Dialectical Behavior Therapy Training Research Articles

The Psychotherapy Practice of Dialectical Behavior Therapy Group Skills Training in Indonesia: An Indonesian Language Module Development

Introduction: There is an increasing number of suicides in Indonesia. A high risk of suicide is often associated with borderline personality disorder (BPD). To address this issue, dialectical behavior therapy (DBT) has been specifically designed for patients with frequent suicidal behavior and BPD. This study aims to develop DBT skills modules in Indonesian language for groups therapy and implement in clinical practice.Methods: This research was conducted in three stages. Stage 1 involved preparing the DBT skills module for 13 weeks, including the adding of TIPP (Temperature, Intense exercise, Paced Breathing, Paired Muscle Relaxation) distress tolerance skills and chain analysis. Stage 2 focused on module validation using face validity and content validity assessment conducted by two psychotherapy consultants. Stage 3 involved modules trials, both of whom had completed DBT training, practicing the prepared modules with two groups of 10 patients.Result: The face validity scores from the two experts for the DBT module on BPD in Indonesian was 3.188, indicating a high level of correctness. The content validity results from the two experts for the DBT module on BPD in Indonesian language were 84.06, indicating that almost everything was done correctly. After practicing DBT group skills training, two psychotherapists achieved a very good interrater score of 0.969 (p=0.003; 95% CI 0.746-0.997).Conclusion: Based on the face validity and content validity scores by the two experts, it was concluded that the DBT module for BPD in Indonesian language is suitable for use in clinical services.

The impact of dialectical behaviour therapy training on therapists in Singapore: A mixed‐methods study

AbstractBackgroundWhile dialectical behaviour therapy (DBT) has much empirical support for treating borderline personality disorder (BPD) and other conditions, little research has examined the dissemination of DBT in Southeast Asia.AimsThis study evaluated training outcomes following a 5‐day intensive DBT training programme in a group of psychologists in Singapore, who were in the process of implementing DBT as part of the training's objectives.MethodologyA mixed‐methods design was employed. Fourteen psychologists from a public psychiatric hospital in Singapore were recruited. Seven self‐selected into DBT training, and the remaining were matched controls who were not attending the training programme. The latter served as a nonrandomised control group. Prior to and 3 months after training, all participants completed measures of stigma towards BPD patients, burnout and therapeutic alliance. DBT training participants additionally attended a focus group discussion assessing their experiences and challenges implementing DBT in Singapore's context.FindingsQuantitative analyses using mixed ANOVA showed that, compared with controls, DBT‐trained participants demonstrated significantly greater increases in acceptance towards BPD patients. No between‐group differences were found on changes in burnout or therapy alliance with patients. Analyses of qualitative data using thematic analysis revealed that DBT training impacted the way participants conceptualised and delivered therapy for BPD patients, and highlighted several challenges in implementing DBT in the local hospital context.ConclusionThe findings demonstrate the potential of DBT training in improving clinicians' attitudes towards BPD patients and support a need for policymakers to prepare organisations for DBT implementation to ensure programme sustainability.

Finding a Dialectical Balance Between Process and Procedure


 The case of "Jane" (Marks, 2022) provides a detailed examination of the evidenced-based treatment, Dialectical Behavior Therapy (DBT), in the treatment of a woman with complex and multifaceted psychiatric difficulties by Michael Marks, an advanced doctoral student clinician in a DBT training clinic. Marks’ presentation provides an excellent example of the challenges clinicians face when treating patients with borderline personality disorder (BPD) and many of the common and multiple co-morbidities that frequently accompany the BPD diagnosis. While DBT is sometimes dismissed as a treatment that just teaches skills, Marks demonstrates the technical demands and nuances that therapists must use to correctly and effectively treat suicidality, emotion dysregulation, mood dependent behaviors, and significant interpersonal deficits that often have destructive and painful consequences. The three authors bring a variety of perspectives in commenting on Marks’ case study. The first is a psychologist who is a senior DBT therapist and the Program Director and Director of Training at an established adolescent DBT Continuum of Care Program; the second is an internationally active psychiatrist who is the Medical Director of the same Continuum of Care Program and a Behavioral Tech DBT Trainer; and the third is a post-doctoral psychology fellow working with the first two authors. A major theme in our discussion will be the challenge, when delivering DBT, of how to balance between technical interventions, on the one hand, and emotional experiencing, on the other. In exploring this theme, we will answer the questions, what was left out and what does it feel like?

