Excerpts From Dialectical Behavior Therapy In Private Practice
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This page is an excerpt from the text "Dialectical Behavior Therapy in Private Practice: A Practical and Comprehensive Guide" by Thomas Marra, Ph.D. (published by New Harbinger Press in 2005). |
| DBT research evaluates outcome on patient populations using the fuller dialectical framework developed by Linehan (Linehan, 1993a, 1993b). This DBT research differs from the acceptance-based research reviewed above due to the inclusion of dialectic analysis (including the core dialectic of psychotherapy itself that demands movement along the change versus acceptance continua), psychoeducation including mindfulness skills, emotion regulation skills, distress tolerance skills, and interpersonal effectiveness skills. While different experimenters may vary their therapeutic intervention depending on the patient population addressed, they all adhere to one degree or another on Linehan’s treatment manual (Linehan, 1993b). |
| Linehan began her academic career in the study of suicidal behavior, which led naturally to the study of borderline personality disorder (BPD). Borderline’s frequently engage in suicidal and what Linehan describes as parasuicidal behavior (behavior that may result in death, although the intent or purpose of the patient may not in the moment be to destroy their lives). Obviously such individuals are emotionally aroused, and the intensity of their affect is one of the defining characteristics of the BPD disorder. However, as the research below demonstrates, many disorders have the same core characteristics identified by Linehan in the BPD spectrum symptoms (high emotional arousal, slow return to emotional baseline following threat, impulsive behaviors designed to reduce arousal, and emotional escape and avoidance strategies). For example, eating disordered patients, generalized anxiety disordered patients, PTSD patients, panic disordered patients, agoraphobic patients, depressed patients, patients suffering the various addictions to substances, impulse control disordered patients, and many of the personality disordered patients demonstrate the same spectrum of symptoms that DBT was designed by Linehan to treat. |
| Linehan (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) compared one group of 22 females (aged 18-45 years) with BPD who underwent DBT for 1 year and 22 matched females with BPD who underwent treatment as usual in the community. The subjects were assessed at pretreatment and at 4, 8, and 12 months posttreatment. There was a significant reduction in the frequency and medical risk of parasuicidal behavior among subjects who received DBT compared with subjects who received treatment as usual. The number of days of inpatient psychiatric hospitalization was fewer for subjects who received DBT than for controls, resulting in greater cost-effectiveness for DBT in spite of DBT intensive treatment design (that includes both individual and group psychotherapy, as well as accessibility for telephone consultation between sessions, for a one year period of time). While DBT was not shown differentially effective in improving patients' depression, hopelessness, suicide ideation, or reasons for living, the reduced parasuicidal behavior intensity and frequency, together with fewer psychiatric hospitalizations (lower cost and greater ability to sustain patients in the least restrictive environment) is impressive. |
| Linehan (Linehan, Heard, & Armstrong, 1993) report on a naturalistic follow up of her initial DBT experimental and control patients one year following the termination of her initial one-year study. She analyzed 39 women who met criteria for borderline personality disorder. Efficacy was measured on parasuicidal behavior (Parasuicide History Interview), psychiatric inpatient days (Treatment History Interview), anger (State-Trait Anger Scale), global functioning (Global Assessment Scale), and social adjustment (Social Adjustment Scale--Interview and Social Adjustment Scale--Self-Report). Subjects were assessed at 6 and 12 months into the follow-up year (after one year of DBT treatment). Comparison of the two conditions revealed that throughout the follow-up year, DBT subjects had significantly higher Global Assessment Scale scores. During the initial 6 months of the follow-up, DBT subjects had significantly less parasuicidal behavior, less anger, and better self-reported social adjustment. During the final 6 months, DBT subjects had significantly fewer psychiatric inpatient days and better interviewer-rated social adjustment. Swenson and colleagues (Swenson, Sanderson, Dulit, & Linehan, 2001) report on the same application of DBT principles to BPD in psychiatric inpatient hospitalizations. |
