Dialectical Behavior Therapy Adapted for the Vocational Rehabilitation of Significantly Disabled Mentally Ill Adults

Cognitive and Behavioral Practice 13 (2006) 146–156 www.elsevier.com/locate/cabp

Dialectical Behavior Therapy Adapted for the Vocational Rehabilitation of Significantly Disabled Mentally Ill Adults Cedar R. Koons, Private Practice, Santa Fe, New Mexico Alexander L. Chapman, Duke University Bette B. Betts, Beth O’Rourke, and Nesha Morse, Private Practice, Santa Fe, New Mexico Clive J. Robins, Duke University Twelve vocational rehabilitation clients with severe mental illness received a comprehensive adaptation of dialectical behavior therapy (DBT) delivered in a group format. Treatment consisted of 2 hours of standard DBT skills training per week and 90 minutes of diary card review, chain analysis, and behavioral rehearsal. Participants were selected based on previous failure to obtain or maintain employment. The participants had a mean of 3 psychiatric diagnoses each, and all participants met criteria for a personality disorder, with 58.3% having a diagnosis of borderline personality disorder. There were 4 dropouts and 8 treatment completers. The treatment completers improved significantly and maintained their improvements (at 6-month follow-up) in depression, hopelessness, and the experience of anger. In addition, the completers improved significantly from pretreatment to 6 months follow-up on anger expression, control of anger expression, work role satisfaction, and on number of hours worked weekly.

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of vocational rehabilitation services for persons with severe mental illness, such as those offered by Divisions of Vocational Rehabilitation, has long been in question (Noble, Honberg, Hall, & Flynn, 1999). In many states, state and federally funded offices of vocational rehabilitation offer extensive services to persons with disabling conditions to help them achieve “meaningful employment” for a period of time, typically a minimum of 90 days. However, persons with severe mental illness often respond poorly to standard services despite attempts to address the specific problems that complicate their rehabilitation (Conley, 1999). Research on vocational rehabilitation has focused on persons with schizophrenia and related psychotic disorders. For these individuals, it has been established that supported employment has evidence for its effectiveness, although more research is needed on long-term outcomes and cost-effectiveness (Bond, Becker, et al., 2001). Over the long term, however, supportive employment is associated with lower earnings from work and does not appear to reduce dependence on public financial support (Clark, Xie, Becker, & Drake, 1998). In addition, receiving public support may interfere with attending HE EFFECTIVENESS

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and benefiting from supported employment (Drew et al., 2001). Competitive employment, on the other hand, is correlated with higher rates of improvement in symptoms and in self-esteem when compared with employment that is more sheltered (Bond, Resnick, et al., 2001). Some controversy still exists over the best way to move clients from supportive employment to competitive employment (Clark et al., 1998). One method, individualized placement and support (IPS), appears to decrease the time necessary to obtain employment and may help maintain employment, despite having little impact on clinical functioning (Drake, Becker, et al., 1999; Drake, McHugo, et al., 1999). Another method, group skills training (GST), may have implications for success in competitive employment because it addresses the issue of social networks at work. One study found that GST was associated with an enhancement in perceived emotional support from relationships on the job as well as greater overall satisfaction with supervisor relationships (Rollins et al., 2002); however, when IPS and GST were compared in a randomized controlled trial (Clark, Xie, et al., 1998), the net benefits did not significantly differ. Not as much is known about the factors that impede or assist persons with personality disorders in finding and sustaining employment. Access to appropriate supported employment remains very limited (Bond et al., 2001). Anecdotally, we know that many personality-disordered persons, even those who are educated and have job

DBT in Vocational Rehabilitation training, are unable to sustain employment long enough to achieve rehabilitation, despite considerable expense and that they often return for services not long after a successful “closure” (Sussman, personal communication, August 2001). In developing the intervention described here, the authors hypothesized that the interpersonal, behavioral, emotional, and concentration skills deficits of personalitydisordered individuals contribute greatly to difficulty obtaining and sustaining employment. The standard vocational counseling or individual therapy services offered through vocational rehabilitation do not address these skills deficits. Traditional case management and job coaching also fail to teach clients how to manage the emotional issues on the job, essentially operating in a “give the person a fish” paradigm by intervening directly with supervisors when conflicts arise on the job. In contrast, we suggest that a program that addresses skill deficits is essential for personality-disordered persons seeking competitive employment. Dialectical behavior therapy (DBT; Linehan, 1993a) is an outpatient cognitive-behavioral treatment developed initially for the treatment of suicidal women and then applied to the treatment of borderline personality disorder (BPD), primarily due to the prevalence of suicidal behaviors among individuals with BPD. DBT usually consists of once-weekly sessions of 50 to 60 minutes of individual therapy; once-weekly skills training group, lasting up to 2.5 hours per week; and a weekly therapist consultation meeting. One key feature of DBT is its conceptualization of stages of disorder and the appropriate hierarchy of behavioral targets to be addressed in each stage. Stage 1 targets include: (a) lifethreatening behaviors, such as suicidal crisis behaviors, parasuicidal behaviors, and suicidal ideation; (b) behaviors that interfere with therapy, such as nonattendance, noncompliance, and disrespectful behaviors; (c) behaviors that interfere with a quality of life, such as drug and alcohol abuse, homelessness, lack of structure and unemployment, or other behaviors that severely decrease the individual’s likelihood of establishing a reasonable quality of life; and (d) the acquisition and strengthening of psychosocial skills in the areas of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Stage 2 addresses emotional avoidance and posttraumatic stress responses, and Stage 3 deals with “ordinary problems of living.” Standard DBT addresses five basic treatment functions considered necessary for difficult-to-treat patients or clients, such as those with BPD. These functions include the following: (a) enhancing client capabilities (skills-training group), (b) improving client motivation (individual therapy), (c) assuring the generalization of skills to the natural environment (telephone coaching by individual

