بررسی یک طرح ابتکاری برای تعبیه رفتار درمانی دیالکتیکی در تنظیمات جامعه

We examined the effectiveness of Dialectical Behavior Therapy (DBT) training in community-based agencies. Data were gathered at four time points over a 2-year period from front-line mental health therapists (N = 64) from 10 community-based agencies that participated in a DBT implementation initiative. We examined change on therapist attitudes toward consumers with Borderline Personality Disorder (BPD), confidence in the effectiveness of DBT, and use of DBT model components. All measures were self-report. Participating in DBT training was associated with positive changes over time, including improved therapist attitudes toward consumers with BPD, improved confidence in the effectiveness of DBT, and increased use of DBT components. Therapists who had the lowest baseline scores on the study outcomes had the greatest self-reported positive change in outcomes over time. Moreover, there were notable positive correlations in therapist characteristics; therapists who had the lowest baseline attitudes toward individuals with BPD, confidence in the effectiveness of DBT, or who were least likely to use DBT modes and components were the therapists who had the greatest reported increase over time in each respective area. DBT training with ongoing support resulted in changes not commonly observed in standard training approaches typically used in community settings. It is encouraging to observe positive outcomes in therapist self-reported skill, perceived self-efficacy and DBT component use, all of which are important to evidence-based treatment (EBT) implementation. Our results underscore the importance to recognize and target therapist diversity of learning levels, experience, and expertise in EBT implementation.

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2. Results 2.1. Participant characteristics 78 percent (n = 50) of the therapists were female ( Table 1). The average age was 44 years (SD = 13.5 years) and 95% were Caucasian. The majority of the therapists were Master's level (70%); 14% had a Bachelor's degree. Fifty-two percent were licensed, with licensed professional counselor (LPC; 39%), social work (LSW or LCSW; 36%), psychologist (13%), and registered nurses (RN; 13%) being the most common licenses. Therapists averaged approximately 14 years of experience in human services work (M = 13.81, SD = 9.4) and 6 years at their present agencies (M = 6.2, SD = 6.1). Table 1. Demographic characteristics of participants. Total sample (n = 64) n (%) or M (SD) Gender (n = 64) Male 14 (21.9%) Female 50 (78.1%) Age (n = 59) 44.1 (13.5) Racea (n = 64) American Indian/Alaska Native 0.0 African American 0.0 Asian 2 (3.1%) Caucasian 61 (95.0%) Hispanic 1 (1.6%) Native Hawaiian or Pacific Islander 0.0 Highest degree (n = 64) Some college 1 (1.6%) Bachelor's degree 9 (14.0%) Some graduate school 6 (9.4%) Master's degree 45 (70.3%) Doctoral degree 3 (4.7%) Years experience In full-time human services work (n = 54) 13.81 (9.4) At present agency (n = 58) 6.2 (6.1) Highest level degree is in (n = 64) Education 2 (3.2%) Nursing 4 (6.3%) Psychology 22 (34.9%) Social work 16 (25.4%) Other 19 (30.2%) Professionally licensed (n = 63) 33 (52.4%) License type (n = 31) Licensed professional counselor 12 (38.7%) Social work 11 (35.5%) Psychologist 4 (12.9%) Registered nurse 4 (12.9%) Table options 2.1.1. Training dose The amount of time spent in training sessions ranged from 32 to 96 h (total possible number of hours = 96) with a Mean of 74.0 h (SD = 23.45); 70% of participants who had the opportunity to complete all trainings completed at least 75% of the training. Phone consultation time ranged from 6 to 110 h with a Mean of 25.67 h (SD = 30.67); 13% of participants who had the opportunity to complete all consultation completed at least 75% of the consultation. 