| Verheul (Verheul et al., 2003) studied 64 women with BPD in the Netherlands. They were randomly assigned to either a year of DBT (n=31) or TAU (n= 33) in a randomized controlled study. Patients assigned to DBT received 12 months of both psychosocial skills education, 2 to 2.5 hours per week, as specified in the Linehan (1993a) manual, as well as “cognitive-behavioral” individual psychotherapy on a weekly basis. It is not clear from the research report if the individual therapy was truly dialectical, since it is described as “Individual therapy focuses primarily on motivational issues, including the motivation to stay alive and to stay in treatment” (p. 135). Balancing acceptance and change as a therapeutic target is clearly deployed, with median adherence score on a 5-point Likert scale achieving 3.8. Patients in the TAU group attended no more than two sessions per month with a psychologist, psychiatrist, or a social worker, clearly indicating that treatment intensity in the TAU was not as great as in the DBT intervention group. |
| The Netherlands study assessed recurrent parasuicidal and self-damaging impulsive behaviors at 11, 22, 33, 44, and 52 weeks after randomization using the Borderline Personality Disorder Severity Index, and the Lifetime Parasuicide Count (modified) to measure self-mutilating behavior such as cutting, burning and pricking. Significantly more patients who were receiving DBT (63%) than patients in the TAU group (23%) continued in therapy with the same therapist for the entire year. Treatment retention thus favored DBT. Self-multilating behavior for the DBT group diminished over the treatment year, while the TAU patients engaged in more self-mutilating behavior. At week 52, 57% of the TAU patients reported self-mutilating at least once the in the previous 6-month period, compared to only 35% of the DBT group. Impulsive behavior was consistent across both the DBT and TAU groups, with no significant differences between the two. The greater improvement of the DBT group could not be accounted for by use of medications, baseline severity of symptoms, or any other measured pre-treatment and during-treatment difference. DBT tended to be more successful the greater the intensity of symptoms, in that DBT was found more effective in the high-symptom severity group but no difference from TAU was found on low-symptom severity groups. Verheul (Verheul et al., 2003) concludes that DBT is an effective form of treatment for BPD, noting that TAU actually resulted in significant deterioration of the patient’s symptom picture over time. They note that DBT is effective regardless of substance abuse issues, and offer the alternative notion that DBT is not targeted for BPD patients per se, but may be appropriate for patients with severe impulse-control disorders other than BPD as well. |
| Bohus (Bohus et al., 2000) reports a pilot study of 24 female patients who were compared at admission to the hospital, and at one month after discharge with respect to psychopathology and frequency of self-injuries after receiving inpatient-based DBT. Significant improvements in ratings of depression, dissociation, anxiety and global stress were found. A highly significant decrease in the number of parasuicidal acts was also reported. Analysis of the average effect sizes shows a strong effect, although they acknowledge lack of a randomized controlled design. |
| Bohus (Bohus et al., 2000) reports a pilot study of 24 female patients who were compared at admission to the hospital, and at one month after discharge with respect to psychopathology and frequency of self-injuries after receiving inpatient-based DBT. Significant improvements in ratings of depression, dissociation, anxiety and global stress were found. A highly significant decrease in the number of parasuicidal acts was also reported. Analysis of the average effect sizes shows a strong effect, although they acknowledge lack of a randomized controlled design. |
| Hawton (Hawton et al., 2000) reviews the literature on self-harm (parasuicidal behavior) to identify and synthesize the findings from all randomized controlled trials that have examined the effectiveness of treatments. All randomized clinical control studies of psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare for patients who shortly before entering the study engaged in any type of deliberately initiated self-injury were included in the review. The outcome measure was parasuicidal or suicidal behavior. A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable, with modest data indicating that DBT-type treatment was differentially effective. The reservations of the experimenters is based mostly on insufficient numbers of patients in trials as a limiting factor. They conclude that there is a need for larger trials of treatments and that such trials must also be replicated. |
