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A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events
CBPRA-00527; No of Pages 8: 4C
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A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events Christy A. Denckla, Adelphi University Robert Bailey, Adelphi University and Department of Veterans Affairs, New York Harbor Healthcare System Christie Jackson, Department of Veterans Affairs, New York Harbor Healthcare System, and New York University School of Medicine John Tatarakis, Department of Veterans Affairs, New York Harbor Healthcare System Cory K. Chen, Department of Veterans Affairs, New York Harbor Healthcare System, and New York University School of Medicine Although clinical services designed to address suicide-related behaviors are available to veterans, some factors may limit their effectiveness. Relevant factors include the presence of barriers to accessing existing services and a lack of interventions that address the unique needs of veterans. In an effort to address this gap, a modified DBT distress tolerance drop-in group was offered to a population of military veterans in an outpatient setting. This exploratory study reports clinical outcomes on this skills training group intervention informed by Dialectical Behavior Therapy (DBT) principles among a population of self- and clinician-referred veterans. Findings suggest a significant reduction in suicide-related behaviors among veterans who attended 8 or more skills training groups. Clinical implications of study findings warrant further research into novel adaptations of evidence-based treatments for this population with unique needs.
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Behavior Therapy (DBT; Linehan, 1993a) is an evidence-based psychotherapy that has been shown to be effective in reducing self-harm behavior, suicide attempts, and suicide-related hospitalizations (e.g., Kliem, Kroger, & Kosfelder, 2010; Linehan et al., 2006; Lynch, Trost, Salsman, & Linehan, 2007). The full DBT protocol incorporates weekly individual psychotherapy sessions, group skills training, consultation team meetings for the DBT therapists, and telephone skills coaching. As the evidence base for DBT has accumulated, disseminating this empirically supported treatment among real-world clinical settings can result in the need to balance fidelity to the treatment as developed in research settings with adaption to varying clinical settings and populations (Koerner, Dimeff, & Swenson, 2007; McHugh, Murray, & Barlow, 2009). As DBT is increasingly used in a wide variety of community-based, outpatient, and inpatient settings, it is important that modifications or alterations to the treatment as previously tested be carefully evaluated. To contribute to this effort, the current study reports exploratory findings on a novel IALECTICAL
modification of DBT skills training offered to military veterans who are at high risk for suicide. Originally designed as a treatment for seriously suicidal clients, studies suggest that DBT may be particularly useful for treating this target behavior (Linehan, Comtois, & Ward-Ciesielski, 2012). The DBT framework conceptualizes suicide as a maladaptive problem-solving strategy employed in the context of unbearable suffering. Because keeping patients alive is the highest priority if they are to benefit from treatment, reducing suicide crisis behaviors (defined as “any behaviors that place the client at an imminent risk for suicide or threaten to do so, including credible suicide threats, planning, preparations, obtaining lethal means, and high suicide intent”; Linehan & Dexter-Mazza, 2008, p. 379) is the first priority in DBT. Reducing suicidal behaviors in DBT occurs by making this target and its high priority explicit in the first DBT treatment session. When suicidal behavior is present, standard behavioral interventions are employed within the context of the DBT framework, which is a blend of three theoretical positions: behavioral science, dialectical philosophy, and Zen practice (Linehan, 1993a). Suicidal Behaviors and Unique Needs of Veterans
Keywords: veterans; suicide; self-harm; distress tolerance; dialectical behavioral therapy
1077-7229/13/© 2014 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
Previous studies suggest that the high rates of suicide among military personnel are a critical public health concern. While findings regarding the comparative increase in risk for suicide among veterans with respect
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
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Denckla et al. to the civilian population are mixed (Langford, Litts, & Pearson, 2013), the results of some epidemiological studies have pointed to the potential of an increased risk for suicide among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans with existing psychiatric disorders (Corson et al., 2013). In a related study, Kuehn (2009) found that suicide rates among military personnel had reached a 28-year high in 2008, which represents the continuation of a disturbing trend that has seen a steady rise in the number of completed suicides among service members. Considering these estimates in the context of further studies that suggest a threefold increase in the onset of PTSD among recently deployed military personnel (Riddle et al., 2007; Smith et al., 2009) and research that demonstrates increased risk for suicide among service members with PTSD (Pietrzak, Russo, Ling, & Southwick, 2011), effective interventions to address the mental health needs of veterans who are at increased risk for suicide are urgently needed. Although mental health services designed to address suicide-related behaviors are available to veterans, there are limitations to the effectiveness of these interventions, including barriers to accessing existing services and a lack of interventions that address the unique needs of veterans (Langford et al., 2013). The U.S. Department of Veterans Affairs (VA) has made significant changes to its mental health delivery system to address the growing need for services among veterans. Specifically, a 2005 VA strategic plan called for the integration of primary care and behavioral health in order to increase access to mental health services (Edwards, 2008). As part of this strategic plan, the VA has also prioritized the dissemination of evidence-based psychotherapies to further integrate research and clinical practice, helping to ensure that veterans receive the most effective treatments available (Karlin & Cross, 2014). Furthermore, recognition of the significance of suicide and self-directed violence as a major veteran mental health issue has led to other system-wide changes in infrastructure. Changes included the addition of personnel, called Suicide Prevention Coordinators to VA Medical Centers, a 24-hour crisis hotline and chatline, and significantly increasing the number of mental health professionals overall (Bruce, 2010). Despite efforts to expand the availability of mental health services, research indicates that these services are underutilized (Fasoli, Glickman, & Eisen, 2010).Studies of mental health service utilization among veterans recently returned from Iraq or Afghanistan indicate that although approximately 25% to 30% of the veterans in this sample reported some mental health concern after deployment, only 23% to 40% of those who met criteria for a psychiatric disorder sought mental health care (Hoge et al., 2004). This underutilization of available mental health