therapist), (d) improving the therapist’s motivation to treat (consultation team meeting), and (e) structuring the patient’s environment to support skillful behavior (individual therapy) and structuring the treatment environment to support the treatment (clinic administration). Ancillary (non-DBT) treatments such as pharmacotherapy and case management may also address some of these functions (see Robins & Koons, 2004, and Chapman & Linehan, 2005, for recent overviews of DBT; and Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006, for a discussion of mechanisms of change associated with DBT). DBT skills are taught in four modules. Mindfulness is a core module that cuts across many of the other skill modules and is repeatedly revisited throughout the course of the skills training group. Mindfulness in DBT broadly involves helping the client learn to be fully awake and present to his or her experience of the present moment, participating in the current moment from an open, nonjudgmental perspective, with a focus on effective behavior (“effectiveness”) and on doing one thing at a time (“one-mindfully”). Through teaching the skills of observing and describing aspects of the current experience, clients also learn how to gain control over their attention. Distresstolerance skills help clients accept situations they cannot change and get through a crisis without making matters worse, through a variety of means, such as distraction, self-soothing through activities that activate sensory experiences, observing one’s breath, and radical acceptance of the current moment, feeling, or situation. The interpersonal effectiveness curriculum teaches clients how to ask for what they need and say no to unwanted requests while maintaining relationship stability and self-respect. Finally, the emotion-regulation module teaches clients how to regulate or modulate their emotional experiences through a variety of strategies geared toward increasing awareness of emotions, reducing factors that make the individual vulnerable to strong emotions, exposing oneself to the current emotion, and acting in a manner that is opposite or inconsistent with the action associated with the emotion. Several randomized controlled trials (RCTs) have found DBT to have superior efficacy when compared with treatment as usual for women with BPD (Koons, Robins, et al., 2001; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Comtois, et al., 2002; Verheul et al., 2003), particularly in reducing the frequency and medical severity of suicide attempts, self-injurious behavior, frequency and total days duration of psychiatric hospitalizations, and client anger, and also in increasing treatment compliance and social adjustment. Standard DBT also has been adapted to several other populations and treatment settings. RCTs

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Koons et al. have supported the efficacy of adaptations of DBT for women with BPD in a community mental health clinic (Turner, 2000), for patients presenting with self-harm to crisis services (Evans et al., 1999), for women with BPD and substance abuse or dependence (Linehan et al., 1999; Linehan, Dimeff, et al., 2002), for women with binge eating disorder (Telch, Agras, & Linehan, 2001) and bulimia (Safer, Telch, & Agras, 2001), and for depressed elders (Lynch, Morse, Mendelson, & Robins, 2003). Controlled but nonrandomized studies also suggest that adaptations of DBT may have efficacy for borderline patients in longer-term (e.g., 3 months) inpatient settings (Barley et al., 1993; Bohus et al., 2004) and for suicidal adolescents (Rathus & Miller, 2002) (for a review of these and other treatment outcome studies on DBT, see Robins & Chapman, 2004). Having been established as an efficacious treatment for BPD, researchers have begun to apply DBT more broadly to different settings and populations. DBT is being applied in acute inpatient hospital units, day treatment programs, assertive community treatment programs, prisons, and elsewhere. Applications of DBT in these settings are often limited in nature, consisting of skills training and coaching only, perhaps with case management, and it is not clear as to whether these more limited applications are as effective as the full package of DBT. Given the state of the literature, the most empirically grounded approach is to ensure that efforts to adapt DBT to different settings and populations address all of the key functions of this treatment; however, depending on the setting, the researcher or clinician may need to find inventive ways of incorporating core DBT practices. For example, when DBT is provided in an inpatient setting, monitoring a diary card and conducting chain analyses can be undertaken in a group or individually by unit staff; improving motivation can be addressed in the milieu. Ensuring that all five functions of a comprehensive DBT program are met in these settings requires flexibility and creativity and can present a considerable challenge. In this paper, we describe and report the results of a comprehensive adaptation of DBT delivered in a vocational rehabilitation setting that serves individuals with mental illness. The current study was a 6-month uncontrolled pilot study of its application with 12 psychiatrically disabled individuals. We assessed changes on measures of depression, hopelessness, anger, social adjustment, employment, and job satisfaction at posttreatment and at 6 months follow-up, and employment rates only at 1 year posttreatment. We hypothesized that this adaptation of DBT would result in decreases in depression, hopelessness, and anger, and increases in social adjustment, employment, and job satisfaction/ functioning.

