Symptom reduction in DBT-informed partial hospital, intensive outpatient, and step-down programs: Mindfulness matters.

Preliminary evidence suggests the efficacy of Dialectical Behavior Therapy (DBT) to reduce clinical symptoms in Partial Hospital (PH) programs. However, less is known about DBT in Intensive Outpatient (IOP) programs, or in PH to IOP step-down models. The current study examined changes in depression, anxiety, stress, hopelessness, and mindfulness skills acquisition, from intake and discharge data of clients at a southeastern behavioral health clinic in the United States. The sample included 146 clients, 65.75% female (ages M = 33.88, SD = 12.34), who attended either a DBT-PH, -IOP, or -PH to IOP step-down program. Participants completed the Depression, Anxiety, Stress Scale (DASS-21), Beck Hopelessness Scale (BHS), and Five Facets of Mindfulness Questionnaire Short Form (FFMQ-SF). Depression, anxiety, and hopelessness decreased from intake to discharge in the PH program, while all symptoms decreased in the IOP and step-down programs. Mindfulness total scores, and most subscales, increased in each program. Mindfulness skills acquisition predicted decreases in depression and stress in the IOP group, and decreases in depression and hopelessness in the step-down group. Overall, clinical symptoms and mindfulness skills acquisition improved over the course of the DBT-PH and—IOP programs.

Keywords: dialectical behavior therapy; DBT-informed treatment; partial hospital; intensive outpatient; mindfulness

Clinical or methodological significance of this article: There has been little research examining DBT-informed treatment to reduce clinical symptoms within Partial Hospital, Intensive Outpatient, and step-down care programs. Our study found that over a short duration of treatment, symptoms of depression, anxiety, stress, and hopelessness decreased for patients in these DBT programs, and may be facilitated by acquisition of mindfulness skills. Future research with stronger causal designs should examine the moderating role of mindfulness skills within these DBT programs.

Dialectical behavior therapy (DBT) was originally developed as an outpatient treatment for suicidal patients with borderline personality disorder (BPD) (Linehan, [13]). Since development, DBT has shown efficacy with a variety of patient populations, often with presenting problems characterized by emotion dysregulation (Linehan & Wilks, [14]). In DBT, patients are taught skills in emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness to achieve a dialectical balance between accepting reality, and changing maladaptive behaviors (Prada et al., [30]). The initial focus of DBT treatment involves reducing life interfering behaviors such as suicide and non-suicidal self-injurious behavior (NSSIB), and increasing adaptive behaviors, such as self-soothing and distracting one's-self from negative emotions (Linehan & Wilks, [14]). Both standard and adapted-DBT programs have been shown to reduce NSSIB, suicidal outcomes, and associated symptoms (Méndez-Bustos et al., [21]). For example, Flynn et al. ([12]) found that suicidal ideation and symptoms of depression, anxiety, and hopelessness decreased over the course of a 12-month standard-DBT program.

Inpatient hospitalization programs often use some components of DBT, as this modality is shown to be effective at treating suicide. However, inpatient stays are usually very short, and expensive. Patients likely do not acquire all DBT skills, as standard-DBT was originally designed to be a year-long program. Incorporating DBT into partial hospital (PH) and intensive outpatient (IOP) programs may help to reduce healthcare costs while providing patients with more skills to regulate their emotions and decrease symptoms (Pasieczny & Connor, [28]).

PH programs can help stabilize patients after inpatient hospitalization, or provide an alternative to inpatient care (Neuhaus, [26]). DBT may be an optimal modality for PH programs to treat suicidal patients. Memel ([20]) compared the outcomes of adolescents in a PH program that incorporated a DBT skills group, to an identical program without DBT. Suicidal ideation decreased for adolescents in the DBT-informed program, and their length of stay was shorter than the cohort without DBT skills training. Additionally, preliminary research suggests that DBT-informed PH programs are effective at treating a variety of mental health disorders and symptoms (Lothes et al., [18]). Lothes and colleagues found that patients with various diagnoses (e.g., major depression, post-traumatic stress disorder (PTSD), bipolar disorder, and generalized anxiety disorder) receiving DBT treatment in a PH program, saw significant reductions in depression, anxiety, hopelessness, and reported levels of suffering from intake to discharge. These results were also replicated in the same facility with new groups of PH patients (Lothes et al., [17]; Lothes et al., [16]; Mochrie et al., [23]; Mochrie et al., [22]). Lothes et al. ([16]) also found that when looking at data from this program over a five year span these results of decreased scores held constant year to year.