services has been a longstanding issue in the VA. For example, Hankin, Spiro, Miller and Kazis (1999) reported that although 40% of veterans met criteria for at least one psychiatric disorder, almost a third of those diagnosed had never sought treatment. Many barriers have been reported that interfere with veterans’ access to care, including (a) stigma associated with mental illness, which may include embarrassment and worries about being perceived as weak, or (b) logistical barriers such as not knowing where to get help and difficulty scheduling appointments (Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). It is likely that these barriers have in part contributed to high rates of dropout, low session attendance, and frequent no-shows among those who do seek out treatment (Erbes, Curry, & Leskela, 2009; Lorber & Garcia, 2010) such that often the number of sessions attended is less than that identified in treatment protocols necessary to result in significant reductions in symptoms (Rotem-Harpaz & Rosenheck, 2011). Taken together, results suggest that psychological interventions offered to veterans must account for the unique needs of this population, as well as existing barriers to treatment, within the current system of service delivery. DBT in the VA Setting In the sparse literature on DBT in the VA setting, studies suggest a superior reduction in suicide-related behaviors, hopelessness, and depression among female military veterans compared to a treatment-as-usual group (Koons et al., 2001). However, implementing the standard DBT protocol in the VA is fraught with the challenges discussed above. Unfortunately, offering a modified DBT protocol to a veteran population is largely untested and therefore the degree of efficacy noted in controlled clinical trials cannot necessarily be expected in modified deliveries. However, a small body of literature is suggesting that certain modified DBT protocols can be delivered with beneficial clinical outcomes. For example, Spoont, Sayer, Thuras, Erbes, and Winston (2003) noted that in order to deliver DBT to their veteran population successfully, addressing the unique needs of this population with cognitive impairment, literacy issues, diagnostic heterogeneity, and limitations on the availability of clinicians and of training funds was necessary. The authors concluded that adaptations to the standard DBT protocol could be made while still successfully achieving both client satisfaction and client- and clinician-rated benefit. Studies also suggest that skills training alone can result in beneficial outcomes for clients. For example, Miller, Wyman, Huppert, Glassman, and Rathus (2000) found that adolescents demonstrating suicide-related behaviors reported that distress tolerance and mindfulness skills were the most helpful in reducing self-injurious behaviors. DBT skills group training alone has also been found to be
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Skills Training Drop-In Group an effective treatment among a number of diagnostic categories. For example, Nelson-Gray et al. (2006) found that a 16-week course of DBT skills training resulted in clinically significant change among a population of behaviorally dysregulated adolescents meeting criteria for oppositional-defiant disorder. Study outcomes demonstrated significant reductions in caregiver reports of externalizing symptoms, as well as a reduction in internalizing symptoms, according to youth report. A randomized controlled trial conducted among a sample of women meeting criteria for a diagnosis of borderline personality disorder found that skills training outperformed group therapy delivered by psychodynamically oriented clinicians in terms of lower dropout rates, reductions in depression, anxiety, irritability, and affective instability (Soler et al., 2009). Furthermore, another study found that offering DBT skills training over nine groups among caregivers for elders with dementia resulted in significant increases in levels of psychosocial functioning, reliance on problem-focused coping strategies, emotional well-being, and reduced fatigue among the 16 group participants who completed the study (Drossel, Fisher, & Mercer, 2011). Taken together, findings suggest that distress tolerance skills may be particularly effective in reducing a number of target behaviors, including high-risk suicidal and self-harm-related behaviors. Past research suggests that deficits in distress tolerance (defined as the ability to withstand negative emotional states) is a risk factor for various forms of psychopathology (Leyro, Zvolensky, & Bernstein, 2010; Vujanovic, Bonn-Miller, Potter, Marshall, & Zvolensky, 2011). Studies indicate that intense negative emotions combined with deficits in the ability to modulate those states are linked with increased rates of suicidal and self-injurious behaviors (Brown, Comtois, & Linehan, 2002; Nixon, Cloutier, & Aggarwal, 2002). For example, adolescents who demonstrated nonsuicidal self-injury (NSSI), showed higher physiological reactivity during a distressing task, as well as reduced ability to tolerate that distress, compared to noninjurers (Nock & Mendes, 2008). Given this evidence, developing interventions that teach distress tolerance skills to veterans who would be unlikely to successfully complete a full treatment course of traditional DBT could potentially extend the number of veterans benefitting from this intervention. The Current Study In the current study, we sought to extend previous research suggesting that distress tolerance skills training alone, modified to meet the unique needs of veterans, may be a potentially effective intervention to address suiciderelated behaviors. Although our facility had a full DBT program, including individual psychotherapy, skills group
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training, telephone coaching, and weekly consultation team meetings, it became clear that a significant number of veterans were unable to or uninterested in participating in a full DBT program. Clinicians noted that a large number of veterans, especially those that were high risk (defined in the VAMC as being at increased risk for suicidal behaviors), had difficulty engaging in full DBT program due to high levels of psychosocial impairment, high rates of transience and interpersonal chaos, and unwillingness to consider the full DBT program. Unfortunately, these veterans were also among those who needed this treatment the most. To meet the needs of this population, one of the current authors (C.J.) considered novel ways to provide the benefits of treatment to this population by offering skills training on an as-needed, drop-in basis so that veterans could begin attendance immediately. This format also offered clinicians a concrete referral resource because they could escort clients to the drop-in group and veterans could begin immediately. Importantly, this population had refused previous referrals for mental health care to address their presenting concerns. The fundamental goal of the group was to teach crisis survival skills to those who need it the most, and we strived to maximize accessibility, feasibility, and veteran buy-in. To evaluate the impact of this intervention, we employed an exploratory design involving a case study method with a behavioral outcome variable consisting of high-intensity contact with medical facilities (i.e., emergency room visit or inpatient hospitalization) due to suicidal ideation or suicide attempt (for similar studies using data collected primarily for clincial and administrative use rather than for research, see Shadish, Navarro, Matt, & Phillips, 2000; Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006). Based on our review of the literature suggesting promising outcomes among individuals who obtain skills training (Neacsiu, Rizvi, & Linehan, 2010; Soler et al., 2009), as well as a need for interventions that address suicide-related behaviors among a veteran population, we conducted an exploratory study to examine suicide-related outcomes among veterans who attended drop-in skills training groups.
Method Participants Review of medical records identified a total of 65 veterans who had attended at least one drop-in skills training group over the year prior to the date the chart review was conducted. We identified a final cohort of 8 veterans (12.3% of the full sample) who had demonstrated suicide-related behaviors at baseline and who had attended at least 8 groups over a 1-year period (mean number of groups attended = 19, SD = 10.74). The veterans included in this current report were not receiving the full DBT program (though the full DBT program was available to them and many veterans did join
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Denckla et al.