Adapting Dialectical Behavior Therapy for Acute-Care Inpatient Adolescents

ABSTRACT This article describes the adaptation of Dialectical Behavior Therapy (DBT) for an acute-care psychiatric inpatient unit for adolescents with a range of diagnoses. There is a growing body of research demonstrating the efficacy of DBT for inpatient adolescents with a range of psychiatric diagnoses. Although the application of DBT has been described for adult inpatient settings, program descriptions and recommendations for adolescents differ from adults and are lacking for an acute-care inpatient adolescent setting. Further, clinical recommendations of DBT applied to adult inpatient settings, as well as adolescent outpatient settings, have largely focused on treatment for those with borderline personality disorder and/or symptoms, rather than a range of psychiatric diagnoses. Given the demonstrated efficacy of our DBT program for adolescents presenting with a range of psychiatric diagnoses, (Saito et al., 2020; Tebbett-Mock et al., 2020), this manuscript aims to address the need for a clinical resource on adapting DBT for acute-care inpatient adolescents. Informed by an implementation framework, we outline phases of our process for adapting DBT to an acute-care adolescent inpatient setting including 1) describing our institution, team, and patient population, 2) selection of DBT as a treatment model, 3) establishing and maintaining stakeholder engagement and partnerships, 4) DBT training, 5) developing and implementing DBT treatment modes and functions, 6) program evaluation and dissemination, and 7) identifying practice considerations, limitations, and future directions.

The Effect of Dialectical Behavior Therapy on Negative Automatic Thoughts, Suicidal Ideation and Life Expectancy in Female Students of Yasooj University of Medical Sciences

Background : Suicide has occurred in all cultures and eras is a disaster for the individual, family, and society. Dialectical behavior therapy is a practical treatment for major depressive disorder. The main aim of the present study was to investigate the effect of dialectical behavior therapy on negative automatic thoughts, suicidal ideation, and life expectancy in female students of Yasooj University of Medical Sciences. Methods: The research method is quasi-experimental and the statistical population of the study included female students of Yasooj University of Medical Sciences in the age range of 18 to 25 years. The sample size was 40 people who were selected by a convenience sampling method and were randomly divided into two groups of dialectical behavior therapy and control group. To collect data, Snyder Hope Scale, Negative Automatic Thought Scale, and Beck Suicidal ideation Questionnaire in pre-test and post-test stages were used. In the intervention phase, the experimental group underwent dialectical behavior therapy for ten sessions of 120 minutes while the control group did not receive any intervention during this period. Data analysis was performed using SPSS software. Results : The findings indicate that dialectical behavior therapy was effective in increasing life expectancy and reducing negative automatic thoughts (Pvalue=0.001) and was not significantly effective in reducing suicidal ideation. Conclusions : Considering the effectiveness of dialectical behavior therapy on reducing negative thoughts and increasing the level of hope, therefore dialectical behavior therapy training is recommended to increase knowledge and empower students against depression and its components. Keywords: Dialectical behavior therapy, Suicidal ideations, Negative automatic thoughts, Life expectancy

Process evaluation of dialectical behavior therapy dissemination: Knowledge retention and recursive training effects

Dialectical behavior therapy (DBT) can be challenging to implement with fidelity to the model. Residential treatment settings are frequently overlooked as sites of implementation for DBT despite the potential benefits. This mixed-methods process evaluation examines the impact of DBT training in five residential programs on provider DBT-specific knowledge, staff turnover rates, and staff perceptions of training impact on their practice. Post-training staff knowledge levels varied considerably, but on average demonstrated substantial DBT-related knowledge retention. Staff turnover rates did not change significantly in four of five programs despite showing an overall trend in reduction. Qualitative results suggest substantial recursive training effects consistent with the DBT model. Themes emerged related to the impact of the training on effectiveness of practice with clients, application of DBT skills in staff personal lives, and positive effects on program culture. Results have implications for better understanding the mechanisms of successful dissemination of DBT across treatment settings.

