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Decker SE, Matthieu MM, Smith BN, Landes SJ. Barriers and Facilitators to Dialectical Behavior Therapy Skills Groups in the Veterans Health Administration. Mil Med 2024; 189:1055-1063. [PMID: 37104810 DOI: 10.1093/milmed/usad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/22/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Dialectical behavior therapy (DBT) is a multimodal evidence-based suicide prevention psychotherapy with barriers to full implementation. This study qualitatively examined barriers and facilitators to the DBT skills group treatment mode, which can be implemented as a stand-alone intervention. Using data from a national mixed-methods program evaluation of DBT in the Veterans Health Administration (VHA), this is the first article to examine barriers and facilitators to DBT skills groups implemented with a DBT consultation team or as a stand-alone intervention. MATERIALS AND METHODS A subset of data from semi-structured telephone interviews of six clinicians and three administrators (n = 9 respondents) was analyzed to provide complementarity and expansion on prior quantitative findings. The data were coded using an iterative process based on content analysis and a codebook based on the Promoting Action on Research Implementation in Health Services framework. The study was approved by the institutional review board for the Palo Alto VA Health Care System. RESULTS Barriers and facilitators were organized by Promoting Action on Research Implementation in Health Services domains of evidence, context, and facilitation. Results showed how reduced leadership support and low receptivity to providing DBT skills groups functioned as barriers and also identified a barrier not described earlier in the literature: the perception that this group could conflict with expanding access to care for more veterans. The results showed how leadership supported implementation, including by mapping clinic grids and supporting training, and also revealed how a supportive culture among providers facilitated division of labor between skills group providers, and how offering a treatment that filled a gap in services supported the group. At some sites, a provider with prior DBT experience was instrumental in starting DBT skills groups or developing ongoing training. CONCLUSIONS Qualitatively analyzed barriers and facilitators to a group-delivered suicide prevention intervention, DBT skills groups, expanded on quantitative findings on the importance of leadership support, culture, and training as facilitators. Future work implementing DBT skills group as a stand-alone treatment will need to address the barrier of receptivity and perceived barriers about access to care.
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Affiliation(s)
- Suzanne E Decker
- VA Connecticut Healthcare System, Mental Illness Research Education and Clinical Center, West Haven, CT 06516, USA
- VA Connecticut Healthcare System, Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, West Haven, CT 06516, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, USA
| | - Monica M Matthieu
- Central Arkansas Veterans Healthcare System, Behavioral Health Quality Enrichment Research Initiative (QUERI), North Little Rock, AR 72114, USA
- College for Public Health and Social Justice, School of Social Work, Saint Louis University, Saint Louis, MO 63103, USA
| | - Brandy N Smith
- Central Arkansas Veterans Healthcare System, Behavioral Health Quality Enrichment Research Initiative (QUERI), North Little Rock, AR 72114, USA
- Central Arkansas Veterans Healthcare System, South Central Mental Illness Research Education and Clinical Center (MIRECC), North Little Rock, AR 72114, USA
| | - Sara J Landes
- Central Arkansas Veterans Healthcare System, Behavioral Health Quality Enrichment Research Initiative (QUERI), North Little Rock, AR 72114, USA
- Central Arkansas Veterans Healthcare System, South Central Mental Illness Research Education and Clinical Center (MIRECC), North Little Rock, AR 72114, USA
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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Hoagwood KE, Richards-Rachlin S, Baier M, Vilgorin B, Horwitz SM, Narcisse I, Diedrich N, Cleek A. Implementation Feasibility and Hidden Costs of Statewide Scaling of Evidence-Based Therapies for Children and Adolescents. Psychiatr Serv 2024; 75:461-469. [PMID: 38268465 PMCID: PMC11099614 DOI: 10.1176/appi.ps.20230183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVE State mental health systems are retraining their workforces to deliver services supported by research. Knowledge about evidence-based therapies (EBTs) for child and adolescent disorders is robust, but the feasibility of their statewide scaling has not been examined. The authors reviewed implementation feasibility for 12 commonly used EBTs, defining feasibility for statewide scaling as an EBT having at least one study documenting acceptability, facilitators and barriers, or fidelity; at least one study with a racially and ethnically diverse sample; an entity for training, certification, or licensing; and fiscal data reflecting the costs of implementation. METHODS The authors reviewed materials for 12 EBTs being scaled in New York State and conducted a literature review with search terms relevant to their implementation. Costs and certification information were supplemented by discussions with treatment developers and implementers. RESULTS All 12 EBTs had been examined for implementation feasibility, but only three had been examined for statewide scaling. Eleven had been studied in populations reflecting racial-ethnic diversity, but few had sufficient power for subgroup analyses to demonstrate effectiveness with these samples. All had certifying or licensing entities. The per-clinician costs of implementation ranged from $500 to $3,500, with overall ongoing costs ranging from $100 to $6,000. A fiscal analysis of three EBTs revealed hidden costs ranging from $5,000 to $24,000 per clinician, potentially limiting sustainability. CONCLUSIONS The evidence necessary for embedding EBTs in state systems has notable gaps that may hinder sustainability. Research-funding agencies should prioritize studies that focus on the practical aspects of scaling to assist states as they retrain their workforces.
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Affiliation(s)
- Kimberly Eaton Hoagwood
- Department of Child and Adolescent Psychiatry, New York University (NYU) Grossman School of Medicine, New York City (Hoagwood, Richards-Rachlin, Horwitz, Narcisse); Department of Psychology, St. John's University, New York City (Richards-Rachlin); McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work, New York City (Baier, Vilgorin, Diedrich, Cleek)
| | - Shira Richards-Rachlin
- Department of Child and Adolescent Psychiatry, New York University (NYU) Grossman School of Medicine, New York City (Hoagwood, Richards-Rachlin, Horwitz, Narcisse); Department of Psychology, St. John's University, New York City (Richards-Rachlin); McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work, New York City (Baier, Vilgorin, Diedrich, Cleek)
| | - Meaghan Baier
- Department of Child and Adolescent Psychiatry, New York University (NYU) Grossman School of Medicine, New York City (Hoagwood, Richards-Rachlin, Horwitz, Narcisse); Department of Psychology, St. John's University, New York City (Richards-Rachlin); McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work, New York City (Baier, Vilgorin, Diedrich, Cleek)
| | - Boris Vilgorin
- Department of Child and Adolescent Psychiatry, New York University (NYU) Grossman School of Medicine, New York City (Hoagwood, Richards-Rachlin, Horwitz, Narcisse); Department of Psychology, St. John's University, New York City (Richards-Rachlin); McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work, New York City (Baier, Vilgorin, Diedrich, Cleek)
| | - Sarah McCue Horwitz
- Department of Child and Adolescent Psychiatry, New York University (NYU) Grossman School of Medicine, New York City (Hoagwood, Richards-Rachlin, Horwitz, Narcisse); Department of Psychology, St. John's University, New York City (Richards-Rachlin); McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work, New York City (Baier, Vilgorin, Diedrich, Cleek)
| | - Iriane Narcisse
- Department of Child and Adolescent Psychiatry, New York University (NYU) Grossman School of Medicine, New York City (Hoagwood, Richards-Rachlin, Horwitz, Narcisse); Department of Psychology, St. John's University, New York City (Richards-Rachlin); McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work, New York City (Baier, Vilgorin, Diedrich, Cleek)
| | - Nadege Diedrich
- Department of Child and Adolescent Psychiatry, New York University (NYU) Grossman School of Medicine, New York City (Hoagwood, Richards-Rachlin, Horwitz, Narcisse); Department of Psychology, St. John's University, New York City (Richards-Rachlin); McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work, New York City (Baier, Vilgorin, Diedrich, Cleek)
| | - Andrew Cleek
- Department of Child and Adolescent Psychiatry, New York University (NYU) Grossman School of Medicine, New York City (Hoagwood, Richards-Rachlin, Horwitz, Narcisse); Department of Psychology, St. John's University, New York City (Richards-Rachlin); McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work, New York City (Baier, Vilgorin, Diedrich, Cleek)
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Joyce M, Kells M, Flynn D, Wall S, Boylan E, Dunne L. Dialectical behaviour therapy: effect of a coordinated implementation approach on programme sustainability. Ir J Psychol Med 2024:1-4. [PMID: 38647028 DOI: 10.1017/ipm.2024.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Sustainability of DBT programmes and the factors which potentially influence this has received little attention from researchers. In this article, we review the literature reporting on sustainability of DBT programmes in outpatient settings. We also seek to advance the limited knowledge on this topic by reporting on the sustainability of DBT programmes delivered by teams that trained via a coordinated implementation approach in Ireland. As part of this perspective piece we conducted a systematic literature search which identified four studies reporting on DBT programme sustainability. All four reported on programmes delivered by teams that had received training as per the DBT Intensive Training Model. The findings of these studies are summarised and we consider the effect on DBT programme sustainability of introducing a coordinated implementation approach in Ireland.
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Affiliation(s)
- M Joyce
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - M Kells
- Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, Inniscarraig House, Cork, Ireland
| | - D Flynn
- Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, St. Finbarr's Hospital, Cork, Ireland
| | - S Wall
- National DBT Office Ireland, Inniscarraig House, Cork, Ireland
| | - E Boylan
- National DBT Office Ireland, Inniscarraig House, Cork, Ireland
| | - L Dunne
- National DBT Office Ireland, Inniscarraig House, Cork, Ireland
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Villalongo Andino M, Garcia KM, Richey JA. Can dialectical behavior therapy skills group treat social anxiety disorder? A brief integrative review. Front Psychol 2024; 14:1331200. [PMID: 38259541 PMCID: PMC10800915 DOI: 10.3389/fpsyg.2023.1331200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/04/2023] [Indexed: 01/24/2024] Open
Abstract
The purposes of this brief integrative review are to identify and critically evaluate recent work in the area of Dialectical Behavior Therapy-Skills Group (DBT-SG) for Social Anxiety Disorder (SAD) with suicidal ideation (SI) and to suggest further how DBT-based skills may be applied to cognitive maintenance factors of SAD. Accordingly, we first evaluate the relevance of DBT in treating SI in other disorders. Second, we evaluate the relationship between SI and SAD, providing considerations for the complexity of comorbid disorders and presentations. Finally, we extend this knowledge to discuss considerations for the use of DBT-SG skills to target specific etiological and maintenance elements of SAD, with a focus on four themes (interpersonal effectiveness, mindfulness, emotion regulation, and distress tolerance). Overall, we conclude that DBT-SG may prove beneficial in reducing SI and symptoms in SAD that impact social and emotional functioning.
