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Evaluation of a dialectical behavior therapy-informed partial hospital program: outcome data and exploratory analyses

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  • Triangle Area Psychology (TAP) Clinic, United States, Durham NC

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The use of dialectical behavioral therapy (DBT) among a variety of programs and patients has recently exploded. Of particular interest is the use of DBT in partial hospital (PH) programs due to the high number of severely ill and suicidal patients who participate in these programs. Recently, Lothes, Mochrie and St. John (2014) examined data from a local DBT-informed PH program and found significant reductions in depression, anxiety, hopelessness, and degree of suffering from intake to discharge. The present study examined these same four symptom constructs by assessing intake and discharge data for additional individuals enrolled in this DBT-informed PH program. In addition, lengths of stay and acuity ratings were analyzed to explore the relationship between these variables and symptom constructs. Significant symptom reduction in depression, anxiety, hopelessness, and degree of suffering from intake to discharge was found among high and medium acuity patients, replicating the results of Lothes et al. (2014). Further, individuals with the highest acuity saw the largest reduction in hopelessness symptoms the longer they participated in the program (i.e., a significant interaction effect between acuity and length of stay). This is meaningful given the connection between hopelessness and suicidal ideation/action, which is of particular concern for those charged with treating clinical populations. DBT-informed PH programs may be a cost-effective and useful way to treat high-risk patients who come from inpatient facilities. Future studies may wish to create follow-up periods (i.e., 3 months, 6 months) post-discharge to assess if symptom reduction remains.
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[page 150] [Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:219]
Research in Psychotherapy: Psychopathology, Process and Outcome 2016; volume 19:150-156
Introduction
There is growing literature examining the use of di-
alectical behavior therapy (DBT; Linehan, 1993a) in nu-
merous settings with a variety of patients (Panos, Jackson,
Hasan, & Panos, 2013). DBT was originally developed as
a one-year outpatient psychosocial treatment for individ-
uals with borderline personality disorder (BPD; American
Psychiatric Association, 2000; Simpson et al., 1998). Of-
ficial DBT programs include four main components: skills
group, individual therapy, crisis coaching and DBT con-
sultation team. The skills group is where patients work
through the four modules of DBT (i.e., core mindfulness,
distress tolerance, emotion regulation, and interpersonal
effectiveness) and are given handouts and worksheets for
structured homework of practicing skills among group
sessions (Linehan, 2014). These groups typically last 1.5
to 2.5 hours per week and are led by a facilitator and co-
facilitator. In addition, patients receive individual therapy
from a DBT-trained therapist who, among other respon-
sibilities, reinforces skills learned in group through appli-
cation to personal situations as identified using
self-monitoring forms (i.e., diary/skills cards) the patient
brings to each session (Linehan, 1993b).
Another component of DBT, a 24-hr crisis coaching
phone, can be accessed at any time the patient needs
coaching or help in a crisis situation to avoid engaging in
Evaluation of a dialectical behavior therapy-informed partial hospital
program: outcome data and exploratory analyses
John E. Lothes II,1Kirk D. Mochrie,2Emalee J.W. Quickel,3Jane St. John4
1Department of Psychology, University of North Carolina Wilmington, Wilmington, NC; 2Psychology
Department, East Carolina University, Greenville, NC; 3Psychology Department, Loyola University Maryland, Baltimore, MD;
4Delta Behavioral Health, Wilmington, NC, USA
ABSTRACT
The use of dialectical behavioral therapy (DBT) among a variety of programs and patients has recently exploded. Of particular interest
is the use of DBT in partial hospital (PH) programs due to the high number of severely ill and suicidal patients who participate in these
programs. Recently, Lothes, Mochrie and St. John (2014) examined data from a local DBT-informed PH program and found significant re-
ductions in depression, anxiety, hopelessness, and degree of suffering from intake to discharge. The present study examined these same
four symptom constructs by assessing intake and discharge data for additional individuals enrolled in this DBT-informed PH program. In
addition, lengths of stay and acuity ratings were analyzed to explore the relationship between these variables and symptom constructs. Sig-
nificant symptom reduction in depression, anxiety, hopelessness, and degree of suffering from intake to discharge was found among high
and medium acuity patients, replicating the results of Lothes et al. (2014). Further, individuals with the highest acuity saw the largest re-
duction in hopelessness symptoms the longer they participated in the program (i.e., a significant interaction effect between acuity and
length of stay). This is meaningful given the connection between hopelessness and suicidal ideation/action, which is of particular concern
for those charged with treating clinical populations. DBT-informed PH programs may be a cost-effective and useful way to treat high-risk
patients who come from inpatient facilities. Future studies may wish to create follow-up periods (i.e., 3 months, 6 months) post-discharge
to assess if symptom reduction remains.
Key words: Dialectical behavior therapy; Partial hospital; Symptom reduction.
Correspondence: John E. Lothes II, Department of Psychology,
University of North Carolina Wilmington, 601 S. College Rd.,
Wilmington, NC 28403, USA.
Tel: +1.910.962.3370 - Fax: +1.910.962.7010.
E-mail: lothesj@uncw.edu
Contributions: KDM conducted literature searches and provided
summaries of previous research studies as well as helped to design
the study. JLII and JSJ were the primary data collectors and wrote
the protocol. EJWQ significantly contributed to analyzing the data,
writing the results section, and editing the manuscript. All authors
have contributed to and have approved the final manuscript.