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the full DBT program after attendance in the drop-in group). Procedure There were three primary sources of referrals for this drop-in group: (a) fliers posted widely throughout the VA; (b) referrals from current group members; and (c) referrals from VA staff to include mental health care providers, suicide prevention coordinators, or emergency department staff. We posted fliers throughout the VA in a number of areas, such as the pain clinic, primary care clinics, the mental health clinic, and the emergency room. Fliers were designed using verbiage directly from the DBT manual and described the group as providing instruction on how to “tolerate painful events, urges, and emotions when you cannot make things better right away.” All distress tolerance skills training drop-in groups are led by a Certified Nurse Specialist who is also a certified DBT practitioner and part of our consultation team. The groups are co-led by psychiatry residents, clinical psychology interns or externs, or nursing or social work graduate students, all of whom received some didactic training in DBT as part of their residencies. Each group is 55 minutes long, and the number of participants in a group can vary from 2 to 15 attendees. Measures Data were collected through a chart review utilizing the VA’s Computerized Patient Record System (CPRS). First, a log of all individuals who attend the drop-in skills training group was collated to produce a record of all veterans who had attended at least one drop-in group in the year prior to initiating data collection. Then, a stepwise review of veteran electronic medical records maintained in the VA was conducted using the following method. First, each patient record was reviewed to determine the number of drop-in groups attended. Then, we reviewed the charts for evidence of any of the following behaviors: (a) suicide-related emergency room visits; (b) suicide-related psychiatric admissions; and (c) suicide attempts. We tallied the total number of episodes of these suicide-related behaviors, thereby generating a behavioral outcome variable we called “crisis events” (CEs). Thus, the outcome variable “CEs” represented a sum count of the number of suicide-related emergency room visits, suicide-related psychiatric admissions, and suicide attempts. We reasoned that the frequency of these events produced a rough measure of suicide-related behavior “severity” because escalation through the health care system implies higher risk of suicide. For example, a suicide attempt followed by a trip to the ER that leads to a psychiatric hospitalization would result in a sum count of 3 crisis events. Alternatively, a veteran presenting to the emergency department with passive suicidal ideation that is
subsequently stabilized and who is discharged would result in a sum count of 1 crisis event. Finally, we collected basic demographic data and active psychiatric diagnoses. We proceeded to conduct paired sample t-tests to compare pre and post CEs across the sample of veterans identified in this study. Finally, in an effort to convey the unique needs of this population, we present a brief case study. Treatment Format The drop-in skills training group intervention reported in the current study focused on distress tolerance skills, as described in Linehan (1993b). Employing guidelines for adapting DBT to novel settings described by Koerner, Dimeff, and Swenson (2007), the current author (C. J.) developed a curriculum in which one of the four DBT distress tolerance skills (ACCEPTS, IMPROVE the Moment, Self-Soothing, and Pros and Cons) was presented weekly (see Linehan, 1993b, for full details). Briefly summarized, the first of the four core distress tolerance skills, ACCEPTS, is an acronym that stands for the primary strategies for employing distraction to survive a crisis moment (distracting with Activities, Contributing, Comparisons, Emotions, Pushing Away, Thoughts, and Sensations). IMPROVE the moment is also an acronym that captures strategies for temporarily relieving stress (by using Imagery, Meaning, Prayer, Relaxation, One thing to do in the moment, Vacation, and Encouragement). Self-soothing captures a category of skills related to simple, typically physically based activities that reduce negative sensations. Finally, Pros and Cons refers to a technique to evaluate the potential outcome of one of two actions (tolerating the distress vs. not tolerating the distress). One of the four distress tolerance skills (ACCEPTS, IMPROVE, Self-soothing, and pros and cons) was presented each week, resulting in a cyclical, ongoing rotation among the four core distress tolerance skills. This means a veteran could attend a group at any time and learn an important skill, and all of the DBT distress tolerance skills could be learned with attendance at four consecutive groups. A second important modification to the group design included the drop-in designation. This meant that attendance was not mandatory because veterans were free to attend groups on an as-needed basis. Commitment to attending a specific number of groups was not required, nor was a formal referral from a mental health care provider. This meant that no between-group assignments were given, and veterans could come and go as they saw fit. However, we did maintain other DBT group rules and norms, such as focusing on skill attainment rather than discussions or exchanges that focused on the processing of personal material. The group begins with members checking in and rating their levels of distress on a 0–10 scale. Since being aware of one’s own distress is the first step in employing distress
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Skills Training Drop-In Group tolerance skills, the members are encouraged to consider their own personal warning signs that they need to practice skills. Then, group leaders introduce an overview of the distress tolerance skills, finally focusing on the specific skill to be discussed that week (either ACCEPTS, IMPROVE, self-soothing, or pros and cons). Corresponding handouts from the DBT manual (Linehan, 1993b) are provided and members discuss how the skills presented can be used in their personal lives. Finally, the group ends with an exercise related to the specific distress tolerance skill introduced that week. Group leaders emphasize that in order to be effective, these skills need to be practiced repeatedly prior to a crisis so that they can be most effective when used under a situation of high duress. Prior studies have not established an empirical rationale for a specific number of skills groups necessary to result in behavioral changes. Previous researchers report a range in the number of skills groups offered from 16 (Nelson-Gray et al., 2006) to 13 (Soler et al., 2009), to 9 weekly groups (Drossel et al., 2011). Based on clinical experience, we reasoned that 8 groups would provide sufficient exposure to the skills to be able to successfully implement them. Also, attending 8 groups would theoretically allow for exposure to each set of distress tolerance skills twice.
Results Sample Characteristics Descriptive demographic indicators for veterans are reported in Table 1. The mean age of participants in our sample was 54 years old (SD = 9.73). The majority of our sample was African American (50%; see Table 1 for more details) and all participants were male. We also examined psychiatric diagnoses and found that adjustment disorder, PTSD, mood disorders, schizophrenia, and other psychotic disorders were represented (see Table 2 for overall frequency data). Outcome Data Analysis We conducted paired samples t-tests to evaluate the change in crisis events (CEs) during the year prior to Table 1
Mean, Standard Deviation, and Percent of Total for Age, Gender and Race Among Study Participants (N = 8) Variable
M (SD)
Age Gender (% Male) Race African-American Asian Caucasian Hispanic Unknown
54 (9.7)
N (% of total)
8 (100%) 4 (50%) 0 (0%) 2 (12.5%) 2 (25%) 1 (12.5%)
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Table 2
Frequency Data for Diagnoses Among Study Participants (N = 8) Diagnosis
Frequency
Percent
Adjustment disorder Mood episode/disorder PTSD Schizophrenia and other psychotic disorders
1 4 1 2
12.5 50.0 12.5 25.0
starting the drop-in group with the number of CEs after initiating drop-in group attendance, which we defined as the first date the veteran signed the attendance log. Results demonstrated a significant reduction in CEs during the year after joining the drop-in group compared to the mean number of CEs the year prior to initial attendance (t = 3.00, df = 7 p b .02, d = 1.06) (see Figure 1).
Case Study Next, we present a focused case study that highlights the unique needs of this veteran population. Mr. R. is a 31-year-old Hispanic male combat veteran diagnosed with PTSD, traumatic brain injury (TBI), major depression, and personality disorder NOS. He served active duty for 4 years in the army and performed two tours in Iraq and Afghanistan. He was honorably discharged from military service several years ago, but since his return home has become increasingly isolated and depressed. Additionally, he reports reduced ability to tolerate frustration. He notes that these difficulties have led to numerous verbal and physical altercations with others, resulting in police intervention on some occasions. For example, Mr. R. describes becoming very angry when he believes that he is being treated with disrespect, which leads to urges to kill the other person and then himself. Mr. R. also has a history of two suicide attempts in the past 2 years. Both times he overdosed on a combination of over-the-counter medications and alcohol. He was hospitalized at his local VA hospital following both attempts. More recently, he presented at the VA emergency department and voiced suicidal ideation, for which he was subsequently admitted to a psychiatric inpatient unit. Though multiple attempts were made to engage him in outpatient psychotherapy following his previous suicide attempts and his hospitalization, Mr. R. did not follow through. He noted that he was very reluctant to come to groups, and stated that he was not interested in individual therapy because he did not want to “talk about his trauma.” Mr. R was referred to the drop-in skills training group by his OIF/OEF case manager. His case manager emphasized that he did not need to have an appointment, but that he
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Denckla et al.
6 10 9
Crisis Events
8 7 6 5 4 3 2 1 0 1
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4
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Veterans CE Pre
reflects the effects of treatments as they are routinely delivered at this particular clinic. Although exploratory in nature, our findings suggest that skills training alone warrants further research into its ability to address some of the most significant and problematic outcomes associated with suicidal ideation among veterans. Study findings also shed some light on the potential utility of specific training in distress tolerance, suggesting that learning the skills to identify distress earlier and more effectively manage that distress may reduce the likelihood of engaging in a suicide-related event.