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Conroy K, Kehrer SM, Georgiadis C, Hare M, Ringle VM, Shaw AM. Learning from Adolescents and Caregivers to Enhance Acceptability and Engagement Within Virtual Dialectical Behavior Therapy for Adolescents Skills Groups: A Qualitative Study. Child Psychiatry Hum Dev 2024:10.1007/s10578-023-01641-7. [PMID: 38183575 DOI: 10.1007/s10578-023-01641-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 01/08/2024]
Abstract
Despite the significant increase in adolescent mental health challenges in recent years, structural barriers continue to limit access to and engagement in mental health services. As such, opportunities to learn directly from adolescents and their families on how to best structure and deliver services are paramount. The current study assumes a multi-informant approach and reports on adolescents' and caregivers' (N = 33) experiences in an adapted telehealth/hybrid Dialectical Behavior Therapy for Adolescents (DBT-A) program. Focus groups were conducted across two cohorts of families who participated in DBT-A skills groups, to collect family-centered data on the acceptability of program modifications, engagement in the adapted telehealth/hybrid DBT-A, and recommendations for improvement. Participants were predominately Latine White and were from a broad range of socioeconomic backgrounds. Additionally, 45.5% of the adolescents identified as LGBTQ + . Focus group findings emphasized how the telehealth platform was both convenient and disengaging, and how in-person sessions offered improved group connection and content engagement. Participants underscored the importance of balancing multi-family group sessions with adolescent- and caregiver-only group sessions in the program, and adolescents emphasized a need for the DBT-A program to better center adolescents' unique experiences and voices throughout sessions. Both adolescents and caregivers suggested modifications to synthesize the content and improve generalizability of the DBT-A skills to their real lives. Overall, these findings add to a new and evolving branch of DBT-A qualitative inquiry, as well as the growing body of work that recommends incorporating the voices of people with lived experiences into the development and modification of psychological services.
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Affiliation(s)
- Kristina Conroy
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL, USA.
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
| | - Sabrina M Kehrer
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL, USA
| | - Christopher Georgiadis
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL, USA
- The Warren Alpert Medical School, Department of Psychiatry, Brown University, Providence, RI, USA
| | - Megan Hare
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Vanesa Mora Ringle
- Counseling Psychology Program, Department of Education and Human Services, Lehigh University, Bethlehem, PA, USA
| | - Ashley M Shaw
- School of Social and Behavioral Sciences, University of New England, Biddeford, ME, USA
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Durpoix A, Lachaux E, Weiner L, Weibel S. Transdiagnostic skills training group of dialectical behavior therapy: a long-term naturalistic study. Borderline Personal Disord Emot Dysregul 2023; 10:37. [PMID: 38124187 PMCID: PMC10734074 DOI: 10.1186/s40479-023-00243-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Dialectical Behavior Therapy (DBT) has assembled a large body of evidence for the treatment of emotional dysregulation in borderline personality disorder (BPD), but also in other disorders characterized by emotional dysregulation (e.g., bipolar disorder (BD) and ADHD). Standalone skills learning groups address the problem of limited resources in several clinical settings. Furthermore, transdiagnostic skills groups facilitate the recruitment and decrease the scattering of resources in psychiatric settings. However, few studies have focused on the pertinence of transdiagnostic standalone skills groups in naturalistic settings as well as their long-term outcomes. The goal of this study is to assess the impact of participation in a transdiagnostic DBT skills group one year after its completion. METHOD Transdiagnostic DBT skills training groups were provided for BPD, BD and ADHD patients in a University Psychiatric Department (Strasbourg, France), between 2019 and 2020. They consisted of 16 group sessions of 2.5 h and 3 individual sessions. At 1-year follow-up, ad-hoc questionnaires were proposed to all participants to assess the perceived impacts, the changes in symptomatology, and the maintenance of skills learned. RESULT 22 of the 31 participants were interviewed at the one-year post-group session (64% BPD, 41% ADHD and 27% BD). 73% participants estimated that group impact was important or very important, 64% stated using the skills learned often or very often, mainly emotion regulation skills. An improvement in emotional instability, substance use, impulsivity and suicidal thoughts was reported by respectively 100%, 91%, 86% and 85% of participants. Quality of life improved according to 90% participants. All patients reported an improvement in suicidality during the post-group year, especially in suicide attempts. Psychotropic medication decreased in 59% of participants. DISCUSSION Our one-year naturalistic study suggests that transdiagnostic DBT skills training groups are promising for the treatment of emotional dysregulation in people with BPD, BD and/or ADHD. The observational design and the lack of control group are the main limitations. Randomized controlled studies are required to confirm the long-term efficacy of transdiagnostic skills learning groups in naturalistic settings.
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Affiliation(s)
- Amaury Durpoix
- Psychiatry, Mental Health and Addictology Department, University Hospitals of Strasbourg, 1 place de l'Hôpital, Strasbourg, 67000, France.
- Faculty of Medicine, Strasbourg University, Strasbourg, 67000, France.
| | - Enzo Lachaux
- Psychiatry, Mental Health and Addictology Department, University Hospitals of Strasbourg, 1 place de l'Hôpital, Strasbourg, 67000, France
- Faculty of Psychology, Strasbourg University, Strasbourg, 67000, France
| | - Luisa Weiner
- Psychiatry, Mental Health and Addictology Department, University Hospitals of Strasbourg, 1 place de l'Hôpital, Strasbourg, 67000, France
- Faculty of Psychology, Strasbourg University, Strasbourg, 67000, France
- Laboratoire de Psychologie des Cognitions, Strasbourg University, Strasbourg, 67000, France
| | - Sébastien Weibel
- Psychiatry, Mental Health and Addictology Department, University Hospitals of Strasbourg, 1 place de l'Hôpital, Strasbourg, 67000, France
- Inserm u1114, Strasbourg, 67000, France
- Faculty of Medicine, Strasbourg University, Strasbourg, 67000, France
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Harned MS, Schmidt SC, Korslund KE, Gallop RJ. Development and Evaluation of a Pragmatic Measure of Adherence to Dialectical Behavior Therapy: The DBT Adherence Checklist for Individual Therapy. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:734-749. [PMID: 37284966 PMCID: PMC10246542 DOI: 10.1007/s10488-023-01274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/08/2023]
Abstract
This paper presents two studies conducted to develop and evaluate a new pragmatic measure of therapist adherence to Dialectical Behavior Therapy (DBT): the DBT Adherence Checklist for Individual Therapy (DBT AC-I). Study 1 used item response analysis to select items from the gold standard DBT Adherence Coding Scale (DBT ACS) using archival data from 1271 DBT sessions. Items were then iteratively refined based on feedback from 33 target end-users to ensure relevance, usability, and understandability. Study 2 examined the psychometric properties of the DBT AC-I as a therapist self-report and observer-rated measure in 100 sessions from 50 therapist-client dyads, while also evaluating predictors of therapist accuracy in self-rated adherence. When used as a therapist self-report measure, concordance between therapist and observer ratings was at least moderate (AC1 ≥ 0.41) for all DBT AC-I items but overall concordance (ICC = 0.09) as well as convergent (r = 0.05) and criterion validity (AUC = 0.54) with the DBT ACS were poor. Higher therapist accuracy was predicted by greater DBT knowledge and adherence as well as more severe client suicidal ideation. When used by trained observers, the DBT AC-I had excellent interrater reliability (ICC = 0.93), convergent validity (r = 0.90), and criterion validity (AUC = 0.94). While therapists' self-rated adherence on the DBT AC-I should not be assumed to reflect their actual adherence, some therapists may self-rate accurately. The DBT AC-I offers an effective and relatively efficient method of evaluating adherence to DBT when used by trained observers.
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Affiliation(s)
- Melanie S Harned
- VA Puget Sound Health Care System, 1660 South Columbian Way, Mailstop S-116-MHC, Seattle, WA, 98108, USA.
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, USA.
- Department of Psychology, University of Washington, Seattle, WA, USA.
| | - Sara C Schmidt
- VA Puget Sound Health Care System, 1660 South Columbian Way, Mailstop S-116-MHC, Seattle, WA, 98108, USA
| | | | - Robert J Gallop
- Department of Mathematics, West Chester University, West Chester, PA, USA
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A Feasibility Study Investigating Mechanisms of Change in Public Mental Health Dialectical Behaviour Therapy Programmes. BEHAVIOUR CHANGE 2023. [DOI: 10.1017/bec.2023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Abstract
Few studies have investigated the feasibility of researching brief forms of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in public mental health settings. This study aimed to provide preliminary evidence for the feasibility of implementing DBT over a 6-month period for BPD symptoms within Australian public mental health services. Of the 79 participants with BPD recruited, 62 commenced and 24 participants completed the therapy. The participants attended one of three outpatient DBT programmes and completed measures of BPD symptoms, DBT skills-use, and difficulties with emotion regulation at baseline and after 6 months of treatment. A major challenge with feasibility identified was the high attrition rate (61%). However, for completers there were significant improvements in BPD symptoms, DBT skills-use, and difficulties with emotion regulation. These effect sizes were used to estimate the sample sizes needed by future larger trials of brief DBT for BPD in public health settings. The implementation of brief DBT for BPD patients within a public mental health outpatient setting, appears to result in significant reductions in BPD symptoms. However, further exploration of strategies to reduce drop-out rates are required.
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Bender AM, Wilson RLH, Borntrager L, Orlowski EW, Gryglewicz K, Karver MS. Evaluating Dialectical Behavior Therapy Training With Mental Health Clinicians. J Pers Disord 2023; 37:95-111. [PMID: 36723420 DOI: 10.1521/pedi.2023.37.1.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A substantial body of research supports dialectical behavior therapy (DBT) as an evidence-based treatment for those with borderline personality disorder (BPD); however, there remains a lack of mental health clinicians trained in this modality, resulting in limited clinician competencies and skills. Furthermore, the effectiveness of DBT trainings with mental health clinicians remains understudied. The present study evaluated a comprehensive 5-day DBT-Linehan Board of Certification training program. Informed by the Theory of Planned Behavior, this study assessed changes in clinician knowledge, attitudes, perceived behavioral control (PBC), intentions, and behaviors relevant to DBT at baseline, posttraining, and 6-month follow-up. Results showed large, significant pre-to-post training improvements in clinicians' knowledge, attitudes, PBC, and intentions related to DBT implementation. Large improvements in knowledge, attitudes, and PBC were sustained at follow-up. A significant improvement in actual behaviors was also found at follow-up. Implications of the present study and directions for future research are discussed.
