Evaluation of behavioural skills training for teaching abduction-prevention skills to young children. Journal of Applied Behavior Analysis, 38, 67-78. Miles, N.I., & Wilder, D.A. The effects of behavioral skills training on caregiver implementation of guided compliance. Journal of Applied Behavior Analysis, 42(2), 405-410. Share Cognitive-Behavioral Therapy has become increasingly popular with therapists and the general public. Surveys completed by therapists indicate that CBT is quickly becoming the preferred method of treatment many clinicians utilize with their patients. Additionally, individuals can utilize CBT self-help books to practice these techniques on their own, and this is becoming. Understanding your clients’ motivations is essential for being able to recommend the most appropriate and effective steps to helping them achieve their lifestyle goals. In fact, identifying their motivations and level of self-efficacy can mean the difference between a client making short-term, temporary fixes and truly achieving lasting, lifestyle changes.
Dialectical behavior therapy (DBT) is a cognitive behavioral treatment that was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD) and it is now recognized as the gold standard psychological treatment for this population. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders. As such, DBT is a transdiagnostic, modular treatment.
The term “dialectical” means a synthesis or integration of opposites. The primary dialectic within DBT is between the seemingly opposite strategies of acceptance and change. For example, DBT therapists accept clients as they are while also acknowledging that they need to change to reach their goals. In addition, the skills and strategies taught in DBT are balanced in terms of acceptance and change. The four skills modules include two sets of acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness).
Many behavioral therapies are ultimately unsuccessful because patients lose interest or can’t commit to the schedule for an extended period of time. One of the ways that DBT is unique is its flexibility. Patients can continue DBT in four different ways: Individual therapy, skills training, phone coaching and therapist consultations.
DBT includes four behavioral skill modules, with two acceptance-oriented skills (mindfulness and distress tolerance) and two change-oriented skills (emotion regulation and interpersonal effectiveness).
There is increasing evidence that DBT skills training alone is a promising intervention for a wide variety of both clinical and nonclinical populations and across settings.
Clients who receive DBT typically have multiple problems that require treatment. DBT uses a hierarchy of treatment targets to help the therapist determine the order in which problems should be addressed. The treatment targets in order of priority are:
DBT is divided into four stages of treatment. Stages are defined by the severity of the client’s behaviors, and therapists work with their clients to reach the goals of each stage in their progress toward having a life that they experience as worth living.
For some people, a fourth stage is needed: finding a deeper meaning. Linehan has posited a Stage 4 specifically for clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.
To date, there have been nine published randomized controlled trials and five controlled trials of DBT (view all publications). Two of these trials (carried out in our research clinic) specifically targeted highly suicidal women with BPD, and we are in the midst of a third trial targeting the same population. In our first study, results favoring DBT were found in each DBT target area. Compared to treatment-as-usual (TAU), DBT subjects were significantly less likely to attempt suicide or to self-injure, reported fewer intentional self-injury episodes at each assessment point, had less medically severe intentional self-injury episodes and lower treatment drop-out, tended to enter psychiatric units less often, had fewer inpatient psychiatric days, reported less anger, and improved more on scores of global as well as social adjustment. In our second study, we compared DBT to a much stronger control condition, treatment by non-behavioral community experts (TBE). In comparison to TBE, DBT reduced suicide attempts by half, had less medically severe self-injurious episodes, lower rates of treatment drop-out, and fewer admissions to both emergency departments and inpatient units due to suicidality. In studies of DBT for BPD patients that have been conducted outside of our research clinic, DBT has outperformed control treatments in reducing intentional self-injury, suicidal ideation, inpatient hospitalizations, hopelessness, depression, dissociation, anger, and impulsivity. In studies of substance dependent BPD patients conducted at our research clinic as well as at other sites, DBT has been found to be superior to control treatments in reducing substance use.
Accumulating evidence indicates that DBT reduces the cost of treatment. For example, the American Psychiatric Association (1998) estimated that DBT decreased costs by 56% – when comparing the treatment year with the year prior to treatment – in a community-based program. In particular, reductions were evident by decreased face-to-face emergency services contact (80%), hospital days (77%), partial hospitalizations (76%), and crises bed days (56%). The decrease in hospital costs (~$26,000 per client) far outweighed the outpatient services cost increase (~$6,500 per client).
