Author: Gary Jackson

Dialectical Behavior Therapy: A Primer 2012-03-01 CARLAT PUBLISHING

Then the therapist began to assign additional mindfulness homework whenever the behaviour occurred. After receiving only two or three additional assignments within the session, the client became motivated to remain mindful as long as possible. Because no comparison group was used in this study, we cannot conclude confidently that DBT-SS is responsible for these improvements. These data also do not verify that participants improved in emotion regulation or self-control skills or that these changes were responsible for improvements in challenging behaviors. The significant reductions in CBs combined with the heavy focus on skills training in DBT-SS leads us to believe that DBT-SS improved the coping abilities of participants and thereby improved their autonomy, positive life experiences, and relationships, but more research is needed to verify the process and outcomes for DBT-SS.

Borderline personal disorder features and utilization of treatment over two years

McPhail and Chamove (1989) did not mention what type of measures were used in their study of relaxation or how their data were analyzed, and initial treatment gains were completely lost at the 3-month follow-up. Lindsay et al. (2004) reported significant treatment effects, yet substantial missing data and failure of randomization were limitations of this study. Most of these studies were vulnerable to bias by not assessing outcomes using blind raters and not analyzing the impact of missing data when follow-up data were available. Although the studies by Nezu et al. (1991) and Hassiotis et al. (2009) were methodologically strong and showed that CBT and ABA can effectively reduce CBs, it was not clear if the posttreatment scores indicate remission from severe maladaptive behaviors because no cutoff scores for the outcome measure were reported. It is possible that many individuals with IDD in those studies continued to engage in severe maladaptive behaviors, even though they occurred less often. Treatment at ICS model consists of 1 hr of individual DBT per week and 1 hr of Skills System (SS) group skills training (DBT-SS).

Treatment of substance dependence in individuals with borderline personality disorder

To counteract this, use statements acknowledging that patient’s behaviors made sense in the context of their experiences. The ICS clinical team was comprised of the director (who is a licensed, independent clinical social worker and DBT trainer for Behavioral Tech, LLC) and two master’s level clinicians, all of whom were intensively trained in DBT through Behavioral Tech, LLC. For the duration of the study, the clinicians received weekly individual supervision with the program director and participated in weekly consultation team following standard DBT protocols (Linehan, 1993a). DBT experts employed at Behavioral Tech, LLC, rated a session of the program director and found her session to be in adherence with DBT. All participants received comprehensive treatment at Justice Resource Institute-Integrated Clinical Services (ICS). Most of the participants lived in community residences with 24-hr supervision, with the exception of 2 individuals who resided in more individualized settings that provide support as needed.

Overview of dialectical behavior therapy

Such a change in response by one individual to another’s behaviour more closely resembles the contingencies in relationships outside of therapy than would constant approval or attention. In another example, whenever the therapist rehearsed mindfulness with the client, the client would mindfully describe one thought and then immediately (and perhaps wilfully) deliver a set of unmindful thoughts. Highlighting and gaining insight into the pattern did not change it, nor did extinction have any obvious impact.

In contrast, during the first 2 years of DBT-SS only 2 of the 40 clients were in any of these settings. One client was in a psychiatric hospital for 20 days and the other client (noted earlier) was hospitalized, but it was not possible to get the exact number of days. Of the 27 clients with complete data on days in OSRT, a psychiatric hospital, or a forensic setting prior to DBT-SS, the average client spent 228 fewer days per year in these settings during DBT-SS.

Treatment Structure

1. There are clear benefits to enabling clients to move from locked settings to community residences.
2. Research studies have documented that CBs are often found in individuals with IDD, including dangerous behaviors such as aggression, self-injury, sexual offending, fire setting, and stealing, although prevalence estimates vary tremendously across studies.
3. To further accommodate the learning needs of the clients, a behavioral categorization system is used in to label increasing levels of intensity of maladaptive behaviors.

Adapted diary cards were integrated when possible; these forms were individualized, simplified, and used pictures to represent targets and skills. Standard DBT dialectical strategies, validation, contingency management, exposure, and DBT stylistic strategies are used. Simplification, shaping, and task analysis are often necessary when doing these strategies as well as when doing problem solving, cognitive modification, contingency management, and case management with this population to be assured the individuals understand each step within complex, multistep skills. Because there is not yet sufficient evidence that existing interventions sufficiently improve severe CBs of adults with mild/moderate IDD who live in community-based settings, it is reasonable to consider exploring additional options for evidence-based interventions. Because numerous complex issues must be effectively treated in order to achieve significant long-term reductions in CBs in individuals with IDD, it is clear that a sophisticated and comprehensive evidence-based treatment is needed. Dialectical behavior therapy (DBT) (Linehan, 1993a) is an one such treatment that is well suited for treating severe CBs because it incorporates the core strategies utilized in ABA and CBT approaches and the top therapy agenda is always to explicitly and thoroughly target severe CBs.

