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Dialectical Behavior Therapy Skills for Families of Individuals With Behavioral Disorders: Initial Feasibility and Outcomes
Dialectical Behavior Therapy Skills for Families of Individuals With Behavioral Disorders: Initial Feasibility and Outcomes Chelsey R. Wilks, Helen Valenstein-Mah, Han Tran, Alexandra M.M. King, Anita Lungu, Marsha M. Linehan PII: DOI: Reference:
S1077-7229(16)30042-6 doi: 10.1016/j.cbpra.2016.06.004 CBPRA 639
To appear in:
Cognitive and Behavioral Practice
Received date: Accepted date:
19 August 2015 15 June 2016
Please cite this article as: Wilks, C.R., Valenstein-Mah, H., Tran, H., King, A.M.M., Lungu, A. & Linehan, M.M., Dialectical Behavior Therapy Skills for Families of Individuals With Behavioral Disorders: Initial Feasibility and Outcomes, Cognitive and Behavioral Practice (2016), doi: 10.1016/j.cbpra.2016.06.004
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Running Head: DBT FOR FRIENDS AND FAMILIES
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Dialectical Behavior Therapy Skills for Families of Individuals With Behavioral Disorders:
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Initial Feasibility and Outcomes
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Chelsey R. Wilks and Helen Valenstein-Mah, University of Washington Han Tran, University of Memphis
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Alexandra M. M. King, University of Nevada Reno
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Anita Lungu and Marsha M. Linehan, University of Washington
We would like to thank the clients, therapists, and staff at the Behavioral Research and Therapy Clinics for their contributions to this research. Dr. Linehan receives royalties from Guilford Press for books she has written on Dialectical Behavior Therapy (DBT) and for DBT training materials from Behavioral Tech, LLC. She also owns Behavioral Tech Research, Inc. a company that develops on-line learning and clinical applications that include products for DBT. Dr. Linehan is compensated for providing DBT training and consultation. Address correspondence to Chelsey Wilks, Behavioral Research and Therapy Clinics, Box 351525, University of Washington, Seattle, WA 98195; [email protected].
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Abstract
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Family members of individuals with behavioral disorders are a valuable source of logistical and
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emotional support for patients. Family members may take on tremendous financial and/or psychological responsibility to care for their loved ones, which can result in poor psychological
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outcomes for the family and, in turn, impede the recovery of the patient. Dialectical Behavior
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Therapy (DBT) skills training is an effective treatment that has been utilized with numerous populations, including family members of individuals with behavioral problems, and has shown
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efficacy in improving various interpersonal outcomes; however, no study has examined feasibility and outcomes of delivering all four unabridged DBT skills modules to this population.
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Twenty participants attended weekly DBT skills classes for 6 months, where they acquired skills
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in mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. There
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were significant pre-post improvements for emotion dysregulation, stress reactivity, and various interpersonal outcomes; there were no significant changes in depression or anxiety. These results suggest that DBT skills may be effective at improving broad clinical domains in a sample of family members of individuals with behavioral problems. This research is the first step in demonstrating that DBT skills might benefit family members of patients with heterogeneous mental health problems and, therefore, fits in to the field's growing interest in cost-effective transdiagnostic interventions.
Keywords: dialectical behavior therapy; caretaking; families; skills only
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Family members of individuals with behavioral disorders are often one of the most important
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sources of support for these individuals. Such support can be emotional (e.g., offering empathy,
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cheerleading), logistical (e.g., providing transportation to treatment, housing), as well as
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financial (e.g., covering day-to-day costs of living, medical expenses), and can depend on the course or severity of the disorder (Clark, 1994; Papastavrou, Chalambous, Tsangari, &
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Karayiannis, 2012; Schulz & Martire, 2004; Tsang et al., 2003). Behavioral disorders in this context refers to individuals with mental health problems such as depression, anxiety, and/or
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personality disorders. Mental disorders are more common among unemployed individuals, and as much as 50% of adults with severe behavioral disorders are living with family members
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(Fryers, Melzer, & Jenkins, 2003; Marshall & Solomon, 2004). Informal caretaking, often done by the patient’s family, is prevalent, yielding approximately 52 million caregivers of individuals
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with physical or mental illnesses or disabilities in the United States alone (Health and Human Services, 1998). As a result, family members often take on tremendous financial and emotional responsibility when caring for their loved ones. Family members can experience increased anxiety and depression as a direct result of caring and providing resources for their loved ones. Benazon and Coyne (2000) found that spouses of depressed individuals experience increased depression that is attributable to their caretaking responsibilities. Likewise, in a systematic review of family members of individuals with eating disorders, family members were consistently found to have high levels of emotional and psychological distress, including diminished concentration and sleep loss due to worry (Zabala, Macdonald, & Treasure, 2009). Finally, family members often experience increased shame, guilt, and self-blame related to their loved-one’s disorder (Muhlbauer, 2002; Phelan et
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al., 1998). In turn, the strain from caring for a family member with behavioral disorders can have deleterious effects on the recovery of the patient; for example, research has documented that
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interpersonal burden of the informal caretaker role contributed to slower patient recovery (Cole
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& Reiss, 1993). Taken together, the stress related to caring for individuals with behavioral disorders can be extensive, with detrimental consequences for both the family member and
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patient.
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Dialectical behavior therapy (DBT; Linehan 1993, 2014) is a modular, transdiagnostic treatment with a strong evidence base for improving emotion dysregulation, interpersonal
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problems, and dysfunctional behaviors (see Linehan & Wilks, 2015). Standard DBT is an intensive, year-long program consisting of weekly 1-hour individual therapy sessions, weekly
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skills training group, 24-hour access to phone coaching, and weekly consultation group for the therapist. More recently, DBT skills training as a standalone treatment has also shown to be
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effective in treating numerous clinical populations, with individuals experiencing reductions in emotion dysregulation, depression, and improving general functioning, among other outcomes (for a review, see Valentine et al., 2014). Further, DBT skills use has been identified as a mediator for treatment targets (e.g., interpersonal problems, suicidal behavior; Neacsiu, Rizvi, & Linehan, 2010).
The DBT skills component includes training in regulating emotions, tolerating distress, interpersonal effectiveness, and mindfulness, directly targeting effective management of one’s own emotional experiences and teaching skills on how to improve relationships. Thus, the emphasis on both self- and other-focused behavioral skills may make DBT skills a particularly appropriate and potent intervention for family caregivers of individuals with behavioral problems who need tools to manage their own distress as well as their relationship with their family
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member. Specifically, DBT skills could improve the ability of family members to better regulate their own emotions, which may increase self-efficacy (Bandura, 1982) and level of control in
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handling stressful interpersonal situations with their family member with behavioral disorders.
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Furthermore, DBT includes distress tolerance skills focused specifically on navigating crisis situations in an effective way, which could be needed in potential crisis situations involving their
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behaviorally disordered family members. Integrated within the distress tolerance module is the
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skill of radical acceptance, which provides family members with a foundation to accept (or work toward accepting) their loved ones as they are in that moment. Additionally, training in
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interpersonal skills (such as assertiveness) may make family members more effective in negotiating demands and improving their relationships, which may reduce caregiver burden as a
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result. For instance, they may interact better with their relative or be more successful in asking for and receiving support from others in the family or community. Mindfulness skills may also
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help family members become more aware of their thoughts and emotions related to their distressed family member and help decrease reactive and ineffective emotions and behaviors. A growing body of research has started to examine the impact of DBT skills training for family members of individuals with behavioral problems. Family Connections® (FC®) is an adaptation of DBT that provides psychoeducation, brief skills training, and support specifically designed for family members of individuals with borderline personality disorder (BPD) (Fruzzetti & Hoffman, 2004). FC is based on the standard DBT skills training curriculum, and there are also several points in which it departs from the standard training. First, in line with its explicit focus on family members of individuals with BPD, two of the six modules taught in FC are dedicated to describing the research on BPD and to providing psychoeducation on the development of BPD and other BPD-specific problems. Second, most of the skills practices in
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FC are focused on teaching family members how to best interact with their loved one who has a BPD diagnosis. In contrast, skills practice in standard DBT group aims to generalize skills
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practice to all areas of life where effective behavior and emotion regulation are needed. Finally,
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each FC skills training group is led by two volunteers, most of whom are former group participants (though some clinicians run FC groups as well). After a family member completes
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the program they can go through leader training, join with another leader, and create their own
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group (Hoffman & Fruzzetti, 2005). This system allows the FC program to be provided to families free of cost.