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Affiliation(s)
- Ansley M Bender
- Department of Psychology, University of South Florida, Tampa, Florida
| | - Ronan L H Wilson
- Department of Psychology, University of South Florida, Tampa, Florida
| | - Lisa Borntrager
- School of Social Work, University of Central Florida, Orlando, Florida
| | - Edmund W Orlowski
- Department of Psychology, University at Albany, SUNY, Albany, New York
| | - Kim Gryglewicz
- School of Social Work, University of Central Florida, Orlando, Florida
| | - Marc S Karver
- Department of Psychology, University of South Florida, Tampa, Florida
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Chanen AM, Nicol K. Five Failures and Five Challenges for Prevention and Early Intervention for Personality Disorder. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2022; 20:434-438. [PMID: 37200880 PMCID: PMC10187394 DOI: 10.1176/appi.focus.22020016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services. Reprinted from Curr Opin Psychol 2021; 37:134-138, with permission from Elsevier. Copyright © 2021.
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Affiliation(s)
- Andrew M Chanen
- Orygen, Melbourne, Australia, and Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Katie Nicol
- Orygen, Melbourne, Australia, and Centre for Youth Mental Health, The University of Melbourne, Australia
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Poon JA, Galione JN, Grocott LR, Horowitz KJ, Kudinova AY, Kim KL. Dialectical behavior therapy for adolescents (DBT-A): Outcomes among sexual minorities at high risk for suicide. Suicide Life Threat Behav 2022; 52:383-391. [PMID: 35019159 PMCID: PMC9233065 DOI: 10.1111/sltb.12828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/27/2021] [Accepted: 01/02/2022] [Indexed: 11/29/2022]
Abstract
The alarming rates and pervasiveness of suicidal and self-destructive behaviors (e.g., non-suicidal self-injury) among young sexual minorities represent a major public health concern. We set out to examine whether an empirically driven treatment for suicide and self-harm, dialectical behavior therapy for adolescents (DBT-A), provides benefits for adolescents who identify as gay, lesbian, bisexual, or questioning (LGBQ). LGBQ adolescents (n = 16) were compared with non-LGBQ peers (n = 23). Psychological measures were collected before and after participation in a comprehensive DBT-A program. LGBQ participants demonstrated significant improvements in emotion regulation, depression, borderline symptoms, and coping strategies; changes were comparable to their heterosexual peers.
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Affiliation(s)
- Jennifer A. Poon
- Department of Psychiatry and Human Behavior, Emma Pendleton Bradley Hospital/Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Janine N. Galione
- Department of Psychiatry and Human Behavior, Rhode Island Hospital/Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lauren R. Grocott
- Department of Psychology, University of Wisconsin – Milwaukee, Milwaukee, Wisconsin, USA
| | - Karyn J. Horowitz
- Department of Psychiatry and Human Behavior, Emma Pendleton Bradley Hospital/Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Anastacia Y. Kudinova
- Department of Psychiatry and Human Behavior, Emma Pendleton Bradley Hospital/Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Kerri L. Kim
- Department of Psychiatry and Human Behavior, Emma Pendleton Bradley Hospital/Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Phalen P, Grossmann J, Bruder T, Jeong JY, Calmes C, McGrath K, Malouf E, James A, Romero E, Bennett M. Description of a Dialectical Behavior Therapy program in a Veterans Affairs Health Care System. EVALUATION AND PROGRAM PLANNING 2022; 92:102098. [PMID: 35525095 DOI: 10.1016/j.evalprogplan.2022.102098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/30/2021] [Accepted: 04/17/2022] [Indexed: 06/14/2023]
Abstract
A comprehensive Dialectical Behavior Therapy (DBT) program was created within a VA Health Care System for patients with recent psychiatric hospitalization, suicidality and/or significant emotion dysregulation. The program was notable for being one of a relatively small number of comprehensive DBT programs in the VA system, and for including patients with psychosis and psychotic disorder, with a majority of patients (58%) having a documented history of psychosis or endorsing psychotic symptoms in assessments. We describe the process of creating this program at a VA medical center and present preliminary program evaluation data. All patients completed assessments of suicidality (C-SSRS), emotion dysregulation (DERS), skills use and dysfunctional coping (DBT-WCCL), borderline symptomatology (BSL-23), and depression (PHQ-9) at program entry and subsequently every 6-8 weeks through program completion. Suicide attempts and hospitalizations were also tracked. Twelve patients completed multiple (up to six) assessment timepoints, allowing for evaluation of change during treatment. Patients demonstrated improvements on most measures and no hospitalizations or suicide attempts during active treatment, and the subsample with psychosis showed average improvements on every outcome measure. Eleven of 12 patients completed a full six-month rotation.
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Affiliation(s)
- Peter Phalen
- VA Maryland Health Care System, United States; University of Maryland School of Medicine, United States.
| | | | | | - Jae Yeon Jeong
- VA Maryland Health Care System, United States; University of Maryland School of Medicine, United States
| | | | | | | | | | - Erin Romero
- VA Maryland Health Care System, United States; University of Maryland School of Medicine, United States
| | - Melanie Bennett
- VA Maryland Health Care System, United States; University of Maryland School of Medicine, United States
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Troup J, Lever Taylor B, Sheridan Rains L, Broeckelmann E, Russell J, Jeynes T, Cooper C, Steare T, Dedat Z, McNicholas S, Oram S, Dale O, Johnson S. Clinician perspectives on what constitutes good practice in community services for people with complex emotional needs: A qualitative thematic meta-synthesis. PLoS One 2022; 17:e0267787. [PMID: 35511900 PMCID: PMC9070883 DOI: 10.1371/journal.pone.0267787] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/15/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood. AIM To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN. METHODS Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies. RESULTS Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate. DISCUSSION Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support.
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Affiliation(s)
- Jordan Troup
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, England
| | | | - Luke Sheridan Rains
- Division of Psychiatry, NIHR Mental Health Policy Research Unit, University College London, London, England
- * E-mail:
| | - Eva Broeckelmann
- Health Service and Population Research Department, NIHR Mental Health Policy Research Unit Complex Emotional Needs Lived Experience Working Group, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, England
| | - Jessica Russell
- Health Service and Population Research Department, NIHR Mental Health Policy Research Unit Complex Emotional Needs Lived Experience Working Group, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, England
| | - Tamar Jeynes
- Health Service and Population Research Department, NIHR Mental Health Policy Research Unit Complex Emotional Needs Lived Experience Working Group, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, England
| | - Chris Cooper
- Department of Clinical, Educational and Health Psychology, University College London, London, England
| | - Thomas Steare
- Division of Psychiatry, NIHR Mental Health Policy Research Unit, University College London, London, England
| | - Zainab Dedat
- Division of Psychiatry, NIHR Mental Health Policy Research Unit, University College London, London, England
| | | | - Sian Oram
- Health Service and Population Research Department, NIHR Mental Health Policy Research Unit, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, England
| | - Oliver Dale
- West London Mental Health Trust, London, England
| | - Sonia Johnson
- Division of Psychiatry, NIHR Mental Health Policy Research Unit, University College London, London, England
- Camden and Islington NHS Foundation Trust, London, England
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Grant JE, Valle S, Chesivoir E, Ehsan D, Chamberlain SR. A double-blind placebo-controlled study of brexpiprazole for the treatment of borderline personality disorder. Br J Psychiatry 2021; 220:1-6. [PMID: 35049469 PMCID: PMC7612273 DOI: 10.1192/bjp.2021.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Borderline personality disorder is associated with impaired quality of life and has a number of untoward public health associations. There is no established first-line pharmacological treatment for borderline personality disorder, and available options are not suitable for all individuals. AIMS To evaluate brexpiprazole, which has effects on the dopaminergic and serotonergic systems, for the reduction of borderline personality disorder symptoms. METHOD Eighty adults with borderline personality disorder were recruited for a randomised, double-blind placebo-controlled study. Participants received 12-week treatment with brexpiprazole (1 mg/day for 1 week, then increasing to 2 mg/day) or placebo in a parallel design. The primary efficacy outcome measure was the clinician-rated Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). Safety data were collected. Effects of active versus placebo treatment were characterised with linear repeated measures models. RESULTS There was a significant interaction between treatment and time on the ZAN-BPD scale (P = 0.0031), solely because of differentiation specifically at week 12. Brexpiprazole was generally well tolerated. Secondary measures did not result in statistically significant differences from placebo. CONCLUSIONS Brexpiprazole appears to have some possible effect on borderline personality disorder symptoms, but further studies are needed because of the significant effects evident, specifically at the final time point. These findings also need to be viewed cautiously, given the small sample size, large drop-out rate and robust placebo response.
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Affiliation(s)
- Jon E. Grant
- University of Chicago, Department of Psychiatry and Behavioral Neuroscience, Chicago, IL USA
| | - Stephanie Valle
- University of Chicago, Department of Psychiatry and Behavioral Neuroscience, Chicago, IL USA
| | - Eve Chesivoir
- University of Chicago, Department of Psychiatry and Behavioral Neuroscience, Chicago, IL USA
| | - Dustin Ehsan
- University of Chicago, Department of Psychiatry and Behavioral Neuroscience, Chicago, IL USA
| | - Samuel R. Chamberlain
- Department of Psychiatry, Faculty of Medicine, University of Southampton, USA; and Southern Health NHS Foundation Trust, Southampton, USA
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Ruork AK, Yin Q, Fruzzetti AE. Phone consultation and burnout among providers of dialectical behaviour therapy. Clin Psychol Psychother 2021; 29:744-753. [PMID: 34490677 DOI: 10.1002/cpp.2668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/17/2021] [Accepted: 08/31/2021] [Indexed: 11/10/2022]
Abstract
Adherent dialectical behaviour therapy (DBT) includes between-session phone consultation to help clients generalize skills, solve problems during crises, and repair relationships. Despite benefits of phone consultation, it is frequently not implemented in outpatient settings. The perceived burden phone consultation places on providers is one of the most frequently cited reasons for its omission. The current study examined phone consultation in relation to providers' burnout using a cross-sectional design. We hypothesized that (1) DBT experience and support from peer consultation team members, including perceived team efficacy and shared coaching responsibilities, would be associated with lower rates of burnout and (2) higher numbers of crisis contacts and "other" contacts, but not noncrisis skills generalization contacts, would be associated with increased burnout. Participants were 65 DBT therapists who completed an anonymous survey online. Results suggest that both having more effective consultation teams and sharing phone consultation among team members were associated with decreased burnout. Additionally, more crisis contacts were found to be associated with higher burnout, whereas higher number of skills generalization calls was not. This study represents an important first step towards evaluating the impact of phone consultation on providers and highlights the importance of effective peer consultation in reducing therapist burnout.