PH program stays are often short, and patients may benefit from additional DBT treatment offered through an IOP program. These IOP programs are typically considered a step down from PH level treatment as they offer less restriction than PH programs (often fewer hours or sessions per week), but more support than traditional outpatient programs. Patients may benefit from stepping down from a PH program into DBT-informed IOP treatment. However, to our knowledge, only two studies have examined DBT-informed IOP interventions on symptom reduction (Mochrie et al., [22]; Ritschel et al., [31]). Ritschel et al. ([31]) found depression and anxiety symptoms decreased, and hope increased over the course of IOP treatment. Additionally, Mochrie et al. ([22]) appears to be the first to examine DBT-informed treatment on symptom reduction among PH, IOP, and PH to IOP step-down groups. This study found depression, anxiety, hopelessness, and degree of suffering to decrease from intake to discharge in each of the three program groups, and no differences in symptom change scores from intake to discharge were observed between the three groups. Additional studies replicating these findings within PH, IOP, and step-down programs are needed.

Skills training provided in standard-DBT helps patients acquire new adaptive behaviors to replace maladaptive ones. However, little is known about which components of skills training may be the most useful for reducing distressing symptoms in PH and IOP programs. There are four skills modules that are taught during skills group training: mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. Mindfulness skills are considered the "core" skills in DBT, and often taught as an introduction to the other skill modules (Linehan & Wilks, [14]; Mochrie et al., [23]). Patients are taught the "what" skills such as observing their environment, describing their experiences using words and participating in the moment effectively, and the "how" skills such as viewing their thoughts in a non-judgmental way, doing one thing in the moment and acting effectively. Each skill module typically requires mindfulness at the core. For example, with emotion regulation, individuals must have awareness of their emotions and thoughts to regulate these emotions. As mindfulness is a core component of DBT, these skills may be particularly beneficial to acquire within PH and IOP programs to reduce symptoms. Correlations have been noted between regular mindfulness practice and reductions in anxiety, perceived stress, and improvements in psychological well-being (Carmody & Baer, [8]).

While research examining specific components of DBT is limited, the utility of DBT mindfulness has been implicated in several studies. For example, Muhomba et al. ([24]) delivered a brief group intervention, including only mindfulness and distress tolerance DBT skills, to a group of students at a college counseling center, resulting in significant reductions in maladaptive coping strategies, increased adaptive coping strategies, and improvement in emotion regulation. Further, Lothes et al. ([15]) taught "what" and "how" DBT mindfulness skills and mindfulness based stress reduction to college students over an 8-week period. Compared to a control group, students receiving the mindfulness instruction reported significant reductions in test anxiety and generalized anxiety at the end of the intervention period.

To our knowledge, only one study has examined specifically the impact of DBT mindfulness skills acquisition on symptom reduction in a PH setting (Mochrie et al., [23]). Mochrie and colleagues found all mindfulness variables assessed (observe, describe, act with awareness, non-judge, and non-react) increased from intake to discharge, and mindfulness skills added a modest amount of unique variance to symptom reduction. Increases in the skills non-judge and non-react were associated with decreased depression and anxiety respectively, but hopelessness and suffering reduction may have been impacted by acquisition of mindfulness more globally. Additional research examining the mindfulness component of DBT within PH and IOP programs is needed.

