In This Issue
Dialectical behavior therapy skills groups in schools: A review of empirical findings
By Jordan Fiorillo and Jaime Long
Dialectical behavior therapy (DBT) is an empirically supported treatment originally developed for female outpatients diagnosed with borderline personality disorder (BPD; Linehan, Armstong, Suarez, Allmon, & Heard, 1991). Miller, Rathus, Linehan, Wetzler, and Leigh (1997) and Miller, Rathus, DuBose, Dexter-Mazza, and Goldklang (2007a) adapted DBT to treat suicidal adolescents (DBT-A). DBT-A has a growing evidence base that suggests it may be a powerful treatment modality for a variety of adolescent problem behaviors, including self-injurious behavior, BPD, bipolar disorder, eating disorders, oppositional defiant disorder, and learning disabilities. As it was designed by Miller, Rathus, & Linehan (2007b), DBT-A is a multimodal approach, consisting of 16 weeks of individual therapy, group skills training, family and individual phone consultation, and a therapist consultation group. Caretakers are generally included in group skills training and some individual therapy sessions.
This paper summarizes and critiques studies that used DBT group skills training with adolescents without family participation. Authors of this review explore the implications of using skills groups in school settings or in settings where caregiver participation is unavailable, as many are unable or unwilling to participate in treatment programs. We examine the feasibility of DBT as a treatment that can change the behavior of the adolescent without having to rely on family change. Finally, we discuss how DBT can be used for a wider variety of applications, and future research recommendations are provided. Structure of Dialectical Behavior Therapy Muehlenkamp (2006) stated that the major principle behind DBT is to achieve equilibrium of behavior change and selfacceptance. DBT embraces elements of Western behavior, cognitive, and clientcentered therapeutic approaches, as well as principles from Zen Buddhism. DBT group training, as originally designed by Linehan (1993a), entails sessions of learning and practicing the skills of Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness. Mindfulness teaches clients to turn attention inward and observe themselves non-judgmentally; Distress Tolerance focuses on teaching the client how to better handle distress; Emotional Regulation increases the client’s control over his or her emotions; and Interpersonal Effectiveness builds skills in dealing with conflict, expressing wants and needs, and increasing self-respect (Linehan, 1993b).
DBT-A was designed to target the affective instability and difficulty in regulating emotions that are characteristic of suicidal and para-suicidal adolescents, and to address issues that can affect suicidal adolescents, such as depression, relationship issues, and school problems (Miller et al., 2007b). Skills groups with multiple families are preferred, as they allow parents and adolescents to learn skills with other families having similar difficulties. Single family therapy sessions are also commonly used to assist in generalization of skills and to help structure the home environment. To date, no comprehensive review of adolescent-only DBT studies exists, and the efficacy of adolescent DBT without parent participation remains unclear.
Analysis of the Literature
Several recent studies have examined the feasibility of adolescent-only DBT. James, Taylor, Winmill and Alfoadari (2008) implemented an outpatient intervention utilizing the four primary skills components of DBT to address self-harm behavior in 16 females between the ages of 15 and 18 years. All participants showed symptoms associated with a diagnosis of Borderline Personality Disorder (BPD), and researchers indicated that all would have met criteria for BPD had they been 18 years old. Treatment included one year of weekly individual therapy sessions and weekly skills group for 1.5 hours; telephone support was also available for participants.
At the end of treatment and at 8-month followup, participants reported reductions in depression and hopelessness, and clinicians reported decreased instances of self-harm and improved overall functioning. Notably, only half of participants were in “normal education or employment” (James et al., 2008, p. 150) pretreatment; upon completion, 13 of 15 (one unknown) were enrolled in school or working.
A second study by James, Winmill, Anderson, and Alfoadari (2011) offered outpatient DBT to 25 adolescents in the British “looked after care” (LAC) system, which is similar to the foster care system in the U.S. Eighteen adolescents completed the full course of treatment (15 females and 3 males) with a mean age of 15.5 years (range 12-18 years). Again, all participants would have met criteria for BPD had they been 18 years old. Treatment components were the same as those in the previous study, except that weekly group skills sessions were 2 (rather than 1.5) hours. Researchers also offered consultation for caretakers and referral agents of the LAC system and training and support for nurses and staff.
For 18 participants who completed treatment there was a significant reduction in selfreported depression and hopelessness, a reduced frequency of self-harm, and an increase in global functioning. At the end of treatment, 14 of 18 participants had totally stopped self-harming. Researchers found no significant changes in negative automatic thoughts or quality of life scores, but all returned to home or independent living from a position of homelessness or accommodation provided by the state.