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The FC curriculum has been examined with family members of individuals with BPD and suicide attempters. In these pilot trials, results revealed that family members reported
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significant reductions in grief, depression, perceived burden, and caregiver fatigue, as well as improved emotional well-being (Rajalin, Wickholm-Pethrus, Hursti, & Jokinen, 2009; Hoffman
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et al., 2005; Hoffman, Fruzzetti, & Buteau, 2007). While the research on FC outcomes is encouraging, the current intervention and data are specific to family members of individuals diagnosed with BPD. We believe the standard DBT skills training is applicable to family members of individuals with a larger variety of behavioral disorders than just BPD. Similarly, we believe there is more commonality than difference in the areas where family members of individuals with different behavioral disorders (not only BPD) need help, making the skills teachable within a heterogeneous group. Providing DBT skills training to family members of individuals with diverse behavioral problems has the potential benefit of making the intervention more cost-effective (as recruitment for groups would include a larger population) and disseminable on a larger scale.
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To the best of our knowledge, no study has examined the feasibility and outcomes of delivering all four unabridged DBT skills modules to family members. Thus, this research aims
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Participants
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Method
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members of individuals with a variety of behavioral disorders.
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to investigate the feasibility and preliminary outcomes of a 6-month DBT skills group for family
Twenty participants were self-referred from the Seattle area using a flyer on the clinic’s
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website and referrals from local providers. Potential participants called the number on the flier to express interest in receiving DBT skills training. A bachelor's- or master's-level clinician
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returned the call providing further information about the study’s intervention and cost. If participants were still interested, the clinician would do a phone screen to assess for eligibility.
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The only inclusion criterion was reporting having a friend or family member with a chronic mental and/or physical health problem. Participants were excluded if they did not speak English, had active suicidality, could not pay for services, and/or lived outside commutable distance from the clinic. The cost of the group was $1,600 per person. Of the 99 participants who contacted the clinic, 22 did not return our phone calls, 21 had logistical barriers (e.g., prior obligations during the group time), 12 did not have a loved one with a disorder, and 4 could not afford the program. No one refused to participate in the intervention after screening, although 2 participants dropped out after joining the skills training group. One participant dropped out due to scheduling demands and the other due to dislike of the intervention. Participants’ completion of the assessment measures was voluntary and did not affect their eligibility to participate in the intervention. Of the 38 participants that started treatment, 18 who completed the intervention did
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not return post-assessments; thus, data from 20 participants were analyzed in the current study. All demographic characteristics were analyzed to check for any statistically significant
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differences between those who completed the post-assessments and those who did not.
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Independent samples t-tests were used to assess differences between groups for continuous variables, Mann-Whitney U tests were used to assess differences between groups for ranked
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variables (e.g., highest level of education), and chi-squares were computed for binomial
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variables, and we found no statistically significant differences between those who turned in postassessments and those who did not on any demographic variables. Despite advertising to both
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friends and family members, all of the group participants (100%) were family members (relatives or spouses) of individuals with behavioral disorders. Mean age of participants was 54.75 (SD =
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10.31). Participants were mostly female (60%), Caucasian (95%), married (80%) and educated (100% had attended some college and 65% had postgraduate degrees). Among the participants,
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75% were living with the family member with a behavioral disorder. Participants reported that their family members had the following diagnoses: anxiety (60%), depression (60%), BPD (40%), as well as posttraumatic stress disorder (25%).
Procedure
Participants completed pre-assessment measures within 2 weeks of starting the group and completed their post-assessment measures within 2 weeks of finishing the group. All study procedures were conducted in accord with the Institutional Internal Review Board (IRB) approved procedures.
Measures
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Eight instruments were used to assess participants’ various indices of emotion regulation, interpersonal functioning, and caregiver-related stress. All of the measures given to participants
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were voluntary; participants’ ability to be in the group was not affected by whether or not they
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did the assessments. No diagnostic evaluations were conducted with the participants. Demographic information about participant age, race, marital status, education, and
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annual income was assessed using an abbreviated Demographic Data Survey (DDS; Linehan &
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Laffaw, 1982).
Participant interpersonal problems were assessed using the Inventory of Interpersonal
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Problems–Personality Disorders 25 (IIP-PD-25; Gunn et al., 2004). The IIP-PD-25 consists of 25 5-point Likert-type questions which fall into five subscales: interpersonal aggression,
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interpersonal ambivalence, interpersonal sensitivity, lack of sociability, and need for social
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2004).
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approval. The measure has high internal consistency with Cronbach’s α = .93 (Gunn et al.,
The Family Attitude Scale was used to assess the participants’ attitudes towards their family relationships (FAS; Kavanagh et al., 1997). The 30-item self-report questionnaire is on a 5-point Likert-type scale and measures several relationship attitude domains, including dissatisfaction, hostility, and burden. The FAS has high validity as well as high internal consistency, with each domain having a Cronbach’s alpha ≥ .95. Caregiver strain was measured using the Caregiver Strain Questionnaire–Short Form 7 (CGSQ-SF7; Brannan, et al., 2012). This 7-item self-report instrument measures both subjective internalized strain as well as objective strain on a 5-point Likert-type scale. The short-form of the CGSQ was found to retain the good validity and internal consistency of the original, which had
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Cronbach’s α’s from .74 to .93 for the subscales and the total measure (Brannan et al., 2012; Brannan et al., 1997; Kang et al., 2005).
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The Difficulties in Emotion Regulation Scale was used to measure the participant’s
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emotion dysregulation (DERS; Gratz & Roemer, 2004). The DERS measures five facets of emotion regulation: awareness of emotions, acceptance of emotions, ability to engage in goal-
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directed behavior, and access to effective emotion-regulation strategies. The self-report
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instrument has 39 items and is on a 5-point Likert-type scale. The DERS has high internal consistency with Cronbach’s α = .93, adequate construct and predictive validity, and good test-
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retest reliability with ρI =.88, p < .01 (Gratz & Roemer, 2004). Depression was used to measure the Patient Health Questionnaire-9 (PHQ-9; Kroenke et
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al., 2001). The PHQ-9 is on a 4-point Likert-type scale and is widely used for determining the
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presence and severity of depression. The measure has good internal validity (Cronbach’s α =
al., 2001).
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.86), high test-retest reliability (r = .84 after 48 hours), and high construct validity (Kroenke et
Anxiety was assessed using the State-Trait Anxiety Inventory (STAI; Grӧs et al., 2007). This instrument is a 40-item self-report measure that assesses both state (e.g., current level) and trait (general level) of anxiety on a 4-point Likert-type scale. The STAI has very good internal consistency with an average Cronbach’s α > .89, very good test-retest reliability over multiple time intervals with average r = .88, adequate convergent and discriminant validity, and lower temporal stability (which is to be expected given that the measure captures a state variable) (Grӧs et al., 2007). Stress was assessed with the Perceived Stress Reactivity Scale (PSRS; Schlotz et al., 2011). The PSRS is a 23-item self-report instrument assessing how strongly an individual reacts
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to stressful everyday events (e.g., making a mistake, having a heavy workload, or being in difficult social situations) with three answer choices for each question: “I am generally
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untroubled”; “I usually feel a little uneasy”; and “I normally get quite nervous.” The measure has
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high internal validity (Cronbach’s α = .87), acceptable test-retest reliability, and good
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discriminant validity (Schlotz et al., 2011).