The purpose of the present study is to examine the treatment outcomes among three DBT-intensive programs. We examined the intake and discharge data from a sample of clients attending DBT-PH and—IOP programs, as well as a PH to IOP step-down program. Specifically, we examined pre–post changes in levels of depression, anxiety, stress, and hopelessness, to test the hypothesis that DBT is associated with symptom reduction. Consistent with preliminary research (Lothes et al., [16]; Mochrie et al., [22]), we expect there to be significant reductions in symptoms from intake to discharge in the PH, IOP, and PH to IOP step-down programs, and no significant differences in symptom reduction based on the program type clients were enrolled in. The Depression, Anxiety, Stress Scale (DASS-21) was used to increase clinical utility (DASS-21; Lovibond & Lovibond, [19]). Prior studies at this clinic used the BDI-II and CUDOS to measure depression, and BAI and CUXOS to measure anxiety (BDI-II; Beck et al., [3]; CUDOS; Zimmerman et al., [34]; BAI; Burns, [7]; CUXOS; Zimmerman et al., [35]). Further, we tested the hypothesis that there is an association between overall hours in treatment and symptom reduction. According to the dose-effect model, patients attending a greater number of sessions should see greater improvements (Nielsen et al., [27]). Correlations between treatment outcomes and time spent in treatment have been previously found in DBT (Linehan, [13]). Regardless of program type, we expect those who attended more overall program hours would have the greatest reductions in symptoms of depression, anxiety, stress, and hopelessness. Additionally, the present study adds to the literature by examining mindfulness skills acquisition among a new set of clients, including those who received step-down care from PH to IOP, and those who attended IOP or PH as a stand-alone treatment. We tested the hypothesis that mindfulness skills acquisition is associated with symptom reduction in DBT programs. We expect all mindfulness skills to increase from intake to discharge in each of the three program groups. Additionally, we examined the relationship between skills acquisition and symptom reduction among the three programs as exploratory analyses, with the expectation that mindfulness skills acquisition would partially account for symptom reduction. Finally, we examined the relationship between mindfulness skills and overall hours in treatment, with the expectation that clients who attended more overall program hours would show the greatest increase in mindfulness.

The PH and IOP programs described below were adapted from Linehan's DBT training manual, Second Edition (Linehan & Wilks, [14]), and met all five modes of standardized DBT (Swenson, [33]).

The PH program is an intensive outpatient day treatment program, meeting 4 h a day/5 days a week, for adults with acute mental health concerns. Treatment included skills training in mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. During each program day, clients attended four separate groups (sample schedule provided in Table I). The first group began with a "check-in" process to discuss homework assignments and problem-solve any barriers of implementing skills outside of the group. The second and third groups included 50-min skills teaching, with one or two DBT skills taught per group session. Skills modules rotated so that each group day incorporated skills from a different module. This format allowed all DBT skills to be covered in a six-week period. The second and third groups concluded with time for questions and homework assignments. The final (fourth) group allowed process time to address potential barriers of skills use until returning to program and to increase skills use motivation. A mindfulness practice was conducted daily, typically at the end of the check-in process or taught during a skills group. Individuals in the PH program also received medication management if needed, and were provided 24-hour access to a coaching phone to promote DBT skills use outside of group and decrease suicidal and NSSIB behaviors (Ben-Porath & Koons, [4]; Chapman, [9]). Additionally, clients met with a weekly individual therapist who was trained in DBT. There were at least three 10-day DBT intensively trained therapists and at least five, 5-day DBT foundationally trained (through Behavioral Tech) therapists on staff. All other therapists/interns who had not attended a 10-day or 5-day intensive training received individual DBT supervision conducted by one of the intensively trained therapists. Therapists and interns attended weekly DBT consultation team meetings.

Table I. Sample week of PH and IOP Programs (week 2).

1 Note. PH = Partial Hospital, IOP = Intensive Outpatient. Blank sections within the right (IOP) column were days/times that the group did not meet. ER = Emotion Regulation, DT = Distress Tolerance, IE = Interpersonal Effectiveness, MI = Mindfulness.

The IOP program met for 3 h a day/3 days a week. Group sessions were the same as the PH program, covering skills training in mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. However, individuals in IOP attended three group sessions a day instead of four (sample schedule in Table I). Like clients in the PH program, those in IOP also received individual therapy, 24-hour coaching phone access, and medication management as needed. DBT consultation team meetings were held weekly.

For step-down care, clients were first enrolled in the PH program, and stepped down to less intensive IOP treatment instead of directly discharging from PH.