Conflict of interest: the authors declare no potential conflict of in-
terest.
Citation: Lothes, J.E.II, Mochrie, K.D., Quickel, E.J.W., & St.
John, J. (2016). Evaluation of a dialectical behavior therapy-in-
formed partial hospital program: outcome data and exploratory
analyses. Research in Psychotherapy: Psychopathology, Process
and Outcome, 19(2), 150-156. doi: 10.4081/ripppo.2016.219
Received for publication: 13 June 2016.
Accepted for publication: 5 October 2016.
This work is licensed under a Creative Commons Attribution Non-
Commercial 4.0 License (CC BY-NC 4.0).
©Copyright J.E. Lothes II et al., 2016
Licensee PAGEPress, Italy
Research in Psychotherapy:
Psychopathology, Process and Outcome 2016; 19:150-156
doi:10.4081/ripppo.2016.219
Non-commercial use only
[Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:219] [page 151]
DBT-informed partial hospital program outcomes
the ineffective behaviors that resulted in referral to DBT
in the first place. The remaining component, the DBT con-
sultation team, sustains therapists in weekly meetings fa-
cilitating on-going personal practice of DBT by therapists,
providing a group mindfulness practice, supporting fi-
delity to the DBT model, and assisting therapists’ effec-
tiveness via discussions of therapist/patient treatment
interfering behaviors. Medical treatment is arranged as
needed but is not an identified component of DBT. Fully
implemented DBT programs have been shown to be ef-
fective in reducing suicidal behavior and emotion dysreg-
ulation for individuals with BPD (Linehan, 2014).
Interestingly, more recently DBT has been used to
treat a wide variety of disorders (Koerner, 2012) over
varying lengths of time (Lothes, Mochrie, & St. John,
2014). Of particular interest is the use of DBT in partial
hospital (PH) programs, which are used to help stabilize
patients after a brief inpatient stay, or as an alternative to
inpatient hospitalization (Neuhaus, 2006). PH programs
allow patients with high-risk behaviors, such as suicide
attempts, to transfer to a lower level of care after hospi-
talization. High-risk patients typically include those who
experience specific mental health disorders, such as BPD,
which are often accompanied by symptoms such as sui-
cidal ideation (Pompili, 2012).
The PH program model can be especially effective in
treating high-risk populations if effective treatment ap-
proaches are utilized. While there is a certain level of acu-
ity in terms of medical necessity (as defined by the third
party payers of each patient) that needs to be met to qual-
ify for enrollment in a PH program, very little research
has examined if acuity plays a role in how programs lead
to symptoms reduction in patients. Although not specifi-
cally identified as a component of PH programs, one ra-
tionale for these programs is to save money by reducing
future hospitalizations. In addition, PH programs can be
an opportunity for teaching patients coping skills that they
can utilize before stepping down to an intensive outpatient
program or to individual therapy, and these skills can con-
tribute to sustained stability at discharge, a strong strategy
with the potential to contribute to lowering inpatient re-
cidivism rates.
DBT may be particularly suited to PH programs due to
the high-risk patients that are typically treated in this set-
ting. Unfortunately, individuals with high-risk behaviors
have been poorly treated in the past; however, with the
emergence of DBT, therapists are better able to help reduce
these symptoms (Panos et al., 2013). DBT in a PH setting
requires an obviously modified schedule of skills delivery,
and a shortened duration of individual therapy; however,
all components of DBT are incorporated. DBT-informed
PH programs have provided preliminary evidence in reduc-
ing symptoms of anxiety and depression from intake to dis-
charge (Lothes et al., 2014); however, further research is
needed to confirm treatment outcome data. PH programs
are increasingly being required to measure treatment effec-
tiveness and patient outcomes for insurance coverage pur-
poses (Granello, Granello, & Lee, 1999; Bateman & Fon-
agy, 2003). Of particular concern is the time needed for
patients to be involved in a PH program (e.g. length of stay)
before significant symptom reduction can be found. Inter-
estingly, Bateman and Fonagy (2003) found that individu-
als who complete long-term (several months to 18 months)
PH programs use less inpatient services and have a higher
intensity and a longer duration of functional improvements
than those who seek other treatment or do not receive any
treatment. More recently, Lothes et al. (2014) conducted a
study assessing symptom reports from intake to discharge
with a sample of 38 patients enrolled in a DBT-informed
PH program. Results showed significant reductions from
intake to discharge in depression, anxiety, hopelessness,
and degree of suffering. Using DBT in PH program settings
can be effective in reducing symptoms of various mental
health disorders. To the best of our knowledge, no known
research exists that examines variables like length of stay
in the context of DBT-informed PH programs. In addition
to overall efficacy of these program models, indicators such
as length of stay that have an impact on funding and pro-
gram evaluation considerations must be examined concur-
rently. While there is a certain level of acuity in terms of
medical necessity that needs to be met to qualify for enroll-
ment into a partial hospital program, very little research has
examined if acuity plays a role in symptom reduction.
Further assessment of outcome data in DBT-informed
PH programs is needed due to the relatively novel inves-
tigation of this topic. For example, the question of what
length of time is needed to achieve symptom reduction in
this population still rears its head. In addition, very little
current research has been conducted assessing acuity rat-
ings in this population. Examining acuity could provide
useful data as to which patients are more likely to have
quicker symptom reduction and progress through the pro-
gram at a faster rate, thus allowing program directors to
make better recommendations to insurance companies
about the optimal program length of stay based on indi-
vidualized patient needs; alternatively, allowing patients
to stay in the program long enough for true change to
occur may prevent relapse and save money on future hos-
pitalizations and treatment.
