Counseling Services, University of Nevada, Reno;
Alan E. Fruzzetti
Department of Psychology, University of Nevada, Reno
Chelsea MacLane
Counseling Services, University of Nevada, Reno
Robert Gallop
Department of Mathematics, Applied Statistics Program, West Chester University
Katherine M. Iverson
Counseling Services and Psychology Department, University of Nevada, Reno
Acknowledgement: Chelsea MacLane is now at the Psychology Department, University of Nevada, Reno. Katherine M. Iverson is now at the Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine.
The project described was supported by National Institute of Mental Health Grant R34MH071904 to Jacqueline Pistorello. The authors would like to thank Patricia Chatham in particular, as well as Grant Miller, Chad Shenk, Victoria Follette, Jennifer Villatte, Karen Erickson, Larry Pruitt, Sabrina Darrow, Susan Daflos, Melanie Watkins, Michael Katrichak, Katrina Crenshaw, Lindsay Fletcher, and the faculty and staff at Counseling Services at the University of Nevada, Reno for their support. We also want to thank Steven C. Hayes for statistical consultation and editing. Last, we want to acknowledge the invaluable contribution made by the brave young women and men who consented to participate in this research project.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health. Pretreatment data from this study were analyzed as part of a dissertation and appear in “An investigation of experiential avoidance, emotion dysregulation, and distress intolerance in young adult outpatients with borderline personality disorder symptoms,” by K. M. Iverson, V. M. Follette, J. Pistorello, and A. E. Fruzzetti, in press, Personality Disorders: Theory, Research, and Treatment. Data collected from therapists in this study appear in two additional publications: “A preliminary examination of burnout among counselor trainees treating clients with recent suicidal ideation and borderline traits,” by G. D. Miller, K. M. Iverson, M. Kemmelmeier, C. MacLane, J. Pistorello, A. E. Fruzzetti, … K. Y. Crenshaw, 2011, Counselor Education and Supervision, 50, pp. 344–359, and “A pilot study of psychotherapist's trainees' alpha-amylase and cortisol levels during treatment of recently suicidal clients with borderline traits,” by G. D. Miller, K. M. Iverson, M. Kemmelmeier, C. MacLane, J. Pistorello, A. E. Fruzzetti, … M. M. Watkins, 2010, Professional Psychology: Research and Practice, 41, pp. 228–235.
Although the college years are often thought of as carefree for young adults, nearly half of this population can be diagnosed with at least one mental health disorder in a given year (
Effective treatment of these problems among college students may deflect the trajectory of these severe mental health problems before they become chronic (
Dialectical behavior therapy (DBT;
There are several reasons to investigate the implementation of DBT in the treatment of college students with complex clinical presentations, including suicidal ideation, severe depression, NSSI, and BPD features. First, DBT is a principle-based treatment that is flexible enough to apply to the severe and multiproblem presentations increasingly seen across campuses (
Integrating DBT into CCCs needs to take into account that CCCs are often designed to deliver short-term psychotherapy (
Participants were 63 college students seeking services at the CCC at a medium-sized public university in the western United States.
Randomization and power
Participants were randomly assigned to treatment conditions using a computerized urn randomization procedure (
Structured Clinical Interview for Axis I DSM–IV (Nonpatient Version; psychotic screen, and Mood, Anxiety, Substance Use, and Eating Disorders modules; SCID–I/NP;
At the end of Session 1, participants rated the therapy they were receiving on seven items adapted from
Interviewers
Potential participants were interviewed by independent assessors, who were blind to treatment condition and held masters or doctoral degrees in clinical psychology. Assessors were trained by experts on the measures administered. A random sample of 25% of the dependent variables' videotapes were evaluated by an additional rater to calculate interrater reliability (kappa for categorical measures, intraclass correlations [ICC] for ordinal ratings).
SCID-II, BPD
The SCID-II, BPD (
Suicide Attempt Self-Injury Interview (SASII;
The SASII is a clinician-administered assessment of the frequency and topography of suicide attempts and NSSI. ICCs for the subscales ranged from .87 to .94 for this study. However, only the occurrence (yes/no) and frequency of NSSI were analyzed in the present study, because the base rate for NSSI and suicide attempts was too low post-baseline, and the subscales can only be computed when NSSI or suicide attempts are present.