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Treatment
Participants completed a 6-month DBT skills group that met for 1.5-hour weekly
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sessions. Two therapists, a leader and a co-leader, taught each group, in line with standard DBT skills training. The groups were led by graduate students or postdoctoral therapists who were part
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of a DBT team and had training in DBT. Specifically, all group leaders had received the DBT Intensive Training, and had received additional didactic courses in DBT. Group leaders also
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participated in 1-hour DBT consultation meetings every week, which served as a source for treatment fidelity monitoring as well as supervision. Additionally, the groups were video recorded and watched by senior DBT clinicians who provided weekly 1-hour supervision to the group leaders. During both direct supervision and DBT team consultation, the group leaders were given feedback regarding their didactic strengths and areas of improvement. Consistent with the standard DBT skills group format, each session began with a brief mindfulness exercise and a review of the homework from the previous week followed by teaching of new DBT skills. All standard DBT skills modules were taught: Mindfulness (2-week module), Distress Tolerance (6-week module), Interpersonal Effectiveness (6-week module), and Emotion Regulation (7-week module). The Mindfulness module started the treatment and was repeated in between the other modules such that over a period of 6 months participants went
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through the Mindfulness module three different times. The groups were semi-open and new members could join the group during the Mindfulness modules. Group members graduated
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when they completed all three additional modules (see Linehan, 2014). This 6-month course
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of treatment is pared down from Standard DBT as was tested in initial randomized controlled
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trials with adult individuals meeting criteria for BPD (Linehan et al., 1991; Linehan et al., 2006; Linehan et al., 2015).
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Recent research has shown that DBT skills groups alone can be effective for many of the problems that we were targeting (Valentine et al., 2014); thus, our intervention only contains the
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skills groups component of Standard DBT. We used a reduced intervention duration and group length considering that our sample population was not as severe as the typical clinical
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populations with which Standard DBT is used. It should be noted that while many family interventions add psychoeducation, we found the existing psychoeducation component to be
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sufficient and did not modify the curriculum.
Statistical Analysis Strategy
Because of the nature of this pilot project and the small number of participants who completed the intervention, all results must be interpreted as strictly exploratory. To determine changes in participants’ functioning pre- to posttreatment, we used a paired sample t-test with a 95% confidence interval to compare scores on all of the measures before and after the group. We used Cohen’s d to calculate effect size for the within-subjects design and was calculated using the following formula: d = t / √ (df). We calculated reliable and clinically significant change to better understand the treatment effects on the outcome variables. Reliable and clinically significant change were calculated
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according to the criteria recommended by Jacobson and Truax (1991). Reliable change (RC) was calculated as RC = x2 – x1/Sdiff and clinically significant change (CSC) was defined as reaching a
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level of functioning after treatment that is closer to the mean of the nonpatient population than to
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the patient population. For measures without nonpatient normative data (CGSQ-SF), CSC was defined as reaching a level of functioning that was greater than two standard deviations below
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the pretreatment sample mean. Normative data were obtained from standardized norms or studies
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using large samples. The RC indices, CSC cut-offs, and sources of normative data are depicted in
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Table 2.
Results
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On average, family members attended 87.61% (SD = .06) of scheduled groups and missed on average 3.05 (SD = 1.43) groups. There was a statistically significant decrease from
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pre- to post- assessment scores on five of the seven measures (see Table 1). Specifically, the results indicate a significant reduction in the index of emotion dysregulation (DERS, t[19] = 3.30, p < .01), caregiver strain (CGSQ, t[19] = 2.41, p < .05), interpersonal problems (IIP, t[19] = 2.49, p < .05), perceived stress reactivity (PSRS, t[19] = 3.02, p < .01) and attitudes toward family members (FAS, t[19] = 2.41, p < .05). No change was identified from pre- to postassessment for measures of anxiety (STAI State, t[19] = -.64, p > .05; STAI Trait, t[19] = .61, p > .05), and depression (PHQ, t[19] = 1.35, p > .05). Prior to starting the skills group, the sample’s mean pretreatment score on the DERS was 75.29 (SD = 17.15), which was below the clinical cutoff of 105.89 (see Table 2 for clinical cutoffs). Pretreatment score on the PHQ-9 was 7.71 (SD = 5.35), which indicates mild depression, but is below the clinical cutoff for depression. For anxiety, family member mean
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STAI-State score was 46.83 (SD = 6.63) and STAI-Trait 46.20 (SD = 5.29), which were both below their respective clinical cutoffs for anxiety. Family member mean pretreatment score on
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perceived stress was almost twice as much of the clinical cutoff at 22.75 (SD = 6.97), indicating
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a high degree of perceived stress. Family member mean score on IIP at pretreatment was 1.41 (SD =.64), which was only .08 below the clinical cutoff, suggesting a notable degree of
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interpersonal problems. The pretreatment FAS mean score was 51.45 (SD = 17.91), which was
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above the clinical cutoff of 31.35. Finally, pretreatment mean score on caregiver strain was 18.95 (SD = 6.02), which was almost three times higher than the clinical cutoff. Seventy-five percent of
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the sample obtained reliable improvement from pre- to posttreatment on attitudes toward family members (FAS); however, only 15% were at a level of normal functioning at post-assessment. In
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addition, over half the sample obtained reliable improvement on caregiver strain (CGSQ), but only 20% were at a level of normal functioning at posttreatment. Conversely, the entire sample
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was at a level of normal functioning at post for emotion dysregulation (DERS) and anxiety trait (STAI-T); further, 90% of the sample was at a level of normal functioning on depression (PHQ9). Table 2 describes indices of clinical significance in the sample.
Discussion
This study examined the feasibility and preliminary outcomes of a 6-month DBT skills training for family members of individuals with behavioral disorders. Pre- to posttreatment scores on assessment measures revealed significant reductions in family members’ ratings of caregiver strain, difficulties regulating emotions, perceived stress, interpersonal problems, as well as improvements in family attitudes. Family members’ depression and anxiety scores did not show a significant pre- to posttreatment reduction. Clinical significance outcomes revealed
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that the majority of participants saw reliable improvement in the areas of family attitudes and caregiver strain. The majority of family members had scores at a normal level of functioning
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posttreatment for emotion dysregulation, interpersonal problems, depression, and anxiety. The
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results suggest that DBT skills training may be an effective intervention for family members seeking treatment related to distress associated with having relatives with behavioral disorders.
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The results of this trial are consistent with previous trials of FC in impact on indices of
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family distress (e.g., burden; Hoffman et al., 2005; Rajalin et al., 2009). While we cannot directly compare outcomes between the two treatments because different measures were used,
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this trial of DBT skills demonstrated large effect sizes for all significant effects. Additionally, our study examined broader domains of functioning, including emotion dysregulation, perceived
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stress, and interpersonal problems more generally. This may indicate that DBT skills are useful for family members of individuals with behavioral disorders. Further, qualitative feedback from
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family members suggested that the skills were helpful in managing their emotions (e.g., “I am more aware of my feelings and more able to articulate those feelings in a more specific way”) and in their interactions with others (e.g., “I've found great improvement in my ability mindfully to listen to a conversation and be comfortable in it without having to interrupt”). Informal anecdotal participant feedback to group leaders suggested that participants found a variety of skills helpful, including both acceptance-based (e.g., mindfulness of one’s own current emotions and thoughts) and change-based skills (e.g., improving communication with their family member). Notably, participants in the trial reported that their family members were diagnosed with vastly different disorders that resulted in varying degrees of interpersonal distress. Future research is needed to determine if the entire skills package is needed and for whom, what skills
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participants find most useful, and whether its constituent parts are sufficient in determining the most effective and cost-efficient intervention for this population.
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There were several limitations to this study. First, this study lacked a control group with
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which to compare family members’ changes in outcomes. However, given the preliminary, pilot nature of this study, determining whether DBT skills provided significant benefits for family
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members of relatives with behavioral disorders is a useful first step (Onken et al., 2014). The
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study also did not assess for other interventions the family members might have utilized while in the DBT skills training group (e.g., psychotropic medication, outside psychotherapy). Another
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major limitation is that we lost nearly half of all participants to follow-up. While there were no differences between participants who did and did not complete post-group questionnaires, we
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cannot generalize these outcomes to our entire sample. Further, our sample lacked diversity. Specifically, most of the individuals in our sample had incomes over $50,000 a year, almost all
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were Caucasian, and all had at least some college education. As such, our findings may not be generalizable to lower-income, less educated, or racial minority populations. Nonetheless, previous evaluations of DBT have produced positive results among individuals with low incomes (e.g., Linehan et al., 1991; Linehan et al., 2006; Linehan et al., 2015). Future research should include more diverse samples. Relatedly, the cost of this intervention ($1,600) may have been prohibitive for some families with lower incomes. Implementing the FC model, which allows graduating family members to lead groups, may result in lower costs for clinics and could pass on savings to the consumer. However, research is needed to determine if outcomes would remain the same. In addition, the study also relied on self-report questionnaires and did not conduct diagnostic evaluation for clinical indices on participants nor the family member for whom they were attending the group (e.g., depression, anxiety).