| A study of incarcerated women with histories of childhood sexual and/or physical abuse (Bradley & Follingstad, 2003) indicated DBT effectiveness. The intervention group used DBT and writing assignments. They randomly assigned 24 participants to DBT-based group treatment (13 completed) and 25 to a no-contact comparison condition (18 completed). The Beck Depression Inventory, Inventory of Interpersonal Problems, and Trauma Symptom Inventory were administered, with the data demonstrating significant reductions in PTSD, mood, and interpersonal symptoms in the DBT group. |
| Evans (Evans et al., 1999) explore the use of DBT-based treatment manuals in parasuicidal patients. This pilot study is significant in that patients are provided with 6 DBT brochures or “self-help manuals” rather than receiving the full and intensive DBT treatment as prescribed in the Linehan (1993b) treatment manual. Thirty four patients (ages between 16 and 50) with histories of self harm within the prior 12 months were randomly assigned to 6 sessions of DBT-informed short-term treatment (16 such patients) linked to the booklets, and the remainder of the subject pool were assigned to treatment as usual (TAU). Assessment of clinical symptoms and social function were made at baseline and repeated by an independent assessor masked to treatment allocation at 6 months. The number and rate of all parasuicide attempts, time to next episode and costs of care were also determined. Thirty-two patients (18 DBT; 14 TAU) were seen at follow-up and 10 patients in each group (56% DBT and 71% TAU) had a suicidal act during the 6 months. The rate of suicidal acts per month was lower with DBT (median 0.17/month DBT; 0.37/month TAU; P = 0.11) and self-rated depressive symptoms also improved (P = 0.03). The treatment involved a mean of 2.7 sessions and the observed average cost of care was 46% less with DBT (P = 0.22). Although the authors acknowledge that this short-term treatment is not DBT as defined by Linehan (1993a,b), they conclude that DBT-informed treatment is efficacious in the typical clinical setting in reducing parasuicidal behavior. |
| One of the issues facing DBT dissemination into traditional clinical practice is the complexity of DBT theory itself, especially when applied to the complex (and frequently comorbid with other disorders) conditions of BPD. Many state Departments of Mental Health have adopted DBT as the treatment of choice for BPD, and DBT enjoys wide acceptance in the public mental health system, since the experimental evidence strongly suggests higher efficacy and lower costs. But can the complexities of DBT be effectively taught to therapists who have widely-varying theoretical backgrounds and experience? Hawkins (Hawkins & Sinha, 1998) used a detailed examination of DBT knowledge, and evaluated the conceptual mastery of 109 clinicians trained via a State Department of Mental Health initiative. Performance on the examination correlated specifically with DBT training. Prior education or background in behavior therapy accounted for little variance in mastery of the concepts, indicating that therapists occupying diverse roles acquired reasonable intellectual mastery over DBT with training. While DBT is a complex model of service delivery, it is teachable and learnable. |
| Examining the degree to which some of the specific elements of DBT contribute to lowered parasuicidal behavior (Shearin & Linehan, 1992), Linehan investigated the influence of the patient-therapist relationship in reducing suicidal behavior in DBT. Subjects were 4 therapist-patient dyads. Weekly patient and therapist relationship ratings were measured over 7 months with a short form of the Structural Analysis of Social Behavior. Dialectical techniques balancing acceptance and change were more effective than pure change or acceptance techniques in reducing suicidal behavior. Therapist ratings consistent with nonpejorative conceptualization (seeing behavior as attempts to operate on the environment, rather than as manipulative or pathological) were also associated with less suicidal behavior. |
| The applicability of DBT to addictions was shown in a study of comorbid BPD and addiction (Linehan et al., 1999). A treatment-as-usual (TAU) regimen for drug-dependent suicidal women displaying borderline personality disorder was compared to DBT. Twenty eight women (aged 18-45 years of age) were randomly assigned to DBT or TAU groups. TAU subjects were either referred to alternative substance abuse or mental health counselors and community programs, or continued with their own psychotherapists). Results show a drop-out rate of 36% from DBT compared with a rate of 73% from TAU. Urinalysis showed a significant reduction in substance abuse among the DBT subjects, and significant improvements in social and global adjustment in DBT subjects at 16-month follow-up. Linehan concludes that DBT is an effective treatment for severely dysfunctional drug-dependent patients. Although DBT was designed for the treatment of BPD and suicidal patients, Linehan (Rizvi & Linehan, 2001) notes that research has expanded to more diverse populations including comorbid substance dependence and BPD, inpatient treatment for BPD, as well as antisocial behaviors in juveniles and adults. The current review shows that DBT has been expanded well beyond these areas. |