Method Setting Offices of Vocational Rehabilitation were opened in all 50 states after World War I to assist injured war veterans in returning to work. In the 1960s and 70s, these services were extended to “any disabled citizen provided that individual wanted to work” (New Mexico Department of Education, Division of Vocational Rehabilitation, 2002). The mission of vocational rehabilitation is “to remove obstacles to employment” and to provide support for the disabled individual to obtain employment consistent with his or her own goals. Services continue to be provided as long as the individual continues to express interest in employment and obstacles remain. In the state of New Mexico, the Division of Vocational Rehabilitation provides mentally ill clients with funding for medical and psychological treatment, including psychiatric services, individual therapy, and case management. They also fund job readiness training; on- and off-the-job training; equipment; job development; job coaching; sheltered work; and assistance with transportation, housing, utilities, and clothing allowances. Division 8 of New Mexico Vocational Rehabilitation (DVR) exclusively serves individuals with mental disabilities and hearing impairment. Enrollees are provided with a vocational counselor, typically a master’s-level mental health professional. At the discretion of the vocational counselor, enrollees are given a full psychological evaluation to establish diagnostic criteria, IQ, employment skills, and job interests. An individualized employment plan (IPE) is developed, with the goal of achieving a minimum of 90 days of continuous employment, the criterion used to determine that the case may be “closed.” As part of this plan, DVR may fund the following services: psychiatric services and individual therapy, as well as supportive group therapy, psychoeducational groups, employment-related groups, and case management. Once an individual is ready to begin applying for jobs, a paraprofessional job developer or coach helps the client prepare for work and provides on-the-spot assistance in the workplace to facilitate the client’s adjustment to his or her work role. Participants Participants were recruited through the New Mexico DVR. A large proportion of the participants (92%) were designated “very significantly disabled.” Significant disability is defined based on three main criteria:

(a) … severe physical or mental impairment that significantly impedes him or her from functional capacities in two or more areas (such as mobility, communication, self-care, self direction, interper-

DBT in Vocational Rehabilitation

sonal skills, cognitive ability, work tolerance, or attendant factors; (b) … competitive employment has not traditionally occurred or has been interrupted or intermittent; and (c) … vocational rehabilitation can be expected to require multiple and intensive vocational and rehabilitation services in order to result in an employment outcome. (New Mexico Department of Education, Division of Vocational Rehabilitation, 2002) Vocational counselors in central New Mexico were asked to refer individuals with mental illness who had been difficult to “close” from their caseloads. Closure of a DVR case is achieved in two ways: (a) The individual elects to give up the job search and forgo “rehabilitation,” or (b) the individual achieves the goal of “meaningful employment” (e.g., at least 90 days of continuous work at a job of their choosing and at a level adequate to their needs). Counselors excluded individuals who endorsed current suicide ideation or self-harm behavior or who had a suicide attempt in the last 6 months, and persons with schizophrenia, substance dependence, traumatic brain injury, or mental retardation. Individuals who recently attempted suicide or who were currently self-harming were excluded because, according to the DBT hierarchy of treatment targets, attending to parasuicidal behavior would always have to take precedence over attending to factors related to obtaining and sustaining employment. Previous research (Koons et al., 2001) has suggested that targeting serious quality-of-life issues (i.e., employment functioning) is likely to be more effective in a population with less extreme or severe behavioral problems. Twenty-two potential participants were referred. Study staff reviewed their charts and 19 were interviewed. Two were excluded because of brain injury or substance dependence and 5 elected not to participate. Informed consent was obtained from the remaining 12, who were enrolled in the study. The mean age of participants was 40.7 years (SD = 7.95) and the ethnic distribution was 58.3% Caucasian and 41.7% Hispanic. All participants were American citizens and fluent in English. There were 11 women and 1 man. Participants reported a mean monthly income of $480 (SD = $311) and had utilized an average of $10,878 (SD = $3,774) of vocational rehabilitation services. Primary sources of income for participants included family, SSDI, SSI, TANF (Temporary Assistance to Needy Families), or part-time (fewer than 20 hours/week) employment. The most common psychiatric diagnoses included personality disorders (83.3%), borderline personality disorder (58.3%), and major depression (50%), although a noteworthy proportion reported substance