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While open to both friends and family members of individuals with behavioral disorders, this study was comprised of only family members. It may be that family members are more
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likely than friends to experience distress related to their behaviorally disordered loved one and
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more likely to seek treatment. Treatment-seeking family members may also have variable symptom severity and differ in other ways (e.g., more financial resources) than non-treatment-
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seeking family members, and therefore may not be a representative sample of all family
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members with a relative with behavioral disorders. More work is needed to better understand the functioning of family members with behaviorally disordered relatives that do not seek treatment.
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Finally, while our results did show reduced emotion dysregulation, caregiver strain, interpersonal problems, stress, and improved attitudes toward family members, we did not see
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significant reduction in family members’ depression or anxiety scores. Notably, family member mean scores on emotion dysregulation, depression, and anxiety were within the range of
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normative functioning at pretreatment (Goldsmith, Chesney, Heath, & Barlow, 2013; Gratz & Roemer, 2004; Grös et al., 2007; Kroenke et al., 2001); thus, there may be a floor effect with the majority of the participants. Further, the standard deviation for the PHQ-9 scores at pretreatment was large, indicating family member depression largely varied before the group started, which highlights the heterogeneity of this sample. Family members’ reported elevated scores on measures related to family functioning and caregiver strain at pretreatment, indicating that family members were entering treatment with focused distress associated with their family member. With regard to clinically significant findings, it is clear that participants entered treatment with focused distress associated with their family member. Since the largest proportion of family members with reliable improvement was on measures related to family member distress (e.g.,
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family attitude, caregiver strain), it is possible that DBT skills for interpersonal effectiveness and mindfulness are particularly well suited for these family members.
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Despite these limitations, this study adds to the literature on feasible and potentially
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efficacious treatments for family members of individuals with behavioral problems. Also, given the relatively low, on average, initial scores on indices of depression and anxiety, we can
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consider the current sample to be close to a non-clinical group, suggesting that such an
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intervention may be beneficial even for nonclinical groups (e.g., children, deployed service
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members; Perepletchikova et al., 2011; Parrish, 2008).
Lessons Learned
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DBT skills offer family caregivers of individuals with behavioral disorders strategies for improving both their relationship with their distressed family member as well as their own
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quality of life. As this was the first trial delivering standard DBT skills to family members of individuals with behavior disorders, the pilot generated several important insights. First, interest in this skills group was high. The clinic often maintained a months-long wait list for this group, suggesting a desire for additional support and skills-based training in this population as well as a potential shortage of services for this group. Second, in addition to experiencing decreases in distress, family members also appeared to find the 1.5-hour weekly skills group acceptable. Informal feedback from family members was generally very positive; they found this approach and format helpful. Finally, from a clinician and program-based perspective, a DBT skills group for family members was relatively easy to implement. Running a DBT skills group for family members required virtually no additional resources above those already maintained in an outpatient clinic (e.g., group room with white board, therapists with availability). In fact, given
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the relative ease of implementing this group, we were only limited by the nights of the week and space in our clinic. For clinicians interested in implementing a DBT skills group for family
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members, training in DBT along with experience in conducting skills-based groups is
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recommended. Additionally, familiarity with the literature on family members’ experience caring for individuals with behavior disorders is suggested to help clinicians understand how DBT skills
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can be most useful to these individuals.
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Brannan, A. M., Athay, M. M., & de Andrade, A. R. (2012). Measurement Quality of the Caregiver Strain Questionnaire-Short Form 7 (CGSQ-SF7). Administration and Policy in Mental Health,
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Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The Phq‐9. Journal of General Internal
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Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New
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behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766. doi: 10.1001/archpsyc.63.7.757 Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., ... MurrayGregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475-482. Linehan, M. M., & Laffaw, J. A. (1982). Suicidal behaviors among clients at an outpatient psychology clinic versus the general population. Suicide and Life-Threatening Behavior, 12(4), 234-239. doi: 10.1111/j.1943-278X.1982.tb00711.x Linehan, M. M., & Wilks, C. R. (2015). The course and evolution of dialectical behavior therapy. American Journal of Psychotherapy, 69(2), 97-110.
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Marshall, T., & Solomon, P. (2004). Confidentiality intervention: Effects on provider-consumerfamily collaboration. Research on Social Work Practice, 14(1), 3-13. doi:
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Muhlbauer, S. A. (2002). Navigating the storm of mental illness: Phases in the family’s journey. Qualitative Health Research, 12(8), 1076-1092. doi: 10.1177/104973202129120458
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Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a
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mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832-839. doi: 10.1016/j.brat.2010.05.017
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Onken, L. S., Carroll, K. M., Shoham, V., Cuthbert, B. N., & Riddle, M. (2014). Reenvisioning clinical science unifying the discipline to improve the public health. Clinical Psychological
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depressive experience of caring: What cancer, schizophrenia, and Alzheimer’s disease caregivers have in common. Cancer Nursing, 35(3), 187-194. doi: 10.1097/NCC.0b013e31822cb4a0 Parrish, B. D. (2008). Dialectical behavior therapy deployed: An aggressive alternative to traditional mental health on the noncontiguous battlefield. United States Army Medical Department Journal, 24-31.
Perepletchikova, F., Axelrod, S. R., Kaufman, J., Rounsaville, B. J., Douglas‐Palumberi, H., & Miller, A. L. (2011). Adapting dialectical behaviour therapy for children: Towards a new research agenda for paediatric suicidal and non‐suicidal self‐injurious behaviours. Child and Adolescent Mental Health, 16(2), 116-121. doi: 10.1111/j.1475-3588.2010.00583.x
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Phelan, J. C., Bromet, E. J., & Link, B. G. (1998). Psychiatric illness and family stigma. Schizophrenia Bulletin, 24(1), 115-126. doi: 10.1093/oxfordjournals.schbul.a033304
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Rajalin, M., Wickholm-Pethrus, L., Hursti, T., & Jokinen, J. (2009). Dialectical behavior therapy-
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Schlotz, W., Hammerfald, K., Ehlert, U., & Gaab, J. (2011). Individual differences in the cortisol
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response to stress in young healthy men: Testing the roles of perceived stress reactivity and threat appraisal using multiphase latent growth curve modeling. Biological Psychology, 87(2),
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Schulz, R., & Martire, L. M. (2004). Family caregiving of persons with dementia: prevalence, health
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effects, and support strategies. The American Journal of Geriatric Psychiatry, 12(3), 240-249. doi:10.1097/00019442-200405000-00002
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Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2014). The use of dialectical behavior therapy skills training as stand‐alone treatment: A systematic review of the treatment outcome literature. Journal of Clinical Psychology. doi: 10.1002/jclp.22114 Zabala, M. J., Macdonald, P., & Treasure, J. (2009). Appraisal of caregiving burden, expressed emotion and psychological distress in families of people with eating disorders: A systematic review. European Eating Disorders Review, 17(5), 338-349. doi: 10.1002/erv.925
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Table 1
Post Mean (SD)
75.29 (17.15) 1.41 (.64) 51.45 (17.91) 18.95 (6.02) 22.75 (6.97) 7.71 (5.35) 46.83 (6.63) 46.20 (5.29)
65.86 (11.13) 1.13 (.56) 42.25 (11.99) 12.75 (6.34) 18.62 (5.92) 6.00 (3.36) 47.84 (5.13) 46.11 (5.10)
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t
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Pre Mean (SD)
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Scale Range DERS-2 39-180 IIP-PD-25 0-4 FAS 0-120 CGSQ-SF7 0-28 PSRS 0-46 PHQ-9 0-18 STAI-State 20-80 STAI-Trait 20-80 Note. * p < .05. ** p < .01.