CE Post
Figure 1. One-year Pre- and Posttest Crisis Events (CEs) Comparisons. Note: “CE pre” refers to the baseline count of CEs over 1 year prior to first drop-in group attendance. “CE post” refers to the count of CEs 1 year after first drop-in group attendance among veterans who attended a minimum of 8 drop-in groups and had at least one baseline CE.
could show up at any time and see what he thought. Mr. R. attended the drop-in group, and while he was quiet in the initial groups, he did take notes and appeared to follow the discussions. After attending more groups, he noted that he found the discussions particularly helpful in discovering ways to respond to distress that was not harmful to his own well-being or that of others. Additionally, he described various skills that he found particularly helpful in managing distressing situations, including focusing on his breath, walking away, and “pushing away” thoughts. After attending several groups, Mr. R. enthusiastically expressed gratitude to the group members and leaders, stating he would have been in jail or dead if not for the skills he had learned. To illustrate, he described a recent encounter at a social service agency in which he became very frustrated and angry, resulting in urges to kill the person at the counter and then kill himself. On this occasion, he described first noticing the urge, and instead taking deep breaths and reminding himself his feelings would not last forever. He stated this helped him to walk away instead of fighting, and by enhancing his sense of control in the situation he experienced improved self-efficacy. He expressed gratitude for the group and for the skills, noting this was a significant change that gave him hope.
Discussion Study findings suggest a significant decrease in suiciderelated CEs (defined as any of three possible high risk suicide-related behaviors: suicide-related emergency room visits; suicide-related psychiatric admissions; and a suicide attempt) among veterans who attended at least 8 drop-in skills training groups and had at least one CE at baseline. This study employed an exploratory design involving a case study method with behavioral outcome measures, and in so doing
Clinical Implications Findings may suggest that this modified drop-in skills training group provides some benefits to veterans in terms of reducing suicide-related behaviors, consistent with those benefits documented in prior studies on skills training (Lindenboim, Comtois, & Linehan, 2007; Neacsiu et al., 2010). In summary, results appear to add to a growing body of literature suggesting that skills training interventions result in improvement across a number of mental health indicators. The study findings also have clinical implications for the delivery of DBT in the VA health-care system. It may be that providing specific adaptations as are suitable to the military culture (for example, providing drop-in services and eliminating the need for a referral) may address remediable barriers to accessing services documented in the literature (Erbes et al., 2009; Lorber & Garcia, 2010; Pietrzak et al., 2009; Rotem-Harpaz & Rosenheck, 2011). Direct quotes from veterans who attended this group serve to anecdotally illustrate this point: “I happen to look forward to attending because it has helped me tremendously; …it has been [a] very helpful group for vets that experience PTSD; It has saved my life in life’s most challeng [ing] moments; and [I suggest] to do distress tolerance prior to the military and once in, continue. It would be more beneficial to the service member and the life of the military.” Taken together, results suggest further research on adaptations to DBT among a veteran population. Of note, veterans who attended this drop-in group have reported to clinicians that prior to learning distress tolerance skills, their only recourse for dealing with crises was to present to the VA emergency room and ask to be admitted. Attendance in the drop-in group may have prepared veterans who would not have otherwise been willing to commit to psychotherapy to initiate more intensive psychotherapy services. Though the findings are anecdotal, it is worth noting that a number of veterans did join the full DBT program after attending the drop-in group reported in the current study. Results suggest that further research is needed to address the implications of adapting DBT for diverse clinical settings, especially for a
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Skills Training Drop-In Group treatment approach in which fidelity is an important element of service delivery (Koerner et al., 2007). Certain limitations should be taken into consideration when interpreting study results. First, we cannot say how many patients in these groups obtained other mental health interventions, so it becomes difficult to determine definitively whether the drop-in skills training group reduced CEs or whether participation in some other aspect of the services offered by the mental health clinic caused the reduction. Ideally, a similar analysis could be performed on participants who only attended the drop-in group and did not experience other interventions, similar to the analysis as reported in Soler et al. (2009). Anecdotally, most drop-in group members did not endorse willingness to engage in psychotherapy. However, we did not examine this empirically and so cannot make definite conclusions. Second, study findings can only be interpreted cautiously given that other factors may have influenced outcome, such as social support provided by simply attending a group. For example, the social contact with other veterans alone could have resulted in a decrease in CEs, rather than the specific intervention delivered. Third, we cannot entirely rule out the possibility that the results noted in this study are potentially an artifact of regression to the mean such that those at a more extreme end of a frequency of CEs moved over time towards the mean frequency. Fourth, the small sample size reported in the current study is a significant limitation to generalizability of the findings and results should be interpreted with caution. A final limitation to the study is that our analysis did not capture CEs that could have occurred outside the VA system. For example, it is plausible that a veteran could have presented to a non-VA emergency department following a suicide attempt. While it is likely that veterans consistently sought services within the VA medical system, we cannot rule out the possibility that our count of CEs underestimated actual CEs. Although the study has certain limitations, there are specific study strengths afforded by the methodology. Employing an outcome variable that captures actual clinical encounters associated with suicide-related behaviors offers a number of advantages. First, this variable serves as a direct behavioral measure of some of the most significant and problematic outcomes of suicidal ideation that health care systems should be most attuned to minimizing. By addressing the effectiveness of a modified treatment as routinely delivered in clinical practice, our study fills a gap in the literature on clinically representative research (see, for example, Stiles et al., 2006). Additionally, by relying on data routinely collected for administrative and patient care, study findings have direct relevance to the health care systems in which these services are routinely provided, may be more clinically meaningful than self-report measures, and do not require additional effort from busy VA clinicians. Finally, given the need to control rapidly increasing health
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costs associated with the escalating health care needs of returning veterans, combined with the high costs associated with emergency room visits and psychiatric hospitalizations, interventions that demonstrate the promise to reduce reliance on these systems are particularly salient (Corson et al., 2013). Taken together, results from this exploratory study suggest that a modified DBT group skills training offered to veterans may hold promise for reducing suicide-related behaviors, warranting further research in this area.