abuse disorders (41.7%), psychotic disorders (33.3%), and anxiety disorders (25%). The mean number of psychiatric diagnoses was three. Only one individual held a solitary diagnosis. The mean score on the Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996) fell within the severe range, M = 30.38 (SD = 15.90) and the mean score on the Beck Hopelessness Scale (BHS; Beck & Steer, 1993) indicated moderate hopelessness (M = 9.75, SD = 5.99). Eight participants (66.7%) completed the treatment program and four dropped out (33.3%). Treatment dropout was defined as the individual missing three sessions in a row, or a total of eight sessions during the 6-month treatment period. Of the four dropouts, three dropped out in the first half of the treatment, two because of physical illness and one because of criminal prosecution. The last dropout occurred during the final month due to family stressors. The primary analyses of treatment outcome reported here are for the completer sample (n = 8). Treatment Designed to be comprehensive, this adaptation of DBT was delivered to participants in a weekly 4-hour block. Participants received 2 hours of standard DBT skills training, followed by a 90-minute group that served many of the functions usually served by individual therapy in standard DBT. The group focused specifically on the targets of getting and keeping a job. DBT therapists, or “leaders” as they were known, also met weekly for consultation. There were four leaders instead of two co-leaders (standard in DBT skills groups) because the group was approximately twice as long, addressed many of the functions usually served by individual DBT, and was somewhat larger than the typical DBT group. Participants also had non-DBT therapists, DVR counselors, psychiatrists, job coaches, and, in one instance, a case manager, all of whom, except the psychiatrists, were invited to attend a 4-hour DBT training and a monthly consultation on the progress of their clients in DBT. Below, we describe how each of the functions of a comprehensive DBT program was addressed. Enhance capabilities. Two hours of weekly skills training were provided. The format of skills training was as in standard DBT (Linehan, 1993b), with the exception that there were four leaders rather than two The leaders were three social workers and a psychologist. The two who were intensively trained in DBT were the primary teachers. The other two functioned as coaches, though they did teach and review homework occasionally toward the end of the program. One full cycle of skills training was completed over a 6-month period. The distress tolerance, emotion regulation, and interpersonal effectiveness skills

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Table 1 The path to working mind Decrease behaviors likely to prevent getting a job. Acquire mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills. Increase use of skills to get ready to work. Decrease behaviors likely to interfere with keeping a job. Increase use of skills on the job. Working mind.

modules each were presented once, and the (brief) mindfulness skills module was interspersed throughout the treatment and presented a total of four times. Participants also received given an additional handout called “The Path to Working Mind” which identified behaviors to increase and decrease toward the goal of obtaining and sustaining the employment goals stated in their IPE (see Table 1). Leaders helped participants to decide where they were on the “path” and to focus on what skills they needed to use to advance toward their goal. They also used teaching examples, metaphors, role-plays, and homework related to obtaining and sustaining employment. Improve client motivation. Ninety minutes of each week’s session was devoted to diary card review, behavior analysis and solution analysis of problem behaviors. Leaders used the strategies of DBT to balance acceptance of the participants as they were, primarily through validation, with encouraging them to change, primarily through problem solving. Each leader had three participants for whom they were “primary” coaches. At the beginning of the weekly sessions, leaders took 10 minutes alone with each of their participants to review the diary cards, refer some matters to be discussed with their community therapists, and select other topics for discussion in the group. Self-harm behavior and suicide ideation were not discussed in the group to avoid the possibility that detailed discussions of these behaviors might have the effect of social “contagion” (i.e., other group members may also experience urges to self-harm or attempt suicide). Each participant kept two diary cards: one for standard DBT targets designed to be given to the community therapist, and one for employment-related targets. The standard card was individualized for each participant based on his or her problem behaviors. DBT leaders checked the standard target card at the beginning of each session to monitor suicide ideation, parasuicidal behavior and urges, and quality-of-life interfering behaviors such as drug and alcohol use. If suicidal behavior or ideation was present on the card, the leader worked to get commitment from the participant to report this behavior to the community therapist, and follow-up contact was made by

phone with the participant to be certain this was done. Suicide ideation and parasuicidal urges and behaviors were also discussed with the community therapist in the monthly consultation. One of the participants had a suicide attempt and was hospitalized twice during the course of treatment. This individual dropped out near the end of treatment and, of the dropouts, was the only one with suicidal ideation or behavior. Three of the treatment completers had intermittent suicidal ideation but none had suicidal behavior. Although quality-of-life interfering behaviors were referred to the community therapist, they were discussed in the program if they interfered with employment. Nonwork behaviors that were targets of behavioral analyses in session included substance use; nonattendance at therapy, psychiatry, DVR or other appointments; isolating; ruminating; ongoing interpersonal conflict; and neglecting physical health needs. The rationale was that these behaviors would interfere with getting and keeping a job. Two of the completers and one of the dropouts had significant substance abuse problems. One abused alcohol, one abused cannabis, and the third abused prescription drugs. The completers addressed their substance use both in the DBT program and in individual therapy and their abuse was discussed with other providers in the monthly consult as well. The employment-related diary card monitored problem behaviors at work or in the pursuit of employment; targeted attendance at work, appointments, and interviews, including on-time arrival and departure; conflict at work with peers and with supervisors; conflict with counselors and coaches; and feelings of competency and satisfaction overall and on the job. At the outset of treatment and frequently during treatment, participants were asked to share with the group where they found themselves on the “path to working mind” and to list the specific behaviors or behavior deficits most likely to be getting in the way of their goals. They were also asked to rate their level of commitment to reducing the problem behaviors and to identify which DBT skills they could be using to address these problems. Throughout treatment, participants coached and encouraged one another in the milieu, sharing how they acquired, practiced, and mastered skills to overcome similar problems. Leaders conducted chain analyses based on a rotational system, with each client choosing for discussion his or her highest target problem behavior that was interfering with his or her employment goal. Leaders also engaged in role-plays and behavioral rehearsal with participants. Participants tolerated the exposure of behavior and solution analyses and the coaching of their peers quite well. Leaders encouraged full participation and “throwing yourself in” to the learning.