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Measure
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Descriptive and Change Statistics From Pre- to Postintervention
3.30** 2.49* 2.41* 4.07** 3.02** 1.35 -.64 .61
d
95% CI
1.51 1.14 1.10 1.87 1.39 .62 -.29 .28
3.47, 15.39 .04, .52 1.19, 17.21 3.01, 9.39 1.26, 6.93 -.94, 4.37 -4.31, 2.29 -3.16, 3.35
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Table 2 Clinical Significant Outcomes and Sources of Normative Data RC index
CSC cut-off
Reliable Improvement # (%)
Normal Functioning # (%)
Both
DERS-2
±6.93
105.89
7 (35.5)
20 (100)
7 (35.0)
IIP-PD-25
±.29
1.49
4 (20.0)
16 (80.0)
1 (5.0)
FAS CGSQ-SF7
±5.66 ± 2.82
31.35 6.91
15 (75.0) 11 (55.0)
3 (15.0) 4 (20.0)
PSRS
±3.82
11.92
3 (15.0)
2 (10.0)
0 (--)
PHQ-9
±2.62
10.0
5 (25.0)
18 (90.0)
0 (--)
2 (10.0) 0 (--)
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4 (20.2) 15 (75.0) 4 (20.0) STAI-State ±2.65 51.92 3 (15.0) 20 (100) 3 (15.0) STAI-Trait ±2.28 54.28 Note: RC = Reliable change; CSC = Clinically significant change
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Goldsmith, Chesney, Heath, & Barlow (2013); Gratz & Roemer (2004) Kim & Pilkonis (1999); Stern et al. (2000) Kavanagh et al. (1997) Brannan, Athay, & de Andrade (2012) Schlotz, Yim, Zoccola, Jansen, & Schulz (2011) Kroenke, Spitzer, & Williams (2001) Gros et al. (2007) Gros et al. (2007)
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Sources of normative data
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Measure
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We examined DBT skills training for 20 family members of individuals with behavioral
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disorders There were significant results in various emotional and interpersonal outcomes
Most participants had clinically significant gains in family attitudes
There were no significant improvements for depression and anxiety
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S1077-7229(16)30042-6 doi: 10.1016/j.cbpra.2016.06.004 CBPRA 639
To appear in:
Cognitive and Behavioral Practice
Received date: Accepted date:
19 August 2015 15 June 2016
Please cite this article as: Wilks, C.R., Valenstein-Mah, H., Tran, H., King, A.M.M., Lungu, A. & Linehan, M.M., Dialectical Behavior Therapy Skills for Families of Individuals With Behavioral Disorders: Initial Feasibility and Outcomes, Cognitive and Behavioral Practice (2016), doi: 10.1016/j.cbpra.2016.06.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Running Head: DBT FOR FRIENDS AND FAMILIES
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Dialectical Behavior Therapy Skills for Families of Individuals With Behavioral Disorders:
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Initial Feasibility and Outcomes
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Chelsey R. Wilks and Helen Valenstein-Mah, University of Washington Han Tran, University of Memphis
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Alexandra M. M. King, University of Nevada Reno
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Anita Lungu and Marsha M. Linehan, University of Washington
We would like to thank the clients, therapists, and staff at the Behavioral Research and Therapy Clinics for their contributions to this research. Dr. Linehan receives royalties from Guilford Press for books she has written on Dialectical Behavior Therapy (DBT) and for DBT training materials from Behavioral Tech, LLC. She also owns Behavioral Tech Research, Inc. a company that develops on-line learning and clinical applications that include products for DBT. Dr. Linehan is compensated for providing DBT training and consultation. Address correspondence to Chelsey Wilks, Behavioral Research and Therapy Clinics, Box 351525, University of Washington, Seattle, WA 98195; [email protected].
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Abstract
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Family members of individuals with behavioral disorders are a valuable source of logistical and
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emotional support for patients. Family members may take on tremendous financial and/or psychological responsibility to care for their loved ones, which can result in poor psychological
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outcomes for the family and, in turn, impede the recovery of the patient. Dialectical Behavior
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Therapy (DBT) skills training is an effective treatment that has been utilized with numerous populations, including family members of individuals with behavioral problems, and has shown
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efficacy in improving various interpersonal outcomes; however, no study has examined feasibility and outcomes of delivering all four unabridged DBT skills modules to this population.
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Twenty participants attended weekly DBT skills classes for 6 months, where they acquired skills
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in mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. There
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were significant pre-post improvements for emotion dysregulation, stress reactivity, and various interpersonal outcomes; there were no significant changes in depression or anxiety. These results suggest that DBT skills may be effective at improving broad clinical domains in a sample of family members of individuals with behavioral problems. This research is the first step in demonstrating that DBT skills might benefit family members of patients with heterogeneous mental health problems and, therefore, fits in to the field's growing interest in cost-effective transdiagnostic interventions.
Keywords: dialectical behavior therapy; caretaking; families; skills only
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Family members of individuals with behavioral disorders are often one of the most important
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sources of support for these individuals. Such support can be emotional (e.g., offering empathy,
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cheerleading), logistical (e.g., providing transportation to treatment, housing), as well as
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financial (e.g., covering day-to-day costs of living, medical expenses), and can depend on the course or severity of the disorder (Clark, 1994; Papastavrou, Chalambous, Tsangari, &
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Karayiannis, 2012; Schulz & Martire, 2004; Tsang et al., 2003). Behavioral disorders in this context refers to individuals with mental health problems such as depression, anxiety, and/or
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personality disorders. Mental disorders are more common among unemployed individuals, and as much as 50% of adults with severe behavioral disorders are living with family members
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(Fryers, Melzer, & Jenkins, 2003; Marshall & Solomon, 2004). Informal caretaking, often done by the patient’s family, is prevalent, yielding approximately 52 million caregivers of individuals
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with physical or mental illnesses or disabilities in the United States alone (Health and Human Services, 1998). As a result, family members often take on tremendous financial and emotional responsibility when caring for their loved ones. Family members can experience increased anxiety and depression as a direct result of caring and providing resources for their loved ones. Benazon and Coyne (2000) found that spouses of depressed individuals experience increased depression that is attributable to their caretaking responsibilities. Likewise, in a systematic review of family members of individuals with eating disorders, family members were consistently found to have high levels of emotional and psychological distress, including diminished concentration and sleep loss due to worry (Zabala, Macdonald, & Treasure, 2009). Finally, family members often experience increased shame, guilt, and self-blame related to their loved-one’s disorder (Muhlbauer, 2002; Phelan et
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al., 1998). In turn, the strain from caring for a family member with behavioral disorders can have deleterious effects on the recovery of the patient; for example, research has documented that
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interpersonal burden of the informal caretaker role contributed to slower patient recovery (Cole
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& Reiss, 1993). Taken together, the stress related to caring for individuals with behavioral disorders can be extensive, with detrimental consequences for both the family member and
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patient.
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Dialectical behavior therapy (DBT; Linehan 1993, 2014) is a modular, transdiagnostic treatment with a strong evidence base for improving emotion dysregulation, interpersonal
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problems, and dysfunctional behaviors (see Linehan & Wilks, 2015). Standard DBT is an intensive, year-long program consisting of weekly 1-hour individual therapy sessions, weekly
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skills training group, 24-hour access to phone coaching, and weekly consultation group for the therapist. More recently, DBT skills training as a standalone treatment has also shown to be
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effective in treating numerous clinical populations, with individuals experiencing reductions in emotion dysregulation, depression, and improving general functioning, among other outcomes (for a review, see Valentine et al., 2014). Further, DBT skills use has been identified as a mediator for treatment targets (e.g., interpersonal problems, suicidal behavior; Neacsiu, Rizvi, & Linehan, 2010).
The DBT skills component includes training in regulating emotions, tolerating distress, interpersonal effectiveness, and mindfulness, directly targeting effective management of one’s own emotional experiences and teaching skills on how to improve relationships. Thus, the emphasis on both self- and other-focused behavioral skills may make DBT skills a particularly appropriate and potent intervention for family caregivers of individuals with behavioral problems who need tools to manage their own distress as well as their relationship with their family
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member. Specifically, DBT skills could improve the ability of family members to better regulate their own emotions, which may increase self-efficacy (Bandura, 1982) and level of control in
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handling stressful interpersonal situations with their family member with behavioral disorders.
