Dialectical Behavioural Therapy Skills for Employment

The complex relationship between mental health and employment is transactional and unique to each individual. Thus the decision to commence (or return) to employment for this population requires an individualized formulation emphasizing the dialectical tension between the benefits of employment and stressors in the workplace. In addition, unemployment is associated with a number of social exclusion risks which may impact upon an individual’s mental health. Vocational functioning in those with personality disorder (PD) is more compromised than social functioning and does not improve in direct association with change in mental health symptoms. Obtaining and retaining employment requires the ability to manage workplace emotions, behaviour, and relationships. Dialectical behavioural therapy (DBT) is an evidence-based treatment that addresses these key areas of dysfunction—adaptations for employment include DBT-W, DBT-ACES, and DBT-SE, each with their own focus. Feasibility studies have shown these adaptations are acceptable to and may be effective for participants.

DBT in Forensic Settings

DBT’s popular application in correctional and mental health forensic settings began within five years of the publication of Linehan’s original 1993 treatment manual. Its use in general correctional programming is arguably the first extension of DBT to non-clinical populations. From both mental health and criminological perspectives, its application rationale is strong. Current review of published implementations finds standard comprehensive DBT modifications are consistent with published modifications for other settings/clinical populations. These include skills-only models, shortening skills session length, and expanding targets to more directly address dynamic risk factors and stressors specific to institutional settings. The most frequently cited modifications are simple changes to language and examples from the original manuals that do not change DBT principles or critical components/procedures. Formative studies to date provide support for DBT in forensic settings; wide variations in measurement, implementation, and methodological rigor require further research to reach conclusions of effectiveness.

Understanding the Bio in the Biosocial Theory of BPD

Originally, the biosocial model of borderline personality disorder (BPD) was based on clinical experience and intuition. Within the last 30 years, tremendous progress has been made strengthening the empirical basis for this model. Currently, most researchers postulate three core domains of BPD psychopathology: affective dysregulation, interpersonal disturbances, and problems in identity. Whereas affective dysregulation research has the strongest empirical support, morphological and functional neuroimaging findings point to alterations of the central regions of the emotion regulation circuitry: prefrontal cortex, amygdala, hippocampus, and insula. It is unclear whether these alterations are due to early adverse childhood experience or instead are more genetically driven, resulting in a pattern of emotional hypersensitivity,. However, evidence shows that successful DBT changes dysfunctional emotions and cognitive patterns as well as related neurobiological underpinnings. This chapter discusses the current state of research on the biological underpinnings of BPD.

The Dialectical Dilemmas of Implementation

Implementing a behavioural health programme involves more than simply providing training to healthcare providers. System-wide behavioural change is necessary, often including prevailing attitudes, values, and mindsets. This process frequently involves multi-faceted, deliberate activity across an organization’s many levels (clinicians, teams, administrators, managers, etc.). As a complex, multi-modal treatment for severe and life-threatening problems, implementing DBT presents unique challenges. A dialectical stance which finds a synthesis between opposing, but true, ideas helps resolve the inevitable tensions associated with introducing and sustaining DBT. This chapter identifies three dialectical dilemmas which commonly occur when implementing DBT, and offers examples of each from real-world projects. It discusses the tension between adopting DBT with full fidelity and adapting it in response to the context in which it is delivered; the tension between short-term risk management decisions and persisting with DBT delivery and maintaining a long-term view; and the tension between meeting both the organizational system’s needs and the needs of people delivering the treatment. Finally, it offers practical suggestions for those considering implementing a DBT programme.

Shaping Therapists Towards Adherence

DBT is a complex principle-driven treatment, with an abundance of treatment strategies, and is applied by contextual factors. This chapter reviews studies investigating whether adherence to the DBT treatment manuals is related to outcome in the treatment and which implementation strategies may promote therapist adherence. It includes a brief introduction to the DBT-ACS, the DBT adherence rating scale that has been used for research purposes, and how training, supervision, and effective use of consultation team all show promise as approaches that enhance therapists’ adherence to and competence in the model. It explores common therapist adherence pitfalls, provides some suggestions for therapists seeking to avoid these difficulties, and promotes the likelihood of providing adherent DBT. Finally, it includes examples of common problems, which pull therapists out of adherence, that occur in consulation team, individual therapy, and group skills class, and offers potential solutions.