| Linehan (Linehan et al., 2002) compared the effects of the use of DBT with 23 heroin-dependent female BPD patients and comprehensive validation therapy in conjunction with a 12-step program (CVT + 12S). During a 12-month period patients received either DBT or CVT + 12S, a manualized approach that provides DBT in combination with participation in a 12-step program. All patients concurrently received the opiate agonist therapy with levomethadyl acetate hydrochloride oral solution. Subjects were assessed for drug use through urinalyses, interviews, and self-reports. Results showed that both treatment conditions were effective in reducing opiate use relative to baseline, but at 4 months following treatment termination, all subjects exhibited a low proportion of opiate-positive urinalyses. Subjects assigned to DBT maintained reductions in mean opiate use through 12 months of active treatment, while those assigned to CVT + 12S treatment significantly increased opiate use during the last 4 months of treatment. In contrast to other studies of DBT (that show that DBT-treated patients tend to sustain involvement in treatment, and show lower drop-out rates during study), in this experiment DBT-treated patients show an increased drop-out rate compared to the 12S subjects: all 12 CVT + 12S Ss completed the 12 months of treatment, while only 64% of DBT-treated subjects completed the clinical trial. |
| Agras and Linehan (Telch, Agras, & Linehan, 2001) report a study of the use of DBT for binge eating disorder (BED). Forty four women with BED were randomly assigned to group DBT or to a wait-list control condition and were administered the Eating Disorder Examination in addition to measures of weight, mood, and affect regulation at baseline and posttreatment. DBT treated women evidenced significant improvement on measures of binge eating and eating pathology compared with controls, and 89% of the women receiving DBT had stopped binge eating by the end of treatment. Abstinence rates were reduced to 56% at the 6-month follow-up. Although comparative measures of weight, mood, and affect regulation were not significant between the DBT treatment group and controls, the authors suggest their results support further research into DBT as a treatment for BED. Linehan (Linehan, Tutek, Heard, & Armstrong, 1994) reports the efficacy of DBT on interpersonal outcome variables for patients diagnosed with BPD. In a one year clinical trial 26 female patients with BPD were randomly assigned to either DBT or a TAU condition. All subjects met criteria of DSM-III-R and Diagnostic Interview for BPD disorder and were chronically suicidal. In both the TAU and DBT completion groups, DBT subjects had significantly better scores on measures of anger, interviewer-rated global social adjustment, and the Global Assessment Scale and tended to rate themselves better on overall social adjustment than TAU subjects. Linehan and her colleagues interpret these results as suggesting that DBT is a promising psychosocial intervention for improving interpersonal functioning among severely dysfunctional patients with BPD. |
| In a more recent study, Koons (Koons et al., 2001) took 20 women veterans who met criteria for BPD and randomly assigned them to DBT or TAU for 6 months. The DBT treated subjects, in comparison to TAU subjects, had significantly greater decreases in suicidal ideation, hopelessness, depression, and anger expression. DBT subjects showed significant decreases in number of parasuicidal acts. “Strong trends” (those factors not statistically significant but showing strong differences between DBT and TAU) included anger experienced but not expressed, dissociation, and number of psychiatric hospitalizations. Both DBT and TAU groups showed significant decreases in depressive symptoms and BPD-like behaviors. Neither the DBT group or the TAU group showed substantial decreases in anxiety. The authors note that the DBT can be successfully implemented independent of the developer (Dr. Linehan did not participate in this study). |