The sample included 146 participants attending one of three DBT program groups at a community mental health clinic, located in the south-east region of the United States. These groups included participants who only attended the PH program (12 females, 6 males), ages 18–55 (M = 27.33, SD = 7.65), participants who only attended the IOP program (53 females, 31 males), ages 18–76 (M = 35.50, SD = 13.56), and participants who started in the PH program and later stepped down to IOP before discharging (30 females, 10 males). For research purposes the groups were treated as three separate categories to see how these different levels of care may have an effect on symptom reduction. Since there is very little research on the outcomes of PH, IOP and step-down care, patients that stepped down from PH to IOP were treated as a different group than those that attended PH only. Clients with higher intake depression scores were more likely to be placed in PH at intake than in IOP, t(96.316) = 4.65, p < 0.001. Similarly, clients with higher intake anxiety scores were more likely to be placed in PH at intake than IOP t(83.806) = 3.44, p < 0.001.

The DASS-21 is a set of three self-reported scales, measuring the negative emotional states of depression, anxiety, and stress at intake and discharge (DASS-21; Lovibond & Lovibond, [19]). The depression scale measures dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest or involvement, anhedonia, and inertia. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress scale measures difficulty relaxing, nervous arousal, and being easily agitated or irritable. Participants answer questions about the presence of symptoms over the previous week on a scale from 0 (did not apply to me) to 3 (applied to me very much or most of the time), with higher scores indicating greater symptoms. This measure has been shown to have good reliability and validity (Coker et al., [10]).

The Beck Hopelessness Scale (BHS; Beck, [2]) was used to examine self-reported levels of hopelessness at intake and discharge. The measure includes 21 true/false items, allowing participants to endorse either a pessimistic statement, or optimistic statement. Higher scores indicate greater hopelessness. The BHS is considered a reliable and valid measure, with strong internal consistency (Cronbach's α = 0.97) among depressed patients (Bouvard et al., [6]).

The Five Facets of Mindfulness Questionnaire Short Form (FFMQ-SF; Bohlmeijer et al., [5]) was used to measure mindfulness at intake and discharge. The FFMQ-SF is a 24-item short form of the original FFMQ (Baer et al., [1]) that assesses five facets of mindfulness: observe (how the world is perceived), describe (how experiences are described and labeled in words), act with awareness (how one acts or responds to a situation), non-judge (self-acceptance and empathy for others), and non-react (acceptance of negative thoughts, and choosing not to act on them). Reliability (Cronbach's α > 0.74 for all factors and total score) and validity have been well established for using this measure among psychiatric patients (Bohlmeijer et al., [5]).

Hours in treatment were calculated by equation ((overall attended days in PH X4) + (overall attended days in IOP X3)).

As the study aimed to replicate the results of prior research with a new set of clients, measures and procedures are similar to those described in Mochrie et al. ([22]). The study was approved by the IRB at a local university. As this was a stand alone clinic not tied to a university or research grants, an evaluation was conducted to determine appropriate program placement based on medical necessity. Symptom severity (depression and anxiety), ability to complete activities of daily living, recent inpatient hospitalizations, suicidal thinking, and non-suicidal self-injurious behaviors were considered during program placement. Individuals recently admitted to inpatient hospitalization within the past month, or who had significant suicidal thinking and/or self-harming behaviors were placed in PH at intake. Those with less severe symptoms, suicidal thinking, self-harming behaviors, and no recent inpatient hospitalization were placed in IOP at intake. An examination to determine medical necessity was conducted at intake and at discharge. There was a collaborative effort between client, therapist, and program staff to determine the best time for the client to discharge from program or transfer to less intensive care (e.g., transfer from PH down to IOP).

All participants signed informed consent for treatment. Participants completed the DASS-21, BHS, and FFMQ-SF at intake and at time of discharge from the program. The study was conducted on outcome data from these programs. Additionally, the study was conducted at a community mental health center that found it unethical to refuse treatment, therefore, the study did not include randomization or a wait-listed control group.