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Pietrzak, R. H., Russo, A. R., Ling, Q., & Southwick, S. M. (2011). Suicidal ideation in treatment-seeking Veterans of Operations Enduring Freedom and Iraqi Freedom: The role of coping strategies, resilience, and social support. Journal of Psychiatric Research, 45, 720–726. http://dx.doi.org/10.1016/j.jpsychires. 2010.11.015 Pietrzak, R. H. P. M. P. H., Johnson, D. C. P., Goldstein, M. B. P., Malley, J. C. P., & Southwick, S. M. M. D. (2009). Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatric Services, 60, 1118–1122. Retrieved from http://search. proquest.com/docview/213073614?accountid=8204 Riddle, J. R., Smith, T. C., Smith, B., Corbeil, T. E., Engel, C. C., Wells, T. S., . . . Blazer, D. (2007). Millennium Cohort: the 2001–2003 baseline prevalence of mental disorders in the U.S. military. Journal of Clinical Epidemiology, 60, 192–201. http://dx.doi.org/10.1016/j.jclinepi. 2006.04.008 Rotem-Harpaz, I., & Rosenheck, R. A. (2011). Servicing those who served: Retention of newly returning veterans from Iraq and Afghanistan in mental health treatment. Psychiatric Services, 62, 22–27. Retrieved from http://search.proquest.com/docview/ 860124106?accountid=8204 Shadish, W. R., Navarro, A. M., Matt, G. E., & Phillips, G. (2000). The effects of psychological therapies under clinically representative conditions: A meta-analysis. Psychological Bulletin, 126, 512–529. http://dx.doi.org/10.1037/0033-2909.126.4.512 Smith, T. C., Wingard, D. L., Ryan, M. A. K., Kritz-Silverstein, D., Slymen, D. J., & Sallis, J. F. (2009). PTSD prevalence, associated exposures, and functional health outcomes in a large, population-based military cohort. Public Health Reports, 124, 90. Retrieved from: http://www.jstor.org/stable/25682152 Soler, J., Pascual, J. C., Tiana, T., Cebria, A., Barrachina, J., Campins, M. J., . . . Perez, V. (2009). Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial. Behavior Research and Therapy, 47, 353–358. http://dx.doi.org/10.1016/j. brat.2009.01.013 Spoont, M. R., Sayer, N. A., Thuras, P., Erbes, C., & Winston, E. (2003). Practical psychotherapy: Adaptation of dialectical behavior therapy by a VA Medical Center. Psychiatric Services, 54, 627–629. http://dx.doi.org/10.1176/appi.ps.54.5.627 Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J., & Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in UK National Health Service settings. Psychological Medicine, 36, 555–566. http://dx.doi.org/ 10.1017/S0033291706007136 Vujanovic, A. A., Bonn-Miller, M. O., Potter, C. M., Marshall, E. C., & Zvolensky, M. J. (2011). An evaluation of the relation between distress tolerance and Posttraumatic Stress within a trauma-exposed sample. Journal of Psychopathology and Behavioral Assessment, 33, 129–135. http://dx.doi.org/10.1007/s10862-010-9209-2 Portions of this paper have been previously presented at the International Society for the Teaching and Improvement of Dialectical Behavior Therapy, National Harbor, MD, 2012. Address correspondence to Christy A. Denckla, Gordon F. Derner Institute of Advanced Psychological Studies, Adelphi University, 158 Cambridge Avenue, Garden City, NY 11530; e-mail: christydenckla@ mail.adelphi.edu. Received: July 2, 2013 Accepted: April 3, 2014 Avilable online xxxx
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
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A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events Christy A. Denckla, Adelphi University Robert Bailey, Adelphi University and Department of Veterans Affairs, New York Harbor Healthcare System Christie Jackson, Department of Veterans Affairs, New York Harbor Healthcare System, and New York University School of Medicine John Tatarakis, Department of Veterans Affairs, New York Harbor Healthcare System Cory K. Chen, Department of Veterans Affairs, New York Harbor Healthcare System, and New York University School of Medicine Although clinical services designed to address suicide-related behaviors are available to veterans, some factors may limit their effectiveness. Relevant factors include the presence of barriers to accessing existing services and a lack of interventions that address the unique needs of veterans. In an effort to address this gap, a modified DBT distress tolerance drop-in group was offered to a population of military veterans in an outpatient setting. This exploratory study reports clinical outcomes on this skills training group intervention informed by Dialectical Behavior Therapy (DBT) principles among a population of self- and clinician-referred veterans. Findings suggest a significant reduction in suicide-related behaviors among veterans who attended 8 or more skills training groups. Clinical implications of study findings warrant further research into novel adaptations of evidence-based treatments for this population with unique needs.
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Behavior Therapy (DBT; Linehan, 1993a) is an evidence-based psychotherapy that has been shown to be effective in reducing self-harm behavior, suicide attempts, and suicide-related hospitalizations (e.g., Kliem, Kroger, & Kosfelder, 2010; Linehan et al., 2006; Lynch, Trost, Salsman, & Linehan, 2007). The full DBT protocol incorporates weekly individual psychotherapy sessions, group skills training, consultation team meetings for the DBT therapists, and telephone skills coaching. As the evidence base for DBT has accumulated, disseminating this empirically supported treatment among real-world clinical settings can result in the need to balance fidelity to the treatment as developed in research settings with adaption to varying clinical settings and populations (Koerner, Dimeff, & Swenson, 2007; McHugh, Murray, & Barlow, 2009). As DBT is increasingly used in a wide variety of community-based, outpatient, and inpatient settings, it is important that modifications or alterations to the treatment as previously tested be carefully evaluated. To contribute to this effort, the current study reports exploratory findings on a novel IALECTICAL
modification of DBT skills training offered to military veterans who are at high risk for suicide. Originally designed as a treatment for seriously suicidal clients, studies suggest that DBT may be particularly useful for treating this target behavior (Linehan, Comtois, & Ward-Ciesielski, 2012). The DBT framework conceptualizes suicide as a maladaptive problem-solving strategy employed in the context of unbearable suffering. Because keeping patients alive is the highest priority if they are to benefit from treatment, reducing suicide crisis behaviors (defined as “any behaviors that place the client at an imminent risk for suicide or threaten to do so, including credible suicide threats, planning, preparations, obtaining lethal means, and high suicide intent”; Linehan & Dexter-Mazza, 2008, p. 379) is the first priority in DBT. Reducing suicidal behaviors in DBT occurs by making this target and its high priority explicit in the first DBT treatment session. When suicidal behavior is present, standard behavioral interventions are employed within the context of the DBT framework, which is a blend of three theoretical positions: behavioral science, dialectical philosophy, and Zen practice (Linehan, 1993a). Suicidal Behaviors and Unique Needs of Veterans
Keywords: veterans; suicide; self-harm; distress tolerance; dialectical behavioral therapy
1077-7229/13/© 2014 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
Previous studies suggest that the high rates of suicide among military personnel are a critical public health concern. While findings regarding the comparative increase in risk for suicide among veterans with respect
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
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Denckla et al. to the civilian population are mixed (Langford, Litts, & Pearson, 2013), the results of some epidemiological studies have pointed to the potential of an increased risk for suicide among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans with existing psychiatric disorders (Corson et al., 2013). In a related study, Kuehn (2009) found that suicide rates among military personnel had reached a 28-year high in 2008, which represents the continuation of a disturbing trend that has seen a steady rise in the number of completed suicides among service members. Considering these estimates in the context of further studies that suggest a threefold increase in the onset of PTSD among recently deployed military personnel (Riddle et al., 2007; Smith et al., 2009) and research that demonstrates increased risk for suicide among service members with PTSD (Pietrzak, Russo, Ling, & Southwick, 2011), effective interventions to address the mental health needs of veterans who are at increased risk for suicide are urgently needed. Although mental health services designed to address suicide-related behaviors are available to veterans, there are limitations to the effectiveness of these interventions, including barriers to accessing existing services and a lack of interventions that address the unique needs of veterans (Langford et al., 2013). The U.S. Department of Veterans Affairs (VA) has made significant changes to its mental health delivery system to address the growing need for services among veterans. Specifically, a 2005 VA strategic plan called for the integration of primary care and behavioral health in order to increase access to mental health services (Edwards, 2008). As part of this strategic plan, the VA has also prioritized the dissemination of evidence-based psychotherapies to further integrate research and clinical practice, helping to ensure that veterans receive the most effective treatments available (Karlin & Cross, 2014). Furthermore, recognition of the significance of suicide and self-directed violence as a major veteran mental health issue has led to other system-wide changes in infrastructure. Changes included the addition of personnel, called Suicide Prevention Coordinators to VA Medical Centers, a 24-hour crisis hotline and chatline, and significantly increasing the number of mental health professionals overall (Bruce, 2010). Despite efforts to expand the availability of mental health services, research indicates that these services are underutilized (Fasoli, Glickman, & Eisen, 2010).Studies of mental health service utilization among veterans recently returned from Iraq or Afghanistan indicate that although approximately 25% to 30% of the veterans in this sample reported some mental health concern after deployment, only 23% to 40% of those who met criteria for a psychiatric disorder sought mental health care (Hoge et al., 2004). This underutilization of available mental health