Beck Depression Inventory (2nd ed.; BDI-II;
The BDI-II is a well-known measure of depressive symptom severity and has good psychometric properties with this population (e.g.,
Suicidal Behaviors Questionnaire (SBQ;
The SBQ includes a scale measuring suicidality (SBQ-23), as well as a table for self-report of NSSI and suicide attempts. On the SBQ table, participants are asked to report the number of self-harming acts across various categories (e.g., cutting, overdosing) and their level of suicidal intent for each incident (e.g., clear intent to die, ambivalent, no intent to die). Events were classified as suicide attempts when the participant indicated ambivalent or clear intent to die and as an NSSI when there was no intent to die. The SBQ-23 total score ranges from 0 to 88, assessing the frequency of suicidal thoughts, and the person's estimation of the likelihood they would consider, attempt, and die from suicide in the future, across various timeframes (e.g., next month, next 4 months, next year, lifetime). The SBQ-23 has been used in other DBT studies (e.g.,
Social Adjustment Scale-Self-Report (SAS-SR;
The SAS-SR is a 54-item assessment of functioning across a number of domains, which combine to yield a total score. In this study, the total score yielded a coefficient alpha of .81.
Global Assessment of Functioning (GAF;
The GAF is a clinician-rated measure of global functioning evaluated by assessors who were blind to condition. Baseline GAF scores, based on a median split, were used to test for moderation.
Participants were randomly assigned to either DBT or an O-TAU condition, relying on supervision by an expert. Treatment and data collection occurred between January 2006 and January 2009.
DBT
The DBT treatment provided as part of this study followed closely the standard outpatient DBT package (
There were four modifications to standard DBT (
Second, as is typical of DBT, therapists relentlessly encouraged attendance and followed up on missed sessions through phone calls and e-mails, but because students generally left town for extended periods of time, participants had to miss four scheduled consecutive individual appointments without contact with the therapist to be considered a dropout. This may differ from typical community DBT in that clients, even if away for 2–3 months during scheduled university breaks, could still be considered to be in ongoing treatment. Although the “four-miss rule” is usually considered in the context of weekly contact, particularly until client is stabilized, the DBT four-miss rule is, in fact, one way to instantiate key DBT principles and targets, to maximize participation in treatment, including, (a) avoiding polarizing around missed sessions (balancing the importance of attending with the realities of some missed appointments) and (b) taking the therapist out of the role of judge of what might be a “legitimate” versus “illegitimate” miss (instead, in DBT, when the client misses, we view it as he or she is simply not present and does not benefit, regardless of the reasons for missing;
Third, skills groups ran for 1.5 hr to accommodate class schedules. Fourth, the three 8-week skills modules followed the campus schedule with one module taught in the spring, one in the fall, and one in the summer (modules taught at each time varied depending on the needs of enrolled clients). Optimal treatment in terms of skills trainings involved attending eight group sessions per semester. Thus, only students completing 12 months of treatment received all three skills training modules and some DBT completers were only exposed to one or two skills group modules (e.g., may have been gone in the summer or finished treatment early), although skills training was also provided individually on occasion. Students in this sample were only exposed to skills modules once, whereas in traditional outpatient DBT that lasts 12 months clients participate in each skills module at least twice (
We considered a treatment completer someone who stayed in treatment between 7 and 12 months, regardless of number of sessions attended. Although participants were offered up to 12 months of treatment, they were asked to make a commitment to stay in treatment at least 7 months. The 7-month criterion was selected to define completers because in pilot work many students experienced significant improvement in one semester of treatment and did not warrant continued intervention. The 7-month cutoff (instead of only one semester) required students to attend treatment across semesters, thus allowing counselors to ensure the student's therapeutic progress was stable. A shorter length of treatment has been applied successfully in other DBT studies (e.g.,
Optimized treatment as usual (O-TAU)
The use of the supervision by experts design controls for the supervisors' allegiance and general expertise with this population but does not lend itself to a rigorous comparison of treatments (
Trainee therapists and their training
Supervisors hired the therapists in their respective conditions based on experience and allegiance to the particular therapeutic orientation. Five DBT and four O-TAU therapists were recruited for the study. Four of the five DBT therapists and three of the four O-TAU therapists were female. All DBT therapists were graduate students in a clinical psychology program. One of the O-TAU psychotherapists was a psychiatry resident, one was a psychology postdoctoral fellow, one was a graduate student in clinical psychology, and one was a master's-level counseling psychology graduate student.