Katz, Cox, Gunasekara, and Miller (2004) treated suicidal adolescents with 2 weeks of intensive DBT using an inpatient program that included the four core skills modules. Treatment was comprised of daily skills training groups, twice weekly individual psychotherapy, and a DBT milieu (with DBTtrained nursing staff) to facilitate skills generalization. The treatment team met regularly for consultation meetings, and a DBT consultant was used to evaluate staff adherence. The adolescents treated with DBT were contrasted with a group of inpatients who received treatment as usual (TAU), which consisted of a daily psychodynamic psychotherapy group, individual psychodynamic psychotherapy at least once per week, and a psychodynamically-oriented milieu.
Participants in both groups of the study had made a suicide attempt or had suicidal ideation severe enough to warrant admission to inpatient treatment, as determined by a psychiatrist. Thirty members were recruited per group and 1-year follow-up data were available on 26 DBT patients and 27 TAU patients. Participants were assigned to groups based on availability of beds at the time of admission, but no significant differences in demographic variables were found. Both groups showed substantial symptomatic improvement at discharge, with no differences on measures of depression, hopelessness, and suicidal ideation. Both groups also demonstrated a significant reduction in the absolute number of parasuicidal behaviors in the year following discharge. Interestingly, there was an absolute difference in the effect sizes between the DBT and TAU groups on self-reported depression (1.67 − 1.05 = 0.62), suicidal ideation (2.12 − 1.36 = 0.76), and hopelessness (0.73 − 0.33 = 0.4). Furthermore, DBT patients had significantly fewer behavioral incidents than the TAU patients and the DBT group had a 100percent retention rate for treatment.
Nelson-Gray and colleagues (2006) examined use of a DBT skills group for outpatient adolescents with diagnoses of oppositional defiant disorder (ODD). Fifty-four adolescents who met criteria for ODD were recruited and assigned to groups with 5 to 9 members for 16 weekly, 2 hour group skills sessions at either a clinic or a public high school. All core skills modules except Mindfulness were taught, and no individual treatment was offered. Sixty-nine percent of participants completed the full course of treatment, and 5 individuals opted to do a second round of DBT.
Researchers attempted to increase generalization of DBT skills through homework assignments and booster sessions, and provided participants with a pizza dinner and monetary rewards for homework completion. Transportation was provided to groups, and telephone calls and home visits were used to collect data from caregivers. Notably, this sample of 32 participants was more diverse than previous studies in age (M = 12.6, range = 10-15), racial characteristics (43percent African American, 40percent Caucasian, and 3percent Latino), and gender composition (27 males, 5 females).
All participants had diagnoses of ODD, based on parent report. For those who completed treatment, t-tests revealed a significant increase in interpersonal strength and reductions in ODD symptoms and externalizing behaviors from pre- to posttreatment. Furthermore, participant reports showed significant reductions in depressive symptoms and internalizing behaviors, and reductions in externalizing behaviors approached significance.
The reliable change index (RCI) was used to measure the clinical significance of change for all pre- and post-treatment measures. The RCI seeks to determine if change is clinically significant by taking into account the reliability of the measure, variability of scores in the group, and the individual’s score change from pre- to post-treatment. Of participants who were in the clinical range on at least one caregiver-completed measure at pre-treatment, 77percent changed to the non-clinical range by the end of treatment. In addition, 71percent showed clinically significant improvement, while 13percent of participants showed clinically significant deterioration from pre- to post-treatment on at least one caregiver-completed measure. For measures completed by participants, 91percent of those who were in the clinical range at pre-test improved to the non-clinical range at post-test.
Sunseri (2004) implemented DBT in a residential facility with adolescent females. The sample consisted of 26 adolescents between the ages of 12-18 in treatment (M = 15.2 years, SD = 1.3), who were compared with a group of 42 residential patients prior to implementation of DBT (M = 14.1 years, SD = 1.8). Apart from the difference in age, groups were not significantly different on demographic or clinical variables. The group of clients treated with DBT had diagnoses of disruptive behavior disorders (n = 13, 50percent), anxiety disorders (n = 15, 58percent), eating disorders (n = 1, 4percent), substance abuse disorders (n = 10, 39percent), mood disorders (n = 22, 85percent), and BPD (n = 22, 85percent).
After DBT was introduced, individual therapy sessions were held at least weekly, and group skills training utilizing the four core modules was held twice per week for 90 minutes. After implementing DBT, there were no premature terminations due to suicide, and the number of inpatient days was significantly reduced, as was the length of time clients were held in restraints or seclusion. The authors also described DBT patients as being less dependent on punishment to change behavior, and noted that staff members worked more collaboratively with the clients and their families.
