theory of BPD: Recent Developments and Implications for Treatment |
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23 | (24) |
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Key Messages For Clinicians |
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Since the publication of Linehan's original treatment manual (Linehan, 1993) there has been considerable progress in understanding the biological underpinnings of BPD |
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There is strong evidence of hyperactivity in the limbic system and decreased activation of the prefrontal cortex, which may contribute to affective instability in BPD, although it is unclear how specific these findings are to BPD |
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Extensive studies of brain activation during pain processing in BPD patients demonstrate changes that complement patient reports of the physical and psychological impact of NSSI |
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The hyperactivity in the limbic system may also impede functional behaviour in social interactions |
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3 Invalidating Environments and the Development of Borderline Personality Disorder |
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47 | (22) |
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Key Points For Clinicians |
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Borderline personality disorder (BPD) emerges as a result of high-risk transactions between inherited vulnerabilities, such as trait impulsivity, and invalidating developmental contexts |
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These transactions, which are characterized by invalidation and coercive processes, socialize emotion dysregulation overtime and across development |
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Emerging research has identified certain child and caregiver characteristics that increase risk for an invalidating developmental context. However, mismatch between the needs of the child and that of his or her caregiver's abilities may also contribute to invalidation |
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Dialectical Behavior Therapy (DBT) for at-risk adolescents and families offers an opportunity to intervene on the invalidating environment and reduce contextual risk for adult BPD |
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4 Behavioural Foundations of DBT: Applying Behavioural Principles to the Challenge of Suicidal Behaviour and Non-suicidal Self-injury |
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69 | (22) |
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Behavioural theory guides many aspects of DBT |
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Behavioural theory and practices help DBT therapists assess and understand their clients' behaviour |
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Functional or chain analyses can help the DBT therapist assemble a case formulation that paves the way to potentially helpful interventions |
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Behavioural theory encourages DBT clinicians to be specific about behaviour, to take an active role in therapy, and to present opportunities for clients to learn new behaviours |
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5 Modifying Behaviour Therapy to Meet the Challenge of Treating Borderline Personality Disorder: Incorporating Zen and Mindfulness |
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91 | (16) |
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Key Messages For Clinicians |
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Zen as a practice has a 2,500-year history |
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Zen forms the basis of acceptance technology found in DBT |
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Zen practice principles are compatible with behaviour therapy |
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Zen provides a set of new targets for both client and therapist |
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DBT core mindfulness and reality acceptance skills are an outgrowth of Zen practice |
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6 Modifying CBT to Meet the Challenge of Treating Emotion Dysregulation: Utilizing Dialectics |
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107 | (14) |
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Key Points For Clinicians |
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A dialectical strategy is any strategy that looks for what is left out of one's position, then facilitates movement toward a synthesis of the two opposing positions |
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Dialectical strategies include magnifying tension between two poles, entering the paradox, and the use of metaphors |
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While the dialectical strategies were developed within DBT, several evidence-based treatments utilize a dialectical approach |
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SECTION III THE STRUCTURE OF TREATMENT |
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7 The Structure of DBT Programmes |
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121 | (26) |
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Key Points For Clinicians |
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Successful programmes pay close attention to the structural elements of DBT |
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It is critical to understand Linehan's description of the functions of treatment when making decisions about the structure of treatment |
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Structural elements of a programme include the physical infrastructure, as well as the customs and practices of the treatment (such as agreements, therapist strategies, careful attention to language, and requests for review of one's work) |
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A sound and well-followed programme structure will enable clinicians and clients to more easily focus on the critical interactions of treatment |
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Each programme needs to create a "programme manual" which defines the treatment provided, particularly when it has been adapted from the original model described by Linehan |
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8 Running an Effective DBT Consultation Team: Principles and Challenges |
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147 | (20) |
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Key Points For Clinicians |
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DBT team is an essential element of comprehensive DBT |
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DBT team supports therapists' capability and motivation, and overall adherence to the DBT manual |
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Agreements, structure, and roles are important in running an effective DBT team |
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The same principles and strategies used with clients in DBT are implemented in DBT team |
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9 Skills Training in DBT: Principles and Practicalities |
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167 | (34) |
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Key Points For Clinicians |
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Rely on research to inform decision-making and clinical practice when adapting DBT skills training |
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The principles and strategies that guide DBT skills training are the some as the principles and strategies underlying DBT as a whole |
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Consider case conceptualization, treatment targets, and contingencies when making decisions about how to best engage a client and teach skills |
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Discuss clinical decisions and skills training adaptations with the DBT consultation team |
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10 Generalization Modalities: Taking the Treatment out of the Consulting Room---Using Telephone, Text, and Email |
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201 | (16) |