Trainees in both conditions underwent 30 hr of training in their approach, separately (DBT or O-TAU), prior to beginning to offer treatment. The DBT training followed
Treatment length and type
As noted above, participants were offered up to a year of treatment, and participants who completed 7–12 months of treatment were considered completers. Although both treatment conditions offered weekly individual and group therapy, in DBT, skills groups are inherently part of the treatment and attendance was emphasized, whereas in O-TAU, all clients were offered group therapy but its emphasis was left up to the clinical judgment of the therapist/supervisor.
Supervision
Both conditions conducted 90-min weekly group supervision. On average, each therapist maintained a caseload of three clients and conducted one group. Additional individual supervision or phone consultation was provided as needed. In DBT supervision, a brief update on all clients was provided with more in-depth discussions prioritized based on DBT's hierarchy (e.g., suicidal and NSSI behaviors first). The structure and process of the group supervision in O-TAU was left up to the supervisor.
Primary analyses were based on either mixed-model analysis of variance (MMANOVA;
Normality of all measures was ensured and transformations applied if needed. Denominator degrees of freedom were estimated with the Kenward-Roger approximation (
Randomization was successful with regard to balancing the three covariate variables: (a) gender (22.6% male in DBT, 15.6% in O-TAU, χ
There were no differences on treatment credibility, DBT M = 5.19, SD = 0.95; O-TAU M = 5.05, SD = 0.93, t(47) = –0.527, p > .10. There were also no differences on treatment dropout and length in treatment: Approximately 35% of the DBT group (11/31) and 47% of the O-TAU group (15/32) dropped out before completing 7 months of therapy (χ
An independent DBT adherence rater (trained to reliability) reviewed a random sample of approximately 10% of the DBT therapists' taped individual sessions (81 of 773), randomly selected across the beginning, middle, and end of treatment, using the DBT Expert Rating Scale (
Suicidality
An HLM analysis revealed that DBT participants showed significantly greater reductions in suicidality, as measured by the SBQ-23—frequency of suicidal thoughts, and the person's estimation of the likelihood they would consider, attempt, and die from suicide in the future—than did O-TAU participants during the treatment period, t(57) = 2.02, p = .049, d = 0.53 (0.02–1.03). Extending time through follow-up showed a similar effect, t(57) = 2.36, p = .022, d = 0.63 (0.12–1.13). Application of the pattern mixture model indicated no significant dependency of the treatment effect on retention, t(59) = 1.39, p = .17, and total hours in treatment, t(55) = 1.12, p = .26.
Reliable change required difference scores of 12.94 or more on the SBQ-23; 31% of O-TAU participants improved and 16% worsened by the 12-month assessment, 37% improved and 22% worsened at follow-up; 32% of DBT participants improved and 0% worsened at 12 months, 48% improved and 0% worsened at follow-up. At 12 months, the two conditions did not differ in net gains (subtracting reliable deterioration from improvement) but did so at follow-up, χ
Depression
An MMANOVA analysis of the BDI-II scores with toeplitz covariance structure revealed a significant effect for time, F(4, 172) = 8.16, p < .0001, d = 0.78, and for condition, t(54) = 2.78, p < .008, d = 0.76 (0.24–1.26). Condition contrasts at fixed time points revealed that the two conditions did not differ significantly (p > .32) until after 6 months of treatment, when significant differences in favor of DBT emerged, F(1, 168) = 7.33, p < .008, d = 0.70 (0.18–1.20). These condition differences continued at 12 months, t(168) = 2.95, p < .004, d = 0.74 (0.22–1.24), and follow up, t(168) = 3.19, p < .002, d = 0.80 (0.28–1.30). The application of the pattern mixture model indicated no significant dependency of the treatment effect on retention, t(52) = 0.54, p = .59, and total hours in treatment, t(52) = 0.14, p = .89.
