It's about me solving my problems: Clients' assessments of dialectical behavior therapy

Dialectical behavior therapy (DBT) in an assertive community treatment structure (ACT): testing integrated care borderline (ICB) in a randomized controlled trial (RECOVER)

BACKGROUND

Though Dialectical Behavior Therapy (DBT) and other treatment models for individuals with Borderline Personality Disorder (BPD) have shown to be efficient in inpatient and outpatient settings, there is a general shortage of these treatments. In Germany, most resources are spent on inpatient treatments and unspecific crisis interventions, while it is difficult to implement the necessary team structures in an outpatient setting. This study is testing an alternative approach focussing on outpatient treatment: Integrated Care Borderline (ICB) provides DBT for persons with severe BPD within the structures of an Assertive Community Treatment (ACT). ICB is team-based, integrating psychiatric and social support as well as crisis interventions into a DBT-strategy.

METHODS

ICB was compared to TAU in a prospective, randomized controlled trial. This study is part of RECOVER, a comprehensive stepped care approach in Germany, which enrolled a total of 891 participants. 146 persons were diagnosed with BPD as main diagnosis. Of these, 100 were allocated to the highest level of severe mental illness (SMI) and randomly assigned to either ICB (n = 50) or TAU (n = 50). Data were collected at baseline and 12 months later. The main outcomes were psychosocial functioning (GAF), severity of BPD (BSL-23) and other mental symptoms (BSI, PHQ-9, GAD-7, self-harm), employment status (VILI), as well as hospital days and associated costs.

RESULTS

Data show a significant increase of psychosocial functioning and a significant decrease of BPD and other psychiatric symptoms in both groups (r = .28 - .64), without any significant differences between the groups. The proportion of self-harming persons decreased in both groups without statistical significance. Patients were significantly more likely to be employed after a year of treatment in ICB (p = .001), but not in the TAU group (p = .454). Analyses showed a significant difference between the groups (p = .032). Moreover, psychiatric hospital days were significantly reduced in ICB (-89%, p < .001, r = .61), but not in TAU (-41%, p = .276, r = .15), resulting in a significant difference between the groups (p = .016) and in lower annual hospital costs in ICB (5,546€ vs. 10,726€, -48%, p = .011) compared to TAU.

CONCLUSION

Our results replicate earlier studies, showing that DBT can be efficient in outpatient settings. Furthermore, they indicate additional effects on employment and hospital days. The ICB-approach seems to offer a viable framework for multiprofessional outpatient DBT-teams. Future research will have to test whether the additional effects are brought about by the additional features of ICB compared to standard outpatient DBT.

TRIAL REGISTRATION

Registration number with ClinicalTrials.gov (NCT03459664), RECOVER.

Individuals who report having benefitted from dialectical behaviour therapy (DBT): a qualitative exploration of processes and experiences at long-term follow-up

BACKGROUND

Qualitative research in the area of DBT is limited, particularly at follow-up. The current study explored the follow-up experiences of individuals who previously received a diagnosis of borderline personality disorder and self-report having benefitted from DBT at the time of treatment.

METHODS

Individuals who completed 12 months of standard DBT and were a minimum of two years post-completion were recruited. Individual semi-structured interviews were completed with a total of twelve participants.

RESULTS

A thematic analysis generated three main themes which indicated that participants found DBT had a positive impact on their lives in the years after the programme and enabled further development; gave them control over their lives and the ability to manage setbacks and difficult situations; and contributed to healthier and more meaningful relationships with others.

CONCLUSIONS

The findings of this study indicated that DBT contributed positively to the participants' lives and helped advance their recovery in the years after the programme. Despite the positive impact of DBT, participants required further support in the years following the intervention. Clinical and research implications of these findings are discussed.

The experience of loneliness among people with a "personality disorder" diagnosis or traits: a qualitative meta-synthesis

BACKGROUND

Loneliness is prevalent among people with a "personality disorder" diagnosis or who have related personality traits, but the experience of loneliness among people with "personality disorder" diagnoses/traits has not been well described. A qualitative approach has potential to help understand the experience of loneliness among people with "personality disorder" diagnoses/traits, and to develop interventions that promote recovery. We therefore aimed to synthesise the qualitative literature relevant to this topic.

METHOD

We conducted a meta-synthesis of qualitative studies exploring the subjective experience of loneliness as reported by people with "personality disorder" diagnoses/traits. We searched four databases using pre-formulated search terms, selected eligible articles, appraised the quality of each, and analyzed data from eligible studies using thematic synthesis.

RESULT

We identified 39 articles that described the experience of loneliness in people with "personality disorder" diagnoses/traits. From extracted data, we identified seven themes: (1) disconnection and emptiness: a "haunting alienation", (2) alienation arising from childhood experiences, (3) thwarted desire for closeness and connection, (4) paradox: for both closeness and distance, (5) experiences of existential loneliness, (6) recovery, embedded in a social world, and (7) group therapy: a setback. Our results suggest that for our sample early alienating and traumatic experiences may pave the way for experiences of loneliness, which further exacerbate "personality disorder" symptoms and distress.