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Affiliation(s)
- Allison K Ruork
- Department of Clinical Psychology, University of Nevada, Reno, Reno, Nevada, USA.,Graduate School of Applied and Professional Psychology, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Qingqing Yin
- Department of Psychology, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Alan E Fruzzetti
- Department of Clinical Psychology, University of Nevada, Reno, Reno, Nevada, USA.,Department of Psychiatry, McLean Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Tebbett-Mock AA, McGee M, Saito E. Efficacy and sustainability of dialectical behaviour therapy for inpatient adolescents: a follow-up study. Gen Psychiatr 2021; 34:e100452. [PMID: 34423253 PMCID: PMC8327801 DOI: 10.1136/gpsych-2020-100452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 06/30/2021] [Indexed: 11/04/2022] Open
Abstract
Background Dialectical behaviour therapy (DBT) is an evidence-based treatment for adolescents targeting suicidal and non-suicidal self-injurious behaviours. Research supports DBT's efficacy in inpatient settings, but implementation and sustainability are understudied. Aims This study is a follow-up of a previous study by Tebbett-Mock et al and examines the efficacy and sustainability of an adolescent DBT inpatient unit within a psychiatric hospital in the Northeast. We hypothesised that adolescents who received DBT in our follow-up group (DBT Group 2) would not have statistical difference (ie, greater or fewer) of the following compared with the first group of patients who received DBT on the unit the year prior (DBT Group 1) and would have significantly fewer of the following compared with the treatment as usual (TAU) group: (1) constant observation hours for suicidal ideation, self-injury and aggression; (2) incidents of suicide attempts, self-injury and aggression; (3) restraints; (4) seclusions; (5) days hospitalised; (6) times readmitted to the unit within 30 days of discharge. Methods We conducted a retrospective chart review for adolescents receiving inpatient DBT (DBT Group 1, n=425; DBT Group 2, n=393) and a historical control group (TAU, n=376). The χ2 tests and one-way analysis of variance were conducted as preliminary analyses to examine group differences on diagnosis, gender and age. Kruskal-Wallis H tests were conducted to examine group differences on outcomes. Mann-Whitney U tests were used as post hoc analyses. Results Patients in DBT Group 2 were comparable to DBT Group 1 for the number of constant observation hours for self-injury (U=83 432.50, p=0.901), restraints (U=82 109, p=0.171) and days hospitalised (U=83 438.5, p=0.956). Patients in DBT Group 2 had a significantly greater number of incidents of suicide attempts compared with DBT Group 1 (U=82 662.5, p=0.037) and of self-injury compared with patients in DBT Group 1 (U=71724.5, p<0.001) and TAU (U=65649.0, p<0.001). Conclusions Results provide support for adolescent inpatient DBT compared with TAU and highlight staff turnover and lack of training as potential barriers to sustainability and efficacy.
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Affiliation(s)
| | - Madeline McGee
- Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
| | - Ema Saito
- Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
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Flynn D, Kells M, Joyce M. Dialectical behaviour therapy: Implementation of an evidence-based intervention for borderline personality disorder in public health systems. Curr Opin Psychol 2021; 37:152-157. [PMID: 33588325 DOI: 10.1016/j.copsyc.2021.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/07/2020] [Accepted: 01/02/2021] [Indexed: 11/16/2022]
Abstract
Dialectical behaviour therapy (DBT) is an intervention with demonstrated efficacy and effectiveness for individuals with borderline personality disorder. In recent years, research has shifted focus to the evaluation of DBT implementation in routine clinical settings. In this article, we consider the empirical evidence that guides clinicians and managers in health services with local implementation of DBT in community settings. Research on this topic has most recently advanced to the evaluation of coordinated implementation efforts. Although coordinated implementation has merit, it does not mitigate all implementation challenges. Consideration of implementation facilitators and barriers in DBT can also be applied to other evidence-based interventions for BPD and for adaptations for individuals with early-stage symptomatology. Ongoing research and evaluation in these areas is recommended.
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Affiliation(s)
- Daniel Flynn
- Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, St. Finbarr's Hospital, Cork, Ireland.
| | - Mary Kells
- Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, Inniscarraig House, Western Road, Cork, Ireland.
| | - Mary Joyce
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland.
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Landes SJ, Matthieu MM, Smith BN, McBain SA, Ray ES. Challenges and Potential Solutions to Implementing Phone Coaching in Dialectical Behavior Therapy. COGNITIVE AND BEHAVIORAL PRACTICE 2021. [DOI: 10.1016/j.cbpra.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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19
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Chanen AM, Nicol K. Five failures and five challenges for prevention and early intervention for personality disorder. Curr Opin Psychol 2021; 37:134-138. [PMID: 33513519 DOI: 10.1016/j.copsyc.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/14/2020] [Indexed: 02/09/2023]
Abstract
Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services.
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Affiliation(s)
- Andrew M Chanen
- Orygen, Melbourne, Australia; Centre for Youth Mental Health, The University of Melbourne, Australia.
| | - Katie Nicol
- Orygen, Melbourne, Australia; Centre for Youth Mental Health, The University of Melbourne, Australia
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Emelianchik-Key K, Labarta A, Glass B. Infusing Dialectical Behavior Therapy Skills into Supervision to Address Challenges and Enhance Performance. JOURNAL OF CREATIVITY IN MENTAL HEALTH 2021. [DOI: 10.1080/15401383.2020.1870599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Bridget Glass
- Florida Atlantic University, Boca Raton, Florida, USA
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21
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Friesen L, Gaine G, Klaver E, Klingle K, Parmar D, Hrabok M, Kelland J, Surood S, Agyapong V. Bridging the Gap in Community Care for Patients With Borderline Personality Disorder: Protocol for Qualitative Inquiry Into Patient, Caregiver, and Clinician Perspectives on Service Gaps and Potential Solutions for Severe Emotion Dysregulation. JMIR Res Protoc 2020; 9:e14885. [PMID: 32815818 PMCID: PMC7471890 DOI: 10.2196/14885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 02/28/2020] [Accepted: 03/22/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Borderline personality disorder (BPD) is characterized by severe emotion dysregulation that is often complicated by comorbid diagnoses, deliberate self-harm, and chronic suicidal ideation. Unfortunately, current care pathways for individuals with BPD are strained by limited resources, inadequate training, and an overuse of emergency departments and crisis teams. Such barriers result in delayed access to effective treatment, which increases risk of deterioration, disability, and morbidity. A first step toward addressing these limitations of the current care pathway is to understand key stakeholders' lived experiences in this pathway and their perspectives on potential solutions. OBJECTIVE The purpose of this paper is to present a protocol for a study that explores the lived experiences of the current care pathway from the perspectives of patients with BPD, as well as their caregivers and clinicians. METHODS A qualitative approach is most appropriate for the exploratory nature of the research objective. Accordingly, 3 to 6 patients with a diagnosis of BPD, 3 caregivers of individuals with BPD, and 3 clinicians of patients diagnosed with BPD will be invited to participate in individual, semistructured interviews that focus on service experiences. RESULTS It is anticipated that results will yield insight into the lived experiences of patients with BPD, caregivers, and clinicians and provide a better understanding of the perceived gaps in services and potential solutions. Results are expected to be available in 12 months. CONCLUSIONS This paper describes a protocol for a qualitative study that seeks to understand the lived experiences and perspectives of key stakeholders (patients, caregivers, and clinicians) on the current care pathway for BPD. Results will provide a basis for future research in this area and will have the potential to inform training, practice, and policy. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/14885.
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Affiliation(s)
- Laura Friesen
- Department of Educational Psychology, University of Alberta, Edmonton, AB, Canada
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Graham Gaine
- Department of Educational Psychology, University of Alberta, Edmonton, AB, Canada
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ellen Klaver
- Department of Educational Psychology, University of Alberta, Edmonton, AB, Canada
| | - Kirsten Klingle
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Devashree Parmar
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Marianne Hrabok
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jill Kelland
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Shireen Surood
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Vincent Agyapong
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
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Larsen CA, McKay AK, Van Steinburg PJ. Creating a Flexible Outpatient Mental Health Transitions Program. Issues Ment Health Nurs 2020; 41:500-505. [PMID: 32275459 DOI: 10.1080/01612840.2019.1681566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Limited resources to support persons with mental illness create a crisis in our health care system. There is a shortage of inpatient beds, and emergency departments are overwhelmed by the number of persons experiencing a mental illness crisis. This article describes the design of a program to address the gaps in treatment. The goal of the program was to decrease the length of stay for inpatient mental health care and to divert emergency department patients. We describe the multidisciplinary brainstorming session that envisioned this program, how it differs from previous programs, the staffing model, curriculum, outcomes, and future plans.
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Affiliation(s)
- Clare A Larsen
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Ann K McKay
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
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Flynn D, Kells M, Joyce M, Corcoran P, Hurley J, Gillespie C, Suarez C, Swales M, Arensman E. Multisite Implementation and Evaluation of 12-Month Standard Dialectical Behavior Therapy in a Public Community Setting. J Pers Disord 2020; 34:377-393. [PMID: 30307826 DOI: 10.1521/pedi_2018_32_402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Dialectical behavior therapy (DBT) is an effective intervention for treating adults with emotional and behavioral dysregulation. The National DBT Project, Ireland was established in 2013 to coordinate the implementation of DBT across public community mental health settings at a national level. This study describes the implementation and evaluation of DBT across multiple independent sites in adult mental health services (AMHS). The Consolidated Framework for Implementation Research was used to guide this national implementation where barriers and facilitators to DBT implementation were considered. Nine AMHS teams completed DBT training and delivered the standard 12-month program. One hundred and ninety-six adults with borderline personality disorder participated in the program, and outcome measures were recorded at four time points. Significant reductions on outcome measures, including frequency of self-harm and suicidal ideation, were observed. This study highlights that DBT can be successfully implemented in community mental health settings as part of a coordinated implementation.