Reliable changes based on study values required change scores of 10.65 or more on the BDI-II. Approximately 47% of O-TAU participants improved and 0% worsened, both at 12 months and at follow up; 61% of DBT participants improved and 0% worsened at 12 months, 68% improved and 0% worsened at follow-up. The two conditions did not differ in net gains of reliable change. For those showing reliable improvement, using the normative data on the BDI-II (
NSSI
Two different measures were used to examine change in NSSI: an interview conducted by a trained assessor (SASII) and client self-reported frequencies (SBQ). Unlike community populations typically treated in DBT studies (e.g.,
Suicide attempts
Attempts were also measured via interview and self-report. In both instances, self-harming behaviors that were reported as either ambivalent or with clear intent to die were classified as suicide attempts (as opposed to NSSI). As illustrated in
Borderline criteria
We performed a piecewise model with two phases of change on the SCID-BPD: baseline to 12 months and 12 months to follow-up. On average, there was a greater reduction for DBT versus O-TAU during treatment (difference estimate = 0.18, SE = 0.041), t(83) = 4.51, p = .0001, d = 1.19 (0.60–1.67), but not during the follow-up period (difference estimate = –0.08, SE = 0.088), t(74.3) = –1.01, p = .31, d = 0.27 (–0.247–0.75).
Social adjustment
The total score of the SAS-SR (see
Psychotropic medication use
This analysis relied on a dichotomous variable of either no medication (0) or at least one psychotropic medication (1), covarying pretreatment usage. Hierarchical generalized linear modeling (HGLM), used to address the binary form of the outcome, indicated that DBT clients used significantly fewer psychotropic medications post-baseline (difference estimate = 0.025, SE = 0.009), t(60.1) = 2.79, p = .007, d = 0.74 (see
There was good balance with respect to level of global functioning across treatment assignment, where 67.7% of DBT participants fell in the higher functioning range versus 65.5% of O-TAU participants using a median split of pretreatment GAF scores. A significant three-way interaction was found for the Treatment × Time × Pretreatment GAF score on the primary dependent variable—suicidality, t(51) = 2.13, p = .038. Contrasts between slopes in the HLM analysis were used to explore this interaction. For higher functioning participants there were no significant differences between conditions at month 12 (difference estimate = 0.58, SE = 0.544), t(56.6) = 1.07, p = .29, d = 0.28 (–0.23–0.76), or at follow-up (difference estimate = 0.75, SE = 0.687), t(53.7) = 1.10, p = .28, d = 0.29 (–0.22–0.77). Among the lower functioning participants, there was a nonsignificant trend toward a difference in favor of DBT at month 12 (difference estimate = 1.57, SE = 0.81), t(62.7) = 1.93, p = .058, d = 0.51 (–0.02–0.99), and a significant difference at follow-up (difference estimate = 2.58, SE = 1.05), t(57.7) = 2.45, p = .017, d = 0.65 (0.11–1.12). With regard to depression, as measured by the BDI-II, there was no statistically significant moderation effect of global functioning at baseline, t(52) = 0.33, p = .75.
Despite underfunding, an emphasis on short-term treatment (
The present study shows that DBT can be adapted and implemented successfully in CCCs to treat students presenting with a complex, multiproblem, suicidal profile. DBT delivered by trainee therapists with regular supervision successfully, and differentially, impacted suicidality, depression, NSSI count, BPD symptoms, psychotropic medication use, and social adjustment. DBT participants made significant gains, with depression moving from a pretreatment score in the severely depressed range to a follow-up score in the minimal range of scores for the BDI-II. Moreover, none of the DBT clients exhibited reliable worsening in suicidality over the course of treatment, whereas this was not the case in the O-TAU condition. This finding suggests that DBT may be a particularly effective and safe treatment for severely distressed clients being treated in the CCC context.
DBT adherence ratings indicate that, on average, the trainee therapists in this study were sufficiently adherent to DBT treatment strategies and interventions. Because we endeavored to mimic “real world” training and supervision conditions, we did not require therapists to achieve adherence levels prior to taking on research treatment cases. Thus, these mean adherence scores reflect both early sessions, with generally lower adherence scores, and later sessions, with generally higher adherence scores. Overall, mean scores around 3.9 suggest reasonably high levels of learning and adherence and suggest that these can be achieved through moderate levels of training and supervision that could be replicated in other counseling centers.