DBT in Vocational Rehabilitation At the beginning of treatment, behavior analyses usually focused on problem behaviors long associated with nonemployment, including missing appointments, sleeping all day, substance abuse, and interpersonal conflict with care providers. As treatment progressed and more of the participants were working, behavior analyses included problem behaviors more associated with on-the-job stressors and behaviors that could lead to termination. These included, among others, nonattendance at work, not saying no to overtime when exhausted, difficulty asking a supervisor for time off for appointments, and difficulty asking someone for help with a job task. Participants learned from the difficulties of their peers and received validation and support. At the beginning of the program, participants usually scattered during the 30-minute lunch break, but by the middle of the program, all the participants were eating together in the treatment room and, coached by the leaders, participating in “skillful social interaction.” Assure generalization. During the orientation to the program, participants agreed to be willing to begin employment any time after the beginning of the program. Vocational counselors began work within the first month, linking clients to all appropriate services, including job developers and coaches. The goal was to have all participants working by the program’s halfway point so that the group could be used for support in generalizing skills use to the job. Due to many factors— including participants’ unwillingness to attend specific job interviews, lack of appropriate and available jobs, and interpersonal conflict between participants, job coaches and vocational counselors—only 50% of participants were employed at the program’s halfway point. By the end of the program, however, only one participant was not yet working. The DBT leaders acted as coaches for all participants; each leader also served as a between-sessions coach for his or her three primary clients. In addition to reviewing their diary cards, the leaders also coached clients on how to interact with their community therapists, psychiatrists, DVR counselors, job coaches, and families, and provided telephone consultation on use of skills in everyday life (if not provided by the community therapist). In addition, at the monthly consultation, the DBT leaders interacted with other care providers on how best to help their clients meet their vocational goals using DBT skills. Improve therapist ability and motivation to treat. DBT leaders met weekly for 1 hour to consult on cases. Four hours of DBT orientation was offered to the vocational counselors, individual therapists, case managers, job developers, and job coaches. These providers were offered payment and continuing education credits for attending. Sixteen providers were invited to the orien-

tation, including 4 DVR counselors, 4 job coaches, 1 case manager, and 7 community therapists. Thirteen providers attended. Six monthly consultations of 90 minutes each were also offered to the same 16 providers, along with payment and continuing education credits. At the monthly meetings the leaders reviewed the skills being taught and discussed issues related to the employment of the participants. Providers were strongly encouraged, but were not required, to attend the consultation meetings. The mean number of these providers attending at each consultation meeting was 12 (SD = 2.75). All of the DVR counselors, job coaches, and the case manager attended at least one meeting. Of the therapists, only one never attended. Structure the environment. During the informed consent procedure, all participants were oriented to the goals of the program and oriented to the attendance requirements, the cost of the program to DVR, and their right to drop out at any time. As soon as participants were identified, they were linked to an individual therapist and a psychiatrist in the community. Participants already seeing a psychotherapist for weekly individual treatment or a psychiatrist for medication were allowed to continue with those clinicians, with the stipulations that these therapists (a) would not undertake or continue any exposure to past traumas during the period of the study, and (b) would attend the orientation and monthly consultation meetings. DVR counselors (who oversaw all funding) referred all participants who were not currently in weekly therapy or seeing a psychiatrist to DVR vendor clinicians or to community mental health providers. All participants also were offered job development and job coaching as needed. Measures In addition to assessment of vocational functioning and satisfaction, we assessed three aspects of emotional functioning—depression, hopelessness, and anger— generally considered salient among the vocational rehabilitation population. Participants were assessed in the 6 weeks prior to treatment, at the close of treatment (posttreatment), and at an assessment 6 months after treatment (follow-up). In addition, data were collected from DVR and from participants as to employment status and DVR closure 1 year posttreatment. Social adjustment scale—self-report version (SAS-SR). The SAS-SR (Weissman & Bothwell, 1976) is a self-report instrument that assesses the ability of an individual to adapt to, and be satisfied with, his or her social roles. Six areas, both instrumental (what we do in the world) and expressive (how we related to others) aspects, are evaluated. Areas include work, social and leisure, extended family, primary relationship, parental and