Multisite Implementation and Evaluation of 12-Month Standard Dialectical Behavior Therapy in a Public Community Setting.

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.

The effect of therapist use of validation strategies on change in client emotion in individual dbt treatment sessions.

Dialectical behavior therapy (DBT) is a treatment for borderline personality disorder, a disorder for which emotion dysregulation is central. Within DBT, there are 6 explicitly defined validation strategies that range hierarchically from validation level (VL) 1 to VL 6. To date, there have been no studies on the frequency of use of VLs in actual DBT sessions. The aim of the current study was to explore DBT therapists' use of VLs and examine the relationship between VLs and change in a client emotion during therapy sessions. DBT treatment sessions (n = 121) across 35 participants in a DBT training clinic were coded for therapist use of VLs. A repeated-measures analysis of variance (ANOVA) was used to assess for change in therapist use of VLs over time and hierarchical linear modeling was used to correlate therapist use of these strategies with change in client emotion. Results indicated no significant relationship between overall frequency of VLs and change in client emotion. However, an increase in frequency of high VLs was associated with an increase in positive affect (PA) and a decrease in negative affect (NA) while an increase in frequency of low VLs was associated with a decrease in PA and no change in NA. An increase in frequency of VL 4 was associated with an increase in NA. VL 6 was associated with an increase in PA and a decrease in NA. Findings suggest that specific validation strategies may be related to session changes in affect and have implications for identifying potential mechanisms of change. (PsycINFO Database Record

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

BackgroundIn 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/ designThis 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.DiscussionIt 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 registrationClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 ‘retrospectively registered’.

Implementation of Dialectical Behavior Therapy in Residential Treatment Programs: A Process Evaluation Model for a Community-Based Agency.

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.

Can Trainees Effectively Deliver Dialectical Behavior Therapy for Individuals With Borderline Personality Disorder? Outcomes From a Training Clinic.

The aim of the current study was to evaluate the effectiveness of a 6-month course of comprehensive dialectical behavior therapy (DBT) provided in a training clinic with doctoral students as therapists and assessors. Clinical outcomes for 50 individuals with borderline personality disorder (80% female, Mage = 29.52 [SD = 9.64]) are reported. Reliable change indices and clinical significance were calculated for measures. Finally, our results were benchmarked against a "gold standard" randomized clinical trial (RCT; McMain etal., 2009). Analyses with both the full sample and the treatment completers indicate significant reductions in mental health symptomatology that were reliable, clinically and statistically significant, and comparable in effect size to the benchmarked RCT. This DBT training clinic produced good outcomes, comparable to that of a large RCT. Results have implications for who can provide DBT treatment, as well as improving access to DBT in community settings where training clinics may be located.

Dialectical Behavior Therapy Training and Desired Resources for Implementation: Results From a National Program Evaluation in the Veterans Health Administration.

Little is known about nonresearch training experiences of providers who implement evidence-based psychotherapies for suicidal behaviors among veterans. This national program evaluation identified the history of training, training needs, and desired resources of clinicians who work with at-risk veterans in a national health care system. This sequential mixed methods national program evaluation used a post-only survey design to obtain needs assessment data from clinical sites (N = 59) within Veterans Health Administration (VHA) facilities that implemented dialectical behavior therapy (DBT). Data were also collected on resources preferred to support ongoing use of DBT. While only 33% of clinical sites within VHA facilities reported that staff attended a formal DBT intensive training workshop, nearly 97% of participating sites reported having staff who completed self-study using DBT manuals. Mobile apps for therapists and clients and templates for documentation in the electronic health records to support measurement-based care were desired clinical resources. Results indicate that less-intensive training models can aid staff in implementing DBT in real-world health care settings. While more training is requested, a number of VHA facilities have successfully implemented DBT into the continuum of care for veterans at risk for suicide.