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Focus on generalization is a critical part of effective treatment but is often overlooked |
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Changes in technology mean a greater focus on generalization can occur via the mediums of phone, texts, and emails |
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This chapter provides guidelines for effectively consulting to the client in order to increase |
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11 Structuring the Wider Environment and the DBT Team: Skills for DBT Team Leads |
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217 | (20) |
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Key Messages For Clinicans |
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Team leads take responsibility for two functions of a DBT programme: Structuring the environment, and enhancing therapists' capabilities and motivation to treat |
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DBT team leads take responsibility for organizational pre-treatment: establishing which organizational goals are relevant to the DBT programme, orientating the or-ganization to the resources needed, and gaining commitment from the organization to support the programme |
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DBT team leads assess the assets of their staff and programme and address any identified deficits |
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DBT team leads ensure that the consultation team fulfils its function of enhancing therapists' skills, capacities, and motivation to deliver the treatment, and that they take a lead in helping the team address any problems that arise in the functioning of the team |
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SECTION IV CLINICAL APPLICATIONS OF DBT |
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12 Case Formulation in DBT: Developing a Behavioural Formulation |
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237 | (22) |
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Key Messages For Clinicians |
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Case conceptualization is iterative and organic, and changes as the treatment progresses |
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Case conceptualizations should be clear and concise so that they can be communicated easily to the client and to team members |
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Case conceptualization uses the tenets of DBT to assess causal and consequential factors of behaviours |
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Case conceptualization assists the therapist and the client in determining specific interventions to use in treatment, as well as the means to determine the effectiveness of the interventions |
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13 Conducting Effective Behavioural and Solution Analyses |
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259 | (24) |
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Key Points For Clinicians |
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Assessment in general, and behavioural chain analysis (BCA) specifically, is a critical strategy in DBT. Lack of assessment or errors in assessment can lead to difficulties in treatment |
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BCA can function to challenge clients' common experience and belief that events "come out of the blue" and aids clients in learning that emotions, actions, or thoughts result from certain interactions or transactions with the environment |
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BCA can be a validating experience for a client, especially when a client may think they that they are engaging in a problem behaviour simply because "something is wrong" with them. BCA provides understanding of their experience, which can lead to decreased judgments and increased use of skills |
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When doing BCA, the therapist should describe things behaviourally and non-judgmentaily, as well as focus on a single instance of a behaviour |
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All components of BCA (e.g., thoughts, emotions, vulnerability factors, or consequences) provide opportunities for intervention |
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When assigning homework generated from solution analysis, the DBT therapist should also use commitment and troubleshooting strategies to increase the likelihood the client will complete the task |
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BCA can be a difficult task for both the client who may feel shame at discussing problem behaviours, and for the therapist Practice, non-judgmental language, and validation can ease the difficulty |
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14 Conceptual and Practical Issues in the Application of Emotion Regulation in Dialectical Behaviour Therapy |
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283 | (24) |
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Key Points For Clinicians |
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Each emotion is designed to elicit a different action |
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Each emotion has a unique signature in a number of domains; temperature, fascial expression, breathing, muscle tone, posture, gesture, voice tone, actions in the environment |
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Emotion regulation involves a number of steps that can be coached through behavioural rehearsal |
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Ascertain what level, if any, would fit the facts |
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Up or down-regulate the emotion by paying attention to the domains of that emotion, until it reaches an appropriate level |
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Remember to do what is appropriate for the ambunt of the emotion that does actually fit the facts |
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Coaching distress tolerance or de-arousal strategies will not strengthen the client's emotion regulations skills |
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An over-reliance on distress tolerance at the expense of emotion regulation may result in clients failing to make anticipated progress in therapy |
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15 DBT as a Suicide and Self-harm Treatment: Assessing and Treating Suicidal Behaviours |
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307 | (18) |
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Key Points For Clinicians |
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Although challenging, clinicians working with people who self-harm should make comprehensive psychosocial assessments of the patient's psychiatric disorder (including assessment of comorbidity with personality disorders and/or substance misuse), risks, resources, and needs in order to provide adequate treatment and protection |
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Many clinicians fear reinforcing suicidal behaviours should they systematically address the topic - of suicidally in therapy sessions-hence, they avoid it. This is not advisable; the risk must be repeatedly re-evaluated and actively addressed since the risk scenario may rapidly change in these patients due to their increased affective reactivity and impu Isivity |
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Important aims in the treatment are to prevent relapse or escalation of self-harm and other high-risk behaviours, and to develop a crisis plan or safety plan is regarded essential. To treat psychiatric conditions, improve social and occupational functioning, and improve quality of life are also highly prioritized treatment aims for the longer term |
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DBT has a well-documented efficacy in reducing suicidal behaviours and NSSI, emergency room visits, psychiatric hospital days, and a Wide range of symptoms and behaviours related to suicidality |
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DBT adopts a behavioural approach to suicide and self-harm in order to identify antecedents and consequences either causing or maintaining the behaviours |