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family unit. The SAS-SR has good concurrent validity between the interview and self-report measures and good external validity between the self-report and informant ratings (Weissman & Bothwell, 1976). Beck depression inventory (BDI-II). The BDI-II (Beck et al., 1996) is a 21-item self-report measure on which respondents rate the severity of various depressive symptoms on a 0 to 3 scale. The BDI-II has demonstrated excellent psychometric properties, including internal consistency, test-retest reliability, and concurrent validity (Beck et al.). A score of 0 to 9 on the BDI-II reflects the absence of depression; scores of 10 to 16 indicate dysphoria; and scores of 17 and above indicate clinically significant depression. Beck hopelessness scale (BHS). The BHS (Beck & Steer, 1993) was used to measure hopeless thinking. The BHS is a 20-item self-report inventory on which respondents indicate “true” or “false” to a variety of questions about their attitudes toward the future. As with the BDI-II, the BHS has demonstrated excellent psychometric properties. State-trait anger inventory (STAXI). The STAXI (Spielberger, Jacobs, Russell, & Crane, 1983) is a 57-item questionnaire on which respondents rate on a scale from 1 (not at all/almost never) to 4 (very much so/almost always) aspects of their experience and expression of anger, including state anger, trait anger, anger experienced but not directly expressed (Anger-In), direct verbal and nonverbal expression of anger (Anger-Out), and anger control (Anger Control In and Anger Control Out). The STAXI has demonstrated adequate internal consistency (α = .70 to .73) in a large community sample (Knight, Chisholm, Pauling, & Waal-Manning, 1988). Measures of vocational functioning and satisfaction. Participants were interviewed at each assessment about the number of hours of weekly employment, work role satisfaction, and the income from that employment.

Results Preliminary Analyses Data screening. The distribution of scores on each variable was evaluated as an approximation of the normal distribution. Number of paying jobs in the past 12 months, SAS-SR work role satisfaction, and STAXI state anger were all significantly positively skewed at pretreatment. Logarithmic transformations (base 10) therefore were performed for each of these variables. In addition, posttreatment and follow-up scores for SAS-SR work role satisfaction and STAXI total anger were log transformed to permit comparisons between these variables and their transformed pretreatment counterparts. Means and standard deviations displayed in Table 2 for these variables are untransformed values, but the inferential test statistics are based on transformed values. Comparison of treatment completers and dropouts. Independent t tests were used to examine potential differences between treatment completers and dropouts. The treatment completers and dropouts did not significantly differ at pretreatment in terms of age, ethnicity, or dollar amount of vocational rehabilitation services utilized. In addition, no differences were observed with respect to number of psychiatric diagnoses, pretreatment depression, hopelessness, anger indices (Anger In, Anger Out, state anger, trait anger), or SAS-SR Work Role Satisfaction. In addition, treatment completers and dropouts did not differ in terms of number of psychiatric diagnoses or presence and type of past treatment or criminal history. Treatment Effects Because of the small sample and pilot nature of this study, analyses were conducted only on the completer sample. Scores of completers (n = 8) at pretreatment and at posttreatment were first compared across all of the continuous variables (see Table 1) by a repeated measures MANOVA, which was significant, F(1, 6) = 281.25, p < .05. A

Table 2 Work role satisfaction and emotional functioning before and after treatment and at follow-up (N = 8) Variable

Work role satisfaction Depression Hopelessness State anger Trait anger Anger Expression In Anger Expression Out Anger Control In Anger Control Out ⁎ p < .05. ⁎⁎ p < .01.