services has been a longstanding issue in the VA. For example, Hankin, Spiro, Miller and Kazis (1999) reported that although 40% of veterans met criteria for at least one psychiatric disorder, almost a third of those diagnosed had never sought treatment. Many barriers have been reported that interfere with veterans’ access to care, including (a) stigma associated with mental illness, which may include embarrassment and worries about being perceived as weak, or (b) logistical barriers such as not knowing where to get help and difficulty scheduling appointments (Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). It is likely that these barriers have in part contributed to high rates of dropout, low session attendance, and frequent no-shows among those who do seek out treatment (Erbes, Curry, & Leskela, 2009; Lorber & Garcia, 2010) such that often the number of sessions attended is less than that identified in treatment protocols necessary to result in significant reductions in symptoms (Rotem-Harpaz & Rosenheck, 2011). Taken together, results suggest that psychological interventions offered to veterans must account for the unique needs of this population, as well as existing barriers to treatment, within the current system of service delivery. DBT in the VA Setting In the sparse literature on DBT in the VA setting, studies suggest a superior reduction in suicide-related behaviors, hopelessness, and depression among female military veterans compared to a treatment-as-usual group (Koons et al., 2001). However, implementing the standard DBT protocol in the VA is fraught with the challenges discussed above. Unfortunately, offering a modified DBT protocol to a veteran population is largely untested and therefore the degree of efficacy noted in controlled clinical trials cannot necessarily be expected in modified deliveries. However, a small body of literature is suggesting that certain modified DBT protocols can be delivered with beneficial clinical outcomes. For example, Spoont, Sayer, Thuras, Erbes, and Winston (2003) noted that in order to deliver DBT to their veteran population successfully, addressing the unique needs of this population with cognitive impairment, literacy issues, diagnostic heterogeneity, and limitations on the availability of clinicians and of training funds was necessary. The authors concluded that adaptations to the standard DBT protocol could be made while still successfully achieving both client satisfaction and client- and clinician-rated benefit. Studies also suggest that skills training alone can result in beneficial outcomes for clients. For example, Miller, Wyman, Huppert, Glassman, and Rathus (2000) found that adolescents demonstrating suicide-related behaviors reported that distress tolerance and mindfulness skills were the most helpful in reducing self-injurious behaviors. DBT skills group training alone has also been found to be
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Skills Training Drop-In Group an effective treatment among a number of diagnostic categories. For example, Nelson-Gray et al. (2006) found that a 16-week course of DBT skills training resulted in clinically significant change among a population of behaviorally dysregulated adolescents meeting criteria for oppositional-defiant disorder. Study outcomes demonstrated significant reductions in caregiver reports of externalizing symptoms, as well as a reduction in internalizing symptoms, according to youth report. A randomized controlled trial conducted among a sample of women meeting criteria for a diagnosis of borderline personality disorder found that skills training outperformed group therapy delivered by psychodynamically oriented clinicians in terms of lower dropout rates, reductions in depression, anxiety, irritability, and affective instability (Soler et al., 2009). Furthermore, another study found that offering DBT skills training over nine groups among caregivers for elders with dementia resulted in significant increases in levels of psychosocial functioning, reliance on problem-focused coping strategies, emotional well-being, and reduced fatigue among the 16 group participants who completed the study (Drossel, Fisher, & Mercer, 2011). Taken together, findings suggest that distress tolerance skills may be particularly effective in reducing a number of target behaviors, including high-risk suicidal and self-harm-related behaviors. Past research suggests that deficits in distress tolerance (defined as the ability to withstand negative emotional states) is a risk factor for various forms of psychopathology (Leyro, Zvolensky, & Bernstein, 2010; Vujanovic, Bonn-Miller, Potter, Marshall, & Zvolensky, 2011). Studies indicate that intense negative emotions combined with deficits in the ability to modulate those states are linked with increased rates of suicidal and self-injurious behaviors (Brown, Comtois, & Linehan, 2002; Nixon, Cloutier, & Aggarwal, 2002). For example, adolescents who demonstrated nonsuicidal self-injury (NSSI), showed higher physiological reactivity during a distressing task, as well as reduced ability to tolerate that distress, compared to noninjurers (Nock & Mendes, 2008). Given this evidence, developing interventions that teach distress tolerance skills to veterans who would be unlikely to successfully complete a full treatment course of traditional DBT could potentially extend the number of veterans benefitting from this intervention. The Current Study In the current study, we sought to extend previous research suggesting that distress tolerance skills training alone, modified to meet the unique needs of veterans, may be a potentially effective intervention to address suiciderelated behaviors. Although our facility had a full DBT program, including individual psychotherapy, skills group
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training, telephone coaching, and weekly consultation team meetings, it became clear that a significant number of veterans were unable to or uninterested in participating in a full DBT program. Clinicians noted that a large number of veterans, especially those that were high risk (defined in the VAMC as being at increased risk for suicidal behaviors), had difficulty engaging in full DBT program due to high levels of psychosocial impairment, high rates of transience and interpersonal chaos, and unwillingness to consider the full DBT program. Unfortunately, these veterans were also among those who needed this treatment the most. To meet the needs of this population, one of the current authors (C.J.) considered novel ways to provide the benefits of treatment to this population by offering skills training on an as-needed, drop-in basis so that veterans could begin attendance immediately. This format also offered clinicians a concrete referral resource because they could escort clients to the drop-in group and veterans could begin immediately. Importantly, this population had refused previous referrals for mental health care to address their presenting concerns. The fundamental goal of the group was to teach crisis survival skills to those who need it the most, and we strived to maximize accessibility, feasibility, and veteran buy-in. To evaluate the impact of this intervention, we employed an exploratory design involving a case study method with a behavioral outcome variable consisting of high-intensity contact with medical facilities (i.e., emergency room visit or inpatient hospitalization) due to suicidal ideation or suicide attempt (for similar studies using data collected primarily for clincial and administrative use rather than for research, see Shadish, Navarro, Matt, & Phillips, 2000; Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006). Based on our review of the literature suggesting promising outcomes among individuals who obtain skills training (Neacsiu, Rizvi, & Linehan, 2010; Soler et al., 2009), as well as a need for interventions that address suicide-related behaviors among a veteran population, we conducted an exploratory study to examine suicide-related outcomes among veterans who attended drop-in skills training groups.
Method Participants Review of medical records identified a total of 65 veterans who had attended at least one drop-in skills training group over the year prior to the date the chart review was conducted. We identified a final cohort of 8 veterans (12.3% of the full sample) who had demonstrated suicide-related behaviors at baseline and who had attended at least 8 groups over a 1-year period (mean number of groups attended = 19, SD = 10.74). The veterans included in this current report were not receiving the full DBT program (though the full DBT program was available to them and many veterans did join
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Denckla et al.