The cost effectiveness of DBT also extends past the treatment year as evidenced by a recent examination in a VA hospital setting. Meyers and colleagues (2014) found that veterans who received DBT treatment had significantly decreased the use of outpatient mental health services in the following year by 48%. Perhaps more importantly, the study demonstrated that utilization of high-cost inpatient services decreased by 50% and length of stay by 69%. The authors concluded that each individual in DBT treatment utilized almost $6,000 less in total services in the year following DBT treatment as compared to the year prior to DBT. In their sample of 41 clients, the total cost decrease was nearly a quarter of a million dollars. Interestingly, the authors also concluded that the cost of providing DBT treatment was not statistically different (actually, about $400 less) than the average outpatient costs from the year before DBT.
Cost effectiveness studies in other countries are difficult to accurately compare with the U.S. due to fluctuations in currency exchange rates, compounding inflation, and vastly different costs in healthcare. However, similar results were reproduced in Australia where a 6-month DBT program reduced number of hospital days by 70% (Prendergast & McCausland, 2007). Another Australian (Pasieczny & Connor, 2011) study found that DBT reduced costs about 33% compared to treatment-as-usual over 6 months. Strikingly, those receiving treatment-as-usual incurred six times more costs due to inpatient bed days. Similar results were reproduced in Sweden (Perseius et al., 2004) and Wales (Amner, 2012).
Alternatively, in attempting to examine benefit instead of cost a Washington State, juvenile offender institution estimated that a $38.05 financial benefit was achieved for every dollar spent on their DBT program (Aos et al., 2004). Similarly, a study in the United Kingdom found that for every 36GBP spent on DBT a 1% reduction in self-harm was achieved (Priebe, 2012). When examining the overall societal cost (based on resource consumption and productivity lose), a German study calculated a nearly 50% reduction in societal cost-of-illness when comparing the treatment year and the year following treatment (Wagner et al., 2014). In summary, economic evaluations of DBT indicate the following: a) reduction in costs when compared to the prior treatment year; b) reduction in costs when compared to treatment-as-usual; c) decrease in long-term service utilization in high service-utilizing individuals; d) a potential financial benefit to the treatment institution and; e) a potential decrease in societal costs.
American Psychiatric Association (1998). Gold Award: Integrating dialectical behavior therapy into a community mental health program. Psychiatric Services, 49(10). 1338–1340.
Amner, K. (2012), The Effect of DBT Provision in Reducing the Cost of Adults Displaying the Symptoms of BPD. British Journal of Psychotherapy, 28: 336–352. doi:10.1111/j.1752-0118.2012.01286.x
Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Olympia: Washington State Institute for Public Policy, available at http://www.wsipp.wa.gov/rptfiles/04-07-3901.pdf
Meyers, L. L., Landes, S. J., & Thuras, P. (2014). Veterans’ service utilization and associated costs following participation in dialectical behavior therapy: a preliminary investigation. Military Medicine, 179(11), 1368-1373.
Pasieczny, N., & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings: an Australian controlled trial. Behaviour Research andTtherapy, 49(1), 4-10.
Prendergast, N., & McCausland, J. (2007). Dialectic behaviour therapy: a 12-month collaborative program in a local community setting. Behaviour Change, 24(01), 25-35.
Perseius, K-I., Samuelsson, M., Andersson, E., Berndtsson, T., Götmark, H., …. Zinkler, M. (2004). Does dialectical behavioural therapy reduce treatment costs for patients with borderline personality disorder. A pilot study. Vårdi Norden, 24, 27-30.
Priebe, S., Bhatti, N., Barnicot, K., Bremner, S., Gaglia, A., Katsakou, C., & … Zinkler, M. (2012). Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: A pragmatic randomised controlled trial. Psychotherapy And Psychosomatics, 81(6), 356-365. doi:10.1159/000338897
Wagner, T., Fydrich, T., Stiglmayr, C., Marschall, P., Salize, H. J., Renneberg, B., … & Roepke, S. (2014). Societal cost-of-illness in patients with borderline personality disorder one year before, during and after dialectical behavior therapy in routine outpatient care. Behaviour Research and Therapy, 61, 12-22.
Wunsch, E.-M., Kliem, S., Kröger, C. (2014). Population-based cost–offset estimation for the treatment of borderline personality disorder: Projected costs in a currently running, ideal health system, Behaviour Research and Therapy, 60, 1-7
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