Abstract
D.Litt. et Phil.
The aim of this study was to evaluate a feasible rating
scale to measure the adherence of therapists carrying out
Dialectical Behavior Therapy (DBT) with Borderline
Personality Disorder (BPD) clients. Adherence referred to
therapists carrying out DBT and how frequently and
thoroughly they executed the specific targets and strategies
of the therapy, which included taking the context into
account. DBT is very specific in its treatment targets and
in their hierarchical order of importance. The 97 item
adherence scale was rated on a 7 point (0-6) scale. Some 86
items, that corresponded with the therapist ethological
scale, were selected and then compared to the therapist and
client ethological scales from an earlier study. These
ethogram scales were process coding instruments which rated
minute-by-minute, the frequency of specific categories of
client and therapist verbal behaviors. The adherence scale
was further compared to client self-report diary card
measures. The diary card measures were also compared to the
therapist and client ethological scales.
Randomly selected client-therapist dyads (N = 10) were used,
meeting criteria for BPD. All clients were women and
between the ages of 18-45. The clients were seen by a total
of 7 DBT trained therapists. Random sessions (N = 6) were
selected from the first 16 sessions for each clienttherapist
dyad. Some 60 sessions were chosen. 57 tapes
were coded as 3 were too inaudible to code.
Results indicated that the adherence rating of the
respective therapist increased as the negative behaviors of
the client increased (p < 0.05). Conversely, the greater
the client's positive behavior on the ethological scale, the
lower the DBT adherence rating of the therapist (p < 0.05).
The problem solving category on both the adherence and
therapist ethological scale covaried significantly (p <
0.02). Other therapist strategies (i.e., reciprocal,
irreverence, primary targets 1-4, contingencies and
validation) between the two scales were not significantly
correlated.
A test of the validity of the adherence scale to measure DBT
fidelity draws its strongest support from two findings: 1)
that when a client portrayed positive behaviors the
therapist needed not to follow the primary targets so
closely, resulting in a decrease in the adherence rating;
and 2) the greater the negative behaviors of the client,
the more stringently the therapist focused upon the primary
targets and a wider array of strategies, which led to an
overall increase in the adherence rating.
The results of this study confirmed that a rating scale of
therapist adherence is possible even with a flexible therapy
such as DBT. Further, that minute-by-minute ethological
ratings may serve to validate a more holistic adherence
scale as tested here. Finally, recommendations are
discussed for the further improvement and enhancement of the
DBT adherence scale when used as a tool for rating DBT's
treatment fidelity.