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In DBT, suicidal behaviours are treated directly and specifically and given top priority. DBT offers multiple and specific strategies to prevent and manage suicidal crises, such as teaching patients skills in emotion regulation, distress tolerance, and interpersonal problem solving |
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Keeping patients alive while they are making progress in treatment builds in DBT on a strong therapeutic relationship that balances the therapeutic strategies of validation and change |
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16 Validation Principles and Practices in Dialectical Behaviour Therapy |
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325 | (20) |
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Key Messages For Clinicians |
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Definition of validation: requires attention, genuine understanding, and communicates that understanding which is applied to specific behavioural targets (e.g., emotions, skillful actions, thoughts, etc.) |
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Validation is a key social behaviour in part because it soothes negative emotional arousal, and thus is essential in any relationship, is part of every modern psychotherapy, and is a key strategy in DBT |
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In DBT we only validate vo//'dbehaviours; invalidating invalid behaviours are part of DBT change strategies |
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Validation communicates acceptance and understanding, builds the therapeutic relationship, and facilitates and balances change |
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At times, validation may be considered a reinforcer, and facilitates change and learning |
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Validation also may be considered an eliciting stimulus, signaling that a different repertoire of responses is likely to be effective, and inviting different, more regulated responses |
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There are multiple levels, or types of validation; type of validation must fit the situation and goals, as well as be appropriate to the way(s) in which a behaviour is valid |
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17 Responding to Clients' In-session Clinical Behaviours |
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345 | (22) |
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Key Points For Clinicians |
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Few models of cognitive-behaviour therapy emphasize attending to and treating clients' in-session clinical behaviours as much as Dialectical BehaviourTherapy (DBT) |
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The term "in-session clinical behaviour" (ICB) encompasses any client behaviour, including a therapy-interfering behaviour (TIB) or secondary target, that occurs during a treatment session and adversely impacts either the treatment session or other aspects of the client's life |
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A key principle of behaviour therapy asserts that interventions are most effective when they stop an episode of a clinical behaviour as quickly as possible and immediately elicit a more adaptive behaviour instead |
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To enhance clients' understanding of and collaboration in treating ICBs, DBT clinicians describe the form of an ICB with behavioural specificity and without assumptions about the function or intent |
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DBT clinicians enhance motivation to address ICBs partly by relating in-session behaviours to out-of-session behaviours and to the clients' goals |
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DBT clinicians use behavioural theory and Unehan's biosocial theory to develop a behavioural conceptualization of the proximal factors causing and maintaining ICBs |
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Solution implementation ranges from applying a single intervention to conducting a comprehensive solution analysis, depending on the context and number of key controlling factors for the ICB |
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18 Teaching Mindfulness Skills in DBT |
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367 | (22) |
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Key Points For Clinicians |
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Therapists: have their own mindfulness practice-model a mindful and dialectical philosophy |
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Use a variety of practices |
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Keep the practice simple and give clear instructions |
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Take feedback after a practice to shape mindful awareness |
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Behaviourally rehearse mindfulness skills in session |
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Coach a non-judgmental stance in the tone of voice, facial expression, body posture, thoughts, and language |
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Assess the level of skill for each client and provide coaching to strengthen this |
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Identify and problem-solve obstacles to being mindful |
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Combine mindfulness with other skills |
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Highlight opportunities for generalizing the skill |
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Make clear the relevance of using the skill in the client's everyday life |
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19 Dialectical Behaviour Therapy with Parents, Couples, and Families to Augment Stage 1 Outcomes |
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389 | (26) |
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Key Points For Clinicians |
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DBT with parents or families utilizes the same theory and overlapping strategies as DBT with individuals; some targets may vary, there are additional skills and strategies, and we use "double chains" to assess and understand the ways family members affect each other |
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Intervening with parents, partners, or other family members is essential when they are "on the chain" toward self-harm or suicidal behaviour-that is, when what they do is either a precipitating event or reinforcer for these life-threatening behaviours. The targets then include reducing aversive and invalidating responses overall, and eliminating positive and negative reinforcement of suicidal and self-harming behaviours |
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Parent and family skills include emotion self-management, relationship mindfulness, accurate expression, validation, and radical acceptance |
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The key transactional focus is to decrease the cycle of inaccurate expression and invalidating. responses, and instead build up accurate expression and validating responses |
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Family interventions may occur in family therapy, or in multi-family groups, with or without the patient |
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Family sessions can sometimes be chaotic, so there are specific strategies employed with families to manage them and keep them productive |
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It is essential to empower parents and other family members with skills and to help them be effective within their roles |
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SECTION V EVIDENCE FOR DBT |
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20 Dialectical Behaviour Therapy from 1991-2015: What Do We Know About Clinical Efficacy and Research Quality? |
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415 | (52) |
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Key Messages For Clinicians |
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Efficacy of Comprehensive DBT is substantiated for suicidal and self-injurious treatment populations, and comortid BPD and substance use, and DBT generally evidenced superior treatment retention to control treatments |