Given these unknowns in the literature, the current
study has two specific aims. First, the present study aims
to replicate the previous study by Lothes et al. (2014) by
measuring levels of reported depression, anxiety, hope-
lessness and degree of suffering at intake and discharge
to assess the effectiveness of a DBT-informed PH pro-
gram in the southeast region of the United States. The
present study included individuals with broader diagnoses
(e.g., eating disorders, substance dependence, psychotic
disorders) to increase generalizability. In addition, the
sample size was substantially larger providing sufficiently
more power for more in depth statistical analyses. Second,
the present study aims to include analyses that consider
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Article
the impact of patient acuity and length of stay on symp-
tom reduction. Understanding how these variables relate
to patient outcomes may inform decisions made regarding
treatment design and implementation, as well as policy
decisions related to funding and relapse prevention.
The PH program is the same program evaluated in the
first study by Lothes et al. (2014), which is an intensive
day treatment option for adults. Patients meet 5 days per
week, for 4 hours each day. During this time they are en-
gaged in a curriculum based on Linehan’s (1993b) DBT
manual with in-depth skills training. The program has re-
cently begun to implement Linehan’s (2014) new DBT
Skills Training Manual into practice; however, the partic-
ipants for this analysis were still being taught with the pre-
vious manual. Treatment includes skills training in
mindfulness, emotion regulation, distress tolerance, and
interpersonal effectiveness, a morning check in process
group, individual therapy, 24-hour coaching phone con-
sultations, DBT team staff meetings, medication manage-
ment, and psychiatric care. All individuals running the
DBT treatment team have attended intensive Behavioral
Tech DBT trainings and interns who conducted skills
training were required to do a semester practicum of clin-
ical training on DBT at the program facility. The skills
modules were rotated through each week so that partici-
pants would be able to receive all four modules over the
course of six weeks. The present study attempts to assess
a number of constructs by examining intake and discharge
data based on length of stay and acuity ratings for indi-
viduals enrolled in this DBT-informed PH program.
First, we hypothesized that the results would replicate
those of the first study by Lothes et al. (2014) by showing
significant decreases in depression, anxiety, hopelessness,
and degree of suffering scores from intake to discharge;
to extend this analysis, we were also interested in exam-
ining the whether the program would be effective at re-
ducing symptoms for individuals with differing levels of
acuity at intake. Second, it was hypothesized that acuity
and length of stay in the program would have an interac-
tion effect on symptom reduction. Specifically, individu-
als with higher acuity ratings entering treatment that also
stayed longer in the program would have the greatest de-
gree of symptom reduction.
Materials and Methods
Participants
Participants included 113 adults, ages 18-73 [mean
(M)=38.05, standard deviation (SD)=12.90]. The sample
was predominantly female (N=84, 74.34%) and Cau-
casian (N=94, 84.07%), and was comprised of patients
who were evaluated for medical necessity for needing a
higher level of care than an intensive outpatient program
or continued individual outpatient therapy at intake and
at discharge. Participants were diagnosed based on a clin-
ical interview, assessment measures [i.e., Beck depression
inventory II (BDI-II), Beck anxiety inventory (BAI), Beck
hopelessness scale (BHS)] and review of medical records.
Table 1 presents demographic characteristics, including
diagnoses assigned according to DSM-IV-TR criteria
(American Psychiatric Association, 2000). Participants
did not receive compensation for participation.
Depression
The BDI-II (Beck, Ward, Mendelson, Moch, & Er-
baugh, 1961) was used to assess self-report ratings of de-
pression at intake and discharge. The BDI-II is a 21-item
measure; items contain a list of statements and the partic-
ipant selects the statement that best describes them. For
each item, statements range from those that indicate no
depressive symptoms (i.e., I do not feel sad), which would
receive a code of 0, to those that indicate severe depres-
sive symptoms (i.e., I am so sad and unhappy that I can’t
stand it), which would receive a code of 3. The BDI
ranges from 0-13 (minimal), 14-19 (mild), 20-28 (mod-
erate) and 29+ (severe). The BDI is reliable and valid for
use in general adult populations (Richter, Werner, Heer-
lein, Kraus, & Sauer, 1998), as well as psychiatric popu-
lations (Beck, 1988; Beck, Steer, & Garbin, 1988).
Anxiety
The Burns anxiety inventory (BAI; Burns, 1999) was
used to assess self-report ratings of anxiety at intake and
discharge. The BAI is a 33-item measure; answer choices
for each item range from 0 (Not at all) to 3 (A lot). The
BAI ranges from 0-20 (mild), through 21-30 (moderate),
to 31+ (severe).
Table 1. Demographic information (n=113).
M SD
Age (years) 38.05 12.90
N %
Gender Male 29 25.66
Female 84 74.34
Race Caucasian 95 84.07
African American 14 12.39
Hispanic 2 1.77
Native American 1 0.88
Other 1 0.88
DSM-IV-TR diagnosis
Major depressive disorder 67 59.29
Bipolar disorders 35 30.97
Anxiety disorders 3 2.66
Substance dependence 3 2.66
Psychotic disorders 3 2.66
Eating disorders 2 1.77
M, mean; SD, standard deviation; DSM-IV-TR, diagnostic and statistical manual of mental
disorders-fourth edition-TR.