Pre

Post

Follow

Pre-Post

Pre-Follow

M

SD

M

SD

M

SD

t

d

t

d

.27 32.86 9.75 23.25 21.37 20.63 16.63 21.38 20.75

.77 17.68 6.65 5.80 6.76 3.74 3.42 7.35 5.75

.90 19.13 6.29 20.75 19.19 18.25 15.75 22.72 20.38

1.01 18.65 6.77 6.52 6.47 4.27 4.17 6.72 4.27

1.24 21.23 5.12 22.04 19.63 17.88 13.68 24.63 23.02

.91 15.23 5.44 5.8 5.45 3.04 2.20 7.37 5.98

−1.59 3.70 ⁎⁎ 2.63 ⁎ 1.14 1.17 3.37 ⁎⁎ .87 −.80 .36

−.70 .76 .52 .50 .33 .59 .23 −.19 .07

−2.52 ⁎ 2.60 ⁎ 2.40 ⁎ .46 .59 2.08 ⁎ 3.94 ⁎⁎ −1.54 −2.15 ⁎

1.15 .70 .76 .26 .28 .81 1.03 .44 .39

DBT in Vocational Rehabilitation repeated measures MANOVA comparing scores at pretreatment and at follow-up also was significant, F(1, 6) = 913.82, p < .05. We therefore examined changes on each variable individually with a series of planned paired-sample t tests. Because we had directional hypotheses for every variable, one-tailed statistical tests were used. The results of these analyses are shown in Table 2 and described below. Depression Depression improved significantly from pretreatment to posttreatment, and the effect size, d, was moderate, using Cohen’s (1988) criteria. These treatment gains were maintained during the follow-up phase, as depression scores also significantly improved from pretreatment to follow-up, with a moderate effect size. The proportion of individuals with clinically significant depression (BDI-II ≥ 17) was 87.5% (n = 7) at pretreatment, 50% (n = 4) at posttreatment, and 62.5% (n = 5) at follow-up. The number of individuals who changed from being depressed to being nondepressed was compared with the number who changed in the opposite direction using the binomial test (onetailed). Neither the change from pretreatment to posttreatment nor the change from pretreatment to follow-up was statistically significant in this small sample, p = .13 and p = .25, respectively, though the changes in proportion who were depressed were large- and medium-sized effects, respectively, by Cohen’s criteria. Hopelessness. Hopelessness significantly improved from pretreatment to posttreatment, and the effect size was moderate. These treatment gains were maintained during the follow-up phase, as hopelessness scores also improved from pretreatment to follow-up, with a moderate effect size. Mean BHS scores at posttreatment and follow-up were below established cutoffs (BHS > 9) for significant hopelessness (Beck, Weissler, Lester, & Trexler, 1974). The proportion of individuals with clinically significant hopelessness was 37.5% (n = 3) at pretreatment, 25% at posttreatment (n = 2), and 25% (n = 2) at follow-up. The changes in proportions from pretreatment to posttreatment and follow-up were not statistically significant, p = .50 in both cases, and the effect sizes were small. Anger measures. No significant treatment effects were found for state anger, trait anger, or Anger Control In. On Anger Expression In, the change from pretreatment to posttreatment was significant and moderate in size, and the change from pretreatment to follow-up was significant and large. On Anger Expression Out, there was no significant change from pretreatment to posttreatment, but there was a significant decrease from pretreatment to follow-up, and the effect size was large. Finally, on Anger Control Out, there was no significant

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change from pretreatment to posttreatment, but the increase from pretreatment to follow-up was significant, albeit with a small effect size. Vocational functioning and satisfaction. There was no significant improvement in work role satisfaction between pretreatment and posttreatment for employed individuals; however, work role satisfaction significantly improved from pretreatment to follow-up, with a large effect size. The percentages of participants employed at least part-time at various points in the study were 50% (n = 4) at pretreatment, 62.5% (n = 5) at posttreatment, and 75% (n = 6) at follow-up. However, these changes in employment rates from pretreatment to posttreatment and from pretreatment to follow-up were not significant, although some of the effect sizes were large by Cohen’s criteria. Among the five treatment completers who reported employment, two participants reported working 40 or more hours per week (40 and 45 hours, respectively), and three individuals reported working between 25 and 30 hours per week (24, 25, and 30 hours). At follow-up, an additional individual reported working 22 hours per week. There was a trend (p < .10) for participants to report fewer hours worked at pretreatment (M = 7.25, SD = 8.55) compared to posttreatment (M = 20.50, SD = 16.41), t = −1.87, p < .10, d = −1.01. In addition, there was a significant difference between hours worked at pretreatment and hours worked at follow-up (M = 23.25, SD = 16.41), t = −2.32, p < .05, d = −1.22. When income from employment was considered, three (50%) of the treatment completers reported some income earned through employment at pretreatment. At posttreatment (62.5%) and follow-up (75%), larger proportions of individuals reported income earned through employment; however, these differences were nonsignificant. There was a trend for participants to report a higher mean weekly income (hourly income × number of hours worked per week) at posttreatment (M = $146.38, SD = $133.57) compared with pretreatment (M = $36.25, SD = $56.99), t = −1.92, p = .10, d = 1.07. It should be noted that these values include individuals who did not work. Among individuals who worked (n = 4), the mean weekly income at pretreatment was $76.50 (SD = $60.63). At posttreatment, the mean weekly income among individuals who worked (n = 5) was $234.20, (SD = $74.25). Data on the actual dollar amounts earned by individuals at follow-up are not available.

Discussion This study applied a comprehensive adaptation of DBT to a group of multidiagnostic clients, all of whom met criteria for personality disorders. It incorporated