All analyses were conducted using RStudio version 3.5.1. A series of paired sample t-tests were conducted to examine symptom change after DBT treatment in PH, IOP, and step-down groups (Table II). All three programs showed significant reductions in depression, anxiety, and hopelessness from intake to discharge. The IOP and step-down groups also showed significant reductions in stress. Figure 1 visually represents changes in symptoms from intake to discharge for each program. A between subjects one-way ANOVA was conducted to see if symptom change scores (depression, anxiety, stress, and hopelessness) were different between programs from intake to discharge. There were no significant differences in symptom reduction from intake to discharge, between program groups (Table II).

Graph: Figure 1. Change in Symptoms from Intake to Discharge. (Note. Intake and discharge scores for (A) depression, (B) anxiety, (C) stress, and (D) hopelessness, in Partial Hospital (PH), Intensive Outpatient (IOP), and step-down (PH/IOP) programs. Error bars represent standard errors. * denotes significant difference between intake and discharge scores).

Table II. Intake and discharge data on symptom reduction and mindfulness.

2 Note. Partial Hospital (PH) program scores are in the top gray panel. Intensive Outpatient (IOP) program scores are in the middle white panel. Step-down (PH/IOP) program scores are in the bottom gray panel. Mindfulness subscales: OB = observe, DS = describe, AA = act with awareness, NR = non-judge, and NR = non-react.

A series of paired sample t-tests examined if mindfulness skills were acquired during participation in programs (Table II). There were significant increases in mindfulness total scores from intake to discharge in all three programs. Additionally, there were significant increases in all mindfulness subscales (observe, describe, act with awareness, non-judge, and non-react) in the IOP program, and increases in describe, act with awareness, non-judge, and non-react in the PH and step-down programs.

Clients in PH-alone attended an average of 72.89 (SD = 26.90) overall hours. Clients in IOP-alone attended an average of 63.14 (SD = 32.18) overall hours. Those who started in PH and stepped down to IOP attended an average of 140.56 (SD = 73.43) overall hours.

A series of linear regression analyses examined the relationship between program hours and symptom reduction. In each analysis, overall program hours were entered as a predictor of symptom change from intake to discharge. Regardless of program type, overall hours were not found to be associated with changes in depression, anxiety, stress, or hopelessness. Examining each program separately, greater program hours was associated with less change in depression F(1, 24) = 5.414, p = 0.029 and anxiety, F(1, 24) = 4.661, p = 0.041, in the step-down group. Overall program hours were not related to changes in stress or hopelessness in the step-down group, or any symptom reduction in the PH and IOP groups. These results are similar to Mochrie et al.'s ([22]) findings on program hours and symptom changes.

A series of linear regression analyses examined the association between program hours and mindfulness skills acquisition. In each analysis, overall program hours were entered as a predictor of change in mindfulness from intake to discharge. Regardless of program type, there was a negative association between overall hours in program and mindfulness skills acquisition F(1, 127) = 7.146, p = 0.009. Examining each program separately, no relationship was found between program hours and changes in mindfulness in the PH and IOP groups. However, a negative relationship was found in the step-down group F(1, 34) = 5.598, p = 0.024.

The relationship between mindfulness acquisition and symptom reduction was analyzed using a series of linear multiple regression analyses. In each analysis, change in each mindfulness variable (intake scores subtracted from discharge scores) were entered simultaneously as predictors of change in symptomatology (depression, anxiety, stress, or hopelessness) from intake to discharge. Each of these analyses were conducted separately for our PH, IOP, and step-down groups (Table III).

Table III. Regression results for mindfulness skills acquisition on symptom reduction.

3 Note. Change in mindfulness variables were entered simultaneously to predict change in depression (top gray panel), anxiety (top white panel), stress (bottom gray panel), and hopelessness (bottom white panel), in each program. PH = Partial Hospital, IOP = Intensive Outpatient, PH/IOP = step-down. OB = observe, DS = describe, AA = act with awareness, NJ = non-judge, NR = non-react. * p <.05, ** p <.01.

Examining the PH group, combined changes in mindfulness did not predict depression, anxiety, stress, or hopelessness differences scores. However, while the combination of mindfulness subscales did not predict change in stress, non-react did emerge as a significant predictor (p = 0.036).