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DBT-informed partial hospital program outcomes
Hopelessness
The Beck hopelessness scale (BHS; Beck, 1988) was
used to assess self-report levels of hopelessness at intake
and discharge and is considered reliable and valid (Owen,
1992). The BHS is a 20-item true/false measure; items in-
clude statements regarding attitudes about the future (i.e.,
I look forward to the future with hope and enthusiasm).
The BHS ranges from 0-3 (minimal), through 4-8 (mild),
9-14 (moderate), to 15+ (severe).
Suffering
Self-report degrees of suffering scores were collected
on a one-item Likert scale ranging from 0 (No suffering
at all) to 10 (Worst suffering ever) at intake and discharge.
Acuity
Participants were also given an acuity rating for over-
all impairment at intake based on their scores on the BDI-
II, BAI, and BHS by assigning points from all three
measures according to each scale’s criteria of low (scoring
minimal or mild on BDI, BAI and BHS scales), moderate
(scoring moderate on BDI, BAI and BHS scales), and
high ratings (scoring severe on BDI, BAI, and BHS
scales). If someone scored in the minimal range they re-
ceived a 1, in the moderate range they received a 2, and
in the severe range they received a 3. This produced both
a continuous (i.e., ranging from 3-9) and a categorical
(i.e., low, medium or high) rating of patient acuity.
Length of stay
Length of stay was measured by total number of days
in the program, consistent with previous research
(Jiménez, Lam, Marot, & Delgado, 2004).
Procedure
All patients who came into the PH program were
asked to complete the BDI-II, BAI, BHS and reported
their degree of suffering as part of the initial intake
process. These measures were used as part of the intake
process to assess for medical necessity into the PH pro-
gram. Patients who did not meet medical necessity for the
PH program were referred to the appropriate source; often
an individual therapist or other appropriate community re-
sources. Information on referrals was not collected. Pa-
tients also filled out the BDI-II, BAI, BHS, and
self-reported degree of suffering at discharge. This infor-
mation was used initially to help re-assess for medical ne-
cessity or to help patients step-down to a more appropriate
program, such as intensive outpatient therapy or to weekly
DBT skills groups supplemented with individual therapy.
The researchers later examined this information as an
exploratory study approved by the Institutional Review
Board at the University of North Carolina, Wilmington,
NC. Since this data was not originally collected as part of
the research design, there was no data collected for patients
that did not meet medical necessity for the PH program.
Results
Results replicated the first study conducted by Lothes
et al. (2014). See Table 2 for average symptom raw scores
at intake and discharge. Raw scores are displayed to pro-
vide the greatest degree of clinical utility to practitioners.
At intake, average depression, anxiety, and hopelessness
scores for this sample fell in the severe, severe, and mod-
erate ranges, respectively; at discharge, average depres-
sion, anxiety, and hopelessness scores for this sample fell
in the mild, moderate, and mild ranges, respectively. A se-
ries of paired samples t-tests demonstrated significant
changes in symptom reports for all four dependent vari-
ables: depression [t(112)=13.47, P<.001, 95% confidence
interval (CI) (15.65, 21.04)]; anxiety [t(112)=11.00,
P<.001, 95% CI (19.21, 27.65)]; hopelessness [t
(112)=11.85, P<.001, 95% CI (5.13, 7.19)]; and suffering
[t(112)=12.91, P<.001, 95% CI (2.98, 4.06)] (Figure 1).
The next goal of the current research was to see if the
program was differentially effective for patients at differ-
ent acuity levels. The program was effective at decreasing
all four symptoms categories in high and medium acuity
patients. According to a series of paired samples t-tests
conducted with all high acuity clients (N=82), depression
scores significantly decreased by 22.62 (SD=13.56) points
on average [t(81)=15.10, P<.001, 95% CI (19.64,
25.60)]; anxiety scores significantly decreased by 28.27
(SD=22.21) points on average [t(81)=11.46, P<.001,
95% CI (22.60, 32.11)]; hopelessness scores significantly
decreased by 7.61 (SD=5.27) points on average [t
(81)=13.09, P<.001, 95% CI (6.45, 8.77)]; and suffering
scores significantly decreased by 3.87 (SD=2.84) points
on average [t(81)=12.31, P<.001, 95% CI (3.24, 4.49)].
Table 2. Descriptive statistics (n=113).
M SD
Acuity 7.39 1.73
Days in program 22.35 13.13
Depression intake 33.00 12.99
Depression discharge 14.65 12.42
Anxiety intake 49.69 22.17
Anxiety discharge 26.26 21.23
Hopelessness intake 11.15 5.75
Hopelessness discharge 4.99 5.00
Suffering intake 6.53 2.31
Suffering discharge 3.01 2.69
M, mean; SD, standard deviation. Ms and SDs reflect raw scores on associated symptom
measures.