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DBT-Skills only has well-established empirical evidence for efficacy with treatment resistant depression, anxiety, binge eating, and bulimia disorders |
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Quality assurance method strengths included standardized assessments, blind raters, and adequate randomization. Limitations included lack of power analyses, in-study reliability, and only 13% of trials conducted follow up assessment at least one year later |
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35% of all DBT trials utilized formal adherence ratings, when reported scores ranged from 3.8-4.2, indicating generally adequate treatment adherence |
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58% of studies reported some or all clinicians received intensive or intensive-equivalent DBT training, most prior to study start |
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More attention is needed towards increasing accessibility and prevalence of ongoing adherence monitoring, supervision, and baseline DBT training |
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21 Dialectical Behaviour Therapy in Routine Clinical Settings |
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467 | (30) |
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Key Messages For Clinicians |
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Overall, in routine clinical settings, treatment with DBT leads to improvement in terms of decreasing suicidal and non-suicidal self-injury ENSSI), days admitted to psychiatric hospitals, depression, and general psychiatric symptoms |
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In the settings reported in this chapter, most of the clinicians had attended ten-day intensive DBT training, either before or during the study |
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There is large variability in routine clinical settings regarding the amount of follow-up consultation received after initial training |
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Drop-out rates for treatment are higher when DBT is delivered in routine clinical settings, as compared to research settings. More research is needed to explore reasons for drop-out and ways to decrease drop-out |
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Many routine clinical settings include phone coaching only during office hours. It is unclear what impact, if any, this modification from the standard protocol has on outcomes |
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22 Cost-effectiveness of Dialectical Behaviour Therapy for Borderline Personality Disorder |
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497 | (18) |
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Key Messages For Clinicians |
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DBT is the treatment for BPD that offers Level 1 (highest level) evidence of efficacy and effectiveness and is the only treatment with sufficient data for meta-analyses |
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Cost-effectiveness studies in treating people with BPD are few in number and highly varied in their design and variables measured, so conclusions need to be considered with caution; more prospective methodologically robust studies are needed |
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Data on cost-savings from reduced hospital days remains largely descriptive although DBT has the most objective data, to date |
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Despite these current limitations, funders and administrators must make decisions on the best current information available |
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Current information of means of reduced mental hospital days suggest that providing DBT is in most situations likely to be financially cost-effective by virtue of hospital cost savings alone |
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In addition, it is reasonable to expect cost savings to increase over the years following treatment as positive client outcomes translate into both increased health cost savings and decreased costs of x providing treatment |
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More systematic assessment of health costs, costs of other services (police, justice, ambulance, social services, housing), and lost income productivity would further enhance future cost-effectiveness analyses |
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DBT offers an evidence-based option for treating people with BPD that is likely to meet the financial objectives of funders, economists, accountants, administrators, providers, and consumers |
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23 Mechanisms of Change in Dialectical Behaviour Therapy |
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515 | (18) |
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Key Points For Clinicians |
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When reviewing literature on mediators and mechanisms of change, determine whether the researchers have established "statistically significant mediators" or met additional criteria necessary to be considered a mechanism of change." |
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The effectiveness of DBT treatment strategies depends upon a strong therapeutic relationship. When DBT therapists adopt a dialectical stance that balances acceptance and change, clients are more open to emotional experiencing and expression, and new learning experiences |
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Increased emotional awareness and acceptance, attentional control, emotional modulation, and use of adaptive coping skills are change processes associated with positive outcomes in DBT. Therapist interventions focused on enhancing each of these processes are likely to yield beneficial effects |
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24 DBT: A Client Perspective |
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533 | (14) |
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Key Messages For Clinicians |
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The label of borderline personality disorder can be more damaging than helpful |
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Non-DBTservices that continue to label clients as having BPD when they no longer meet the criteria for the disorder are unhelpful-once a broken leg is healed, it is no longer a broken leg. Clinicians need to emphasize this point to their clients, as well as to the systems in which they work |
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OBT should be delivered by confident, competent, and courageous practitioners who are not afraid to both challenge and set limits for their clients |
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The rationale behind some of the skills (e.g., exposure via mindfulness) require repeated x explanation; clients may have difficulty in understanding the purpose of learning the skills |
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Consistency is key; DBT needs practitioners who are prepared to engage for at least two cycles of the skills programme. They must also be willing to work consistently as an individual therapist with their clients |
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DBT works, if the correct elements are in place-motivation from the client, a certain level of understanding from the client, and the appropriate, skilled practitioner are all needed for success in DBT |
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SECTION VI ADAPTING THE TREATMENT FOR NEW CLINICAL POPULATIONS |
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547 | (26) |
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Key Messages For Clinicians |
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Dialectical Behavior Therapy has been adapteol and has been shown to be effective for multi-problem, complex adolescents with and without risk for suicide and/or non-suicidal self-injury |
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DBT-A includes all of the same modes of standard, adult DBT-individual therapy, group skills training (offered in the teen adaptation in a multi-family skills training group format), telephone consultation, and therapist consultation team |