These findings suggest that modified DBT holds promise for effectively treating individuals with intellectual and developmental disabilities. There is a vast literature on the effectiveness of applied behavior analysis (ABA) for individuals with IDD and CBs (Grey & Hastings, 2005; M. Harvey, Luiselli, & Wong, 2009; Hassiotis et al., 2011; Luiselli, 2009; Luyben, 2009; Neef, 2001; Neidert et al., 2010; Robertson et al., 2005). Our search yielded only one other methodologically strong study evaluating changes in CBs, an RCT that found support for cognitive behavior therapy (CBT; Nezu et al., 1991). We found eight other studies (all RCTs), of which six did not measure CBs (e.g., only self-reports of anger intensity; Hagiliassis, Gulbenkoglu, Marco, Young, & Hudson, 2005; Rose, Dodd, & Rose, 2008; Rose, Loftus, Flint, & Carey, 2005; Rose, O’Brien, & Rose, 2009; Rose, West, & Clifford, 2000; Willner, Jones, Tams, & Green, 2002).

DBT–ACES in a multicultural community mental health setting: implications for clinical practice

The weekly goal group and corresponding goal worksheet target such skill deficits and help clients take greater responsibility for their actions and their lives. In addition to in-session use of behavioral strategies typical in standard DBT (such as contingency management, extinction, and exposure), formal behavioral treatment plans are used with this population; these often include the use of tangible rewards for adaptive behaviors and systematic contingency plans to address problematic behaviors. To further accommodate the learning needs of the clients, a behavioral categorization system is used in to label increasing levels of intensity of maladaptive behaviors. Through the process of behavioral analysis the client and therapist classify problematic behaviors as Red Flags (low intensity), Dangerous Situations (medium), and Lapse behaviors (high) to clarify phases of the person’s escalating chains of behavior. This framework improves self-awareness and facilitates early intervention with more adaptive self-regulation alternatives. In-session behaviours often provide the best opportunities to use therapist responses to shape client behaviour.

The DBT-SS model is designed to treat emotional dysregulation within a framework that accommodates the complex needs of individuals with cognitive impairment who demonstrate chronic patterns of CBs. This long-term, comprehensive treatment may enhance core self-regulation skills that are required for increasing independence and mobilizing effective self-determination. There are clear benefits to enabling clients to move from locked settings to community residences. This adapted DBT model utilizing the Skills System is designed to improve the individual’s core emotional, cognitive, and behavioral regulation capacities that are foundational to gaining increased levels of independence. Effectively addressing these lifelong severe problem behaviors appears to require long-term, comprehensive clinical support.

Clients with histories of sexual offending behaviors receive an additional hour of group per week to specifically address those clinical issues in addition to the standard DBT-SS. The DBT-SS individual therapy was adherent to the standard DBT structure of treatment. No accommodations were necessary related to the DBT (stages of treatment, hierarchy of targets, assumptions, consultation agreements, phone calls, and consultation team) described by Linehan (1993a). Clients who have difficulty reading and writing worked with their therapists to create shift summary forms that were completed by support staff, documenting adaptive and problematic target behaviors to facilitate behavior analysis.

We hypothesized that dialectical behavior individual therapy and the Skills System (DBT-SS) would help individuals with intellectual disabilities reduce severe CBs by teaching them self-control. As expected, there were large statistically and clinically significant reductions in all three behavior categories in the 1st year and the improvement was maintained over 4 years. Most of the improvement in the less severe behaviors occurred in the 1st year, but the more severe behaviors improved more gradually across the first 4 years. Statistical analyses estimated the there was a 76% reduction in serious behaviors (e.g., fewer violent, self-injurious, and illegal behaviors) across 4 years of DBT-SS. Eleven (28%) were inpatients in a psychiatric hospital, 11 (28%) were in out-of-state residential treatment (OSRT), and 5 (13%) were in jail or other locked forensic settings. Ten of the 11 clients in OSRT were in that setting for the two full years, and one was in OSRT for 16 months.

Choosing contingencies requires awareness of one’s own limits as well as the limits of the therapeutic milieu, when applicable. For example, on an inpatient ED unit, the program contingency for not meeting the weekly 1- to 2-pound weight goal for several weeks might be to add a nasogastric tube. A strong consultation team will help each of its members to set contingencies with their clients that will reduce (not add to) burnout as well as support therapists when they flex their limits to help shape a client behavior.