| Of course, not all experimenters fully adhere to the DBT manual (Linehan, 1993b), given the experimenters clinical population of interest, diagnosis, and previous theoretical orientation of the experimenters. However, studies conducted by experimenters not coming from the behavioral tradition but adopting some of the aspects of DBT have also shown substantial patient improvement. For example, a study by Barley (Barley et al., 1993) with mostly female subjects (age range from 16 to 57 years of age) psychiatrically hospitalized for an average of 106 days (range of hospitalization from 3 to 629 days) for 130 subjects present interesting results. The inpatient unit was psychodynamically oriented, and psychodynamically-informed case formulations and treatment continued with the gradual introduction of DBT. The non-random study divided assessment periods into three broad segments: no DBT, introduction of DBT into the unit treatment regimens, and full DBT program. Results across the three time intervals were compared with parasuicide rates to another unit in the hospital not introducing DBT. The results indicate that following the introduction of DBT, parasuicidal behaviors significantly declined compared to the no-DBT psychiatric unit also treating personality disorders. While the lack of a randomized control group limits the degree to which findings can be generalized, this naturalistic study demonstrates that DBT-informed treatment (even when administered by professionals who have a psychodynamic theoretical history) can substantially decrease patient parasuicidal behavior. |
| Linehan’s training corporation (Dimeff, Koerner, & Linehan, 2001) report an unpublished study (Miller, Rathus, Leigh, & Landsman, 1996) where 111 suicidal teens were assigned to DBT or TAU based upon the severity of their symptoms (the more severe teens receiving the DBT treatment). Twenty-two percent of the sample were male (most studies to date are primarily female participants). DBT treatment was modified from the treatment manual in several substantial ways: the treatment lasted only 12 weeks rather than the standard one year, treatment handouts were modified to be more appropriate to a teen population, and the number of skills modules taught were reduced. Family therapy was included in addition to individual psychotherapy. Mindfulness skills were taught only 3 times in the 12-week psychoeducation program. Although this was only a quasi-experimental study without randomization, the results are impressive. Subjects in the DBT group completed treatment significantly better than TAU subjects (62% vs. 40%), and had significantly lower psychiatric hospitalizations (0% vs. 13%). No significant differences were found between the two groups on parasuicidal behaviors, although Dimeff and colleagues note that since patients were assigned to DBT based upon the severity of their symptoms, the no difference between conditions is noteworthy. Moreover, pre- and post-treatment measurement within the DBT group showed substantial changes over the following measures: decreases in suicidal ideation, reductions in global severity index of symptoms and distress, and (on the SCL-90) decreases in anxiety, depression, interpersonal sensitivity, and obsessive-compulsive symptoms. Trends in positive directions not meeting statistical significance included lower paranoia, confusion about self, impulsivity, emotion dysregulation, and interpersonal difficulties. In another unpublished study (Dimeff et al., 2001) DBT is substantially altered from the original treatment manual by reducing treatment from the initially studied one year of intensive treatment to six months (Stanley, Ivanoff, B., Oppenheim, & Mann, 1998). DBT again was compared to TAU (all subjects having BPD and female). Reported results show statistically significant reduction in self-mutilation behavior and urges, and suicidal ideation and urges. No suicide attempts occurred in either the DBT or TAU groups during the six- month study. This finding is significant in that it demonstrates that even shorter-term DBT interventions can be effective, even with borderline patients. |
| An early study by Springer (Springer, Lohr, Buchtel, & Silk, 1996) is especially significant because these experimenters deleted the acceptance-based module traditionally seen as a “core” skill of DBT (Linehan, 1993a). They eliminated the mindfulness module that teaches patients to attend to their feelings, even when painful, but taught patients improved psychological coping skills (the remaining three modules of Linehan’s BPD program, including emotion regulation, distress tolerance, and interpersonal effectiveness). The results of the DBT-informed treatment were compared to a wellness discussion group that included TAU. This general inpatient unit population included only short-term treatment (subjects in both conditions attended an average of six sessions during their hospital stay). The results were not encouraging, in that although patients in the DBT-informed group felt that they had better skills to handle their difficulties post-discharge, increased self-mutilative behaviors were observed. Linehan (Dimeff et al., 2001) comments that perhaps “contagion effects” (discussing parasuicidal behavior in a group context) explain the results, but perhaps the excessively short treatment episodes (an average of six sessions) and the absence of acceptance-based technologies are equally important factors. |