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Parental support and involvement is a critical component of DBT-A which is facilitated through additional modes of family sessions, parenting sessions, and parent phone coaching |
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There are particular challenges to working with multi-problem youth and their families, such as managing confidentiality, suicidal risk, rapport, and establishing/maintaining commitment to the treatment |
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Research, including the completion of two randomized controlled trials, now supports the adaptation of DBT for adolescents. Future directions include applying DBT with younger children and in school settings |
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26 DBT for Eating Disorders: An Overview |
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573 | (22) |
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Key Points For Clinicians |
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Because eating pathology can function as a strategy to cope with emotion sensitivity and vulnerability, dialectical behaviour therapy (DBT) can fill a needed gap for individuals who have not responded to standard treatment approaches |
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The following characteristics in individuals with eating disorders (ED) may indicate the utility of a DBT approach |
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a Failed treatment attempts with evidence-based treatment approaches |
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b Affect or emotion regulation deficits |
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c Multidiagnostic, complex clinical presentations, especially |
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i Recurrent suicidality or self-harm behaviours |
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ii Borderline Personality Disorder or Substance Use Disorders |
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d Slow rate of weight gain (for adolescents who need to gain weight as part of their treatment recommendations) |
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The "non-judgmental stance" in DBT can be a powerful tool for clinicians to help reduce their burnout and prevent judgments related to behaviours that are often considered as dangerous, shallow, or deceitful. Participating in "therapy for the therapists" in DBT consultation teams is vital in order to receive support from other DBT clinicians and to uphold treatment fidelity |
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ED behaviours can fit into the target hierarchy by assessing the level of threat the behaviour poses. The ED behaviours may move targets over time depending on medical instability and implications of the behaviour |
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While the standard DBT protocol utilizes a 24-hour rule for phone coaching, for ED behaviours, this rule should be adapted to the "Next Meal/Snack Rule" due to the frequency of exposure to food and expected meals/snacks in one 24-hour period |
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27 Dialectical Behaviour Therapy for Substance Use Disorders |
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595 | (20) |
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Key Messages For Clinicians |
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Co-occurring Borderline Personality Disorder (BPD) and Substance Use Disorders (SUD) are associated with higher risk behaviours and with greater treatment engagement challenges than either independently |
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DBT adapted for SUDs includes all aspects of the standard model of DBT for BPD with added formulations, strategies, and skills for addressing problems of addiction |
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DBT-SUD includes attachment strategies to help prevent individuals with BPD and SUDs from "falling out of treatment." |
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DBT-SUD addresses the challenges involved with structuring clients' living environments and the treatment environment with a re-balancing of the Consultation to the Client and Intervening in the Environment DBT case management strategies |
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A modified primary target treatment hierarchy helps provide an integrated treatment of BPD and SUD related problem behaviours |
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The Active Passivity vs. Apparent Competency dialectical dilemma formulation and related secondary targets of passive coping and inaccurate communication are particularly useful for maintaining phenomenological empathy and responding strategically to lying, a common challenge in SUD presentations |
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Implementation challenges of DBT-SUD involve synthesizing standard DBT principles and strategies with SUD treatment best practices such as opioid replacement medications, and addressing common complications of individuals struggling with SUDs such as severe life chaos and the potential for SUD contagion among clients |
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Several RCTs provide at least modest to moderate support of DBT with and without SUD modifications for co-occurring BPD and SUD. Preliminary evidence extends DBT-SUD effectiveness to new populations including co-occurring SUD and eating disorders and primary substance use disorders, and to diverse ethnic, linguistic, and geographic settings |
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28 DBT in Forensic Settings |
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615 | (30) |
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Key Messages For Clinicians |
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DBT is adopted in forensic settings as a treatment model for characteristics of Borderline Personality Disorder and other emotion regulation disorders |
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DBT is also adopted in forensic settings as general behavioural programming to address risk factors of criminal recidivism |
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Examples and language used throughout DBT standard manuals need to be modified to match a forensic population and setting conditions: this does not constitute treatment "adaptation." |
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Modifications to standard DBT (Linehan, 1993a, b) in forensic settings most commonly include skills-only interventions, shortening group session length, incorporating targets related to dynamic criminogenic risk factors, and adding coping skills related to stressors in the institution |
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Variation across studies and lack of methodological rigor call for more research to reach conclusions regarding the effectiveness of implementing DBT in forensic settings |
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29 Delivering DBT in an Inpatient Setting |
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645 | (26) |
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Key Messages For Clinicians |
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Decide on whether what is being offered is a crisis resolution programme, where there is a need for a brief admission focused on quick discharge, or a specialist treatment unit. This might depend more on the actual length of stay versus the desired one. The length of stay for patients will inform treatment targets in individual therapy and also the breadth of DBT skills taught in the Skills Training Groups |
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In terms of treatment targets, focus on those behaviours that got the patient into inpatient treatment and keep them there-watch for "mission creep" and having to treat every last problem that actually could be managed in the community once the risk has abated |
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The evidence for short-term DBT programmes indicates teaching a concentrated version of DBT skills (fewer skills taught more frequently) with a focus on crisis resolution |