Surveying the Effectiveness of Dialectical Behavioral Therapy on Clinical Symptoms, Body Image, Self-Efficacy of People with Bulimia Disorder

This research is a semi-experimental research (pretest-posttest with control group) with the purpose of surveying the effectiveness of Dialectical Behavioral Therapy (DBT) on clinical symptoms, self-efficacy and body image of people with bulimia disorder. Statistical population of this study was women with bulimia disorder referred to nutrition clinics in Mashhad. The statistical sample of this research was 40 women with bulimia disorder chosen randomly by convenience sampling method and divided into two groups (20 women in experimental group and 20 women in control group), randomly. Applied tools were clinical symptoms questionnaire made by researcher, Sherer self-efficacy questionnaire and PSDQ (Physical Self-Description Questionnaire). For experimental group, Dialectical Behavior Therapy training sessions were held during 12 sessions, 75 minutes per session. During this time, control group didn’t get any intervention. After the 12th session, research tools performed on subjects again, as posttest. The data of questionnaires were analyzed by descriptive statistic methods of mean and standard deviation, and Inferential statistics of covariance analysis. The results showed that the clinical symptoms of experimental group were decreased comparing to control group, and self-efficacy and self-descriptin were increased. DOI: 10.5901/mjss.2016.v7n3s3p136

The Use of “Bug-in-the-Eye” Live Supervision for Training in Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) has been shown effective for the treatment of borderline personality disorder (BPD) and other high-risk, suicidal, and diagnostically complex populations. However, little has been written about how to train therapists in DBT’s highly structured framework of target hierarchies, behavioral chain analyses, and stylistic strategies. This case study illustrates the utility of a live supervision method known as “bug-in-the-eye” (BITE) in training a novice DBT therapist. “Willow,” a 35-year-old Hispanic female with BPD, engaged in 6 months of comprehensive DBT that included 25 individual therapy sessions. BITE supervision was implemented in Sessions 12 through 17. Therapist adherence to DBT was assessed from Sessions 8 to 21. Client and therapist satisfaction with BITE was assessed after Session 21. Results indicate that therapist adherence to DBT increased following the implementation of BITE supervision. In addition, both therapist and client found BITE supervision to be acceptable and minimally intrusive, with the therapist reporting increased confidence in delivering DBT. Furthermore, results indicate that DBT was effective in reducing Willow’s suicidal ideation and self-harm urges, decreasing her feelings and displays of intense fear and jealousy, and increasing her independence. Recommendations for implementing live supervision into DBT training settings are provided.

IOM REPORT ON PSYCHOSOCIAL INTERVENTIONS: COMMENTARY FROM A DBT PERSPECTIVE.

IOM REPORT ON PSYCHOSOCIAL INTERVENTIONS: COMMENTARY FROM A DBT PERSPECTIVE.

The Use of Dialectical Behavior Therapy (DBT) in Music Therapy: A Sequential Explanatory Study.