Using Novel Technology in Dialectical Behaviour Therapy

Dialectical behaviour therapy is a comprehensive behavioural treatment that can be applied trans- and multi-diagnostically to address clinical problems involving behavioural, emotional, or cognitive dysregulation, and target mild to severe dysfunction, including high suicide risk. Dissemination of treatment, particularly to those with severe mental illness and those underserved, is an important primary target for DBT. Clinicians are trained to provide DBT via traditional face-to-face therapy, but many individuals who need DBT do not receive it as the need still exceeds the number of trained and available clinicians. This chapter discusses the conceptual match between elements of DBT, its theoretical and scientific foundation, and how new technologies can be used effectively for treatment dissemination purposes. It provides an overview of the products already developed for DBT that include technology, and discusses future endeavours and highlights possible future developments, while cautioning against potential pitfalls that can threaten core DBT values.

The Structure of DBT Programmes

The look and feel of Dialectical Behaviour Therapy (DBT) is heavily influenced by the structure of the programme on which each session and meeting rest. Programme structure has always been a focus for Linehan, the treatment developer, who wove recommendations throughout her descriptions of the treatment. This chapter attempts to pull together in one place recommendations from the literature, real-world practice, and guidance of the model developer and experts to assist team leaders who are creating a DBT programme, or who wish to review their existing programme structure. Decisions about programme structure should be driven by a deep understanding of Linehan’s Functions of Treatment, as well as the principles and practices of behaviour therapy, and DBT in particular. A programme manual and routinization of administrative practices ensure that programme structure is well defined, supportive for clinicians and clients, and resistant to treatment drift.

Dialectical Behaviour Therapy in Routine Clinical Settings

Dialectical Behaviour Therapy (DBT) has been researched in routine clinical settings in Europe, the US, and Australasia. This chapter reports on those studies, five evaluated outcomes over 12 months of intervention, and eight studies over five or six months. The majority of studies showed a significant reduction in self-injurious behaviour, but significant differences were found in secondary outcomes of depression, quality of life, psychiatric hospital admission days, and general psychiatric symptoms. Adaptations of DBT in routine care settings included briefer phone coaching time, reduced length of skills training, individual skills training, and skills training only. Two studies evaluated an intervention following completion of standard DBT. Overall, the studies reported showed a large difference in the amount of training and supervision received by clinicians and fidelity monitoring was included in only four studies. In addition to quantitative outcomes, this chapter reports on qualitative research describing the experience of DBT participants.

Dialectical Behaviour Therapy

Dialectical Behaviour Therapy (DBT) synthesizes principles from behaviourism, Zen, and dialectics. Originally developed to address the comprehensive problems of adult women with a diagnosis of borderline personality disorder (BPD) and repetitive suicidal and self-harming behaviours, the flexibility of its principle-driven approach has led to its deployment in treating a wider range of client groups and in more varied settings than was originally conceptualized. This chapter begins by briefly describing the origins of DBT and orients the reader to the handbook by describing distinctive features of the treatment in terms of its theoretical foundations, structure, and clinical features. Developments over the last 25 years in the evidence-base, adaptations, and implementation of DBT and where these are addressed in the Handbook are subsequently outlined.

Future Directions for Dialectical Behaviour Therapy

The Oxford Handbook of DBT has reviewed and considered theoretical, structural, clinical, and implementation aspects of DBT, comprehensively detailing its journey in research and clinical practice since the landmark, yet small, RCT published in Archives of General Psychiatry over 25 years ago (Linehan et al, 1991).. This closing chapter reflects on the treatment’s achievements since that first trial and considers future directions in relation to theory, clinical outcomes, adaptations, and implementation in practice. Building on initial demonstrations of efficacy to deliver any intervention effectively at scale, reaching all those who may benefit, requires changes in dissemination, implementation and research strategies. Targeting research on treatment mechanisms that drive change may usefully inform this agenda. This chapter explores these issues and concludes by discussing challenges within the wider psychotherapy field and their implications for DBT.