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According to a series of paired samples t-tests con-
ducted with all medium acuity clients (N=29), depression
scores significantly decreased by 6.97 (SD=10.36) points
on average [t(28)=3.62, P=.001, 95% CI (3.02, 10.91)];
anxiety scores significantly decreased by 13.86
(SD=22.90) points on average [t(28)=3.26, P=.003, 95%
CI (5.15, 22.57)]; hopelessness scores significantly de-
creased by 2.28 (SD=4.38) points on average [t(28)=2.80,
P=.009, 95% CI (0.61, 3.94)]; and suffering scores sig-
nificantly decreased by 2.59 (SD=2.88) points on average
[t(28)=4.83, P<.001, 95% CI (1.49, 3.68)]. There were
only two clients that started the program in the low acuity
category, so their data was unable to be statistically ana-
lyzed separately. However, they showed clinically mean-
ingful decreases in all four-symptom areas as well. Their
depression scores changed from an average of 10.00 to
2.00, anxiety scores changed from an average of 6.00 to
4.50, hopelessness scores changed from an average of
4.00 to 1.00, and suffering scores changed from an aver-
age of 3.00 to 0.00. However, these changes should be in-
terpreted with caution.
To assess the possibility that length of stay might inter-
act with patient acuity to produce symptom change, a series
of moderated hierarchical linear regression analyses were
conducted. Length of stay and patient acuity at intake were
entered in step 1, and the interaction between length of stay
and acuity in step two. The results showed that there was
no interaction effect between acuity ratings at the start of
the program and length of time spent in the program on de-
pression, anxiety, or suffering score change. However, a
moderated, hierarchical linear regression analysis showed
that there was a significant interaction between acuity at
the start of the program and length of time spent in the pro-
gram on hopelessness score change [F (3, 109)=15.74,
P<.001; Figure 2]. For ease of interpretation, acuity and
length of stay are depicted as ±1 SD from the mean in Fig-
ure 2; continuous measures of these variables were entered
into the regression analyses. The final model (predictors:
acuity, length of stay, interaction term) explained 30.2% of
the variability in hopelessness change. The addition of the
interaction term explained an additional 4.20% of the vari-
ability in hopelessness change (P=.012).
Discussion
The purpose of the current study was to replicate and
add to the findings of Lothes et al. (2014) by assessing
the effectiveness of a DBT-informed PH program on de-
pression, anxiety, hopelessness and degree of suffering
based on patient length of stay and acuity ratings at intake.
The present study results were able to successfully repli-
cate Lothes et al. (2014) by showing significant decreases
in depression, anxiety, hopelessness, and degree of suf-
fering from intake to discharge for all participants. Thus,
integrating DBT into PH programs’ treatment protocol ap-
pears to be an effective method at decreasing symptoms
that are associated with a wide variety of diagnoses and
clinical concerns, including suicidal ideation and action.
Additionally, it was found that length of stay in the
program moderated the relationship between acuity and
change in hopelessness such that those who were most
acute and stayed in the program for the longest had the
greatest reduction in perceived hopelessness. This sug-
gests that severely acute patients may benefit from staying
longer in a PH program than less acute patients. In addi-
tion, preemptively assessing for hopelessness levels could
prove more useful than anxiety or depression scores in de-
termining length of stay needed in the program. Thus, a
one-size-fits-all conceptualization of treatment in PH pro-
grams that is currently being practiced by insurance com-
panies warrants some consideration. Perhaps some
patients need more time in a PH program to receive the
benefits of treatment. In addition, researchers have noted
that significant declines in depression, anxiety, and hope-
lessness are important factors in the reduction of suicide
Figure 1. Change in hopelessness scores by acuity level and
length of stay.
Figure 2. Change in symptoms from intake to discharge.
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[Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:219] [page 155]
DBT-informed partial hospital program outcomes
risk, suggesting that a longer length of stay in a PH pro-
gram may reduce the risk for suicide and the risk of return
to an inpatient facility among this population (Neuhaus,
2006; Pompili et al., 2012); however, further studies are
needed to specifically assess this.
The results of this study replicated and extended those
of Lothes et al. (2014), suggesting that patients with
higher levels of acuity may need longer lengths of stay to
experience the same symptom reduction effect in a DBT-
informed PH program as those with lower levels of acuity.
The promising outcome is that there is still a significant
decline in ratings of depression, anxiety, hopelessness and
degrees of suffering from start to discharge, even for the
most highly rated patients on these measures. Length of
inpatient stay after exposure to DBT-informed treatment
may be reduced and should be assessed in future studies.
Economically, DBT could be a factor in looking at the re-
duction of overall treatment cost to the patient since at-
tendance to a PH program is considerably more cost
efficient than an inpatient stay (McMain et al., 2009).
Batcheler (2005) reported on a pre-post study of DBT in
New Zealand, finding a reduction in hospital days used
(25.04 to 4 to 1.09 days) when comparing 12 months pre-
treatment, 12 months of DBT treatment, and 12 months
post DBT treatment, respectively. Using a DBT-informed
PH program as first choice instead of an inpatient facility
may also be a cost savings method of treatment as well.
The study has several limitations. First, there is a lack
of generalizability due to not having a control group.
However, the researchers felt it would be ethically inap-
propriate to deprive high-risk patients of care by placing
them on a control-waiting list. Also, the researchers at-
tempted to reach out to other non-DBT PH programs to
use as a comparison group. None of the clinics contacted
were willing to let us collect data on their programs. In
the future, comparison studies to other PH programs are
recommended. Second, the measures used are all self-re-
port and therefore may not have accurately assessed spe-
cific levels of psychological impairment at intake and
discharge. Finally, data was not gathered on how many
coaching phone calls were made by each patient, how
many hospitalizations occurred while in program, or how
many relapses of problem behaviors occurred (e.g., cut-
ting, using, drinking, purging). Also not assessed was
medication compliance.
