Dialectical Behavior Therapy for College Students

A few weeks ago we reviewed the merits of bringing mindfulness and acceptance to college students with statistics, research, and key points from the new edited title, Mindfulness & Acceptance for Counseling College Students: Theory and Practical Applications for Intervention, Prevention, and Outreach. To be more specific, Dialectical Behavior Therapy (DBT) has shown significant efficacy when tested among college students with “severe, complex profiles.”

Statistics have shown that today’s college students are experiencing increasingly higher levels of psychopathology, such as suicidality, non-suicidal self-injury, and personality disorders (particularly borderline personality disorder). Data collected from a survey of CCC directors noted an increase in overall psychopathology, but the greatest stress on the resources of CCC’s appears to come from an increase in the number of extremely distressed students presenting with complex profiles:

• 78% of directors noted an increase in crises requiring immediate attention and a threefold increase in number of hospitalizations since the mid-1990s (Gallagher, 2011).
• Directors estimate that 37% of students seeking services have severe psychological problems: 6% with problems that are so severe that they cannot remain in school, and 31% with problems that can be managed while still in school (Gallagher, 2011).
• Most directors reported that their jobs are more stressful than they used to be, partly because of the pressure to manage students with increasing complexity (73%) and to prevent tragic events from occurring on campuses (51%; Gallagher, 2011).
• The percentage of students presenting with depression, suicidality, and personality disorders appears to have at least doubled within a decade (Benton, Robertson, Tseng, Newton, & Benton, 2003).
• Approximately 32% of students presenting to treatment at counseling centers nationwide are experiencing some level of suicidal ideation, 30% have taken a psychotropic medication, and 7.1% have been previously hospitalized for psychiatric reasons (via survey from the Center for Collegiate Mental Health).

The severity and complexity of cases presenting for treatment at CCCs is escalating, and DBT is one of the few empirically validated approaches for treating severe multi-problem presentations including suicidality, non-suicidal self-injury, and BPD features.

DBT Overview

Dialectical Behavior Therapy was developed by Marsha Linehan and colleagues specifically to treat problems associated with emotion dysregulation. Comprehensive DBT deviates from traditional psychotherapy interventions in a variety of ways. First, outpatient DBT is a comprehensive program that includes five different functions:

1. Psychological skill training, typically in groups, to help clients learn specific psychological skills;
2. Individual therapy, to address client motivation (Targeting, doing chain analyses of problems, developing and pushing for solutions, and providing support and validation);
3. Planning and coaching to help clients generalize their new skills to difficult situations in their lives;
4. A therapist consultation team meeting to help therapists improve their treatment skills and maintain motivation to treat effectively;
5. Couple, parent, family, or other social interventions to help people in the social environment support the client’s progress.

Therapists teach clients, usually in group format, four core skills to help them with emotion modulation and self-management:

1. Mindfulness (to facilitate attention control, reduce judgments toward the self and others, and to build self-awareness and self-management skills);
2. Interpersonal effectiveness (to help reduce chaos and invalidation and build social support);
3. Emotion regulation (to reduce emotional vulnerability, reactivity, and misery, and to facilitate emotion modulation and self-management);
4. Distress tolerance (to interrupt negative emotion escalation and urges to engage in out-of-control behavior, and to “accept” things in life that are very undesirable but unchangeable).

Also, DBT uses a dialectical epistemology across all aspects of treatment, which means that DBT practitioners utilize principles of both acceptance (understanding and validating) and change (behavior therapy and problem solving) in the treatment. It also means that every dimension of the treatment can be conceptualized within a dialectical framework. For example, the therapist communicates dialectically with the client, using both a warm, supportive, genuine communication style and an unorthodox, pushy, matter-of-fact irreverent communication style. Similarly, the therapist typically consults with the client on how to solve his or her problems, but sometimes intervenes directly to solve them. More acceptance-oriented solutions (mindfulness, distress tolerance, accepting emotions and situations) are developed and more traditional change-oriented solutions (changing the situation, others, or, in some situations, emotions) are implemented.

College counseling centers lack resources, but face a high demand for services, coupled with a clear need for treatments designed for complex presentations. Some CCCs have begun providing DBT skills training groups alone as adjunctive treatment (Dimeff & Koerner, 2007). This is most often due to limited financial resources and, sometimes, the assumption that, for many clients, the comprehensive DBT package may not be required (Dimeff & Koerner, 2007).

DBT is supported by dozens of controlled trials and other studies. Initial studies focused on treating BPD and suicidal and self-harming behaviors; more recently, DBT has been applied successfully to a variety of severe problems including aggression, depression, PTSD, eating disorders, substance abuse and family and relationship problems. Originally developed as an outpatient treatment program, DBT has also been shown to be effective in day treatment, residential, inpatient, and forensic settings.