Critique of the Literature and Future Directions
No studies examining DBT-A (with or without parent participation) have been randomized controlled trials (RCTs); clearly, RCTs are needed to increase the quality of evidence for this treatment. For all studies of DBT-A, variations on how treatment was implemented complicates the interpretation of overall efficacy with adolescents. This inconsistency is evident in the studies contained in this review: some researchers included only group skills training, while others used group and individual treatment sessions. Furthermore, not all of the treatment modules were used in all studies, thereby making it difficult to compare results across empirical trials.
In the future, we recommend that researchers use a standardized format of treatment, perhaps with one format for family-based treatment and another format for adolescent skills groups only. In addition, there are usually high noncompliance and dropout rates in adolescent DBT programs (Miller et al., 2007b). Future researchers should seek to increase treatment adherence, as was done by Nelson-Gray et al. (2006), who used incentives for attendance and homework completion. Furthermore, larger studies with more varied samples are needed.
More studies exploring the optimal duration of DBT-A skill groups in a school environment are needed. Nelson-Gray et al. (2006) employed 16 week groups, but future studies could explore if shorter treatment options could work. Although the treatment setting was an inpatient facility, Katz et al. (2004) found significant improvements after only two weeks of treatment. If a 2 week skills group in a school could reduce symptoms and improve the personal skills of adolescents, it would be an extremely costeffective and attractive treatment option. Only one published study explored using DBT-A in a school environment, and participants showed significant reductions in both internalizing and externalizing symptoms. (Nelson-Gray et al., 2006). Although the results have not been published in a peer-reviewed journal, Lincoln High School in Portland, OR reported initially promising results with ongoing skills groups (Hanson, 2012). The school developed a DBT program for course credit that included weekly group skills classes and individual sessions, as well as parent training and telephone consultation for the adolescents. The treatment included the four core modules of DBT and was offered in semesterlong or year-long options. The treatment team consisted of the school psychologist, counselor, social worker, nurse, practicum students, and interns. Students in the five groups that have been completed were assessed pre- and post-intervention with the Behavior Assessment System for Children, Second Edition (BASC-2); results suggested that students experienced decreased anxiety, depression, social stress, and anger control,and demonstrated increased school attendance and GPA. Although this treatment was more comprehensive than skills-groups alone, it offers a treatment format that can be replicated and evaluated in future studies.
Recommendations for Practice
Taken together, findings from the studies reviewed herein suggest that DBT skills groups that do not include parent participation have potential for reducing selfharm and oppositional behavior, as well as for improving symptoms of depression and general functioning. There appears to be potential for meaningful improvements without parent involvement, which may increase the settings where DBT-A can be offered, including schools.
While the aforementioned variety of treatment settings should be explored in future research, conducting DBT groups in schools appears to be a particularly promising way to treat a large number of adolescents. Substance Abuse and Mental Health Services Administration (SAMHSA, 2012) found that youth aged 12 to 17 are most likely to receive mental health care in an educational setting, with 2.9 million children receiving treatment in schools in 2010. Treatment in a group format is cost-effective, and school-based DBT groups can target a large number of students in the setting in which they are already most likely to receive counseling. Skills groups could easily be held during one class period and integrated into the school day, and students could receive course credit for participation, as was provided by Hanson (2012). Furthermore, DBT-A is largely manualized, making standardized implementation easier, such that a variety of professionals or interns could implement the programs.
DBT-A is a treatment that is well-suited to address many of the common concerns of adolescents, and it has shown promise in treating psychological symptoms and disorders. However, more robust studies, in particular RCTs, are needed to test the efficacy of the treatment. Future research studies may also wish to identify which skill modules are most useful in addressing adolescent concerns, and seek to develop the most efficient use of DBT by exploring shorter treatment sequences. Despite the limited number of studies available to date, this review of empirical literature suggests that DBT skills groups for adolescents may be a promising prevention and treatment tool in school settings. School-based skills groups for adolescents can be administered to a large number of middle and high school students, even those who are not diagnosed as having a disorder, and can be facilitated by trained school personnel. Taken together, findings from the existing evidence base suggest that DBT skills groups in schools have the potential to be a powerful intervention that may prevent the development of serious disorders or even suicide.
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About the Authors
Jordan Fiorillo, MA, is a fourth year graduate pursuing a doctoral degree in school psychology at The University of Montana and is the current president of the Psychology Graduate Student Association and treasurer of the School Psychology Student Organization at The University of Montana.
Jaime Long is a fourth year graduate student in school psychology at the University of Montana. Jaime recently completed her masters project on depression, academics, and online social networking usage in adolescents. She is an adjunct faculty member and enjoys teaching introduction to psychology online.