Conclusions
Ideally, follow up studies (e.g., 3 months, 6 months
and/or 12 months post discharge) are recommended for
future studies to examine if depression, anxiety, hopeless-
ness, and degree of suffering are still significantly below
intake level. Further, it is suggested for follow up studies
to examine rates of return to inpatient facilities. Finally,
it may prove useful to examine differences in symptom
reduction between more traditional cognitive behavioral
therapy models of PH programs compared to DBT-in-
formed PH programs.
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... Importantly, a more recent study on a DBT-informed PH program by Lothes and colleagues examined various symptoms in relation to treatment duration among 113 adults with similar mental health diagnoses reported in their original study who spent an average of 23 days in the program. Findings revealed that patients with a higher level of symptom acuity at intake in combination with those who were able to attend the program for a longer duration achieved greater reductions in various clinical symptoms from intake to discharge (Lothes, Mochrie, Quickel, & St. John, 2016). Importantly, these findings do suggest that while DBT can be effectively adapted for different treatment settings such as IOP and PH programs; however, there remains a lack of research in this area. ...
... Prior study findings support using adapted versions of DBT within PH programs (Lenz & Del Conte, 2018;Lothes et al., 2016). However, few studies have assessed outcomes in DBT-informed IOP programs, with only preliminary evidence to suggest their effectiveness at reducing various symptoms (Ritschel et al., 2012). ...
... However, few studies have assessed outcomes in DBT-informed IOP programs, with only preliminary evidence to suggest their effectiveness at reducing various symptoms (Ritschel et al., 2012). The present study findings successfully replicated previous findings from Lothes et al. (2016), showing symptom reduction from intake to discharge with unique clinical measures of depression (CUDOS) and anxiety (CUXOS) in a DBT-informed PH program as well extended these findings to include assessment of a DBT-informed IOP program and step-down care within these programs. ...
Article
Full-text available
Few studies to date have examined Partial Hospital (PH) and Intensive Outpatient (IOP) programs that utilize a Dialectical Behavior Therapy (DBT)-informed model. Preliminary findings suggest that DBT-informed PH programs are effective in reducing clinical symptoms; however, less is known about IOP programs as well as step-down care models. The present study utilized clinically relevant outcome indices and included a heterogeneous clinical sample. Specifically, the present study assessed pre-post data to examine changes in symptoms of depression, anxiety, hopelessness, and overall degree of suffering from intake to discharge in DBT-informed PH and IOP programs as well as a step-down condition (PH to IOP). Participants included 205 adults (ages M = 35.28, SD = 12.49). The sample was predominantly female (N = 139, 67.8%) and Caucasian (N = 181, 88.3%). The sample was divided into three distinct groups: PH program patients, PH to IOP program step-down patients, and IOP patients. Findings indicated significant symptom reduction from intake to discharge for all three conditions. There were no significant differences in mean change scores in symptom reduction between the three groups. Severity of depression symptoms at intake predicted program placement. However, type of program did not predict significant changes in symptoms from intake to discharge. This DBT-informed PH and IOP program was successful at reducing various psychiatric symptoms in the sample. Clinicians might consider the advantages of placing patients with higher symptoms of depression into PH programs with the intention of transitioning to step-down care through IOP programs that utilize DBT.
... PH programs, which are used to help stabilize patients after a brief inpatient stay, or as an alternative to inpatient hospitalization (Neuhaus, 2006), are particularly interesting due to their high utilization by suicidal patients. PH programs allow patients with high-risk behaviors, such as suicide attempts or nonsuicidal self-injurious behaviors (e.g., cutting), to transfer to a lower level of care after a hospitalization (Lothes, Mochrie, Quickel, & St. John, 2016). Unfortunately, PH programs are expensive, and patients typically stay for only a few weeks, which adds significant barriers to behavioral change. ...
... The current PH program is considered an intensive outpatient day treatment option for adults with acute mental illness in the form of a PH program. It uses DBT constructed from Linehan's DBT training manual, Second Edition (Linehan, 2014), in a program that has previously conducted program evaluation self-studies that suggest preliminary efficacy in symptom reduction (see Lothes et al., 2014Lothes et al., , 2016. The PH program patients met 5 days a week for 4 hr each day. ...
... Few studies to date have examined PH programs that utilize a DBT model; however, preliminary findings suggest DBT PH programs can be effective in reducing symptoms such as depression, anxiety, hopelessness, and suffering (Lothes et al., 2016). However, there are no studies to date that examine the role of mindfulness skill acquisition in relation to symptom reduction in a DBT PH program. ...
Article
Objective Preliminarily findings suggest dialectical behavior therapy (DBT)‐informed partial hospital (PH) programs can reduce patient symptoms. The present study assessed changes in various mental health symptoms as well as mindfulness skill acquisition in relation to these outcomes in a DBT‐informed PH program. Method Participants included 212 adults, ages 18–66 (Mean = 35.63, Standard Deviation = 12.39). The sample was predominantly female (N = 140, 66.00%) and Caucasian (N = 185, 87.30%). Results Findings showed significant symptom reduction (i.e., depression, anxiety, hopelessness, and degree of suffering) from intake to discharge. Overall mindfulness skill acquisition significantly increased from intake to discharge, and specific scales of mindfulness acquisition accounted for significant proportions of the variance in symptom reduction for depression and anxiety. Conclusions Mindfulness skill acquisition may be a mechanism by which DBT impacts symptom reduction in PH settings. Future studies might examine mindfulness practice to determine optimum doses.