There are published examples of how dialectical behavior therapy (DBT) and music therapy are effectively being used as separate therapies in the treatment of individuals with a variety of mental health disorders. However, research examining DBT-informed music therapy is limited. The purpose of this study was to determine whether music therapists working in mental health settings are implementing components of DBT in their work, and if so, how and why; and if not, why not and what is their level of interest in such work. We used a sequential explanatory mixed-methods research design implemented in two phases. Phase 1 was a quantitative survey of board-certified music therapists (n=260). Due to a low survey response rate (18%), and to enhance the validity of the findings, Phase 2, an embedded qualitative procedure in the form of interviews with clinicians experienced in the DBT approach, was added to the study. Both survey and interviews inquired about DBT training, use of DBT-informed music therapy, music therapy experiences used to address DBT skills, and experiences of implementing DBT-informed music therapy. Respondents indicating they implement DBT-informed music therapy (38.3%) are using components and adaptations of the standard DBT protocol. Advantages of implementing DBT-informed music therapy were identified, and more than half of the respondents who do not implement DBT in their music therapy practice also perceived this work as at least somewhat important. Disadvantages were also identified and support the need for further research. Components of DBT are used in music therapy and are valued, but there is a lack of empirical evidence to inform, refine, and guide practice.

Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with Multi-Problems: Training, Adherence, and Retention

We evaluated the feasibility of DBT training, adherence, and retention preparing for a randomized controlled trial of Dialectical Behavior Therapy (DBT) adapted for Norwegian adolescents engaging in self-harming behavior and diagnosed with features of borderline personality disorder. Therapists were intensively trained and evaluated for adherence. Adherence scores, treatment retention, and present and previous self-harm were assessed. Twenty-seven patients were included (mean age 15.7 years), all of them with recent self-harming behaviors and at least 3 features of Borderline Personality Disorder. Therapists were adherent and 21 (78%) patients completed the whole treatment. Three subjects reported self-harm at the end of treatment, and urges to self-harm decreased. At follow up, 7 of 10 subjects reported no self-harm. DBT was found to be well accepted and feasible. Randomized controlled trials are required to test the effectiveness of DBT for adolescents.

Evaluation of an implementation initiative for embedding Dialectical Behavior Therapy in community settings

We examined the effectiveness of Dialectical Behavior Therapy (DBT) training in community-based agencies. Data were gathered at four time points over a 2-year period from front-line mental health therapists (N=64) from 10 community-based agencies that participated in a DBT implementation initiative. We examined change on therapist attitudes toward consumers with Borderline Personality Disorder (BPD), confidence in the effectiveness of DBT, and use of DBT model components. All measures were self-report. Participating in DBT training was associated with positive changes over time, including improved therapist attitudes toward consumers with BPD, improved confidence in the effectiveness of DBT, and increased use of DBT components. Therapists who had the lowest baseline scores on the study outcomes had the greatest self-reported positive change in outcomes over time. Moreover, there were notable positive correlations in therapist characteristics; therapists who had the lowest baseline attitudes toward individuals with BPD, confidence in the effectiveness of DBT, or who were least likely to use DBT modes and components were the therapists who had the greatest reported increase over time in each respective area. DBT training with ongoing support resulted in changes not commonly observed in standard training approaches typically used in community settings. It is encouraging to observe positive outcomes in therapist self-reported skill, perceived self-efficacy and DBT component use, all of which are important to evidence-based treatment (EBT) implementation. Our results underscore the importance to recognize and target therapist diversity of learning levels, experience, and expertise in EBT implementation.

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.

Barriers and Solutions to Implementing Dialectical Behavior Therapy in a Public Behavioral Health System

Dialectical behavior therapy (DBT) is an evidence-based treatment that is considered to be the standard of care in treating individuals with BPD, however there have been few published studies to identify the challenges and solutions for implementing DBT in community-based settings. The current study identified the barriers and solutions within a system-wide roll-out of DBT within a large, urban public health system encompassing both mental health and substance abuse treatment settings. Qualitative interviews were conducted with 19 clinicians receiving DBT training over a period of 13months. A content analysis revealed three themes that were identified as challenges to the DBT implementation process including program development and recruitment of patients, a lack of administrative support or organizational investment in DBT, and time commitment of DBT. In order to transfer DBT into a public behavioral health system, investment from both clinic- and system-level administrators is required. Strategies to prevent drift, such as incorporating atrain-the-trainer model, are discussed.