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Affiliation(s)
- Daniel Flynn
- Cork Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, St Finbarr's Hospital, Cork, Ireland
| | - Mary Kells
- Cork Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, Inniscarraig House, Cork, Ireland
| | - Mary Joyce
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Paul Corcoran
- School of Public Health, University College Cork, Cork, Ireland
| | - Justina Hurley
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Conall Gillespie
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Catalina Suarez
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Michaela Swales
- Betsi Cadwaladr University Health Board and North Wales Clinical Psychology Programme, School of Psychology, Bangor, Wales
| | - Ella Arensman
- School of Public Health, University College Cork, Cork, Ireland
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Flynn D, Joyce M, Gillespie C, Kells M, Swales M, Spillane A, Hurley J, Hayes A, Gallagher E, Arensman E, Weihrauch M. Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: a mixed methods approach. BMC Psychiatry 2020; 20:235. [PMID: 32410670 PMCID: PMC7227064 DOI: 10.1186/s12888-020-02610-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 04/19/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., Implementation Sci. 4:50, 2009) provided structural guidance for this national level coordinated implementation. METHODS A mixed methods approach was utilised to explore the national multisite implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders (n = 8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists (n = 74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis. RESULTS Five themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management. CONCLUSIONS The barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework (Toms et al., Borderline Personal Disord Emot Dysregul. 6: 2, 2019). Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 'retrospectively registered'.
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Affiliation(s)
- Daniel Flynn
- Cork Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, St Finbarr's Hospital, Cork, Ireland
| | - Mary Joyce
- National Suicide Research Foundation, University College Cork, Western Gateway Building, Cork, Ireland.
| | - Conall Gillespie
- National Suicide Research Foundation, University College Cork, Western Gateway Building, Cork, Ireland
| | - Mary Kells
- Cork Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, Inniscarraig House, Western Road, Cork, Ireland
| | - Michaela Swales
- Betsi Cadwaladr University Health Board & North Wales Clinical Psychology Programme, School of Psychology, Bangor University, Bangor, Wales
| | - Ailbhe Spillane
- National Suicide Research Foundation, University College Cork, Western Gateway Building, Cork, Ireland
| | - Justina Hurley
- National Suicide Research Foundation, University College Cork, Western Gateway Building, Cork, Ireland
| | - Aoife Hayes
- National Suicide Research Foundation, University College Cork, Western Gateway Building, Cork, Ireland
| | - Edel Gallagher
- National Suicide Research Foundation, University College Cork, Western Gateway Building, Cork, Ireland
| | - Ella Arensman
- National Suicide Research Foundation and School of Public Health, University College Cork, Western Gateway Building, Cork, Ireland
| | - Mareike Weihrauch
- National Suicide Research Foundation, University College Cork, Western Gateway Building, Cork, Ireland
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Implementing Dialectical Behavior Therapy Skills Training With at-Risk Male Youth in a Military-Style Residential Program. COGNITIVE AND BEHAVIORAL PRACTICE 2020. [DOI: 10.1016/j.cbpra.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Stratton N, Mendoza Alvarez M, Labrish C, Barnhart R, McMain S. Predictors of Dropout From a 20-Week Dialectical Behavior Therapy Skills Group for Suicidal Behaviors and Borderline Personality Disorder. J Pers Disord 2020; 34:216-230. [PMID: 30179573 DOI: 10.1521/pedi_2018_32_391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Treatment dropout among individuals with borderline personality disorder (BPD) is associated with negative psychosocial outcomes. Identifying predictors of dropout among this population is critical to understanding how to improve treatment retention. The present study extends the current literature by examining both static and dynamic predictors of dropout. Chronically suicidal outpatients diagnosed with BPD (N = 42) were randomly assigned to a 20-week dialectical behavior therapy (DBT) skills training group. Static and dynamic predictors were assessed at baseline, 5, 10, 15, 20 weeks, and 3 months post-intervention. A post-hoc two-stage logistic regression analysis was conducted to predict dropout propensity. Receiving disability benefits at baseline and decreases in mindfulness were associated with significantly increased probability of dropout. Clinicians working with chronically self-harming outpatients diagnosed with BPD would benefit from prioritizing clinical interventions that enhance mindfulness in order to decrease dropout propensity.
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Affiliation(s)
- Natalie Stratton
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | | | | | | | - Shelley McMain
- Centre for Addiction and Mental Health, Toronto.,Department of Psychiatry, University of Toronto
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27
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Lyng J, Swales MA, Hastings RP, Millar T, Duffy DJ, Booth R. Standalone DBT Group Skills Training Versus Standard (i.e. All Modes) DBT for Borderline Personality Disorder: A Natural Quasi-experiment in Routine Clinical Practice. Community Ment Health J 2020; 56:238-250. [PMID: 31673877 DOI: 10.1007/s10597-019-00485-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/25/2019] [Indexed: 11/26/2022]
Abstract
We describe a naturally occurring, real-world comparison of outcomes following 6 months in standalone DBT skills training group for adults with Borderline Personality Disorder (BPD) without recent suicidal or severe self-harming behaviours and standard (i.e. all modes) DBT for BPD including patients with recent high-risk behaviours. 34 patients chose standalone skills over waiting for standard DBT and 54 were offered standard DBT. Dropout was higher for standalone skills than standard DBT (38.2% vs. 16.7%). No statistically or clinically significant differences were found among completers between conditions on borderline symptoms, general psychopathology, and suicide ideation. There was a moderate effect for standalone skills on hopelessness and emotion regulation difficulties which may have reflected non-equivalence of treatment groups. Significant methodological factors limit generalisability of findings which offer support for feasibility of standalone DBT skills as an effective alternative to waitlist for standard DBT for at least some patients with BPD in the community.
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Affiliation(s)
- Jim Lyng
- Department of Psychology, Cluain Mhuire Community Mental Health Services, Blackrock, Co. Dublin, Ireland.
- School of Psychology, Bangor University, Adeilad Brigantia, Bangor, Gwynedd, LL57 2AS, UK.
| | - Michaela A Swales
- School of Psychology, Bangor University, Adeilad Brigantia, Bangor, Gwynedd, LL57 2AS, UK
| | - Richard P Hastings
- Centre for Educational Development, Appraisal and Research, University of Warwick, Coventry, West Midlands, CV4 7AL, UK
| | - Tracy Millar
- South Eastern Health and Social Care Trust, Dundonald, BT16 1RH, UK
| | - Daniel J Duffy
- Department of Psychology, Cluain Mhuire Community Mental Health Services, Blackrock, Co. Dublin, Ireland
| | - Richard Booth
- Department of Psychology, St Patrick's University Hospital, Dublin, D08 K7YW, Ireland
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28
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Doorn KAV, Kamsteeg C, Portier K, Chitre G. A Dialectical Behavior Therapy Skills Group in a Psychoanalytic Community Service: A Pilot Study. J Cogn Psychother 2020; 34:21-46. [PMID: 32701474 DOI: 10.1891/0889-8391.34.1.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This exploratory study reports on the implementation and effectiveness of a 20-week Dialectical Behavior Therapy (DBT) skills group provided to 8 outpatients (7 women, average age 33 years old) within a psychoanalytic community clinic. We report on the practical implementation of this DBT skills group, and describe how the theoretical/technical differences between DBT and psychoanalysis were negotiated by the two co-therapists. The effectiveness of the skills group was evaluated on standardized measures of borderline personality symptoms, depression, anxiety, interpersonal problems, quality of life, and mindfulness skills that patients completed before and after treatment. At post-treatment, patients evaluated the DBT skills group on a satisfaction questionnaire and therapists completed a countertransference measure. Pre-post outcome data indicated reduced symptom levels of anxiety, depression, and improved quality of life. Both therapists reported moderate therapist responses typically associated with borderline personality disorder psychopathology. Their therapist responses were not associated with symptom levels or change but were related to patient satisfaction. Accumulative pilot studies like these add to the practice-based evidence of DBT components offered within psychoanalytically-oriented community clinics. However, given the exploratory nature of this study, strong conclusions are precluded until further effectiveness research is conducted.
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Affiliation(s)
| | | | | | - Geetali Chitre
- Access Institute for Psychological Services, San Francisco, California
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29
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Quetsch LB, Herschell AD, Kogan JN, Gavin JG, Hale G, Stein BD. Community-based behavioral health administrator perspectives on sustainability of Dialectical Behavior Therapy: a qualitative evaluation. Borderline Personal Disord Emot Dysregul 2020; 7:5. [PMID: 32161650 PMCID: PMC7047370 DOI: 10.1186/s40479-020-0120-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Substantial resources have been invested in evidence-based practice (EBP) implementation in community settings; however, research suggests that EBPs do not always sustain over time. METHOD This qualitative study explored the perspectives of 13 community behavioral health agency leaders regarding the sustainability of an EBP 25 to 28 months following the original training period. Administrators from 10 agencies were interviewed to understand the complexities of the implementation process, sustainability of Dialectical Behavior Therapy, and their recommendations to enhance implementation and sustainability. RESULTS A content analysis revealed five emergent themes: treatment model opinions, resource concerns, staff selection/ turnover, population characteristics, and recommendations for future implementation. CONCLUSIONS These themes likely would be helpful in informing the design of future implementation and sustainability initiatives sensitive to the challenges of integrating EBPs in community settings.
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Affiliation(s)
| | - Amy D Herschell
- 2Community Care Behavioral Health Organization, UPMC Insurance Services Division, Pittsburgh, USA
| | - Jane N Kogan
- 3UPMC Center for High-Value Health Care, UPMC Insurance Services Division, Pittsburgh, USA
| | - James G Gavin
- 2Community Care Behavioral Health Organization, UPMC Insurance Services Division, Pittsburgh, USA
| | | | - Bradley D Stein
- 2Community Care Behavioral Health Organization, UPMC Insurance Services Division, Pittsburgh, USA.,5RAND Corporation, Pittsburgh, USA
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30
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Carlyle D, Green R, Inder M, Porter R, Crowe M, Mulder R, Frampton C. A Randomized-Controlled Trial of Mentalization-Based Treatment Compared With Structured Case Management for Borderline Personality Disorder in a Mainstream Public Health Service. Front Psychiatry 2020; 11:561916. [PMID: 33262710 PMCID: PMC7688510 DOI: 10.3389/fpsyt.2020.561916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/20/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Treatment of borderline personality disorder (BPD) in publicly funded mental health services generally use approaches based on medical interventions and generic case management. Specific psychological therapies developed for BPD may be more effective but have rarely been evaluated in routine clinical practice. Aim: To examine the effectiveness of Mentalization Based Treatment (MBT) in adults with an established diagnosis of BPD under the care of a publicly funded Mental Health Service (MHS), on rates of non-suicidal self-harm (NSSH) and attempted suicide (SA). Methods: A randomized, controlled trial (RCT) comparing 18 months of MBT with Enhanced Therapeutic Case Management (ETCM), a form of Structured Clinical Case Management (ICTRP: ACTRN12612000951853). Participants were adults recruited from a patient population under the care of a publicly funded mental health service (MHS) with a confirmed diagnosis of BPD. The primary outcome measures were the incidence of non-suicidal self-harm or suicide attempt over 18 months of treatment. Results: 72 participants (71 females, 1 male) were randomized to MBT (n = 38) or ETCM (n = 34). Both groups showed a significant reduction in the overall incident rate of SA and NSSH. Between groups, SA rates were higher in the MBT group and conversely NSSH rates were higher in the ECTM group. Conclusions: The introduction of a structured service that delivered a structured psychotherapy (MBT) and an effective case management approach (ETCM) both resulted in a reduction in SA and NSSH. The differences in improvements found between groups within this study setting will require further research.