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Furthermore, DBT includes distress tolerance skills focused specifically on navigating crisis situations in an effective way, which could be needed in potential crisis situations involving their
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behaviorally disordered family members. Integrated within the distress tolerance module is the
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skill of radical acceptance, which provides family members with a foundation to accept (or work toward accepting) their loved ones as they are in that moment. Additionally, training in
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interpersonal skills (such as assertiveness) may make family members more effective in negotiating demands and improving their relationships, which may reduce caregiver burden as a
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result. For instance, they may interact better with their relative or be more successful in asking for and receiving support from others in the family or community. Mindfulness skills may also
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help family members become more aware of their thoughts and emotions related to their distressed family member and help decrease reactive and ineffective emotions and behaviors. A growing body of research has started to examine the impact of DBT skills training for family members of individuals with behavioral problems. Family Connections® (FC®) is an adaptation of DBT that provides psychoeducation, brief skills training, and support specifically designed for family members of individuals with borderline personality disorder (BPD) (Fruzzetti & Hoffman, 2004). FC is based on the standard DBT skills training curriculum, and there are also several points in which it departs from the standard training. First, in line with its explicit focus on family members of individuals with BPD, two of the six modules taught in FC are dedicated to describing the research on BPD and to providing psychoeducation on the development of BPD and other BPD-specific problems. Second, most of the skills practices in
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FC are focused on teaching family members how to best interact with their loved one who has a BPD diagnosis. In contrast, skills practice in standard DBT group aims to generalize skills
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practice to all areas of life where effective behavior and emotion regulation are needed. Finally,
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each FC skills training group is led by two volunteers, most of whom are former group participants (though some clinicians run FC groups as well). After a family member completes
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the program they can go through leader training, join with another leader, and create their own
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group (Hoffman & Fruzzetti, 2005). This system allows the FC program to be provided to families free of cost.
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The FC curriculum has been examined with family members of individuals with BPD and suicide attempters. In these pilot trials, results revealed that family members reported
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significant reductions in grief, depression, perceived burden, and caregiver fatigue, as well as improved emotional well-being (Rajalin, Wickholm-Pethrus, Hursti, & Jokinen, 2009; Hoffman
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et al., 2005; Hoffman, Fruzzetti, & Buteau, 2007). While the research on FC outcomes is encouraging, the current intervention and data are specific to family members of individuals diagnosed with BPD. We believe the standard DBT skills training is applicable to family members of individuals with a larger variety of behavioral disorders than just BPD. Similarly, we believe there is more commonality than difference in the areas where family members of individuals with different behavioral disorders (not only BPD) need help, making the skills teachable within a heterogeneous group. Providing DBT skills training to family members of individuals with diverse behavioral problems has the potential benefit of making the intervention more cost-effective (as recruitment for groups would include a larger population) and disseminable on a larger scale.
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To the best of our knowledge, no study has examined the feasibility and outcomes of delivering all four unabridged DBT skills modules to family members. Thus, this research aims
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Participants
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Method
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members of individuals with a variety of behavioral disorders.
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to investigate the feasibility and preliminary outcomes of a 6-month DBT skills group for family
Twenty participants were self-referred from the Seattle area using a flyer on the clinic’s
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website and referrals from local providers. Potential participants called the number on the flier to express interest in receiving DBT skills training. A bachelor's- or master's-level clinician
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returned the call providing further information about the study’s intervention and cost. If participants were still interested, the clinician would do a phone screen to assess for eligibility.
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The only inclusion criterion was reporting having a friend or family member with a chronic mental and/or physical health problem. Participants were excluded if they did not speak English, had active suicidality, could not pay for services, and/or lived outside commutable distance from the clinic. The cost of the group was $1,600 per person. Of the 99 participants who contacted the clinic, 22 did not return our phone calls, 21 had logistical barriers (e.g., prior obligations during the group time), 12 did not have a loved one with a disorder, and 4 could not afford the program. No one refused to participate in the intervention after screening, although 2 participants dropped out after joining the skills training group. One participant dropped out due to scheduling demands and the other due to dislike of the intervention. Participants’ completion of the assessment measures was voluntary and did not affect their eligibility to participate in the intervention. Of the 38 participants that started treatment, 18 who completed the intervention did
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not return post-assessments; thus, data from 20 participants were analyzed in the current study. All demographic characteristics were analyzed to check for any statistically significant
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differences between those who completed the post-assessments and those who did not.
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Independent samples t-tests were used to assess differences between groups for continuous variables, Mann-Whitney U tests were used to assess differences between groups for ranked
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variables (e.g., highest level of education), and chi-squares were computed for binomial
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variables, and we found no statistically significant differences between those who turned in postassessments and those who did not on any demographic variables. Despite advertising to both
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friends and family members, all of the group participants (100%) were family members (relatives or spouses) of individuals with behavioral disorders. Mean age of participants was 54.75 (SD =
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10.31). Participants were mostly female (60%), Caucasian (95%), married (80%) and educated (100% had attended some college and 65% had postgraduate degrees). Among the participants,
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75% were living with the family member with a behavioral disorder. Participants reported that their family members had the following diagnoses: anxiety (60%), depression (60%), BPD (40%), as well as posttraumatic stress disorder (25%).
Procedure
Participants completed pre-assessment measures within 2 weeks of starting the group and completed their post-assessment measures within 2 weeks of finishing the group. All study procedures were conducted in accord with the Institutional Internal Review Board (IRB) approved procedures.
Measures
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Eight instruments were used to assess participants’ various indices of emotion regulation, interpersonal functioning, and caregiver-related stress. All of the measures given to participants
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were voluntary; participants’ ability to be in the group was not affected by whether or not they
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did the assessments. No diagnostic evaluations were conducted with the participants. Demographic information about participant age, race, marital status, education, and
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annual income was assessed using an abbreviated Demographic Data Survey (DDS; Linehan &
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Laffaw, 1982).
Participant interpersonal problems were assessed using the Inventory of Interpersonal
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Problems–Personality Disorders 25 (IIP-PD-25; Gunn et al., 2004). The IIP-PD-25 consists of 25 5-point Likert-type questions which fall into five subscales: interpersonal aggression,
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interpersonal ambivalence, interpersonal sensitivity, lack of sociability, and need for social
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2004).
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approval. The measure has high internal consistency with Cronbach’s α = .93 (Gunn et al.,
The Family Attitude Scale was used to assess the participants’ attitudes towards their family relationships (FAS; Kavanagh et al., 1997). The 30-item self-report questionnaire is on a 5-point Likert-type scale and measures several relationship attitude domains, including dissatisfaction, hostility, and burden. The FAS has high validity as well as high internal consistency, with each domain having a Cronbach’s alpha ≥ .95. Caregiver strain was measured using the Caregiver Strain Questionnaire–Short Form 7 (CGSQ-SF7; Brannan, et al., 2012). This 7-item self-report instrument measures both subjective internalized strain as well as objective strain on a 5-point Likert-type scale. The short-form of the CGSQ was found to retain the good validity and internal consistency of the original, which had
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Cronbach’s α’s from .74 to .93 for the subscales and the total measure (Brannan et al., 2012; Brannan et al., 1997; Kang et al., 2005).
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The Difficulties in Emotion Regulation Scale was used to measure the participant’s
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emotion dysregulation (DERS; Gratz & Roemer, 2004). The DERS measures five facets of emotion regulation: awareness of emotions, acceptance of emotions, ability to engage in goal-
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directed behavior, and access to effective emotion-regulation strategies. The self-report
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instrument has 39 items and is on a 5-point Likert-type scale. The DERS has high internal consistency with Cronbach’s α = .93, adequate construct and predictive validity, and good test-
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retest reliability with ρI =.88, p < .01 (Gratz & Roemer, 2004). Depression was used to measure the Patient Health Questionnaire-9 (PHQ-9; Kroenke et
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al., 2001). The PHQ-9 is on a 4-point Likert-type scale and is widely used for determining the
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presence and severity of depression. The measure has good internal validity (Cronbach’s α =
al., 2001).