... Findings revealed that patients with a higher level of symptom acuity at intake who were able to attend the program for a longer duration than those individuals with lower acuity and shorter duration stay achieved greater reductions in symptoms from intake to discharge (Lothes et al., 2016). This suggests that patients may need increased stays in DBT-informed PH programs to receive the most benefit. ...
... Prior study findings support adapting DBT to PH programs (Brown et al., 2020;Lenz & Del Conte, 2018;Lothes et al., 2016;Mochrie et al., 2019;Yen et al., 2009). The present study findings replicate previous findings from Lothes et al., (2014;2016) (Mochrie et al., 2020;Ritschel et al., 2012). ...
Article
Objectives A small number of studies to date have examined Partial Hospital (PH) that utilize a Dialectical Behavior Therapy (DBT) model. Preliminary findings suggest DBT PH programs can be effective in various symptom reduction. Methods This study examined clinically relevant outcomes and included a heterogeneous clinical sample over a five-year period. Specifically, the present study assessed pre–post data to examine changes in symptoms of depression, anxiety, hopelessness, and overall degree of suffering from intake to discharge in a DBT PH. Results Findings showed symptom reduction from intake to discharge for depression, anxiety, hopelessness, and suffering for all 5 years. This DBT PH program was successful at reducing various symptoms in a sample of psychiatric patients. Conclusion Clinicians might consider the advantages of placing patients in PH programs versus an inpatient stay or consider utilizing DBT-informed PH programs after an inpatient hospitalization as a form of step-down care.
... All of these DBT-informed intensive adaptations show positive treatment associations. However, many of these studies are limited by not including program completion data (e.g., Ritschel et al., 2012), or only reporting outcome data from program completers, not dropouts (e.g., Lothes et al., 2016). This is a third area for additional assessment. ...
Article
Standard dialectical behavior therapy (DBT), with its 12-month format, has a documented record of efficacy. While emerging evidence is supportive of DBT adaptations in community mental health settings and brief, intensive formats, many of these studies are limited by sample size of its DBT group, by omission of program completion rates and specific data from program noncompleters, and by focusing solely on symptom-focused measures-which inadvertently omits observing gains associated with well-being. We used a nonexperimental design to assess client outcomes on pathology-focused and positive-psychology measures in a brief DBT intensive-outpatient Community Mental Health Center in the midwestern United States for program graduates and program dropouts who completed at least two surveys (n = 77). This is the shortest average program length (M = 19.01 days) known for a DBT program. Scores on measures of depression (d = 0.41), anxiety (d = 0.5), stress (d = 0.5), and difficulties in emotion regulation (d = 0.51) all decreased from entrance to exit. Scores on measures of mindfulness (d = 0.43), Snyder's hope (d = 0.51), and integrative hope (d = 0.41) increased from entrance to exit. These results provide evidence that pathology decreases and measures associated with well-being increase in this brief, intensive-outpatient community health DBT program. This study provides support for future investigations of brief, intensive community health programs. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Effective in reducing suicidal and parasuicidal behaviors, while simultaneously increasing treatment retention (Neacsiu et al. 2010;Panos et al. 2014;Soler et al. 2009;Swenson et al. 2002), DBT aims to both decrease quality-of-life interfering behaviors and enhance behavioral skills such as emotional regulation, distress tolerance, and interpersonal skills (Feigenbaum 2007;Linehan 1993). DBT has been found effective in increasing mindfulness while decreasing symptoms of depression and anxiety in individuals participating in partial hospitalization services (Lothes et al. 2016;Mochrie et al. 2019). More recently, emerging evidence supports DBT's effectiveness in treating bipolar disorder (Van Dijk et al. 2013), co-occurring substance abuse disorders (van den Bosch et al. 2002), and binge eating disorders (Lenz et al. 2014;Telch et al. 2001). ...
Article
Full-text available
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.
Chapter
This chapter focuses on a set of therapies that arguably fall under the umbrella of “third wave treatments” for anxiety, obsessive compulsive disorder (OCD), and obsessive compulsive and related disorders (OCRDs; e.g., trichotillomania, skin picking). Our goals for the chapter are to provide a brief conceptual description of the three waves as it applies to these disorders, describe this overall line of work as it applies to anxiety, OCD, and OCRDs, review the research, provide clinical examples, and describe what is original about the third wave in this area.KeywordsThird-wave behavior therapythird-wave cognitive behavior therapyAnxiety-related disordersAnxiety disordersObsessive compulsive disorderObsessive compulsive related disorders
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Objective Preliminary evidence suggests the efficacy of Dialectical Behavior Therapy (DBT) to reduce clinical symptoms in Partial Hospital (PH) programs. However, less is known about DBT in Intensive Outpatient (IOP) programs, or in PH to IOP step-down models. The current study examined changes in depression, anxiety, stress, hopelessness, and mindfulness skills acquisition, from intake and discharge data of clients at a southeastern behavioral health clinic in the United States. Method The sample included 146 clients, 65.75% female (ages M = 33.88, SD = 12.34), who attended either a DBT-PH, -IOP, or -PH to IOP step-down program. Participants completed the Depression, Anxiety, Stress Scale (DASS-21), Beck Hopelessness Scale (BHS), and Five Facets of Mindfulness Questionnaire Short Form (FFMQ-SF). Results Depression, anxiety, and hopelessness decreased from intake to discharge in the PH program, while all symptoms decreased in the IOP and step-down programs. Mindfulness total scores, and most subscales, increased in each program. Mindfulness skills acquisition predicted decreases in depression and stress in the IOP group, and decreases in depression and hopelessness in the step-down group. Conclusion Overall, clinical symptoms and mindfulness skills acquisition improved over the course of the DBT-PH and—IOP programs.