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The evidence for longer-term DBT programmes emphasizes the importance of structuring the environment with a strong emphasis on behavioural principles and discharge |
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Maximize the opportunities to strengthen and generalize the use of skillful behaviour |
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Pay attention to Rathus and Miller's (2000) dialectical dilemmas for treating suicidal adolescents and their families, and how they manifest themselves in inpatient settings |
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30 Dialectical Behaviour Therapy in College Counselling Centres |
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671 | (20) |
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Key Messages For Clinicians |
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The complexity and severity of mental illness are increasing across college campuses; this includes increasing rates of anxiety, depression, and suicidality |
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Of the surveyed CCC directors, 94% report a steady increase in the number of students arriving on campus with severe psychological problems (Gallagher, 2014) |
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Research on DBT in the CCC shows promising results regarding reductions in suicidality, life problems, and psychopathology and increases of adaptive coping skills. More research is needed examining implementation, standard DBT protocol, and utilizing more controlled designs |
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Designing a DBT programme within your CCC operating under different policies and parameters than the CCC as a whole may be a way to implement standard DBT without violating policies regarding session limits and contact outside of business hours |
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Implementing brief DBT skills group is an evidence-based, time-limited treatment for a wide range of students that requires a lesser degree of training than standard DBT |
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The biosocial theory in its current form as a theory of emotion dysregulation is relevant and appropriate for explaining many common symptoms found in college students |
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Before implementing DBT, a thorough assessment of the needs and goals of the CCC and student body is necessary |
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After implementing a new DBT programme, the CCC should conduct a thorough outcome evaluation to assess progress toward goals |
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Challenges to implementation include (1) misfit between CCC structure or scope of practice and DBT treatment practices, (2) low support from university administration, (3) misfit between DBT theory and clinician's beliefs about treatment or pre-existing theoretical orientations, (4) difficulties obtaining commitment from students to participate in new treatment modalities, and (5) challenges arising from students in treatment together who know one another from classes or elsewhere on campus |
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31 Dialectical Behaviour Therapy for Pre-adolescent Children |
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691 | (28) |
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Francheska Perepletchikova |
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Key Messages For Practitioners |
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DBT-C retains the theoretical model, principles, and therapeutic strategies of standard DBT |
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DBT-C incorporates almost all of the adult DBT skills and didactics into the curriculum, but modified to the developmental and cognitive level of pre-adolescent children |
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DBT-C includes a parent-training component |
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A major departure from standard DBT is the treatment target hierarchy, which emphasizes increasing adaptive patterns of parental responding as central to improving the child's emotional and behavioural regulation |
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32 DBT Skills in Schools: Implementation of the DBT STEPS---A Social Emotional Curriculum |
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719 | (16) |
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Elizabeth T. Dexter-Mazza |
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Key Points For Clinicians |
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DBT Skills in schools offers a unique upstream approach to provide adolescent emotion regulation skills |
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DBT STEPS-A is designed at the universal level and to be delivered by general education teachers |
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DBT STEPS-A is part of a continuum of DBT services that can be provided in school-based settings, is developed for school-based adolescents, and is adapted from Marsha Linehan's DBT |
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33 Dialectical Behavioural Therapy Skills for Employment |
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735 | (34) |
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Key Points For Clinicians |
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Vocationalactivityisanimportantgoalforrecoveryfrommentalillhealth |
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Adaptations of DBT focusing on employment have shown positive results |
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DBT for employment can be delivered as a group-based treatment thus improving cost-effectiveness |
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AllthreeadaptationsofDBTforemploymentprovideallfivefunctionsofstandardDBT |
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The adaptations of DBT for employment have been developed as stage 2 treatments, provided to those individuals who are no longer engaging in high-risk behaviours |
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34 Improving Accessibility to Dialectical Behaviour Therapy for Individuals with Cognitive Challenges |
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769 | (28) |
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Key Points For Clinicians |
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Accommodations to DBT for individuals with ID need to remain adherent to the model; the delivery mechanisms are altered, rather than core processes |
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It is essential for the DBT therapist to have heightened self-awareness regarding perceptions and communication patterns to foster positive transactional patterns in the client |
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The DBT therapist treating individuals with ID must understand how to manage factors associated with cognitive load in order to design and adjust treatment interventions |
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The therapist needs to understand, be empathetic about, and manage the complex environmental factors that impact the lives of individuals with ID |
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The complex and detailed skills curricula that form part of standard DBT require some adaptation for clients with ID. The Skills System is one such adaptation that provides the client with an accessible emotion regulation skills framework that promotes self-regulation and co-regulation processes to enhance the generalization of skills into the individual's natural environment |
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35 Integrating Post-traumatic Stress Disorder Treatment into Dialectical Behaviour Therapy: Clinical Application and Implementation of the DBT Prolonged Exposure Protocol |
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797 | (18) |
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Key Points For Clinicians |
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DBT+DBT PE is delivered in three stages, with Stage 1 using DBT to achieve behavioural control, Stage 2 targeting PTSD via the DBT PE protocol, and Stage 3 using DBT to address any problems that remain after PTSD is treated |