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Affiliation(s)
- Dave Carlyle
- Department Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Robert Green
- Canterbury District Health Board, Mental Health Services, Christchurch, New Zealand
| | - Maree Inder
- Department Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Porter
- Department Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Marie Crowe
- Department Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Roger Mulder
- Department Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Chris Frampton
- Department Psychological Medicine, University of Otago, Christchurch, New Zealand
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31
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Rojas SM, Carter SP, McGinn MM, Reger MA. A Review of Telemental Health as a Modality to Deliver Suicide-Specific Interventions for Rural Populations. Telemed J E Health 2019; 26:700-709. [PMID: 31502929 DOI: 10.1089/tmj.2019.0083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: Despite recent advancements in the development of new suicide prevention interventions, suicide rates continue to rise in the United States. As such, suicide prevention efforts must continue to focus on expanding dissemination of suicide-specific interventions. Methods: This review explores telemental health through two-way synchronous clinical video telehealth (CVT) technologies as one approach to improving access to suicide-specific interventions. Results: Studies were reviewed if (1) the modality of interest was telemental health by CVT and (2) management, assessment, or intervention of suicidal thoughts or behaviors was discussed. A total of 22 studies were included. Conclusions: Findings from the limited existing studies are synthesized, and recommendations are provided for future research, clinical, and educational advancements.
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Affiliation(s)
- Sasha M Rojas
- VA Puget Sound Health Care System, Seattle, Washington.,University of Arkansas, Fayetteville, Arkansas, USA
| | - Sarah P Carter
- VA Puget Sound Health Care System, Seattle, Washington.,Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, VA Puget Sound Health Services, Seattle, Washington, USA.,Department of Health Services, University of Washington, Seattle, Washington, USA
| | - Meghan M McGinn
- VA Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Mark A Reger
- VA Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
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32
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Iliakis EA, Sonley AKI, Ilagan GS, Choi-Kain LW. Treatment of Borderline Personality Disorder: Is Supply Adequate to Meet Public Health Needs? Psychiatr Serv 2019; 70:772-781. [PMID: 31138059 DOI: 10.1176/appi.ps.201900073] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study aimed to assess the supply of and demand for treatment of borderline personality disorder (BPD) to inform current standards of care and training in the context of available resources worldwide. METHODS The total supply of mental health professionals and mental health professionals certified in specialist evidence-based treatments for BPD was estimated for 22 countries by using data from publicly available sources and training programs. BPD prevalence and treatment-seeking rates were drawn from large-scale national epidemiological studies. Ratios of treatment-seeking patients to available providers were computed to assess whether current systems are able to meet demand. Training and certification requirements were summarized. RESULTS The ratio of treatment-seeking patients with BPD to mental health professionals (irrespective of professionals' interest or training in treating BPD) ranged from approximately 4:1 in Australia, the Netherlands, and Norway to 192:1 in Singapore. The ratio of treatment-seeking patients to clinicians certified in providing evidence-based care ranged from 49:1 in Norway to 148,215:1 in Mexico. Certification requirements differed by treatment and by country. CONCLUSIONS Shortages of both providers available to treat BPD and providers certified in specialist treatments of BPD exist in most of the 22 countries studied. In well-resourced countries, training clinicians to provide generalist or abbreviated treatments for BPD, in addition to specialist treatments, could help address the current implementation gap. More resource-efficient alternatives must be considered in countries with insufficient staff to implement even generalist treatments. Consideration of realistic allocation of care may shape future guidelines and standards of BPD treatments, beyond intensive evidence-based psychotherapies.
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Affiliation(s)
- Evan A Iliakis
- Adult Borderline Center and Training Institute, McLean Hospital, Belmont, Massachusetts (Iliakis, Ilagan, Choi-Kain); Center for Addiction and Mental Health, University of Toronto, Toronto (Sonley); Department of Psychiatry, Harvard Medical School, Boston (Choi-Kain)
| | - Anne K I Sonley
- Adult Borderline Center and Training Institute, McLean Hospital, Belmont, Massachusetts (Iliakis, Ilagan, Choi-Kain); Center for Addiction and Mental Health, University of Toronto, Toronto (Sonley); Department of Psychiatry, Harvard Medical School, Boston (Choi-Kain)
| | - Gabrielle S Ilagan
- Adult Borderline Center and Training Institute, McLean Hospital, Belmont, Massachusetts (Iliakis, Ilagan, Choi-Kain); Center for Addiction and Mental Health, University of Toronto, Toronto (Sonley); Department of Psychiatry, Harvard Medical School, Boston (Choi-Kain)
| | - Lois W Choi-Kain
- Adult Borderline Center and Training Institute, McLean Hospital, Belmont, Massachusetts (Iliakis, Ilagan, Choi-Kain); Center for Addiction and Mental Health, University of Toronto, Toronto (Sonley); Department of Psychiatry, Harvard Medical School, Boston (Choi-Kain)
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33
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Popowich AD, Mushquash AR, Pearson E, Schmidt F, Mushquash CJ. Barriers and facilitators affecting the sustainability of dialectical behaviour therapy programmes: A qualitative study of clinician perspectives. COUNSELLING & PSYCHOTHERAPY RESEARCH 2019. [DOI: 10.1002/capr.12250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Erin Pearson
- School of Kinesiology Lakehead University Thunder Bay Ontario Canada
| | - Fred Schmidt
- Department of Psychology Lakehead University Thunder Bay Ontario Canada
- Children's Centre Thunder Bay Thunder Bay Ontario Canada
| | - Christopher J. Mushquash
- Department of Psychology & Northern Ontario School of Medicine Lakehead University Thunder Bay Ontario Canada
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34
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Toms G, Williams L, Rycroft-Malone J, Swales M, Feigenbaum J. The development and theoretical application of an implementation framework for dialectical behaviour therapy: a critical literature review. Borderline Personal Disord Emot Dysregul 2019; 6:2. [PMID: 30805193 PMCID: PMC6373034 DOI: 10.1186/s40479-019-0102-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dialectical behaviour therapy (DBT) is a third wave behaviour therapy combining behaviour based components with elements of mindfulness. Although DBT effectiveness has been explored, relatively little attention has been given to its implementation. Frameworks are often the basis for gathering information about implementation and can also direct how the implementation of an intervention is conducted. Using existing implementation frameworks, this critical literature review scoped the DBT implementation literature to develop and refine a bespoke DBT implementation framework. METHOD AND RESULTS The initial framework was developed by consolidating existing implementation frameworks and published guidance on DBT implementation. The critical literature review retrieved papers from Medline, CINAHL, PsycInfo, PubMed, and the reference lists of included papers. Framework elements were used as codes which were applied to the literature and guided the synthesis. Findings from the synthesis refined the framework.The critical literature review retrieved 60 papers but only 14 of these explicitly focused on implementation. The DBT implementation framework captured all the execution barriers and facilitators described in the literature. However, the evidence synthesis led to a more parsimonious framework as some elements (e.g., research and published guidance) were seldom discussed in DBT implementation. CONCLUSION To our knowledge this is the first published review exploring DBT implementation. The literature synthesis suggests some tentative recommendations which warrant further exploration. For instance, if DBT implementation is not pre-planned, having someone in the organisation who champions DBT can be advantageous. However, as the literature is limited and has methodological limitations, further prospective studies of DBT implementation are needed.
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Affiliation(s)
- Gill Toms
- Gill Toms, School of Healthcare Sciences, Bangor University, Fron Heulog, Bangor, Gwynedd LL57 2EF UK
| | - Lynne Williams
- Gill Toms, School of Healthcare Sciences, Bangor University, Fron Heulog, Bangor, Gwynedd LL57 2EF UK
| | - Jo Rycroft-Malone
- Gill Toms, School of Healthcare Sciences, Bangor University, Fron Heulog, Bangor, Gwynedd LL57 2EF UK
| | - Michaela Swales
- North Wales Clinical Psychology Programme, School of Psychology, Brigantia Building, Bangor University, Bangor, Gwynedd LL57 2DG UK
| | - Janet Feigenbaum
- Research Department of Clinical, Education and Health Psychology, University College London, Gower Street, London, WC1E 6BT UK
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35
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Flynn D, Kells M, Joyce M, Corcoran P, Gillespie C, Suarez C, Swales M, Arensman E. Innovations in Practice: Dialectical behaviour therapy for adolescents: multisite implementation and evaluation of a 16-week programme in a public community mental health setting. Child Adolesc Ment Health 2019; 24:76-83. [PMID: 32677228 DOI: 10.1111/camh.12298] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dialectical behaviour therapy for adolescents (DBT-A) is an intervention with a growing evidence base for treating adolescents with emotional and behavioural dysregulation. This study describes the implementation and effectiveness of 16-week DBT-A across multiple sites in publicly funded child/adolescent mental health services (CAMHS) in Ireland. METHOD The Consolidated Framework for Implementation Research was used to guide this national implementation. Fifty-four clinicians from seven CAMHS teams completed DBT training and delivered the 16-week DBT-A programme. Eighty-four adolescents with emotional and behavioural dysregulation participated in the intervention and outcome measures were administered at preintervention, postintervention and 16-week follow-up. RESULTS Significant reductions on all outcome measures were observed for DBT-A participants including presence and frequency of self-harm, suicidal ideation and depression. Reductions in the number of acute inpatient admissions, bed days and emergency department visits were also reported. CONCLUSIONS DBT-A can be successfully implemented in CAMHS settings and yield positive outcomes for adolescents with emotional and behavioural dysregulation.