| Although patients with BPD tend to engage in the highest frequency of parasuicidal acts due to their high emotional arousal, other personality disorders can also profit from DBT. While most DBT studies have occurred in either outpatient or inpatient treatment settings, DBT has been adapted for use in forensic settings (McCann, Ball, & Ivanoff, 2000). Patients in the criminal justice system tend to have violent histories and multiple diagnoses, including BPD and antisocial personality disorder. In this study, where the authors report that half of their subjects have BPD and half antisocial personality disorder, they also report a high frequency of Axis I psychotic and mood disorders. This is thus a complex diagnostic group to treat. Twenty-one DBT patients are compared to 14 TAU patients over a 20 month period. While DBT was altered somewhat to include the violent acting out behavior (externalizing behavior in addition to internalizing behavior), the fundamental theoretical framework of DBT was maintained. Results showed that DBT patients, in comparison to TAU patients, had a significant decrease in depressed and hostile mood, paranoia, and psychotic behavior. DBT patients were shown to have less interpersonal coping difficulties on the forensic unit compared to TAU patients, and DBT therapists reported lower staff burnout compared to TAU therapists. This study is thus significant in several respects. First, DBT is found effective for antisocial personality disorder as well as for patients who have Axis I mood and psychotic disorders. Second, it should be noted that unlike in other studies these are not “voluntary” patients. They are incarcerated patients within an intermediate security ward of a prison. DBT is thus found effective even for highly resistive patients. Third, increased support is offered for the DBT model since the TAU group is highly monitored. Since the TAU group is also incarcerated, increased information is available about medication compliance and treatment adherence. The TAU group was compliant with treatment, and when compared with the compliant DBT group additional improvement is noted with the DBT group compared to the TAU group. Finally, staff attitudes were measured and the DBT group therapists report lower burnout than the TAU therapists. |
| In a randomized controlled trial involving 24 outpatient suicide attempters, DBT was compared to client-centered therapy (Turner, 2000). Blinded, independent rater evaluations and a battery of patient self-report measures were completed at baseline, 6 months, and 1 year during the course of treatment. Measures of suicide attempts and self-harm episodes were collected on a weekly basis. The number of psychiatric hospitalization days per 6-month period was also measured. Outcomes showed the DBT group improved more than the client-centered group on most measures. Subjects in the DBT condition show statistically significant gains at both 6 and 12-month follow up in suicide/self-harm behavior. At 12-month follow up the DBT group show significantly less anger, impulsivity, and depression, while showing improved global mental health functioning compared to the client-centered treated subjects. The DBT group showed significantly reduced hospitalization rates at both 6 and 12-month follow-up periods. The quality of the therapeutic alliance accounted for significant variance in patients' outcomes across both treatments. Remarkable is that the DBT treatment included psychodynamic techniques, and that psychosocial skills training occurred during the individual psychotherapy sessions (a clear departure from Linehan’s recommendation that skills training occur separately from the individual psychotherapy session). |
| Another recently published study with juvenile female offenders in a mental health facility compared one cottage in the correctional facility using DBT with a comparable cottage using treatment as usual (TAU) (Trupin, Stewart, Beach, & Boesky, 2002). The study compared twice-weekly DBT groups, together with coaching the use of DBT skills throughout the 4-week study period, to TAU. The authors report aggression, parasuicide, and class disruption were lower in the DBT group, and decreased progressively during the intervention period. The DBT group therapists had to use fewer restrictive punitive responses compared to the TAU therapists during the intervention period. Following DBT treatment, the experimental group participants showed significantly improved transition to off-cottage but on-campus services compared to TAU participants. |