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.86), high test-retest reliability (r = .84 after 48 hours), and high construct validity (Kroenke et
Anxiety was assessed using the State-Trait Anxiety Inventory (STAI; Grӧs et al., 2007). This instrument is a 40-item self-report measure that assesses both state (e.g., current level) and trait (general level) of anxiety on a 4-point Likert-type scale. The STAI has very good internal consistency with an average Cronbach’s α > .89, very good test-retest reliability over multiple time intervals with average r = .88, adequate convergent and discriminant validity, and lower temporal stability (which is to be expected given that the measure captures a state variable) (Grӧs et al., 2007). Stress was assessed with the Perceived Stress Reactivity Scale (PSRS; Schlotz et al., 2011). The PSRS is a 23-item self-report instrument assessing how strongly an individual reacts
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to stressful everyday events (e.g., making a mistake, having a heavy workload, or being in difficult social situations) with three answer choices for each question: “I am generally
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untroubled”; “I usually feel a little uneasy”; and “I normally get quite nervous.” The measure has
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high internal validity (Cronbach’s α = .87), acceptable test-retest reliability, and good
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discriminant validity (Schlotz et al., 2011).
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Treatment
Participants completed a 6-month DBT skills group that met for 1.5-hour weekly
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sessions. Two therapists, a leader and a co-leader, taught each group, in line with standard DBT skills training. The groups were led by graduate students or postdoctoral therapists who were part
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of a DBT team and had training in DBT. Specifically, all group leaders had received the DBT Intensive Training, and had received additional didactic courses in DBT. Group leaders also
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participated in 1-hour DBT consultation meetings every week, which served as a source for treatment fidelity monitoring as well as supervision. Additionally, the groups were video recorded and watched by senior DBT clinicians who provided weekly 1-hour supervision to the group leaders. During both direct supervision and DBT team consultation, the group leaders were given feedback regarding their didactic strengths and areas of improvement. Consistent with the standard DBT skills group format, each session began with a brief mindfulness exercise and a review of the homework from the previous week followed by teaching of new DBT skills. All standard DBT skills modules were taught: Mindfulness (2-week module), Distress Tolerance (6-week module), Interpersonal Effectiveness (6-week module), and Emotion Regulation (7-week module). The Mindfulness module started the treatment and was repeated in between the other modules such that over a period of 6 months participants went
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through the Mindfulness module three different times. The groups were semi-open and new members could join the group during the Mindfulness modules. Group members graduated
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when they completed all three additional modules (see Linehan, 2014). This 6-month course
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of treatment is pared down from Standard DBT as was tested in initial randomized controlled
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trials with adult individuals meeting criteria for BPD (Linehan et al., 1991; Linehan et al., 2006; Linehan et al., 2015).
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Recent research has shown that DBT skills groups alone can be effective for many of the problems that we were targeting (Valentine et al., 2014); thus, our intervention only contains the
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skills groups component of Standard DBT. We used a reduced intervention duration and group length considering that our sample population was not as severe as the typical clinical
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populations with which Standard DBT is used. It should be noted that while many family interventions add psychoeducation, we found the existing psychoeducation component to be
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sufficient and did not modify the curriculum.
Statistical Analysis Strategy
Because of the nature of this pilot project and the small number of participants who completed the intervention, all results must be interpreted as strictly exploratory. To determine changes in participants’ functioning pre- to posttreatment, we used a paired sample t-test with a 95% confidence interval to compare scores on all of the measures before and after the group. We used Cohen’s d to calculate effect size for the within-subjects design and was calculated using the following formula: d = t / √ (df). We calculated reliable and clinically significant change to better understand the treatment effects on the outcome variables. Reliable and clinically significant change were calculated
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according to the criteria recommended by Jacobson and Truax (1991). Reliable change (RC) was calculated as RC = x2 – x1/Sdiff and clinically significant change (CSC) was defined as reaching a
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level of functioning after treatment that is closer to the mean of the nonpatient population than to
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the patient population. For measures without nonpatient normative data (CGSQ-SF), CSC was defined as reaching a level of functioning that was greater than two standard deviations below
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the pretreatment sample mean. Normative data were obtained from standardized norms or studies
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using large samples. The RC indices, CSC cut-offs, and sources of normative data are depicted in
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Table 2.
Results
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On average, family members attended 87.61% (SD = .06) of scheduled groups and missed on average 3.05 (SD = 1.43) groups. There was a statistically significant decrease from
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pre- to post- assessment scores on five of the seven measures (see Table 1). Specifically, the results indicate a significant reduction in the index of emotion dysregulation (DERS, t[19] = 3.30, p < .01), caregiver strain (CGSQ, t[19] = 2.41, p < .05), interpersonal problems (IIP, t[19] = 2.49, p < .05), perceived stress reactivity (PSRS, t[19] = 3.02, p < .01) and attitudes toward family members (FAS, t[19] = 2.41, p < .05). No change was identified from pre- to postassessment for measures of anxiety (STAI State, t[19] = -.64, p > .05; STAI Trait, t[19] = .61, p > .05), and depression (PHQ, t[19] = 1.35, p > .05). Prior to starting the skills group, the sample’s mean pretreatment score on the DERS was 75.29 (SD = 17.15), which was below the clinical cutoff of 105.89 (see Table 2 for clinical cutoffs). Pretreatment score on the PHQ-9 was 7.71 (SD = 5.35), which indicates mild depression, but is below the clinical cutoff for depression. For anxiety, family member mean
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STAI-State score was 46.83 (SD = 6.63) and STAI-Trait 46.20 (SD = 5.29), which were both below their respective clinical cutoffs for anxiety. Family member mean pretreatment score on
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perceived stress was almost twice as much of the clinical cutoff at 22.75 (SD = 6.97), indicating
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a high degree of perceived stress. Family member mean score on IIP at pretreatment was 1.41 (SD =.64), which was only .08 below the clinical cutoff, suggesting a notable degree of
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interpersonal problems. The pretreatment FAS mean score was 51.45 (SD = 17.91), which was
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above the clinical cutoff of 31.35. Finally, pretreatment mean score on caregiver strain was 18.95 (SD = 6.02), which was almost three times higher than the clinical cutoff. Seventy-five percent of
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the sample obtained reliable improvement from pre- to posttreatment on attitudes toward family members (FAS); however, only 15% were at a level of normal functioning at post-assessment. In
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addition, over half the sample obtained reliable improvement on caregiver strain (CGSQ), but only 20% were at a level of normal functioning at posttreatment. Conversely, the entire sample
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was at a level of normal functioning at post for emotion dysregulation (DERS) and anxiety trait (STAI-T); further, 90% of the sample was at a level of normal functioning on depression (PHQ9). Table 2 describes indices of clinical significance in the sample.
Discussion
This study examined the feasibility and preliminary outcomes of a 6-month DBT skills training for family members of individuals with behavioral disorders. Pre- to posttreatment scores on assessment measures revealed significant reductions in family members’ ratings of caregiver strain, difficulties regulating emotions, perceived stress, interpersonal problems, as well as improvements in family attitudes. Family members’ depression and anxiety scores did not show a significant pre- to posttreatment reduction. Clinical significance outcomes revealed
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that the majority of participants saw reliable improvement in the areas of family attitudes and caregiver strain. The majority of family members had scores at a normal level of functioning
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posttreatment for emotion dysregulation, interpersonal problems, depression, and anxiety. The
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results suggest that DBT skills training may be an effective intervention for family members seeking treatment related to distress associated with having relatives with behavioral disorders.
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The results of this trial are consistent with previous trials of FC in impact on indices of
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family distress (e.g., burden; Hoffman et al., 2005; Rajalin et al., 2009). While we cannot directly compare outcomes between the two treatments because different measures were used,
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this trial of DBT skills demonstrated large effect sizes for all significant effects. Additionally, our study examined broader domains of functioning, including emotion dysregulation, perceived
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stress, and interpersonal problems more generally. This may indicate that DBT skills are useful for family members of individuals with behavioral disorders. Further, qualitative feedback from
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family members suggested that the skills were helpful in managing their emotions (e.g., “I am more aware of my feelings and more able to articulate those feelings in a more specific way”) and in their interactions with others (e.g., “I've found great improvement in my ability mindfully to listen to a conversation and be comfortable in it without having to interrupt”). Informal anecdotal participant feedback to group leaders suggested that participants found a variety of skills helpful, including both acceptance-based (e.g., mindfulness of one’s own current emotions and thoughts) and change-based skills (e.g., improving communication with their family member). Notably, participants in the trial reported that their family members were diagnosed with vastly different disorders that resulted in varying degrees of interpersonal distress. Future research is needed to determine if the entire skills package is needed and for whom, what skills
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participants find most useful, and whether its constituent parts are sufficient in determining the most effective and cost-efficient intervention for this population.