2.1.2. Therapist turnover and study retention Nine of the 10 agencies that began the study remained involved through the conclusion of the four assessments. One agency dropped out because of substantial changes in management and organizational structure. The number of therapists steadily declined through the course of the study due to therapists leaving their agencies (time point 1: n = 64; time point 2: n = 50; time point 3: n = 41; time point 4: n = 35). By the end of the training initiative, 35 of the original 64 therapists (55%) remained at their agencies. There was some effort to replace therapists who left their agencies within the DBT training initiative so that at the last time point 38 therapists were involved in DBT training. Study completers (those who were present at the final training session; n = 29) did not differ significantly from the non-completers (n = 35) on any of the background variables presented in Table 1 except for “Years experience in full-time human services work.” Completers were more experienced (M = 18.5 years) than non-completers (M = 10.4 years), F(1, 52) = 11.80, p = .001. 2.2. Attitudes toward consumers with borderline personality disorder We found that therapists’ attitude toward individuals with BPD improved over the course of the training, as indicated by the positive slope (β = 0.21, p < .01) in the unrestricted linear growth model presented in Table 2. Individuals with lower attitudes toward consumers with BPD at baseline had significantly greater improvements in attitudes over the course of the training (r = −.69, p < .01). However, there were no significant differences in changes in attitudes toward individuals with BPD associated with therapist level of education, years of experience, degree area, licensure status, or having a change in job description. Fig. 1 depicts the mean scores for the attitude toward consumers with BPD scale over the course of the training. Table 2. Linear model of attitude toward consumers with BPD—unconditional at level-2. Fixed effect Coefficient SE t-Ratio p-Value Intercept, β00 3.59 0.07 48.18 0.00 Slope, β10 0.21 0.03 6.02 0.00 Random effect Variance component χ2 p-Value Level-1 Temporal variation in scores, eti 0.10 Level-2 (between subjects) Intercept, r0i 0.28 213.37 0.00 Slope, r1i 0.03 84.74 0.00 Table options Full-size image (14 K) Fig. 1. Mean scores for the three primary outcome variables over the course of the training. Error bars represent standard errors (SEs). Figure options 2.3. Confidence in the effectiveness of DBT Confidence in the effectiveness of DBT also increased over the course of the training as indicated by the positive slope (β = 0.16, p < .01) presented in Table 3. Level of education predicted change in confidence in the effectiveness of DBT over the course of the training. Specifically, participants with a bachelor's degree or lower gained more confidence in the effectiveness of DBT over the course of the training relative to participants with a master's degree or higher (β = −0.15, p < .05). None of the other professional background variables predicted change in confidence in the effectiveness of DBT over the course of the training. Change in job description also did not predict the amount of change over the course of the training. However, it should be noted that more experienced participants had greater baseline confidence in the effectiveness of DBT compared to less experienced participants (β = 0.02, p < .01). There was also a strong negative correlation (r = −.46, p < .01) between the intercept and slope of the level-1 model, indicating that the greatest improvement in confidence in the effectiveness of DBT was seen for participants who reported relatively low confidence in the effectiveness of DBT at baseline. Fig. 1 depicts the mean scores for the Confidence in the effectiveness of DBT scale over the course of the training. Table 3. Linear model of confidence in the effectiveness of DBT—unconditional at level-2. Fixed effect Coefficient SE t-Ratio p-Value Intercept, β00 3.77 0.06 59.41 0.00 Slope, β10 0.16 0.04 4.11 0.00 Random Effect Variance component χ2 p Value Level-1 Temporal variation in scores, eti 0.09 Level-2 (between subjects) Intercept, r0i 0.16 110.97 0.00 Slope, r1i 0.03 96.18 0.00 Table options 2.4. Use of DBT components We found that self-reported use of DBT components increased over the course of the training (Table 4; β = 0.33, p < .01). More experienced participants reported more use of DBT components at baseline compared to less experienced participants (β = 0.02, p < .05). None of the other professional background variables, nor change in job expectations predicted baseline use of DBT components. There was a moderate negative correlation (r = −.29, p < .05) between the intercept and slope of the level-1 model, indicating that the greatest improvement in the use of DBT components was seen for participants who reported relatively low use of DBT components at the first assessment. Fig. 1 depicts the mean scores for the Use of DBT Components scale over the course of the training. Table 4. Linear model of use of DBT components—unconditional at level-2. Fixed effect Coefficient SE t-Ratio p-Value Intercept, β00 3.49 0.08 42.58 0.00 Slope, β10 0.33 0.04 8.46 0.00 Random effect Variance component χ2 p-Value Level-1 Temporal variation in scores, eti 0.26 Level-2 (between subjects) Intercept, r0i 0.25 80.46 0.00 Slope, r1i 0.00 58.34 0.20 Table options Using follow-up ANOVAs, there were significant increases in components that were consistent with the DBT model (Table 5). Missing data analyses showed that completers and non-completers did not significantly differ on baseline DBT component use, suggesting that any missing data were missing at random (MAR). As a result, we determined that it was reasonable to use completer analyses for our ANOVAs. When a Bonferroni correction was applied to correct for multiple comparisons (p = .0017), the four components that increased significantly were: skills training (F = 19.07, p < .001), treatment targets (F = 25.88, p < .001), daily diary cards (F = 23.75, p < .001), and dialectical strategies (F = 25.26, p < .001). Little change was observed in Ancillary Treatments. Although not significant using the conservative Bonferroni correction, there was a trend (p < .01) for intensive, high cost, ancillary treatments (e.g., hospitalizations and emergency room use) to decrease from time 1 to time 4 – as reported by therapists. Table 5. Summary of pre–post DBT-specified mode, component, and ancillary treatment use. Item Pre (n = 61) Post (n = 29) Difference “To what extent do you use _______ for consumers with BPD” Mean SD Mean SD F DBT-Specified Modes 24-h phone consultation 2.90 1.83 3.57 1.73 .84 Individual outpatient therapy 4.34 1.03 4.45 1.27 .02 Process groups 3.02 1.34 2.69 1.17 4.34* Skills training 3.15 1.39 4.48 .69 19.07*** DBT-Specified Components Behavior therapy 3.77 .94 4.21 1.08 2.51 Consumer agreements 3.66 .79 4.31 .93 10.19** Daily diary cards 2.26 1.37 4.20 1.05 23.75*** Dialectic strategies 3.25 1.01 4.38 .90 25.26*** Problem solving 4.23 .69 4.41 .73 .24 Protocol around suicidal behavior 3.70 1.16 4.24 1.02 1.35 Therapist agreements 2.97 1.28 4.10 1.19 7.42* Treatment targets 2.65 1.25 4.28 .96 25.88*** Validation 4.08 1.16 4.72 .53 7.12* Ancillary treatments After hour crisis line 3.54 1.62 3.76 1.50 .04 Case management 3.67 1.29 3.46 1.35 .02 Crisis services 3.10 1.62 2.72 1.39 4.09 Day treatment or clubhouse 3.03 1.55 2.96 1.34 1.26 Emergency room visits 2.93 1.21 2.55 .91 9.85** Hospitalization 2.97 1.09 2.48 .87 10.21** Medication management 4.15 1.22 4.20 1.20 .16 Occupational/recreational therapy 2.48 1.35 2.21 1.18 .11 Peer counseling 2.28 1.34 2.48 1.33 .74 Psychoeducation groups 3.23 1.23 3.31 1.11 .00 Respite services 2.05 1.27 1.71 1.05 .66 Substance abuse/dual diagnosis 3.69 1.12 3.34 1.17 .72 Support groups 3.00 1.18 3.25 .93 .71 Vocational rehab 3.02 1.16 2.72 1.16 6.29* Note: all scores have a possible range of 1–5. * p < .05. ** p < .01. *** p < .001. Table options 2.5. Associations between attitudes, confidence, and use Finally, we examined the associations between attitudes toward consumers with BPD, confidence in the effectiveness of DBT, and use of DBT components. Improvement in attitudes toward consumers with BPD was positively correlated with increased use of DBT components, r = .30, p < .05. Increased confidence in the effectiveness of DBT was also positively correlated with increased use of DBT components, r = .45, p < .01. In other words, both greater improvement in attitudes toward consumers with BPD and greater confidence in the effectiveness of DBT were associated with greater increase in the use of DBT components.