Article
Full-text available
Objective: Mental health programs are increasingly being asked to evaluate the effectiveness of the treatment they provide. This study looks to examine the efficacy of a Dialectical Behavioral Therapy (DBT) informed Partial Hospital (PH) program on different clinical symptoms. Method: This study examines a Quality Improvement study that was conducted at a DBT informed PH program in the Southeast Region of the United States. This article presents the results of one program’s attempt to assess treatment outcomes of clients for depression, anxiety, hopelessness and perceived degrees of suffering. Participants (N=38, ages 19-67 (M=37), 29 females and 9 males) were evaluated for medical necessity at admission and at discharge. Results: Paired t-test results show that a DBT informed PH program did significantly reduce depression, anxiety, hopelessness, and perceived degrees of suffering in a clinical population from time of intake to discharge. Conclusion: This article outlines the procedure that was used for assessment and uses the results to show that a DBT informed PH Program may help in reducing depression, anxiety, hopelessness and degrees of suffering from time of admission to discharge.
Book
The Book is the Italian Edition of M-M: Linehan DBT skills training manual pp.900
Article
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
Article
Objective The objective was to quantitatively and qualitatively examine the efficacy of DBT (e.g., decreasing life-threatening suicidal and parasuicidal acts, attrition, and depression) explicitly with borderline personality disorder (BPD) and using conservative assumptions and criteria, across treatment providers and settings. Method Five randomized controlled trials (RCTs) were identified in a systematic search that examined the efficacy of DBT in reducing suicide attempts, parasuicidal behavior, attrition during treatment, or symptoms of depression, in adult patients with BPD. Results Combining effect measures for suicide and parasuicidal behavior (five studies total) revealed a net benefit in favor of DBT (pooled Hedges’ g −0.622). DBT was only marginally better than treatment as usual (TAU) in reducing attrition during treatment in five RCTs (pooled risk difference −0.168). DBT was not significantly different from TAU in reducing depression symptoms in three RCTs (pooled Hedges’ g −0.896). Discussion DBT demonstrates efficacy in stabilizing and controlling self-destructive behavior and improving patient compliance.
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In this handbook, the author teaches how the techniques of CBT can be used to overcome depression, conquer anxiety, and enjoy greater intimacy. These skills can also be adapted to hurdle roadblocks to success, from test anxiety and fear of public speaking to procrastination and self-doubt. Filled with quizzes, charts, weekly self-assessment, and a daily mood log, The Feeling Good Handbook actively engages its readers in their own recovery. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Research studies focusing on the psychometric properties of the Beck Depression Inventory (BDI) with psychiatric and nonpsychiatric samples were reviewed for the years 1961 through June, 1986. A meta-analysis of the BDI's internal consistency estimates yielded a mean coefficient alpha of 0.86 for psychiatric patients and 0.81 for nonpsychiatric subjects. The concurrent validitus of the BDI with respect to clinical ratings and the Hamilton Psychiatric Rating Scale for Depression (HRSD) were also high. The mean correlations of the BDI samples with clinical ratings and the HRSD were 0. 72 and 0.73, respectively, for psychiatric patients. With nonpsychiatric subjects, the mean correlations of the BDI with clinical ratings and the HRSD were 0.60 and 0.74, respectively. Recent evidence indicates that the BDI discriminates subtypes of depression and differentiates depression from anxiety.
Article
Phenomenology studies conscious experience as experienced from the subjective or first-person point of view. This paper was developed with the aim of shedding light on the phenomenology of suicide; that is, to focus on suicide as a phenomenon affecting a unique individual with unique motives for the suicidal act. To explore this topic, the author looks back at the past centuries to understand why suicide was thought to be confined to psychiatric illness and to document the bias in studies supporting this notion. One major step forward in the conceptualization of suicide as a psychological disorder was provided by Edwin Shneidman, who focused on the pain of negative emotions. Such a radical approach is laudable in an era where diagnostic criteria and the need to cure are more important than understanding what is not working at the emotional level.
Article
The authors sought to evaluate the clinical efficacy of dialectical behavior therapy compared with general psychiatric management, including a combination of psychodynamically informed therapy and symptom-targeted medication management derived from specific recommendations in APA guidelines for borderline personality disorder. This was a single-blind trial in which 180 patients diagnosed with borderline personality disorder who had at least two suicidal or nonsuicidal self-injurious episodes in the past 5 years were randomly assigned to receive 1 year of dialectical behavior therapy or general psychiatric management. The primary outcome measures, assessed at baseline and every 4 months over the treatment period, were frequency and severity of suicidal and nonsuicidal self-harm episodes. Both groups showed improvement on the majority of clinical outcome measures after 1 year of treatment, including significant reductions in the frequency and severity of suicidal and nonsuicidal self-injurious episodes and significant improvements in most secondary clinical outcomes. Both groups had a reduction in general health care utilization, including emergency visits and psychiatric hospital days, as well as significant improvements in borderline personality disorder symptoms, symptom distress, depression, anger, and interpersonal functioning. No significant differences across any outcomes were found between groups. These results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder.