by Michael D. Anestis, M.S.
We spend a lot of time on PBB presenting you with data demonstrating that particular forms of psychotherapy are more or less successful on treating particular forms of mental illness. The ones with sufficient evidence supporting their use are considered empirically supported treatments (ESTs) and are promoted as front line forms of health care. That being said, a point that is raised here and elsewhere by individuals who are not entirely convinced that this is the right approach is that we need to be certain that results from controlled studies actually translate to comparable levels of success in real world practice. In this sense, I completely agree with these folks, even though we hold such strongly differing opinions on the answer to the broader question.
From time to time, Joye and I have written articles discussing the evidence for ESTs in real world practice (click here for one example) and, fortunately, the general trend seems to be that what we find in the lab is no different than what we find in clinical practice, even though a number of variables are different when we don't exert as much control over things. Today, I'd like to add to our description of "effectiveness" research - studies looking at the impact of ESTs in real world practice - by covering an article written by Nathan Pasieczny and Jason Connor that is in press at Behaviour Research and Therapy. In this article, the authors examined the effectiveness of dialectical behavior therapy (DBT), the gold standard treatment for borderline personality disorder (BPD), in an Australian sample. We have described this treatment in detail in earlier articles, so simply click on the DBT link to read more about the specifics of the approach.
To open their manuscript, the authors noted that, despite a heavily funded health care system that values evidence-based care, receiving such treatment for BPD in Australia is fairly difficult. One reason for this, they noted, is that the vast majority of the research supporting the use of DBT has been conducted in labs and those that have been conducted in "real world" practice have been uncontrolled and, as such, unable to provide strong enough data. As such, there has been even more resistance to the use of DBT than there is for other ESTs.
In an effort to address this gap, the authors designed a study in which individuals from a large inner city integrated public mental health service who met diagnostic criteria for BPD were assigned to either receive six-months of DBT or treatment as usual (TAU) pending entry to DBT when room became available for additional patients. Based upon need, some clients were offered an additional six months of DBT as well. All participants were required to attend bimonthly meetings with an assigned psychiatrist as well for medication monitoring, although no therapy or counseling took place at those sessions.
Impressively, the participants (and therapists) in this study followed the complete DBT protocol outlined by Linehan (1993). Participants assigned to the DBT group attended weekly individual psychotherapy (1 hour) and group skills training (2 hours) and had access to phone coaching calls between sessions. Any participant who missed four consecutive meetings at any point during treatment was considered to have dropped out of the program. Additionally, DBT therapists were required to attend a weekly consultation team meeting (1.5 hours).
A total of 18 therapists provided DBT services to patients and they ranged widely in their education levels and professional titles (e.g., social worker, clinical nurse). All DBT therapists received at least four days of basic training from local DBT experts. Additionally, four of the DBT therapists received ten days of intensive training from Behavioral Tech, Linehan's training organization.
Although no manualized publicly available treatment adherence instruments were available, the authors assessed treatment adherence by developing a measure based upon one outlined in the DBT manual. Results from that measure revealed high levels of adherence (mean = 10.75 out of 12; range = 9-12).
So what were the results? First of all, prior to treatment, the folks in the DBT group did not differ from folks in the TAU group on any demographic or treatment relevant variable (e.g., age, number of suicide attempts, previous hospitalizations, depression, anxiety). Additionally, the DBT group (93%) and TAU group (87%) did not differ on the proportion of patients completing six-months of treatment, an important point in considering whether or not a treatment is producing effective results.
Taking things a step further, participants in the DBT group exhibited a greater reduction in suicide attempts, non-suicidal self-injury (NSSI), emergency room visits, psychiatric admissions, and inpatient days as compared to the TAU group. In addition to these observable outcomes, half of the sample (45 individuals) were randomly selected to fill out questionnaires on other mental health issues and, after six months of treatment, the DBT group exhibited greater improvement on depression, suicidal ideation, state anxiety, trait anxiety, and general mental health symptoms. Lastly, although the DBT group did not differ from the TAU group in employment status prior to treatment, after treatment 60% of the DBT sample was employed as compared to only 20% of the TAU group (p < .01).
The authors then examined the results for participants who were invited to take part in an additional 6 months of DBT and found that these participants demonstrated further gains in all areas except psychiatric admissions and number of inpatient days.
Clearly, the above referenced results are impressive and indicate that DBT can have significant impact in real world settings; however, the authors did not stop here. They also examined the degree to which the DBT training of specific therapists impacted results for their clients. The results indicated that participants whose therapists received more intensive DBT training exhibited greater improvement in both number of suicide attempts and NSSI.
The last set of analyses ran by these authors examined the cost effectiveness of implementing DBT. After all, if the treatment produces better results but is unaffordable, the importance of the findings would be minimal. As it turns out, the service saved an average of $5,927 (Australian dollars) per patient receiving DBT and a total of $237,080 over the three years of the program. Due to the lack of change in psychiatric admissions and inpatient days in the group receiving an additional six months of DBT, the cost-effectiveness results were not the same for that additional component of treatment ($10,769 per patient in DBT vs $7,014 per patient in TAU).
So...what does all of this mean? Without question, DBT resulted in substantially greater improvements for individuals diagnosed with BPD across a wide range of outcomes as compared to TAU. In addition to this, when the treatment was administered simply as a 6-month approach, it resulted in significant financial savings, thereby indicating that it is perfectly reasonable to expect that such a program could be implemented in real world practice. Lastly, the DBT group as a whole demonstrated impressive results, patients treated by the clinicians who received more intensive training demonstrated even better improvement, indicating that low levels of training can be sufficient, but greater training will result in better results for patients.
Now, obviously this is only one study, the authors were not able to examine the degree to which each component of DBT was actually necessary in order to produce the effects, and no measures of some of the core components of BPD were used (e.g., emotion dysregulation, distress tolerance, mindfulness). That being said, this adds to the growing evidence that ESTs do, in fact, translate perfectly well to the day-to-day practice of therapists not associated with research labs.
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If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.
Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University
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