The Role of the Team in Managing Telephone Consultation in Dialectical Behavior Therapy: Three Case Examples

Effects of Phone-Based Psychological Intervention on Caregivers of Patients with Early-Onset Alzheimer’s Disease: A Six-Months Study during the COVID-19 Emergency in Italy

Caregivers of patients with early-onset Alzheimer’s disease (EOAD) experience higher level of burden, stress, and depression, due to premature role changes and social isolation. Moreover, the SARS-CoV-2 pandemic compelled restrictions regarding social interactions and mobility in Italy from March 2020, prompting telemedicine approaches for supporting patients and their families confined at home. We reported our experience regarding the effects of psychological phone-intervention (phone-I) on EOAD caregivers during pandemic. Twenty caregivers of EOAD patients were randomly assigned to treatment (TG) or control (CG) group. TG weekly underwent a phone-I for one month. All participants were assessed for caregiver burden and needs, anxiety and depression levels, and subjective impact of traumatic events at baseline (T0), at the fifth week (T1) and after 6 months (T2) from phone-I. We observed higher vulnerability to post-traumatic stress in TG compared to CG in all timepoints (p ≤ 0.05). Decreased stress effects and caregiver burden were revealed in TG at T1 compared to T0 (p ≤ 0.05), although showing an increase of these measures at T2 in the treated caregivers. Our findings suggest that although TG showed a peculiar vulnerability to post-traumatic stress, they showed increased wellbeing immediately after phone-I. However, this benefit disappeared six months later, along with the second infection wave, probably due to “exhaustion stage” achievement in “General Adaptation Syndrome”. This trend may suggest a beneficial but not solving role of a prompt phone-I on burden of caregivers of EOAD patients during the SARS-CoV-2 emergency.

Towards optimal treatment selection for borderline personality disorder patients (BOOTS): a study protocol for a multicenter randomized clinical trial comparing schema therapy and dialectical behavior therapy

BACKGROUND

Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated.

METHODS

The BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being.

DISCUSSION

The current study contributes to the optimization of treatments for BPD patients by extending our knowledge on "Which treatment - DBT or ST - works the best for which BPD patient, and why?", which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments).

TRIAL REGISTRATION

Netherlands Trial Register, NL7699 , registered 25/04/2019 - retrospectively registered.

Reviewing the availability, efficacy and clinical utility of Telepsychology in dialectical behavior therapy (Tele-DBT)

BACKGROUND

Telepsychology is increasingly being implemented in mental health care. We conducted a scoping review on the best available research evidence regarding availability, efficacy and clinical utility of telepsychology in DBT. The review was performed using PRISMA-ScR guidelines. Our aim was to help DBT-therapists make empirically supported decisions about the use of telepsychology during and after the current pandemic and to anticipate the changing digital needs of patients and clinicians.

METHODS

A search was conducted in PubMed, Embase, PsycARTICLES and Web of Science. Search terms for telepsychology were included and combined with search terms that relate to DBT.

RESULTS

Our search and selection procedures resulted in 41 articles containing information on phone consultation, smartphone applications, internet delivered skills training, videoconferencing, virtual reality and computer- or video-assisted interventions in DBT.

CONCLUSIONS

The majority of research about telepsychology in DBT has focused on the treatment mode of between-session contact. However, more trials using sophisticated empirical methodologies are needed. Quantitative data on the efficacy and utility of online and blended alternatives to standard (i.e. face-to-face) individual therapy, skills training and therapist consultation team were scarce. The studies that we found were designed to evaluate feasibility and usability. A permanent shift to videoconferencing or online training is therefore not warranted as long as face-to-face is an option. In all, there is an urgent need to compare standard DBT to online or blended DBT. Smartphone apps and virtual reality (VR) are experienced as an acceptable facilitator in access and implantation of DBT skills. In addition, we have to move forward on telepsychology applications by consulting our patients, younger peers and experts in adjacent fields if we want DBT to remain effective and relevant in the digital age.

Phone consultation and burnout among providers of dialectical behaviour therapy

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.

Challenges and Potential Solutions to Implementing Phone Coaching in Dialectical Behavior Therapy

Dialectical Behavioral Therapy (DBT) is an effective treatment for borderline personality disorder (BPD), yet many healthcare facilities struggle to implement one of the modes of DBT, phone coaching. The aims of this study were to present barriers and reported solutions regarding the implementation of DBT phone coaching. We conducted a sequential mixed methods national program evaluation that included a quantitative self-report survey completed by Department of Veterans Affairs (VA) facilities (N=59) offering any of the four modes of DBT. Subsequent qualitative interviews using a semi-structured interview guide informed by the Promoting Action on Research Implementation in Health Services (PARIHS) were completed with DBT providers and administrators from a subset (n = 16) of these VA sites. Four themes, the lack of tools and policies, compensation for phone coaching, clinician willingness to conduct phone coaching, and consistent program and leadership support were identified and illustrated in a case study. This study also offered concrete recommendations for those health care organizations, managers, administrators, and clinicians who may be interested in implementing phone coaching at their health care facilities.

Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies

BACKGROUND

Despite comparable clinical outcomes, therapists and patients express reservations about the delivery of psychological therapy by telephone. These concerns centre around the quality of the therapeutic relationship and the ability to exercise professional skill and judgement in the absence of visual cues. However, the empirical evidence base for such perceptions has not been clearly established.

METHODS

We conducted a systematic review to establish what is known empirically about interactional differences between psychotherapeutic encounters conducted face-to-face vs. by telephone.

RESULTS

The review identified 15 studies that used situated, comparative approaches to exploring interactional aspects of telephone and face-to-face psychological therapy. These studies revealed evidence of little difference between modes in terms of therapeutic alliance, disclosure, empathy, attentiveness or participation. However, telephone therapy sessions were significantly shorter than those conducted face-to-face.

LIMITATIONS

We identified only a small number of heterogeneous studies, many of which used non-randomised, opportunity samples and did not use validated measures to assess the constructs under investigation. Disparate therapeutic modalities were used across studies and samples included both clinically diagnosed and non-clinical populations.

CONCLUSIONS

Available evidence suggests a lack of support for the viewpoint that the telephone has a detrimental effect on interactional aspects of psychological therapy. The challenge for clinical practice is to translate this evidence into a change in practitioner and patient attitudes and behaviours. In order to do so, it is important to understand and address the breadth of factors that underpin ongoing ambivalence towards the telephone mode, which pose a barrier to wider implementation.

Phone coaching in Dialectical Behavior Therapy: frequency and relationship to client variables

Telephone coaching is a treatment mode in Dialectical Behavior Therapy (DBT) that is designed to help clients generalize skills, prevent suicidal behaviors, and repair therapeutic ruptures. To date, phone coaching has received scant empirical investigation. The aims of this study were to (1) describe patterns in frequency of telephone calls and text messaging in DBT and (2) investigate whether demographic factors, baseline severity, suicidal behaviors, and therapeutic alliance are associated with phone and text frequency. Participants were 51 adults (35 treatment completers) with borderline personality disorder (BPD) in a six-month comprehensive DBT treatment program. Phone coaching frequency was documented by therapist weekly session notes. The average number of contacts per month was 2.55 (SD = 4.49). Four of the 35 treatment completers comprised 56% of the contacts. Having a recent history of suicidal behaviors, degree of severity at baseline, or the strength of the therapeutic alliance was not associated with phone coaching use. However, lower income was significantly associated with a higher frequency of phone coaching use. These preliminary results can help clinicians and administrators make informed decisions on how to better provide phone coaching and clarify the degree of effort involved in providing this service to clients with BPD.

Clinical Observations About the Potential Benefits and Pitfalls of Between-Session Contacts with Borderline Patients

Borderline Personality Disorder (BPD) has a reputation for being a challenging disorder to treat due to the nature of the illness. With the development of evidence-based treatments, therapists are becoming more skilled at successfully helping this cohort of patients. A common factor associated with all validated treatments for BPD is the active involvement of therapists. For example, DBT is one treatment where therapists are expected to be available to patients for coaching outside of sessions. However, understanding the benefits and pitfalls associated with therapists' accessibility in between sessions is relevant to any treatment with intersession contact. In this article, three benefits of intersession contact are described: to generalize the use of skills, to improve understanding of the patient's needs, and to facilitate an alliance. This article also addresses the pitfalls of therapists being so accessible to patients. Both the benefits and pitfalls of intersession contact are illustrated using case vignettes. Assessing the function served by a patient's contact in between sessions is an important way to determine whether such contact is a productive part of treatment. Recommendations are provided to avoid detrimental outcomes for both the therapist (therapist burnout) and the patient.

Examining challenging behaviors of clients with borderline personality disorder

Few studies have examined effects of challenging behaviors of clients with borderline personality disorder (BPD) on psychotherapy outcomes. Dialectical behavior therapy (DBT) is an evidence-based treatment designed to treat chronic suicidality, self-directed violence (SDV), and emotion dysregulation, while targeting challenging behaviors. DBT has been shown to be effective with clients with BPD. We evaluated whether therapist reported challenging behaviors, such as high volume phone contacts or violating the therapist's limits, during DBT would be associated with dropping out of DBT, severity and frequency of SDV, emotion regulation deficits, psychological symptom severity and client's and therapist's satisfaction of treatment. The current study examined challenging behaviors reported by therapists in a sample of 63 psychiatrically disabled outpatient DBT clients diagnosed with BPD (73% women, average age 37 years). More frequent phone contacts were associated with a decrease in dropout and psychological symptoms, and an increase in client and therapist satisfaction. More avoidance/disengagement behavior was associated with more than twice the risk of SDV and a decrease in therapist satisfaction. Findings suggest that the phone coaching might serve to maximize client satisfaction and reduce the likelihood of dropout.