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During the pre-treatment phase of DBT, therapists begin orienting clients to the DBT PE protocol and establishing effective contingencies regarding achieving behavioural control in order to receive PTSD treatment |
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Stage 1 DBT is delivered without adaptation with the goal of helping clients to achieve the stability and skills necessary to safely and effectively engage in subsequent PTSD treatment |
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Clients must meet specified, principle-driven readiness criteria to begin the DBT PE protocol in Stage 2, including a requirement of abstinence from all forms of suicidal self-injury and NSSI for at least two months |
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The DBT PE protocol is an adapted version of Prolonged Exposure (PE) therapy that uses the core procedures of in vivo exposure to feared but objectively safe situations and imaginal exposure and processing of trauma memories |
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The DBT PE protocol includes three treatment phases: pre-exposure (2-3 sessions), exposure (flexible number of sessions), and termination/consolidation (1 session) |
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On average, the DBT PE protocol is started after 20 weeks of DBT and lasts 13 sessions |
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Research supports the feasibility, acceptability, safety, and effectiveness of integrating the DBT PE protocol into DBT for suicidal and self-injuring clients with BPD, PTSD, and multiple additional diagnoses |
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Successful implementation of the DBT PE protocol in routine practice settings requires attention to several common client-, therapist-, and programme-level barriers |
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36 DBT-PTSD: A Treatment Programme for Complex PTSD After Childhood Abuse |
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815 | (16) |
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Key Points For Clinicians |
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DBT-PTSD is a safe and highly effective multicomponent treatment programme for complex PTSD |
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Thus far, there is no evidence that ongoing self-harm is a safety risk or negative predictor for treatment outcome |
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Borderline patients with co-occurring PTSD should search for a trauma-focused treatment |
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In most cases, there is no need for patients with complex PTSD or PTSD and BPD to complete standard DBT ahead of a specifically designed treatment programme for treating trauma |
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SECTION VII IMPLEMENTATION OF DBT |
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37 Implementing DBT: An Implementation Science Perspective |
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831 | (14) |
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Key Messages For Clinicians |
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When considering DBT trainings to enhance implementation, trainings that facilitate discussion or answering of questions or consultation are important as stake-holders work through determining how DBT will fit in their setting |
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Trainers must have experience with a range of solutions to typical appropriateness concerns so clinicians, agencies, or systems do not implement DBT in a rigid way that fits the manual, but not their clinical structure |
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A DBT pilot programme is an implementation strategy that can be evaluated to determine whether it should be implemented more widely |
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Once a pilot project is determined to be successful, expanding the programme to improve reach to appropriate clients is a vital next step |
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Those considering implementing DBT could use the data presented within this chapter about barriers to inform an implementation plan (e.g., knowing that staff turnover is an issue, plan for how to address it using the suggestions provided). ~~ |
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DBT fidelity appears to be associated with more training |
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38 The Dialectical Dilemmas of Implementation |
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845 | (16) |
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Key Messages For Clinicians |
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Successful implementation of DBT involves multi-level change within organizations |
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As a complex activity, tensions are inevitable among stakeholders when implementing DBT. Dialectics offer a means of promoting flexibility and resolving the challenges of implementation |
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Three common dialectical dilemmas occur during implementation of DBT |
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1 Tension between adopting and adapting DBT |
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2 Tension between risk management and delivering the treatment as intended |
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3 Tension between meeting both the needs of the system and the needs of providers |
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39 DBT in Private Practice |
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861 | (26) |
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Key Messages For Clinicians |
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The challenge for clinicians implementing comprehensive DBT in private practice is to determine how to implement modes of treatment that meet all of functions of DBT. The modes may differ from standard DBT, but the practitioner must be able to articulate how each function is served by the modes provided |
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Solo practitioners can best deliver standard comprehensive DBT by utilizing a shared location that enables cross-referrals between therapists' skills groups while maintaining separate business entities |
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The dual roles of business manager and individual therapist can be difficult to balance. Many DBT clinicians may have negative judgments of earning money from clients "in-need" and must seek dialectical solutions that honour business, service to clients, and personal limits |
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For private practice DBT, an essential topic in the pre-treatment phase is orientation to all business and payment-related policies. Potential problems such as non-payment, late cancellations/no-shows, etc., are conceptualized and targeted as TIBs |
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The consultation team is an essential component for any practitioner wishing to use DBT in their solo practice |
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40 Implementation in National Systems: DBT in an Irish Context |
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887 | (22) |
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Key Messages For Clinicians |
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Existing knowledge about DBT implementation for teams can be applied to implementation at a system-level |
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System change requires innovation champions who understand both the evidence-based treatment model as well as the political and societal climate within which it exists |
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Innovation champions cannot achieve change alone; change requires DBT champions and health service management working together tdfecilitate successful implementation |
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Research evaluation of all aspects of implementation is essential so as to understand, refine, and address potential implementation barriers |
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41 International Implementation of Dialectical Behaviour Therapy: The Challenge of Training Therapists Across Cultures |