These positive findings in favor of DBT are unlikely to be due to methodological weaknesses such as a weak control condition, higher expectations by experimental participants, lack of expertise by clinician/supervisor in treating BPD, differential access to treatment, differential training, or differential allegiance to treatment. Both treatments were provided within the same clinic, overseen by expert supervisors with strong allegiance to their particular treatment approach, and delivered by therapists with similar training and supervision intensity.
The O-TAU comparison condition appears to have been effective in its own right. The supervisor was selected based on community recognition of expertise with this population (similar to
This study surprisingly obtained higher dropout rates (35%) than some other DBT studies (e.g.,
In the future, the association between treatment dosage to outcome in DBT should be studied systematically, including randomized trials where participants are assigned to different lengths and/or modalities of DBT treatment. This study's higher dropout rate and participants' reduced access to skills groups due to campus schedules has resulted, on average, in relatively fewer number of DBT sessions than that expected for weekly treatments lasting up to 1 year (i.e., the mean number of individual sessions among DBT treatment completers was 34, SD = 10). Thus, although the findings favor DBT, it is possible that the limited number of individual and group sessions completed could have reduced the potency of the DBT treatment.
Moderation analyses suggest that DBT might be particularly effective for complex suicidality among college students who are lower in global functioning (GAF baseline score 50 and below). This is not particularly surprising, as DBT was originally developed to work with lower functioning individuals (
Despite multiple strengths, this study has methodological limitations. It is not possible to conclude from the present study that DBT outperformed psychodynamically oriented therapy, despite the fact that the O-TAU supervisor is well known in this area, because the implementation of the O-TAU intervention, as a psychodynamic approach, was not carefully controlled or monitored for adherence. Moreover, O-TAU and DBT therapists differed somewhat in terms of background and professional affiliation, and it is not known how these differences may have affected results.
Although total number of hours in treatment did not moderate treatment effects, there were significant treatment differences in attendance of group sessions, which emerged as an inherent difference between these approaches. DBT requires clients to participate in both the individual and group components of therapy to remain in treatment. Beyond requiring that O-TAU offer both individual and group treatment (weekly), the study did not impose conditions on how treatment should be carried out, as more intrusive requirements could have fundamentally changed the O-TAU treatment, resulting in essentially developing an ad hoc manualized alternative, which was not the intent of the study design.
Similarly, the present study speaks to the effectiveness of a comprehensive DBT package (individual, group, between-session consultation to the patient, and consultation team for therapists) in treating students presenting to CCCs but cannot address the role of DBT components if applied separately. Most CCC administrators might prefer to offer DBT skills groups only, to keep costs low. However, in comprehensive DBT, the individual therapist plays a major role in promoting group attendance and motivating the student to get back into group after missing session, and ensuring the generalization of skills and having a consultation team for therapists are also essential (
There are noteworthy limitations in terms of adherence procedures and the assessment timeline. Although we utilized the DBT adherence system available when this project was first proposed, it is not the most current one, and although purposeful for other reasons, our study did not require DBT therapists to achieve adherence levels before starting to see clients—a factor that may have influenced mean adherence ratings. Additionally, O-TAU sessions were not rated for DBT adherence, and therefore, the study failed to address treatment diffusion. Last, this study was envisioned as a combination of effectiveness and efficacy elements, requiring some compromise relative to an efficacy-only randomized trial. For example, allowing participants to stay in treatment between 7 and 12 months meant that not all participants completed a post-test treatment assessment at the same time. The use of mixed effects analyses in evaluating treatment effects helped compensate for this design feature as they detect different change patterns across condition and time, instead of relying on differences at specific time points.
Universities are increasingly faced with difficult choices of how to allocate resources, but it seems clear that CCCs must find a way to address complex and severe problems of students on campus (
In that context, evidence-based treatments in general offer hope to students and to the institution alike (
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Submitted: October 10, 2011 Revised: May 10, 2012 Accepted: May 14, 2012