Examining the IOP group, combined changes in mindfulness accounted for 29.84% of the variability in depression differences scores F(5, 46) = 5.339, p < 0.001. For depression, only observe (p = 0.039) and describe (p = 0.022) subscales were significant predictors. Combined changes in mindfulness did not predict anxiety difference scores. For stress, combined changes in mindfulness accounted for 19.70% of the variability in stress difference scores F(5, 46) = 3.502, p = 0.009. Only observe (p = 0.023) and non-react (p = 0.022) subscales were significant predictors in this analysis. Combined changes in mindfulness did not predict hopelessness difference scores.

Examining participants who started in PH and stepped down to IOP, combined changes in mindfulness accounted for 44.85% of the variability in depression difference scores F(5, 17) = 4.578, p = 0.008. For depression, only the observe subscale was a significant predictor (p = 0.016). Combined changes in mindfulness did not predict either anxiety or stress differences scores. However, for stress, act with awareness subscale did emerge as a significant predictor (p = 0.048). Combined changes in mindfulness accounted for 30.23% of the variability in hopelessness scores F(5, 29) = 3.946, p = 0.007. However, for hopelessness, no single mindfulness subscale emerged as a significant predictor.

Since Ritschel et al.'s ([31]) seminal research examining DBT's application in an intensive outpatient setting, and Lothes and colleagues' ([18]) influential research examining DBT's application in PH programs, the literature has started to expand in applying DBT in other mental health settings (Dimeff et al., [11]; Lothes et al., [17]; Lothes et al., [16]; Mochrie et al., [22]; Swenson, [33]). Preliminary research examining outcome data of PH and IOP programs supports the use of DBT in these settings (Lothes et al., [17], [16]; Mochrie et al., [22]; Ritschel et al., [31]).

The purpose of this study was to not only expand on the works from Lothes et al.'s ([18], [17]) and Mochrie et al.'s ([23], [22]) research, but to also consider how mindfulness and hours in program may play a role in symptom changes from intake to discharge. Some preliminary results from Mochrie et al. ([23]) are showing that mindfulness skills taught in these programs may be synergistic to symptom reduction in depression and anxiety. Previous research also suggests symptom reduction in depression and anxiety may act as a protective factor in suicide prevention (Pompili et al., [29]), an important consideration when working with high risk clients in PH and IOP programs. Considering that mindfulness skills acquisition was associated with decreases in depression and stress in the IOP group, and decreases in depression and hopelessness in the step-down group, acquiring mindfulness appears to be an important skill that should be examined further within DBT-informed programs. Clinical implications based on outcomes from this study and from Mochrie et al.'s ([23]) study would suggest that clients attending these programs have a regular mindfulness practice to help mitigate symptoms. These practices should include in-session practices where clients can receive real-time feedback from their therapist or group leader, and a continued practice while not attending groups to continue to cultivate mindfulness skills.

This study replicated the results of previous research, finding decreases in depression, anxiety, stress, and hopelessness among clients in our three programs. Additionally, PH, IOP, and step-down programs all appeared to be just as effective at reducing clinical symptoms. These results are congruent with outcomes from previous studies (Lothes et al., [16]; Mochrie et al., [22]).

Based on the dose-effect model (Nielsen et al., [27]), we expected clients who attended a greater number of program hours to have the greatest reduction in symptoms. However, regardless of program type, overall program hours were not associated with changes in depression, anxiety, stress, or hopelessness. Examining each program separately, greater program hours were associated with less change in depression and anxiety in the step-down group. These results may be better interpreted by a good-enough level model, which suggests that clients who attend fewer sessions tend to experience a faster rate of symptom change, and end therapy when they have reached a "good-enough level" (Nielsen et al., [27]). It is possible that if individuals were not experiencing changes in depression or anxiety, they opted to stay in program longer.

Outcomes from this study are promising, as there is still a significant reduction in symptoms from intake to discharge on different scales assessing depression, anxiety, and the addition of stress being examined in this study. Clinical implications for these outcomes may also suggest that clients that are not experiencing symptom reduction as quickly may consider a step-down option instead of a complete discharge from PH. It would also be sensible for therapists to keep these outcomes in mind when discussing treatment options with clients, as DBT sees the therapeutic relationship as reciprocal, and options should be discussed between the patient and therapist verus made for them.