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the full DBT program after attendance in the drop-in group). Procedure There were three primary sources of referrals for this drop-in group: (a) fliers posted widely throughout the VA; (b) referrals from current group members; and (c) referrals from VA staff to include mental health care providers, suicide prevention coordinators, or emergency department staff. We posted fliers throughout the VA in a number of areas, such as the pain clinic, primary care clinics, the mental health clinic, and the emergency room. Fliers were designed using verbiage directly from the DBT manual and described the group as providing instruction on how to “tolerate painful events, urges, and emotions when you cannot make things better right away.” All distress tolerance skills training drop-in groups are led by a Certified Nurse Specialist who is also a certified DBT practitioner and part of our consultation team. The groups are co-led by psychiatry residents, clinical psychology interns or externs, or nursing or social work graduate students, all of whom received some didactic training in DBT as part of their residencies. Each group is 55 minutes long, and the number of participants in a group can vary from 2 to 15 attendees. Measures Data were collected through a chart review utilizing the VA’s Computerized Patient Record System (CPRS). First, a log of all individuals who attend the drop-in skills training group was collated to produce a record of all veterans who had attended at least one drop-in group in the year prior to initiating data collection. Then, a stepwise review of veteran electronic medical records maintained in the VA was conducted using the following method. First, each patient record was reviewed to determine the number of drop-in groups attended. Then, we reviewed the charts for evidence of any of the following behaviors: (a) suicide-related emergency room visits; (b) suicide-related psychiatric admissions; and (c) suicide attempts. We tallied the total number of episodes of these suicide-related behaviors, thereby generating a behavioral outcome variable we called “crisis events” (CEs). Thus, the outcome variable “CEs” represented a sum count of the number of suicide-related emergency room visits, suicide-related psychiatric admissions, and suicide attempts. We reasoned that the frequency of these events produced a rough measure of suicide-related behavior “severity” because escalation through the health care system implies higher risk of suicide. For example, a suicide attempt followed by a trip to the ER that leads to a psychiatric hospitalization would result in a sum count of 3 crisis events. Alternatively, a veteran presenting to the emergency department with passive suicidal ideation that is
subsequently stabilized and who is discharged would result in a sum count of 1 crisis event. Finally, we collected basic demographic data and active psychiatric diagnoses. We proceeded to conduct paired sample t-tests to compare pre and post CEs across the sample of veterans identified in this study. Finally, in an effort to convey the unique needs of this population, we present a brief case study. Treatment Format The drop-in skills training group intervention reported in the current study focused on distress tolerance skills, as described in Linehan (1993b). Employing guidelines for adapting DBT to novel settings described by Koerner, Dimeff, and Swenson (2007), the current author (C. J.) developed a curriculum in which one of the four DBT distress tolerance skills (ACCEPTS, IMPROVE the Moment, Self-Soothing, and Pros and Cons) was presented weekly (see Linehan, 1993b, for full details). Briefly summarized, the first of the four core distress tolerance skills, ACCEPTS, is an acronym that stands for the primary strategies for employing distraction to survive a crisis moment (distracting with Activities, Contributing, Comparisons, Emotions, Pushing Away, Thoughts, and Sensations). IMPROVE the moment is also an acronym that captures strategies for temporarily relieving stress (by using Imagery, Meaning, Prayer, Relaxation, One thing to do in the moment, Vacation, and Encouragement). Self-soothing captures a category of skills related to simple, typically physically based activities that reduce negative sensations. Finally, Pros and Cons refers to a technique to evaluate the potential outcome of one of two actions (tolerating the distress vs. not tolerating the distress). One of the four distress tolerance skills (ACCEPTS, IMPROVE, Self-soothing, and pros and cons) was presented each week, resulting in a cyclical, ongoing rotation among the four core distress tolerance skills. This means a veteran could attend a group at any time and learn an important skill, and all of the DBT distress tolerance skills could be learned with attendance at four consecutive groups. A second important modification to the group design included the drop-in designation. This meant that attendance was not mandatory because veterans were free to attend groups on an as-needed basis. Commitment to attending a specific number of groups was not required, nor was a formal referral from a mental health care provider. This meant that no between-group assignments were given, and veterans could come and go as they saw fit. However, we did maintain other DBT group rules and norms, such as focusing on skill attainment rather than discussions or exchanges that focused on the processing of personal material. The group begins with members checking in and rating their levels of distress on a 0–10 scale. Since being aware of one’s own distress is the first step in employing distress
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Skills Training Drop-In Group tolerance skills, the members are encouraged to consider their own personal warning signs that they need to practice skills. Then, group leaders introduce an overview of the distress tolerance skills, finally focusing on the specific skill to be discussed that week (either ACCEPTS, IMPROVE, self-soothing, or pros and cons). Corresponding handouts from the DBT manual (Linehan, 1993b) are provided and members discuss how the skills presented can be used in their personal lives. Finally, the group ends with an exercise related to the specific distress tolerance skill introduced that week. Group leaders emphasize that in order to be effective, these skills need to be practiced repeatedly prior to a crisis so that they can be most effective when used under a situation of high duress. Prior studies have not established an empirical rationale for a specific number of skills groups necessary to result in behavioral changes. Previous researchers report a range in the number of skills groups offered from 16 (Nelson-Gray et al., 2006) to 13 (Soler et al., 2009), to 9 weekly groups (Drossel et al., 2011). Based on clinical experience, we reasoned that 8 groups would provide sufficient exposure to the skills to be able to successfully implement them. Also, attending 8 groups would theoretically allow for exposure to each set of distress tolerance skills twice.
Results Sample Characteristics Descriptive demographic indicators for veterans are reported in Table 1. The mean age of participants in our sample was 54 years old (SD = 9.73). The majority of our sample was African American (50%; see Table 1 for more details) and all participants were male. We also examined psychiatric diagnoses and found that adjustment disorder, PTSD, mood disorders, schizophrenia, and other psychotic disorders were represented (see Table 2 for overall frequency data). Outcome Data Analysis We conducted paired samples t-tests to evaluate the change in crisis events (CEs) during the year prior to Table 1
Mean, Standard Deviation, and Percent of Total for Age, Gender and Race Among Study Participants (N = 8) Variable
M (SD)
Age Gender (% Male) Race African-American Asian Caucasian Hispanic Unknown
54 (9.7)
N (% of total)
8 (100%) 4 (50%) 0 (0%) 2 (12.5%) 2 (25%) 1 (12.5%)
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Table 2
Frequency Data for Diagnoses Among Study Participants (N = 8) Diagnosis
Frequency
Percent
Adjustment disorder Mood episode/disorder PTSD Schizophrenia and other psychotic disorders
1 4 1 2
12.5 50.0 12.5 25.0
starting the drop-in group with the number of CEs after initiating drop-in group attendance, which we defined as the first date the veteran signed the attendance log. Results demonstrated a significant reduction in CEs during the year after joining the drop-in group compared to the mean number of CEs the year prior to initial attendance (t = 3.00, df = 7 p b .02, d = 1.06) (see Figure 1).
Case Study Next, we present a focused case study that highlights the unique needs of this veteran population. Mr. R. is a 31-year-old Hispanic male combat veteran diagnosed with PTSD, traumatic brain injury (TBI), major depression, and personality disorder NOS. He served active duty for 4 years in the army and performed two tours in Iraq and Afghanistan. He was honorably discharged from military service several years ago, but since his return home has become increasingly isolated and depressed. Additionally, he reports reduced ability to tolerate frustration. He notes that these difficulties have led to numerous verbal and physical altercations with others, resulting in police intervention on some occasions. For example, Mr. R. describes becoming very angry when he believes that he is being treated with disrespect, which leads to urges to kill the other person and then himself. Mr. R. also has a history of two suicide attempts in the past 2 years. Both times he overdosed on a combination of over-the-counter medications and alcohol. He was hospitalized at his local VA hospital following both attempts. More recently, he presented at the VA emergency department and voiced suicidal ideation, for which he was subsequently admitted to a psychiatric inpatient unit. Though multiple attempts were made to engage him in outpatient psychotherapy following his previous suicide attempts and his hospitalization, Mr. R. did not follow through. He noted that he was very reluctant to come to groups, and stated that he was not interested in individual therapy because he did not want to “talk about his trauma.” Mr. R was referred to the drop-in skills training group by his OIF/OEF case manager. His case manager emphasized that he did not need to have an appointment, but that he
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Denckla et al.