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Affiliation(s)
- Daniel Flynn
- Cork Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, St Finbarr's Hospital, Cork, Ireland
| | - Mary Kells
- Cork Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, Cork, Ireland
| | - Mary Joyce
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Paul Corcoran
- School of Public Health, University College Cork, Cork, Ireland
| | - Conall Gillespie
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Catalina Suarez
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Michaela Swales
- Betsi Cadwaladr University Health Board & North Wales Clinical Psychology Programme, School of Psychology, Bangor University, Bangor, UK
| | - Ella Arensman
- National Suicide Research Foundation, University College Cork, Cork, Ireland
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36
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Navarro-Haro MV, Harned MS, Korslund KE, DuBose A, Chen T, Ivanoff A, Linehan MM. Predictors of Adoption and Reach Following Dialectical Behavior Therapy Intensive Training™. Community Ment Health J 2019; 55:100-111. [PMID: 29508180 DOI: 10.1007/s10597-018-0254-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
Dialectical behavior therapy (DBT) is an evidence-based treatment for borderline personality disorder. The DBT Intensive Training™ is widely used to train community clinicians to deliver DBT, but little is known about its effectiveness. This study prospectively evaluated predictors of adoption and reach of DBT among 52 community teams (212 clinicians) after DBT Intensive Training™. Pre-post training questionnaires were completed by trainees and a follow-up survey by team leaders approximately 8 months later. Overall, 75% of teams adopted all DBT modes and delivered DBT to an average of 118 clients. Lower training and program needs, fewer bachelor's-level clinicians, and greater prior DBT experience predicted adoption of more DBT modes. More prior DBT experience, smaller team size, more negative team functioning, and staff with lower job satisfaction, growth, efficacy, and influence predicted greater DBT reach. DBT Intensive Training™ appears effective in promoting DBT adoption and reach in routine clinical practice settings.
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Affiliation(s)
- Maria V Navarro-Haro
- Behavioral Research and Therapy Clinics, Department of Psychology, University of Washington, Seattle, WA, USA. .,Hospital Universitario General de Cataluña, Instituto Trastorno Límite, Sant Cugat, Barcelona, Spain.
| | - Melanie S Harned
- Behavioral Research and Therapy Clinics, Department of Psychology, University of Washington, Seattle, WA, USA.,Behavioral Tech, LLC, Seattle, WA, USA
| | - Kathryn E Korslund
- Behavioral Research and Therapy Clinics, Department of Psychology, University of Washington, Seattle, WA, USA
| | | | - Tianying Chen
- Behavioral Research and Therapy Clinics, Department of Psychology, University of Washington, Seattle, WA, USA.,University of Michigan, Ann Arbor, MI, USA
| | | | - Marsha M Linehan
- Behavioral Research and Therapy Clinics, Department of Psychology, University of Washington, Seattle, WA, USA
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Enduring Effects of One-Day Training in Good Psychiatric Management on Clinician Attitudes About Borderline Personality Disorder. J Nerv Ment Dis 2018; 206:865-869. [PMID: 30371640 DOI: 10.1097/nmd.0000000000000893] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Time-limited interventions may attenuate stigma and negative beliefs about borderline personality disorder (BPD) among mental health clinicians. This study examined whether a 1-day training in good psychiatric management (GPM) changed clinician attitudes and beliefs and whether those changes persisted over time. Fifty-two mental health clinicians attended a 1-day GPM training and completed a 13-item assessment of attitudes about BPD before and after the training and again 6 months later. One-way repeated-measures analysis of variances and dependent sample t-tests demonstrated significant changes for all items, 11 of which were in the direction of more positive attitudes about BPD. For six items, attitudes did not change immediately after training, but 6 months later had changed significantly. Findings indicate that brief training can foster enduring improvements in clinician attitudes and beliefs about BPD.
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38
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Implementation of Dialectical Behavior Therapy in Residential Treatment Programs: A Process Evaluation Model for a Community-Based Agency. Community Ment Health J 2018; 54:921-929. [PMID: 29330697 DOI: 10.1007/s10597-017-0224-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
Abstract
Dialectical behavior therapy (DBT) can be challenging to implement in community-based settings. Little guidance is available on models to evaluate the effectiveness or sustainability of training and implementation efforts. Residential programs have much to gain from introduction of evidence-based practices, but present their own challenges in implementation. This paper presents a low-cost process evaluation model to assess DBT training piloted in residential programs. The model targets staff and organizational factors associated with successful implementation of evidence-based practices and matches data collection to the four stages of the DBT training model. The strengths and limitations of the evaluation model are discussed.
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39
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Lang CM, Edwards AJ, Mittler MA, Bonavitacola L. Dialectical Behavior Therapy With Prolonged Exposure for Adolescents: Rationale and Review of the Research. COGNITIVE AND BEHAVIORAL PRACTICE 2018. [DOI: 10.1016/j.cbpra.2017.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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40
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McMain SF, Chapman AL, Kuo JR, Guimond T, Streiner DL, Dixon-Gordon KL, Isaranuwatchai W, Hoch JS. The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol. BMC Psychiatry 2018; 18:230. [PMID: 30016935 PMCID: PMC6050694 DOI: 10.1186/s12888-018-1802-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 06/27/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although Dialectical Behaviour Therapy (DBT) is an evidence-based psychosocial treatment for borderline personality disorder (BPD), the demand for it exceeds available resources. The commonly researched 12-month version of DBT is lengthy; this can pose a barrier to its adoption in many health care settings. Further, there are no data on the optimal length of psychotherapy for BPD. The aim of this study is to examine the clinical and cost-effectiveness of 6 versus 12 months of DBT for chronically suicidal individuals with BPD. A second aim of this study is to determine which patients are as likely to benefit from shorter treatment as from longer treatment. METHODS/DESIGN Powered for non-inferiority testing, this two-site single-blind trial involves the random assignment of 240 patients diagnosed with BPD to 6 or 12 months of standard DBT. The primary outcome is the frequency of suicidal or non-suicidal self-injurious episodes. Secondary outcomes include healthcare utilization, psychiatric and emotional symptoms, general and social functioning, and health status. Cost-effectiveness outcomes will include the cost of providing each treatment as well as health care and societal costs (e.g., missed work days and lost productivity). Assessments are scheduled at pretreatment and at 3-month intervals until 24 months. DISCUSSION This is the first study to directly examine the dose-effect of psychotherapy for chronically suicidal individuals diagnosed with BPD. Examining both clinical and cost effectiveness in 6 versus 12 months of DBT will produce answers to the question of how much treatment is good enough. Information from this study will help to guide decisions about the allocation of scarce treatment resources and recommendations about the benefits of briefer treatment. TRIAL REGISTRATION NCT02387736 . Registered February 20, 2015.
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Affiliation(s)
- Shelley F. McMain
- Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON M6J 1H4 Canada
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Alexander L. Chapman
- Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, V5A 1S6 Canada
- DBT Centre of Vancouver, Vancouver, Canada
| | - Janice R. Kuo
- Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3 Canada
| | - Tim Guimond
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - David L. Streiner
- Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON M6J 1H4 Canada
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Box 585, 100 West 5th Street, Room B386, Hamilton, ON L8N 3K7 Canada
| | - Katherine L. Dixon-Gordon
- Psychological and Brain Sciences, University of Massachusetts, 617 Tobin Hall, 135 Hicks Way, Amherst, MA 01003-9271 USA
| | - Wanrudee Isaranuwatchai
- Centre for Excellence in Economic Analysis Research, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jeffrey S. Hoch
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Public Health Sciences, University of California, One Shields Avenue, Med Sci 1-C, Davis, CA 95616-8638 USA
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An Examination of the Effectiveness of Dialectical Behavior Therapy Skills Groups. JOURNAL OF COUNSELING AND DEVELOPMENT 2018. [DOI: 10.1002/jcad.12198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Landes SJ, Rodriguez AL, Smith BN, Matthieu MM, Trent LR, Kemp J, Thompson C. Barriers, facilitators, and benefits of implementation of dialectical behavior therapy in routine care: results from a national program evaluation survey in the Veterans Health Administration. Transl Behav Med 2018; 7:832-844. [PMID: 28168608 DOI: 10.1007/s13142-017-0465-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
National implementation of evidence-based psychotherapies (EBPs) in the Veterans Health Administration (VHA) provides important lessons on the barriers and facilitators to implementation in a large healthcare system. Little is known about barriers and facilitators to the implementation of a complex EBP for emotional and behavioral dysregulation-dialectical behavioral therapy (DBT). The purpose of this study was to understand VHA clinicians' experiences with barriers, facilitators, and benefits from implementing DBT into routine care. This national program evaluation survey measured site characteristics of VHA sites (N = 59) that had implemented DBT. DBT was most often implemented in general mental health outpatient clinics. While 42% of sites offered all four modes of DBT, skills group was the most frequently implemented mode. Fifty-nine percent of sites offered phone coaching in any form, yet only 11% of those offered it all the time. Providers were often provided little to no time to support implementation of DBT. Barriers that were difficult to overcome were related to phone coaching outside of business hours. Facilitators to implementation included staff interest and expertise. Perceived benefits included increased hope and functioning for clients, greater self-efficacy and compassion for providers, and ability to treat unique symptoms for clinics. There was considerable variability in the capacity to address implementation barriers among sites implementing DBT in VHA routine care. Mental health policy makers should note the barriers and facilitators reported here, with specific attention to phone coaching barriers.
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Affiliation(s)
- Sara J Landes
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA. .,University of Arkansas for Medical Sciences, 4301 W. Markham St., #755, Little Rock, AR, 72205, USA. .,Central Arkansas VA Health Care System, VISN 16 South Central Mental Illness Research Education and Clinical Center (MIRECC), NW, Washington, DC, USA.
| | - Allison L Rodriguez
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Brandy N Smith
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Monica M Matthieu
- Central Arkansas VA Health Care System, 2200 Fort Roots Drive, Building 58, North Little Rock, AR, 72114, USA.,College for Public Health and Social Justice, School of Social Work, Saint Louis University, Tegeler Hall, Suite 300, 3550 Lindell Blvd., Saint Louis, MO, 63103, USA
| | - Lindsay R Trent
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road Suite 3217, Stanford, 94305-5719, USA
| | - Janet Kemp
- VISN 2 Center of Excellence for Suicide Prevention, NW, Washington, DC, USA
| | - Caitlin Thompson
- Office for Suicide Prevention, Mental Health Service, US Department of Veterans Affairs, NW, Washington, DC, 20420, USA
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Walsh C, Ryan P, Flynn D. Exploring dialectical behaviour therapy clinicians' experiences of team consultation meetings. Borderline Personal Disord Emot Dysregul 2018; 5:3. [PMID: 29556397 PMCID: PMC5838873 DOI: 10.1186/s40479-018-0080-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This article presents a detailed idiographic analysis of Dialectical Behaviour Therapy (DBT) clinicians' experiences of team consultation meetings. DBT is an evidence-based psychological intervention with a demonstrated efficacy in the treatment of borderline personality disorder (BPD). Team consultation meetings encompass one of the primary components involved in this treatment model; where DBT clinicians regularly meet to discuss client work and enhance further learning. The present study's aim was to assess what are DBT clinicians' experiences of the consultation meeting component and whether it is useful or not. METHOD Semi-structured interviews were completed with 11 DBT clinicians (nine females, two males) from three different consultation teams. The research project utilised an interpretative phenomenological analysis (IPA) framework. Audio-recorded interview data was analysed using this framework. RESULTS Four superordinate themes emerged from the interview data, which included ten subordinate themes. The superordinate themes focused on: (1) the acquisition of DBT technical knowledge and other MDT related expertise (2) participants' emotional experiences of DBT and consultation meetings, and how this can evolve over time (3) the underlying processes that occur in the consultation team including the development of a team bond and the impact of membership changes and (4) the largely consistent and reliable nature of consultation meetings and how they help maintain clinician motivation. CONCLUSIONS Team consultation meetings were found to be supportive; playing an important role in maintaining clinician motivation through the availability of team support, opportunities to reflect and learn, and assistance in regulating emotions. Challenges arose in relation to team membership changes and acclimatisation to the type of feedback utilised in team consultation. The study's implications for practise are considered.