| A study of elderly depressed patients using DBT was recently published (Lynch, Morse, Mendelson, & Robins, 2003). This randomized controlled trial of 34 patients compared DBT to TAU plus clinical management in a 28-week treatment. DBT included only group skills training (not individual dialectically-based psychotherapy). Both DBT and TAU included antidepressant medication. Both groups were assessed at baseline, 28 weeks, and at 6-month follow-up. While between group analysis showed few differences between groups at termination of treatment, at 6-month follow-up the DBT treated group showed greater improvement on the Beck Depression Inventory. On the HAMD 67% of the DBT patients met criteria for being improved and asymptomatic at postreatment, while only 50% of the TAU group met such improvement. At 6-month follow-up, 73% of the DBT patients and 40% of the TAU patients were in the asymptomatic range. DBT patients showed greater functional status and coping compared to TAU patients. |
| How can these research findings be interpreted? Note that these findings from various researchers in different settings treating different patient populations with different diagnoses all show promise using DBT-informed treatment principles. The exact treatment manual developed by Linehan (Linehan, 1993b) is frequently departed from, with continued treatment gains shown. My own experience in using DBT in both inpatient and outpatient settings is consistent with the above research findings. For example, during an 18-month period every patient admitted to Monterey Psychiatric Health Facility (over 150 patients) that I directed was treated with DBT regardless of diagnosis. Patient diagnoses included major depressive disorders, anxiety disorders, eating disorders, impulse control disorders, obsessive-compulsive disorders, impulse control disorders, schizophreniform disorder, addictive disorders, and personality disorders. Remarkable was that these varied patient problems were treated together, without patient segregation, and the DBT principles were found applicable and relevant by most patients. Treatment staff were multidisciplinary (including psychiatrists, psychologists, clinical social workers, psychiatric nurses, and paraprofessional staff). The acute psychiatric inpatient unit never had to use seclusion and restraint procedures against any patient, due to the respectful and validating nature of the treatment process. Furthermore, only one patient discontinued treatment against medical advice and only one patient was discharged prior to completion of treatment (for use of drugs within the facility). While we have no formal data to present from this 18-month period, staff (who came from other more traditional acute psychiatric inpatient programs, but were all formally trained in DBT prior to opening of the new free-standing psychiatric facility) reported that patients were more involved in their own treatment process, staff experienced less patient resistance to treatment interventions, and high patient satisfaction ratings with both treatment staff and treatment procedures were found. In fact, the facility obtained Accreditation with Commendation from the Joint Commission on the Accreditation of Healthcare Facilities (indicating that the Commission’s independent peer review ratings placed the facility in the top 10% of hospitals rated). While many hospitals (10%) can claim such Commendation, few obtain such ratings during their first six months of operation. DBT is thus a powerful, robust, and effective treatment orientation worthy of consideration. My subsequent experience applying DBT in outpatient private practice as a psychologist suggests that DBT-informed strategies of treatment are equally effective in solo practice settings. In teaching both dialectic approaches to psychotherapy as well as the psychological coping skill sets (mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness skills) to therapists, I have found that professionals from a variety of theoretical orientations (dynamic, cognitive-behavioral, and eclectic) easily learn the DBT approach to treatment. They report subsequent to training that they actually use some, if not all, of the principles in their practices (be such practices in solo private practice, public mental health settings, or hospital-based settings). DBT has much to offer the professional who treats patients in acute emotional pain. |
References |
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