The first randomized controlled trial (RCT) of DBT with college students was composed of a total of 63 college students between the ages of 18 and 25 who were suicidal at baseline, reported at least one lifetime non-suicidal self injury (NSSI) act or a suicide attempt, and exhibited significant BPD features. Treatment was provided by mental health trainees (doctoral students, postdoctoral fellows, or psychiatry residents), and supervision was conducted by a locally nominated expert. Participants were randomly assigned to either DBT or an optimized Treatment as Usual (O-TAU) control condition. Both treatments lasted between 7 and 12 months and included both individual and group components. Assessments were conducted at pretreatment, 3-months, 6-months, 9-months, and 12-months, as well as a follow-up at 18-months.

Analyses revealed that DBT, compared to the control condition, showed significantly greater decreases in suicidality, depression, number of NSSI events, and PBP features, and significantly greater improvements in social adjustment and global assessment of functioning—the latter as rated by a blind assessor, the therapist, and the supervisor. Moderation analyses showed that DBT was particularly effective for suicidal students who were lower functioning at pretreatment. This is relevant to CCCs as it suggests that a more labor-intensive approach such as comprehensive DBT could be reserved for a smaller percentage of severe students—those who are lower in functioning.

The efficacy of DBT group skills training as a stand-alone intervention in a CCC setting remains to be studied, but attempts to do so are partly justified given preliminary findings that, if carried out competently, DBT skills training alone in other settings may be efficacious (e.g., Feldman, Harley, Kerrigan, Jacobo, & Fava, 2009; Harley, Baity, Blais, & Jacobo, 2007).

There’s a clear need for DBT at CCCs. Data indicate that comprehensive DBT, even when compared to a strong control condition, is effective with college students presenting with a complex profile. As of June 2013, this is the only empirically validated application of DBT with college students, and thus, comprehensive DBT is the most indicated treatment option for this population. Given findings that DBT was particularly effective with lower-functioning students, CCCs with limited resources might consider offering comprehensive DBT only to those students. Data suggests that perhaps treatment duration could be titrated according to the students’ needs. While the use of DBT skills training as a stand-alone or adjunctive treatment remain in need of empirical validation, rates of stabilization among students after only a few months of comprehensive treatment are promising. 

Next Steps

The next step in the application of DBT to CCCs is to conduct a stepped care study, where students are assigned to different levels of DBT care (e.g. skills group only vs. comprehensive). Editors of Mindfulness & Acceptance for Counseling College Students question the efficacy of providing a DBT skills group alone with concurrent individual therapy or any orientation to such a complex and high-risk population. On the other hand, given the lack of affordable comprehensive DBT treatment available off campus in most areas of the country and some promising findings in terms of skills training alone in other settings (Feldman et al., 2009; Harley et al., 2007), this practice is routinely followed across a number of other clinical environments and may be cautiously justified.

For more on applying DBT in college counseling centers, check out Mindfulness & Acceptance for Counseling College Students.

References

Gallagher, R. P. (2011). National survey of counseling center directors. Alexandria, VA: International Association of Counseling Services.

Benton, S.A., Robertson, J.M., Tseng, W.C., Newton, F.B., & Benton, S.L. (2003). Changes in counseling center client problems across 13 years. Professional Psychology: Research and Practice, 34(1), 66–72. Center for Collegiate Mental Health (CCMH, 2012). 2011 Annual Report (Publication No.STA 12-59).

Dimeff, L. A., & Koerner, K. (2007). Dialectical Behavior Therapy in practice: Applications across disorders and settings. New York: Guilford Press.

Feldman, G., Harley, R., Kerrigan, M., Jacabo, M., & Fava, M. (2009). Change in emotional processing during a dialectical behavior therapy-based skills group for major depressive disorder. Behavior Research and Therapy, 47, 316-321.

Harley, R. M., Baity, M. R., Blais, M. A., & Jacobo, M. C. (2007). Use of dialectical behavior therapy skills training for borderline personality disorder in a naturalistic setting. Psychotherapy Research, 17, 351-358.

Feldman, G., Harley, R., Kerrigan, M., Jacabo, M., & Fava, M. (2009). Change in emotional processing during a dialectical behavior therapy-based skills group for major depressive disorder. Behavior Research and Therapy, 47, 316-321.

Harley, R. M., Baity, M. R., Blais, M. A., & Jacobo, M. C. (2007). Use of dialectical behavior therapy skills training for borderline personality disorder in a naturalistic setting. Psychotherapy Research, 17, 351-358.