Mindfulness, as indicated by total FFMQ-SF scores, increased from intake to discharge in all programs (large effect sizes), as well as most subscales. These results suggest that teaching DBT mindfulness skills, and having them practiced during group sessions, may help improve overall mindfulness skills acquisition in patients attending PH or IOP programs. Mindfulness has been shown to promote positive health outcomes such as increased concentration and stronger awareness (Shapiro et al., [32]), and those with emotion dysregulation concerns may benefit from a stronger focus on acquiring mindfulness skills to facilitate emotion regulation (Neasciu et al., [25]). Linehan ([13]) has hypothesized that emotion dysregulation is one of the foundational concerns for people dealing with BPD and other emotion regulation based disorders (e.g., anxiety, substance use disorders, depression, etc). Such findings continue to support the benefit of examining mindfulness within a DBT-informed approach to PH and IOP programs.

We conducted exploratory analyses to examine if specific subscales of mindfulness, or mindfulness globally, were associated with symptom reduction. Mindfulness acquisition was not related to symptom reduction in the PH group. However, this result was likely due to very small sample size (depression, anxiety and stress, n = 14; hopelessness n = 18). Mochrie et al. ([23]) found mindfulness holistically to be associated with depression, anxiety, suffering, and hopelessness reduction. A larger sample of PH clients is likely needed to replicate these results. However, it is also possible that due to the symptoms expressed by these clients being more severe than IOP clients, that other mechanisms of DBT needed to be assessed to see if they had an effect on symptom reduction. Other mechanisms may include Distress Tolerance skills, coaching phone usage, diary card completion or chain analysis completion for target behaviors such as substance use, self-harm or suicide attempts while they were in program. For the IOP group, mindfulness acquisition was associated with decreases in depression and stress. Additionally, for the step-down group, mindfulness acquisition was associated with decreases in depression and hopelessness. While specific subscales of mindfulness were identified as significant predictors of symptom reduction, these specific subscales are not consistent with results from Mochrie et al. ([23]). However, one study found overlap of multiple mindfulness facets to be related to reduction in psychological symptoms and perceived stress (Carmody & Baer, [8]). It is likely that mindfulness and other DBT components combined are synergistic to each other in symptom reduction, with mindfulness laying the foundation for the other skills to be built upon.

The study has several limitations. Study variables included self-reported data, as these measures are commonly used when collecting intake and discharge data on symptoms and mindfulness. However, behavioral observations from clinical staff may be useful as further insight into treatment outcomes in these programs. We were not able to collect discharge data from participants who dropped out of the program early against medical recommendation. Therefore, there could be a skew of data for this sample. Additionally, weekly medication management was provided to clients in the study, which may have had therapeutic effects. However, many PH programs do offer medication management as part of their program, so these results may still be useful for PH programs with medication management. Additionally, data was collected from one clinic in the south-east region of the country, therefore, the findings may not be generalizable to other DBT PH/IOP programs.

There was no recruitment for individuals to participate in a "study" of DBT in a PH or IOP program. Potential clients were either referred to the PH or IOP program by their individual therapist in the community, or as a step down from being discharged from an inpatient facility at a local hospital. The study did not include a control group, or random assignment, as wait-listing possible referrals for study purposes would likely be harmful to these high-risk patients. It is noted that causal inferences cannot be made due to the lack of a control group. Additionally, there is a potential for Type-1 errors due to the number of tests conducted. It might be useful for future studies, possibly research clinics or universities, to employ a waitlisted control or randomized control trial against a non-DBT PH program to examine if these outcomes hold constant.

Mindfulness skills acquisition was associated with symptom reduction. Future research may want to examine mediational relationships between skills acquisition, time spent engaging in mindfulness practices, and symptom reduction in these programs. Additionally, future research should examine coaching phone usage, medication adherence, and other DBT skill domains, to determine which components of DBT are most useful for symptom reduction in PH and IOP programs. Comparing results across locations and treatment facilities would increase generalizability and help clinicians to design efficacious treatment protocols. Further, it is important for future studies to examine follow up data after discharge from PH/IOP programs.

No potential conflict of interest was reported by the author(s).