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Koons et al. the functions of individual therapy into a group delivery system with only minor use of individual time for betweensession coaching. Applying individual DBT in a group setting may make this treatment more adaptable to typical community mental health settings in which applying individual DBT to all patients who need it may be infeasible due to personnel, training, and supervision needs. In addition, the group format provided a supportive milieu both for clients and for treating clinicians, perhaps reducing isolation and burnout. These factors are important in considering the issue of effectiveness and the application of DBT to the clinical realities faced in community settings. The results indicated that this comprehensive adaptation of DBT shows promise for the reduction of depression, hopelessness, and anger expression in multidiagnostic, complex, difficult-to-treat persons seeking vocational rehabilitation. Of 11 outcome variables, participants experienced significant improvement on 7. Participants improved from pretreatment to posttreatment on depression, hopelessness, and Anger Expression In, and maintained their gains on all three variables at follow-up. In addition, participants improved significantly from pretreatment to follow-up on Anger Expression Out, Anger Control Out, work role satisfaction, and income from employment. The findings from the present study also indicate that DBT had a notable impact on vocational functioning. The results for rate of employment demonstrated a strong but statistically nonsignificant trend toward a higher rate of employment at follow-up. The proportion of participants reporting income from employment, however, improved significantly by posttreatment and was maintained at follow-up. One year after treatment was concluded, six of the eight completers remained employed and their DVR cases remained closed. Two of the completers still had open DVR cases. One participant was terminated from employment and returned to services; the other individual had not yet begun working. Of the four noncompleters, one participant had found employment and three remained unemployed. Two of the dropouts still had open cases at DVR, and the third had given up the job search. The study was conducted within, and funded by, a DVR agency. The participants were selected primarily because they had been especially difficult to “close.” An important feature of the culture of DVR is the lack of contingencies affecting how long an individual case can be “open” and the fact that DVR clients are protected against premature closure or denial of services by agency rules and an active advocacy group. In addition, most DVR clients receive some public assistance, ranging from SSI and SSDI to

subsidies for housing, utilities, transportation, and health care. Clients stand to lose at least some of this support when they return to work, which is a powerful disincentive to employment. With the reinforcement contingencies working to discourage employment in these ways, it is a challenge for counselors, who are also accountable for their budgets, to avoid burnout. This adaptation of DBT may assist in the dissemination of this complex treatment to a variety of treatment settings, most especially to the arena of vocational rehabilitation. Some limitations of the present study warrant consideration. First, the sample size was small, a common limitation of pilot studies. Larger controlled trials are needed to corroborate the results. Second, this study did not include a control condition. Therefore, it is unclear whether the improved functioning noted among DBT treatment completers exceeds what would be observed among individuals who underwent no treatment or an alternative treatment. However, at follow-up, DBT treatment completers exhibited better employment status than dropouts, despite a lack of differences in functioning at pretreatment. Third, all participants also received other services while in the DBT program, including individual therapy, psychiatric services, and vocational counseling. It is possible that their improvements are attributable to these other services rather than to the DBT program. However, the participants had been unemployed or marginally employed for at least 3 years, a mean of $10,385 had already been spent on their rehabilitation without gaining “closure,” and all had been receiving the same or similar standard mental health services without a change in their employment status. Finally, another limitation is that it is unclear to what level of adherence DBT was provided. The team leader was a DBT trainer, and one other clinician had undergone intensive training in DBT, but the other two had minimal DBT training (average 4.5 days) at the time of the study. It is possible that the results would have been even stronger had these two individuals received further training in DBT. However, in most clinical settings, therapists are not trained to adherence prior to treating patients, and the present results suggest that the treatment may demonstrate effectiveness in such settings. In addition to increased training for therapists, the current adaptation of DBT may be improved in some additional ways. For instance, effects might be enhanced if DBT-trained individual therapists were able to implement between-session telephone consultation (a key intervention in DBT), designed to enhance the generalization of skillful behavior to the natural environment. Treatment effects also may be augmented if the treatment was lengthened from 6 months to the

DBT in Vocational Rehabilitation standard 1 year of treatment. In addition, changes to this adaptation of DBT might involve requiring attendance for all community therapists, vocational counselors, and job coaches at a regular (i.e., monthly or weekly) therapist consultation team. In DBT, the therapist consultation team is designed to enhance therapist motivation to engage in effective treatment and to provide training and support to prevent burnout. Given the severity of the population in this study, the therapist consultation team may be particularly helpful. In conclusion, this study provides data on a unique application of DBT to patients in a vocational rehabilitation setting. The findings indicated that a comprehensive DBT program, delivered primarily in a group, resulted in significant improvements in both employment functioning and emotional functioning. Despite the limitations associated with this pilot study, the findings presented here suggest that DBT may be a promising treatment for serious quality of life issues in a severe, chronic population characterized by significant difficulties in obtaining and maintaining vocational functioning. The present study also demonstrates some specific adaptations of DBT that may be particularly useful in clinical practice with vocational rehabilitation patients (i.e., “path to working mind”; group format; focus on targeting factors interfering with job functioning). In sum, our findings open the door for more extensive, well-controlled studies of this adaptation of DBT to vocational rehabilitation.

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Alexander L. Chapman is now at the Department of Psychology, Simon Fraser University. The authors would like to acknowledge the significant contributions of Brenda Sussman, MSW, and Catherine MacClaen, Ph.D., of Area 8, Division of Vocational Rehabilitation (DVR), in Albuquerque, New Mexico. Address correspondence to Cedar R. Koons, 1012 Marquez Place, Suite 211, Santa Fe, NM 87505, USA; e-mail: [email protected]. Received: February 11, 2004 Accepted: April 15, 2005 Available online 13 March 2006