6 10 9
Crisis Events
8 7 6 5 4 3 2 1 0 1
2
3
4
5
6
7
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Veterans CE Pre
reflects the effects of treatments as they are routinely delivered at this particular clinic. Although exploratory in nature, our findings suggest that skills training alone warrants further research into its ability to address some of the most significant and problematic outcomes associated with suicidal ideation among veterans. Study findings also shed some light on the potential utility of specific training in distress tolerance, suggesting that learning the skills to identify distress earlier and more effectively manage that distress may reduce the likelihood of engaging in a suicide-related event.
CE Post
Figure 1. One-year Pre- and Posttest Crisis Events (CEs) Comparisons. Note: “CE pre” refers to the baseline count of CEs over 1 year prior to first drop-in group attendance. “CE post” refers to the count of CEs 1 year after first drop-in group attendance among veterans who attended a minimum of 8 drop-in groups and had at least one baseline CE.
could show up at any time and see what he thought. Mr. R. attended the drop-in group, and while he was quiet in the initial groups, he did take notes and appeared to follow the discussions. After attending more groups, he noted that he found the discussions particularly helpful in discovering ways to respond to distress that was not harmful to his own well-being or that of others. Additionally, he described various skills that he found particularly helpful in managing distressing situations, including focusing on his breath, walking away, and “pushing away” thoughts. After attending several groups, Mr. R. enthusiastically expressed gratitude to the group members and leaders, stating he would have been in jail or dead if not for the skills he had learned. To illustrate, he described a recent encounter at a social service agency in which he became very frustrated and angry, resulting in urges to kill the person at the counter and then kill himself. On this occasion, he described first noticing the urge, and instead taking deep breaths and reminding himself his feelings would not last forever. He stated this helped him to walk away instead of fighting, and by enhancing his sense of control in the situation he experienced improved self-efficacy. He expressed gratitude for the group and for the skills, noting this was a significant change that gave him hope.
Discussion Study findings suggest a significant decrease in suiciderelated CEs (defined as any of three possible high risk suicide-related behaviors: suicide-related emergency room visits; suicide-related psychiatric admissions; and a suicide attempt) among veterans who attended at least 8 drop-in skills training groups and had at least one CE at baseline. This study employed an exploratory design involving a case study method with behavioral outcome measures, and in so doing
Clinical Implications Findings may suggest that this modified drop-in skills training group provides some benefits to veterans in terms of reducing suicide-related behaviors, consistent with those benefits documented in prior studies on skills training (Lindenboim, Comtois, & Linehan, 2007; Neacsiu et al., 2010). In summary, results appear to add to a growing body of literature suggesting that skills training interventions result in improvement across a number of mental health indicators. The study findings also have clinical implications for the delivery of DBT in the VA health-care system. It may be that providing specific adaptations as are suitable to the military culture (for example, providing drop-in services and eliminating the need for a referral) may address remediable barriers to accessing services documented in the literature (Erbes et al., 2009; Lorber & Garcia, 2010; Pietrzak et al., 2009; Rotem-Harpaz & Rosenheck, 2011). Direct quotes from veterans who attended this group serve to anecdotally illustrate this point: “I happen to look forward to attending because it has helped me tremendously; …it has been [a] very helpful group for vets that experience PTSD; It has saved my life in life’s most challeng [ing] moments; and [I suggest] to do distress tolerance prior to the military and once in, continue. It would be more beneficial to the service member and the life of the military.” Taken together, results suggest further research on adaptations to DBT among a veteran population. Of note, veterans who attended this drop-in group have reported to clinicians that prior to learning distress tolerance skills, their only recourse for dealing with crises was to present to the VA emergency room and ask to be admitted. Attendance in the drop-in group may have prepared veterans who would not have otherwise been willing to commit to psychotherapy to initiate more intensive psychotherapy services. Though the findings are anecdotal, it is worth noting that a number of veterans did join the full DBT program after attending the drop-in group reported in the current study. Results suggest that further research is needed to address the implications of adapting DBT for diverse clinical settings, especially for a
Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001
Skills Training Drop-In Group treatment approach in which fidelity is an important element of service delivery (Koerner et al., 2007). Certain limitations should be taken into consideration when interpreting study results. First, we cannot say how many patients in these groups obtained other mental health interventions, so it becomes difficult to determine definitively whether the drop-in skills training group reduced CEs or whether participation in some other aspect of the services offered by the mental health clinic caused the reduction. Ideally, a similar analysis could be performed on participants who only attended the drop-in group and did not experience other interventions, similar to the analysis as reported in Soler et al. (2009). Anecdotally, most drop-in group members did not endorse willingness to engage in psychotherapy. However, we did not examine this empirically and so cannot make definite conclusions. Second, study findings can only be interpreted cautiously given that other factors may have influenced outcome, such as social support provided by simply attending a group. For example, the social contact with other veterans alone could have resulted in a decrease in CEs, rather than the specific intervention delivered. Third, we cannot entirely rule out the possibility that the results noted in this study are potentially an artifact of regression to the mean such that those at a more extreme end of a frequency of CEs moved over time towards the mean frequency. Fourth, the small sample size reported in the current study is a significant limitation to generalizability of the findings and results should be interpreted with caution. A final limitation to the study is that our analysis did not capture CEs that could have occurred outside the VA system. For example, it is plausible that a veteran could have presented to a non-VA emergency department following a suicide attempt. While it is likely that veterans consistently sought services within the VA medical system, we cannot rule out the possibility that our count of CEs underestimated actual CEs. Although the study has certain limitations, there are specific study strengths afforded by the methodology. Employing an outcome variable that captures actual clinical encounters associated with suicide-related behaviors offers a number of advantages. First, this variable serves as a direct behavioral measure of some of the most significant and problematic outcomes of suicidal ideation that health care systems should be most attuned to minimizing. By addressing the effectiveness of a modified treatment as routinely delivered in clinical practice, our study fills a gap in the literature on clinically representative research (see, for example, Stiles et al., 2006). Additionally, by relying on data routinely collected for administrative and patient care, study findings have direct relevance to the health care systems in which these services are routinely provided, may be more clinically meaningful than self-report measures, and do not require additional effort from busy VA clinicians. Finally, given the need to control rapidly increasing health
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costs associated with the escalating health care needs of returning veterans, combined with the high costs associated with emergency room visits and psychiatric hospitalizations, interventions that demonstrate the promise to reduce reliance on these systems are particularly salient (Corson et al., 2013). Taken together, results from this exploratory study suggest that a modified DBT group skills training offered to veterans may hold promise for reducing suicide-related behaviors, warranting further research in this area.
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Please cite this article as: Denckla et al., A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.001