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909 | (22) |
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Key Points For Clinicians |
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The global demand for DBT stems from high levels of mortality and morbidity due to suicide, the need for effective treatments for disorders of emotion regulation, and an increased demand for evidence-based mental health treatments |
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Due to the resource-intensive framework of DBT, careful examination of past implementation efforts is necessary for continued success in the international implementation of DBT |
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DBT implementation includes the required programmatic elements of the treatment and the provider behaviours that need to align with the strategies of the treatment |
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For successful international DBT implementation, factors including technology, language/translation, variability in healthcare systems, and challenges of working in a foreign country must be considered |
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42 Using Novel Technology in Dialectical Behaviour Therapy |
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931 | (34) |
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Key Points For Clinicians |
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The demand for DBT is outpacing the supply of clinicians trained in delivering it effectively |
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DBT Is compatible with the implementation of technology, including persuasive technology, modularity, and logical flow |
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There is growing research support for the use of technology to both augment and supplant DBT, including videos, mobile apps, and computerized interventions |
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There are several mobile apps on the market that can be downloaded and used in therapy, although there appears to be no research on these applications |
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SECTION VIII TRAINING IN DBT |
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43 Evidence-Based Training: The Intensive Model of Training in Dialectical Behaviour Therapy |
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965 | (16) |
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Key Messages For Clinicians |
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Along with evidence-based psychological treatments, there is also a need for evidence-based training |
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An intensive model of training in DBT was developed to meet the growing demand that could not be met through traditional training methods |
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The model of DBT intensive training typically is provided as a bipartite training consisting of two five-day workshops separated by a period for self-study and implementation |
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Strategies and principles of the treatment are also incorporated within the training, such as mindfulness at the start of each training day and chain analyses targeting behaviours that interfere with training |
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Early evaluations of DBT intensive training has demonstrated successful initial implementation and adoption of DBT modes. However, further research is needed to examine long-term sustainability--- and treatment penetration |
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44 Shaping Therapists Towards Adherence: A How-to Guide |
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981 | (24) |
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Key Messages For Clinicians |
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Translating evidence-based therapies from research settings to routine community settings requires that interventions provided, in both form and content, match those delivered as part of the research protocol in order to maintain outcomes |
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Treatment adherence and treatment fidelity: DBT uses "treatment adherence" to describe therapists' behaviours used when conducting the therapy, and "treatment fidelity" when discussing therapy modes offered in DBT programmes |
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DBT is a complex therapy to master given the abundance of treatment strategies, all of which are context specific. DBT is a principle-driven, not protocol-driven, therapy, although protocols do also exist within DBT |
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The DBT Adherence Coding Scale (DBT ACS), created for research purposes, establishes whether a therapist's therapy provision matches the behaviours set out in the treatment manual |
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The DBT ACS scale reflects the complexity of the treatment and requires the review of an entire therapy session and the subsequent coding of therapist strategies on 66 items, some of which embody complex "if-then" rules of therapy |
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Currently DBT does not have a scale that is briefer, easier to administer, or easier to deploy in community settings to measure therapist competence |
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Research on the acquisition of and the increase of competence in DBT suggests that more training and supervision leads to increased use of DBT strategies |
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Consultation team habits can shape the DBT practice of its team members |
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45 Future Directions for Dialectical Behaviour Therapy: Theory, Development, and Implementation |
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1005 | (12) |
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Key Points For Clinicians |
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Since the publication of the first treatment trial in 1991 evidential support for using DBT for clients with suicidal behaviour in the context of BPD has been complemented by promising adaptations and outcomes in other populations |
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DBT's flexible modular structure has aided the process of adopting and adapting the treatment for new client groups and new populations |
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Building on DBT's flexible transdiagnostic basis to realize its potential to reach a greater number of clients suffering from difficulties in the experience and management of emotion should be a focus for the next two decades |
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Understanding more about effective mechanisms, both in treatment and for training staff, to deliver consistently improved outcomes for clients will aid the dissemination endeavour |
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Synthesizing the desire to disseminate the treatment and improving reach with ensuring fidelity to maintain clinical outcomes is a central issue for DBT now and into the future |
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Despite DBT's success in delivering good clinical outcomes many clients remain functionally impaired in the medium to longer term. Dedicated research to understanding and scoping this problem would be a useful focus for the next decade |
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Funding research to examine which modes of treatment and which treatment lengths and intensities are most effective remains a priority. "Big data" collected in routine practice settings may assist with this task |
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DBT is well placed to adapt to forthcoming changes in diagnostic classification that utilize a dimensional trait based approach to describing difficulties |
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DBT as a principle-based treatment fits well with ideas of interventions that focus on evidence-based principles of change |
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| Index |
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1017 | |