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Affiliation(s)
- Cian Walsh
- Cork Mental Health Services, Health Service Executive, Psychology Department, Inniscarrig House, Western Road, Cork, Ireland
| | - Patrick Ryan
- Department of Psychology, University of Limerick, Limerick, Ireland
| | - Daniel Flynn
- Cork Mental Health Services, Health Service Executive, Block 2, St Finbarr’s Hospital, Cork, Ireland
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Flynn D, Kells M, Joyce M, Suarez C, Gillespie C. Dialectical behaviour therapy for treating adults and adolescents with emotional and behavioural dysregulation: study protocol of a coordinated implementation in a publicly funded health service. BMC Psychiatry 2018; 18:51. [PMID: 29482538 PMCID: PMC5828478 DOI: 10.1186/s12888-018-1627-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 01/30/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the Republic of Ireland, borderline personality disorder (BPD) is a feature of approximately 11-20% of clinical presentations to outpatient clinics within mental health services. These estimates are similar to other countries including the UK and USA. Dialectical behaviour therapy (DBT) is an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with BPD. While a number of randomised controlled trials (RCTs) have demonstrated the efficacy of DBT, there is limited research which evaluates the effectiveness of this model when applied to real world settings. Funding was secured to co-ordinate DBT training in public community-based mental health services across Ireland. As no other study has evaluated a co-ordinated national implementation of DBT, the current study proposes to investigate the effectiveness of DBT in both adult and child/adolescent community mental health services across Ireland, evaluate the coordinated implementation of DBT at a national level, and complete a comprehensive economic evaluation comparing DBT versus treatment-as-usual. METHODS/ DESIGN This study takes the form of a quasi-experimental design. Individuals attending community mental health services who meet criteria for participation in the DBT programme will be allocated to the intervention group. Individuals who live in areas in Ireland where DBT is not yet available, and individuals who choose not to participate in the intervention, will be invited to participate in a treatment-as-usual comparison group. Self-report clinical measures and health service use questionnaires for DBT participants (and parent/guardians as appropriate) will be administered at pre-, mid- and post-intervention, as well as follow-up for participants who complete the intervention. Survey and interview data for DBT therapists will be gathered at three time points: prior to DBT training, 6 months after teams begin delivery of the intervention, and 2 years following training completion. DISCUSSION It is anticipated that the results of this study will provide evidence for the effectiveness of DBT for patients, and report on recommendations regarding best practice guidelines for implementation of DBT and its economic merit in a publicly funded service. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03180541 ; Registered June 7th 2017 'retrospectively registered'.
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Affiliation(s)
- Daniel Flynn
- Cork Mental Health Service, Cork Kerry Community Healthcare, Health Service Executive, St Finbarr’s Hospital, Cork, Ireland
| | - Mary Kells
- Cork Mental Health Service, Cork Kerry Community Healthcare, Health Service Executive, Inniscarraig House, Western Road, Cork, Ireland
| | - Mary Joyce
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
| | - Catalina Suarez
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
| | - Conall Gillespie
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
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Chugani CD, Mitchell ME, Botanov Y, Linehan MM. Development and Initial Evaluation of the Psychometric Properties of the Dialectical Behavior Therapy Barriers to Implementation Scale (BTI-S). J Clin Psychol 2017; 73:1704-1716. [PMID: 28380249 DOI: 10.1002/jclp.22478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 02/22/2017] [Accepted: 03/05/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We examined the psychometric properties of the Dialectical Behavior Therapy (DBT) Barriers to Implementation Scale (BTI-S). METHOD Participants were clinicians completing a bipartite training, separated by 6 months of self-study, to implement DBT. Exploratory factor analysis was conducted with data collected from the initial training period (N = 790), while confirmatory factor analysis was based on data from the final training period (N = 660). RESULTS The final model included 26 items and 4 factors with overall acceptable fit, χ2 (293, N = 660) = 460.989, p < .001, comparative fit index = .909, Tucker-Lewis index = .899, root mean square root mean square error of approximation (90% confidence interval) = .015. The internal reliability of the scores was low (range = .56 to .72). CONCLUSION The final model fits reasonably well and measures four domains considered important for implementation of DBT. However, the low reliability of the scores indicates that the BTI-S would be improved with further development.
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Flynn D, Kells M, Joyce M, Corcoran P, Gillespie C, Suarez C, Weihrauch M, Cotter P. Standard 12 month dialectical behaviour therapy for adults with borderline personality disorder in a public community mental health setting. Borderline Personal Disord Emot Dysregul 2017; 4:19. [PMID: 28989706 PMCID: PMC5610433 DOI: 10.1186/s40479-017-0070-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/13/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Dialectical behaviour therapy (DBT) is noted to be an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with borderline personality disorder (BPD). Evidence for the effectiveness of DBT in publicly funded community mental health settings is lacking however. No study to our knowledge has been published on the effectiveness of a 12 month standard DBT programme without adaptations for individuals with BPD in a publicly funded community mental health setting and no study has included data across multiple time-points. The main objective of the current study was to determine if completion of a 12 month DBT programme is associated with improved outcomes in terms of borderline symptoms, anxiety, hopelessness, suicidal ideation, depression and quality of life. A secondary objective includes assessing client progress across multiple time-points throughout the treatment. METHODS Fifty-four adult participants with BPD completed the standard DBT programme across four sites in community mental health settings in the Republic of Ireland. Data was collected by the DBT therapists working with participants and took place at 8 week intervals across the 12 month programme. To explore the effects of the intervention for participants, linear mixed-effects models were used to estimate change utilising data available from all time-points. RESULTS At the end of the 12 month programme, significant reductions in borderline symptoms, anxiety, hopelessness, suicidal ideation and depression were observed. Increases in overall quality of life were also noted. In particular, gains were made during the first 6 months of the programme. There was a tendency for scores to slightly regress after the six-month mark which marks the start of the second delivery of the group skills cycles. CONCLUSIONS The current study provides evidence for the effectiveness of standard DBT in publicly funded community mental health settings. As participants were assessed at the end of every module, it was possible to observe trends in symptom reduction during each stage of the intervention. Despite real-world limitations of applying DBT in community settings, the results of this study are comparable with more tightly controlled studies. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03166579; Registered May 24th 2017 'retrospectively registered'.
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Affiliation(s)
- Daniel Flynn
- Cork Mental Health Services, Health Service Executive, Block 2, St Finbarr's Hospital, Cork, Ireland
| | - Mary Kells
- Cork Mental Health Services, Health Service Executive, Block 2, St Finbarr's Hospital, Cork, Ireland
| | - Mary Joyce
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
| | - Paul Corcoran
- Department of Epidemiology and Public Health, Western Gateway Building, University College Cork, Cork, Ireland
| | - Conall Gillespie
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
| | - Catalina Suarez
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
| | - Mareike Weihrauch
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
| | - Padraig Cotter
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
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Burgess AM, Chang J, Nakamura BJ, Izmirian S, Okamura KH. Evidence-Based Practice Implementation Within a Theory of Planned Behavior Framework. J Behav Health Serv Res 2016; 44:647-665. [DOI: 10.1007/s11414-016-9523-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chugani CD, Landes SJ. Dialectical Behavior Therapy in College Counseling Centers: Current Trends and Barriers to Implementation. JOURNAL OF COLLEGE STUDENT PSYCHOTHERAPY 2016. [DOI: 10.1080/87568225.2016.1177429] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Dialectical behaviour therapy for younger adults: evaluation of 22 weeks of community delivered dialectical behaviour therapy for females 18-25 years. Ir J Psychol Med 2015; 32:299-305. [PMID: 30185251 DOI: 10.1017/ipm.2014.69] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Dialectical behaviour therapy (DBT) is a multi-modal psychological therapy with established efficacy in treating borderline personality disorder (BPD). Younger adults represent a group more likely to drop out of treatment than their older counterparts and treatments specifically targeted at this younger cohort may be advantageous. The current study We describe an evaluation of a DBT programme in a mental health centre for younger adults 18-25 years who met criteria for BPD (n=11). Methodology We used a simple pre/post-test design, measuring BPD symptoms, general mental health symptoms, and coping skills using self-report questionnaires at the beginning of DBT and again following the delivery of 22 weeks of DBT. Findings Statistically significant reductions were found in BPD symptoms and several mental health symptoms alongside an increase in DBT skills use. Dropout was 31% at 22 weeks of treatment. Methodological weaknesses and avenues for future research are discussed.
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Ditty MS, Landes SJ, Doyle A, Beidas RS. It Takes a Village: A Mixed Method Analysis of Inner Setting Variables and Dialectical Behavior Therapy Implementation. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2015; 42:672-81. [PMID: 25315183 PMCID: PMC4400206 DOI: 10.1007/s10488-014-0602-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Guided by the Consolidated Framework for Implementation Research, this mixed method study explored the relationship between inner setting variables and dialectical behavior therapy (DBT) implementation. Intensively trained DBT clinicians completed an online quantitative survey (n = 79) and a subset were sequentially interviewed using qualitative methods (n = 20) to identify relationships between inner setting variables and DBT implementation. Four interpersonal variables-team cohesion, team communication, team climate, and supervision-were correlated with the quantity of DBT elements implemented. Qualitative themes corroborated these findings. Additional variables were connected to implementation by either quantitative or qualitative findings, but not both.
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Affiliation(s)
- Matthew S Ditty
- The Ebright Foundation, LLC, 2800 Lancaster Ave., Suite 6, Wilmington, DE, 19810, USA.
| | - Sara J Landes
- National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, CA, USA
- University of Washington, Seattle, WA, USA
| | - Andrea Doyle
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Rinad S Beidas
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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