The temporal relationships between therapist adherence and patient outcomes in dialectical behavior therapy.

Abstract

Objective: Although Dialectical Behavior Therapy (DBT) is a well-established evidence-based psychotherapy, little is known about the role of therapist adherence in promoting positive outcomes. This study evaluated the temporal relationships between therapist adherence to DBT and patient outcomes, as well as potential moderators of these relationships. Method: Data were from six clinical trials conducted in research and community settings with a variety of patient populations. In these trials, trained observers rated 83 therapists for adherence during 1,262 DBT individual therapy sessions with 288 patients. Patient outcomes included suicide attempts, nonsuicidal self-injury (NSSI), treatment dropout, psychiatric hospitalizations, and global functioning. Longitudinal mixed-effects models evaluated the time-ordered, bidirectional relationships between adherence and outcomes. Results: Higher therapist adherence significantly predicted fewer subsequent suicide attempts ( p = .002, η = 0.32) and a lower risk of dropout ( p = .002, η = 0.33), and the latter relationship was strongest among patients with comorbid opioid dependence. Higher therapist adherence predicted fewer subsequent hospitalizations among community therapists ( p = .001, η = 0.35) and patients that were not exclusively suicidal/selfinjuring ( p < .001, η = 0.41). Conversely, more frequent NSSI ( p = .03, η = 0.22) and worse global functioning ( p = .01, η = 0.26) predicted higher subsequent therapist adherence, and the latter relationship was moderated by patient population. Conclusions: Therapist adherence improves several key patient outcomes and retention, highlighting the importance of delivering DBT with adherence to the manual. Therapists may find it easier to deliver DBT adherently to more severely impaired patients. What is the public health significance of this article?This study highlights the importance of delivering DBT according to the manual, as this is likely to result inbetter patient outcomes. Therapists may find it easier to deliver DBT adherently to patients who are more severely impaired.

Practitioner Review: Common elements in treatments for youth suicide attempts and self‐harm – a practitioner review based on review of treatment elements associated with intervention benefits

“…expert therapist videos explaining key therapeutic concepts and skills, digital apps), with measurement‐based care involving real‐time monitoring of patient outcomes used to inform and adjust treatment strategies to optimize treatment benefits (e.g. clinical dashboards illustrating self‐harm outcomes; Asarnow et al., 2020; Craske et al., 2009; Harned, Gallop, Schmidt, & Korslund, 2022).…”

Applications of dialectical behavioural therapy in the perinatal period: A scoping review

“…sleep deprivation, assumption of parental roles, negotiating partner needs and feeding challenges) corroborate a need for inclusion of coaching services to support skills use. Finally, although none of the reviewed studies assessed treatment fidelity, findings from Harned et al (2022) indicated that therapist adherence to DBT predicts therapeutic outcomes, particularly for high‐risk concerns such as hospitalisation, suicide attempts and early dropout. As such, outcomes for high‐risk perinatal individuals, including caregivers with elevated risks of suicide, self‐harm or serious mental illness, are likely to be optimised through the provision of comprehensive and adherent DBT.…”

Development and Evaluation of a Pragmatic Measure of Adherence to Dialectical Behavior Therapy: The DBT Adherence Checklist for Individual Therapy

“…This is particularly concerning given that therapists in routine practice often deliver DBT non-adherently according to this study (44% of sessions) and prior research (48% of sessions; Harned et al, 2021a , b ). Moreover, many clients who receive DBT are at high risk for suicide and therapist adherence is an important mechanism by which suicidal behavior is reduced (Harned et al, 2022 ). The DBT AC-I represents a significant advance towards enabling stakeholders to evaluate if the treatment being provided is consistent with DBT as it is defined in the treatment manual.…”

“…Therapist adherence is a core component of fidelity and refers to the degree to which therapists deliver the treatment procedures as intended (Perepletchikova et al, 2007 ). In DBT, higher therapist adherence leads to better outcomes for clients (Harned et al, 2022 ), making it a particularly important target for implementation and quality assurance efforts.…”

“…The DBT ACS has excellent inter-rater reliability, strong discriminant validity, and generates dependable adherence scores (Harned et al, 2021a , b ). The DBT ACS is also effective in predicting reductions in key client outcomes, including suicide attempts, psychiatric hospitalizations, and treatment dropout (Harned et al, 2022 ).…”