CONCLUSION

Despite describing a need to belong and efforts to cope with unmet social needs, people with "personality disorder" diagnoses/traits (particularly "emotionally unstable personality disorder") report experiencing an intense disconnection from other people. This seems rooted in early adversities, reinforced by later traumatic experiences. Given the apparent salience of loneliness to people with "personality disorder" diagnoses/traits, interventions focused on helping people connect with others, which may include both psychological and social components, have potential to be beneficial in reducing loneliness and promoting recovery.

Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis

BACKGROUND

There is a recognised need to develop clear service models and pathways to provide high quality care in the community for people with complex emotional needs, who may have been given a "personality disorder" diagnosis. Services should be informed by the views of people with these experiences.

AIMS

To identify and synthesise qualitative studies on service user experiences of community mental health care for Complex Emotional Needs.

METHODS

We searched six bibliographic databases for papers published since 2003. We included peer reviewed studies reporting data on service user experiences and views about good care from community-based mental health services for adults with CEN, including generic mental health services and specialist "personality disorder" services. Studies using any qualitative method were included and thematic synthesis used to identify over-arching themes.

RESULTS

Forty-seven papers were included. Main themes were: 1) The need for a long-term perspective on treatment journeys; 2) The need for individualised and holistic care; 3) Large variations in accessibility and quality of mental health services; 4) The centrality of therapeutic relationships; 5) Impacts of 'personality disorder' diagnosis. Themes tended to recur across studies from different countries and years.

DISCUSSION

Recurrent major themes included wanting support that is individualised and holistic, provides continuity over long journeys towards recovery, and that is delivered by empathetic and well-informed clinicians who are hopeful but realistic about the prospects of treatment. Care that met these simple and clearly stated priorities tended to be restricted to often limited periods of treatment by specialist "personality disorder" services: generic and primary care services were often reported as far from adequate. There is an urgent need to co-design and test strategies for improving long-term support and treatment care for people with "personality disorders" throughout the mental health care system.

The development and theoretical application of an implementation framework for dialectical behaviour therapy: a critical literature review

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.

Process and impact of dialectical behaviour therapy: A systematic review of perceptions of clients with a diagnosis of borderline personality disorder

PURPOSE

To identify, appraise, and synthesize findings from qualitative studies of individuals diagnosed with borderline personality disorder who have experienced dialectical behaviour therapy, to gain further understanding of their perceptions of the process and impact of therapy.

METHODS

We conducted a comprehensive systematic search of the literature from several online databases, and appraised them using an adapted version of the Critical Appraisal Skills Programme tool. A meta-ethnographic approach was used to synthesize the data.

RESULTS

Seven studies met the criteria to be included and their quality subsequently appraised. Four main themes were identified through the synthesis process: life before DBT; the relationships that support change; developing self-efficacy; and a shift in perspectives.

CONCLUSIONS

The findings of the synthesis highlight the importance of a number of key factors in the process of DBT, and the impact that the therapy has both on day-to-day life and on individuals' identity.

PRACTITIONER POINTS

Existing outcome measures may not capture the complexity and magnitude of impact of DBT on individuals with BPD. Exploring first-hand accounts of individuals undertaking DBT can offer unique insight into the processes of therapy.

Dialectical behaviour therapy in an inpatient unit for women with a learning disability: Service users' perspectives

There is a general lack of self-report data from service users with an intellectual disability (ID) about their views of psychological interventions. This research explored the views and experiences of female inpatients, with a diagnosis of a personality disorder and an ID, about dialectical behaviour therapy (DBT). Semi-structured interviews were used with 10 women, recruited from two independent mental health hospitals. The interviews were analysed using interpretative phenomenological analysis. Participants showed varying levels of understanding of DBT. Findings highlight the need for a standardized approach with a suitably adapted structure and curriculum to meet the needs of inpatients with an ID. Factors such as the therapeutic relationship were identified as playing a role in participants' motivation, engagement and participation in DBT.

Overcoming Barriers to Skills Training in Borderline Personality Disorder: A Qualitative Interview Study

Despite evidence suggesting that skills training is an important mechanism of change in dialectical behaviour therapy, little research exploring facilitators and barriers to this process has been conducted. The study aimed to explore clients’ experiences of barriers to dialectical behaviour therapy skills training and how they felt they overcame these barriers, and to compare experiences between treatment completers and dropouts. In-depth qualitative interviews were conducted with 40 clients with borderline personality disorder who had attended a dialectical behaviour therapy programme. A thematic analysis of participants’ reported experiences found that key barriers to learning the skills were anxiety during the skills groups and difficulty understanding the material. Key barriers to using the skills were overwhelming emotions which left participants feeling unable or unwilling to use them. Key ways in which participants reported overcoming barriers to skills training were by sustaining their commitment to attending therapy and practising the skills, personalising the way they used them, and practising them so often that they became an integral part of their behavioural repertoire. Participants also highlighted a number of key ways in which they were supported with their skills training by other skills group members, the group therapists, their individual therapist, friends and family. Treatment dropouts were more likely than completers to describe anxiety during the skills groups as a barrier to learning, and were less likely to report overcoming barriers to skills training via the key processes outlined above. The findings of this qualitative study require replication, but could be used to generate hypotheses for testing in further research on barriers to skills training, how these relate to dropout, and how they can be overcome. The paper outlines several such suggestions for further research.

Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder

Borderline personality disorder (BPD) is a complex disorder that is difficult to treat. However, dialectical behaviour therapy (DBT), developed by Dr. Marsha Linehan in the early 1990s, has emerged as a promising treatment option for those diagnosed with BPD. DBT is a multi-pronged treatment approach delivered normally in outpatient settings over 12 months and requires highly skilled and trained therapists. Many trials have provided evidence to support the use of DBT in the treatment of BPD. However, outcome measures vary and are mostly limited to measurable behavioural outcomes such as incidences of deliberate self-harm or suicidal thoughts. Two recent Cochrane reviews conclude that DBT does benefit those with BPD, but more robust evidence is needed. DBT training for health care professionals also has the potential to shift health care professionals' attitudes from one of therapeutic pessimism to one of optimism.

Utilization of evidenced based dialectical behavioral therapy in assertive community treatment: examining feasibility and challenges

Assertive Community Treatment (ACT) programs have been treating individuals with chronic and severe mental illness since the 1970s. While ACT programs were developed to address the treatment needs of severely mentally ill persons traditionally suffering from chronic mental illnesses, ACT programs are seeing a growing number of persons with co-morbid personality disorders. The efficacy of traditional ACT programs in treating individuals with co-occurring personality disorders is uncertain, in particular individuals with co-morbid Borderline Personality Disorder (BPD). Dialectical Behavior Therapy (DBT) has been proposed as an effective approach to treating clients with BPD in this setting. The purpose of this paper is to examine the value of DBT for individuals with BPD in ACT programs. The writers discuss the prevalence of Borderline Personality Disorders in ACT populations, briefly review the literature on DBT in ACT, address the feasibility of implementing DBT in an ACT model, examine potential barriers to this implementation, and highlight potential areas for future research.

Service user experience of adapted dialectical behaviour therapy in a community adult mental health setting

BACKGROUND

Dialectical behaviour therapy (DBT), a skill-based cognitive behavioural treatment, is increasingly used in the treatment of borderline personality disorder (BPD).

AIMS

The study examined service users' perspective on the effectiveness of an adapted DBT programme, delivered within a community adult mental health setting.

METHODS

Semi-structured interviews and focus groups were conducted with eight participants with a diagnosis of BPD about their experience of the programme.

RESULTS

Thematic analysis focused on two key themes: evaluation of therapy and treatment impact. Therapy-specific factors and personal challenges emerged as important themes. Treatment impact raised issues relating to a renewed sense of identity and changes in daily life.

CONCLUSIONS

The study describes the positive and negative experiences of service users with BPD attending an adapted DBT programme.

The Role of Assertive Community Treatment in the Treatment of People with Borderline Personality Disorder

It is known that Assertive Community Treatment (ACT) is being used to treat people with borderline personality disorder (BPD), a puzzling trend given the lack of empirical support for this practice and the consensus that reserving ACT for a carefully selected population is critical to the sustainability of this costly intervention. Little is known about the contributors to this phenomenon and the ways in which ACT programs have adapted to the influx of patients with BPD. Many ACT programs in the US and Canada have integrated Dialectical Behavioral Therapy into the regular ACT programming, a practice that also lacks rigorous evidence of effectiveness. We provide a framework for policy-makers to decide on the optimal role of ACT in the continuum of care for people with BPD, and offer policy recommendations to address this phenomenon. There is an urgent need to generate the missing evidence and to improve and expand the services available to people with BPD, particularly those who are now being treated on ACT programs.

Component analysis of dialectical behavior therapy skills training

OBJECTIVE

This paper aims to examine patient perceptions of the relative effectiveness of components of dialectical behavior therapy group skills training.

METHOD

Nineteen patients rated their perceptions of the relative effectiveness of 27 separate dialectical behavior therapy skills after completing 6 months standard dialectical behavior therapy. Two-tailed t-tests were used, comparing the first ranked skill with all other skills.

RESULTS

The 27 skills were ranked by means in order of perceived value. Eleven skills were statistically significantly different from the first ranked skill.

CONCLUSIONS

The data in this pilot study contributes in a small way to dialectical behavior therapy dismantling research and warrants a larger multi-centred study. A planned future study will compare patient rankings of skills with clinical outcomes.