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There were several limitations to this study. First, this study lacked a control group with
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which to compare family members’ changes in outcomes. However, given the preliminary, pilot nature of this study, determining whether DBT skills provided significant benefits for family
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members of relatives with behavioral disorders is a useful first step (Onken et al., 2014). The
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study also did not assess for other interventions the family members might have utilized while in the DBT skills training group (e.g., psychotropic medication, outside psychotherapy). Another
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major limitation is that we lost nearly half of all participants to follow-up. While there were no differences between participants who did and did not complete post-group questionnaires, we
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cannot generalize these outcomes to our entire sample. Further, our sample lacked diversity. Specifically, most of the individuals in our sample had incomes over $50,000 a year, almost all
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were Caucasian, and all had at least some college education. As such, our findings may not be generalizable to lower-income, less educated, or racial minority populations. Nonetheless, previous evaluations of DBT have produced positive results among individuals with low incomes (e.g., Linehan et al., 1991; Linehan et al., 2006; Linehan et al., 2015). Future research should include more diverse samples. Relatedly, the cost of this intervention ($1,600) may have been prohibitive for some families with lower incomes. Implementing the FC model, which allows graduating family members to lead groups, may result in lower costs for clinics and could pass on savings to the consumer. However, research is needed to determine if outcomes would remain the same. In addition, the study also relied on self-report questionnaires and did not conduct diagnostic evaluation for clinical indices on participants nor the family member for whom they were attending the group (e.g., depression, anxiety).
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While open to both friends and family members of individuals with behavioral disorders, this study was comprised of only family members. It may be that family members are more
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likely than friends to experience distress related to their behaviorally disordered loved one and
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more likely to seek treatment. Treatment-seeking family members may also have variable symptom severity and differ in other ways (e.g., more financial resources) than non-treatment-
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seeking family members, and therefore may not be a representative sample of all family
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members with a relative with behavioral disorders. More work is needed to better understand the functioning of family members with behaviorally disordered relatives that do not seek treatment.
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Finally, while our results did show reduced emotion dysregulation, caregiver strain, interpersonal problems, stress, and improved attitudes toward family members, we did not see
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significant reduction in family members’ depression or anxiety scores. Notably, family member mean scores on emotion dysregulation, depression, and anxiety were within the range of
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normative functioning at pretreatment (Goldsmith, Chesney, Heath, & Barlow, 2013; Gratz & Roemer, 2004; Grös et al., 2007; Kroenke et al., 2001); thus, there may be a floor effect with the majority of the participants. Further, the standard deviation for the PHQ-9 scores at pretreatment was large, indicating family member depression largely varied before the group started, which highlights the heterogeneity of this sample. Family members’ reported elevated scores on measures related to family functioning and caregiver strain at pretreatment, indicating that family members were entering treatment with focused distress associated with their family member. With regard to clinically significant findings, it is clear that participants entered treatment with focused distress associated with their family member. Since the largest proportion of family members with reliable improvement was on measures related to family member distress (e.g.,
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family attitude, caregiver strain), it is possible that DBT skills for interpersonal effectiveness and mindfulness are particularly well suited for these family members.
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Despite these limitations, this study adds to the literature on feasible and potentially
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efficacious treatments for family members of individuals with behavioral problems. Also, given the relatively low, on average, initial scores on indices of depression and anxiety, we can
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consider the current sample to be close to a non-clinical group, suggesting that such an
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intervention may be beneficial even for nonclinical groups (e.g., children, deployed service
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members; Perepletchikova et al., 2011; Parrish, 2008).
Lessons Learned
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DBT skills offer family caregivers of individuals with behavioral disorders strategies for improving both their relationship with their distressed family member as well as their own
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quality of life. As this was the first trial delivering standard DBT skills to family members of individuals with behavior disorders, the pilot generated several important insights. First, interest in this skills group was high. The clinic often maintained a months-long wait list for this group, suggesting a desire for additional support and skills-based training in this population as well as a potential shortage of services for this group. Second, in addition to experiencing decreases in distress, family members also appeared to find the 1.5-hour weekly skills group acceptable. Informal feedback from family members was generally very positive; they found this approach and format helpful. Finally, from a clinician and program-based perspective, a DBT skills group for family members was relatively easy to implement. Running a DBT skills group for family members required virtually no additional resources above those already maintained in an outpatient clinic (e.g., group room with white board, therapists with availability). In fact, given
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the relative ease of implementing this group, we were only limited by the nights of the week and space in our clinic. For clinicians interested in implementing a DBT skills group for family
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members, training in DBT along with experience in conducting skills-based groups is
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recommended. Additionally, familiarity with the literature on family members’ experience caring for individuals with behavior disorders is suggested to help clinicians understand how DBT skills
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can be most useful to these individuals.
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Rajalin, M., Wickholm-Pethrus, L., Hursti, T., & Jokinen, J. (2009). Dialectical behavior therapy-
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Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2014). The use of dialectical behavior therapy skills training as stand‐alone treatment: A systematic review of the treatment outcome literature. Journal of Clinical Psychology. doi: 10.1002/jclp.22114 Zabala, M. J., Macdonald, P., & Treasure, J. (2009). Appraisal of caregiving burden, expressed emotion and psychological distress in families of people with eating disorders: A systematic review. European Eating Disorders Review, 17(5), 338-349. doi: 10.1002/erv.925
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Table 1
Post Mean (SD)
75.29 (17.15) 1.41 (.64) 51.45 (17.91) 18.95 (6.02) 22.75 (6.97) 7.71 (5.35) 46.83 (6.63) 46.20 (5.29)
65.86 (11.13) 1.13 (.56) 42.25 (11.99) 12.75 (6.34) 18.62 (5.92) 6.00 (3.36) 47.84 (5.13) 46.11 (5.10)
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t
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Pre Mean (SD)
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Scale Range DERS-2 39-180 IIP-PD-25 0-4 FAS 0-120 CGSQ-SF7 0-28 PSRS 0-46 PHQ-9 0-18 STAI-State 20-80 STAI-Trait 20-80 Note. * p < .05. ** p < .01.
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Measure
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Descriptive and Change Statistics From Pre- to Postintervention
3.30** 2.49* 2.41* 4.07** 3.02** 1.35 -.64 .61
d
95% CI
1.51 1.14 1.10 1.87 1.39 .62 -.29 .28
3.47, 15.39 .04, .52 1.19, 17.21 3.01, 9.39 1.26, 6.93 -.94, 4.37 -4.31, 2.29 -3.16, 3.35
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Table 2 Clinical Significant Outcomes and Sources of Normative Data RC index
CSC cut-off
Reliable Improvement # (%)
Normal Functioning # (%)
Both
DERS-2
±6.93
105.89
7 (35.5)
20 (100)
7 (35.0)
IIP-PD-25
±.29
1.49
4 (20.0)
16 (80.0)
1 (5.0)
FAS CGSQ-SF7
±5.66 ± 2.82
31.35 6.91
15 (75.0) 11 (55.0)
3 (15.0) 4 (20.0)
PSRS
±3.82
11.92
3 (15.0)
2 (10.0)
0 (--)
PHQ-9
±2.62
10.0
5 (25.0)
18 (90.0)
0 (--)
2 (10.0) 0 (--)
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4 (20.2) 15 (75.0) 4 (20.0) STAI-State ±2.65 51.92 3 (15.0) 20 (100) 3 (15.0) STAI-Trait ±2.28 54.28 Note: RC = Reliable change; CSC = Clinically significant change
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Goldsmith, Chesney, Heath, & Barlow (2013); Gratz & Roemer (2004) Kim & Pilkonis (1999); Stern et al. (2000) Kavanagh et al. (1997) Brannan, Athay, & de Andrade (2012) Schlotz, Yim, Zoccola, Jansen, & Schulz (2011) Kroenke, Spitzer, & Williams (2001) Gros et al. (2007) Gros et al. (2007)
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Sources of normative data
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Measure
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We examined DBT skills training for 20 family members of individuals with behavioral
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disorders There were significant results in various emotional and interpersonal outcomes
Most participants had clinically significant gains in family attitudes
There were no significant improvements for depression and anxiety
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