This study comprises 33 female patients aged 17-50 (M=25.3 years, SD=8.6) who all participated in a step-down DBT program at Jelgersma Center for Personality Disorders, based on Linehan’s protocol (19) which consisted of 3 months residential DBT plus 6 months of outpatient DBT. (20) Originally the group of patients consisted of 36, but three patients dropped out.
All patients met the criteria for Borderline Personality Disorder according to the Dutch version of the Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID-II) (21, 22) and showed a severe level of borderline symptomatology (> 24 on the Borderline Severity Index; BPDSI) (23) with parasuicidal behaviour present in the last month preceding the start of residential DBT. Other inclusion criteria were adequate understanding of the Dutch language and living within travelling distance from Leiden. Exclusion criteria were an IQ<80, a chronic psychotic condition, bipolar disorder, drug abuse that requires inpatient detoxification, forced treatment framework, and DBT treatment in the year preceding intake.
The network training was considered part of the residential DBT program, but in the event of a network that could not or did not want to cooperate the patient could continue the residential DBT program. Patients were informed about the residential program through an extensive script, they were asked to read the script and there was an appointment where they could ask questions about it. Then they were asked to fill in an informed consent about the program, about permission to make video recordings of sessions and where they gave permission to evaluate the effectiveness of the program. In conclusion they were informed about the fact that all information would be processed anonymously. Patients could bring family members, partners, friends or other persons of importance to them to the DBT network training. All 33 patients followed the DBT network training, 31 of them together with their network. The network group consisted of 61 people: mothers (N=21), fathers (N=16), partners (N=11), sisters (N=6) and friends (N=7). All patients and network members were asked to sign a written informed consent about the use of the data for scientific purposes.
The perceived criticism (PC) scale (15) reflects how critical an individual is towards his or her environment and how critical someone experiences their environment to him or her. Two questions are asked: ‘how critical are you of your relative?’ and ‘how critical is your relative of you?’. The scale is a 10-point Likert scale from not at all critical to very critical indeed. Patients filled in the PC scale that refers to the family member(s), partner or other important relative they brought with them to the DBT network training. Network members who came with a patient to the DBT network training filled in the PC scale that refers to the patient. The scales were filled in at the end of the first session and again at the end of the last one, after 16 weeks.
The DBT network training consisted of 8 sessions of two hours (break included), every other week. This network training was based on the network training of Hoffman, Fruzzetti & Swenson. (18) The meetings were always planned in the beginning of the evening to give network members with jobs the opportunity to participate without having to take leave. The DBT network training was led by experienced skills trainers from the DBT team who received supervision on a regular basis by the second author, who is a certified DBT clinician.
The first two meetings of the training consisted of psycho-education (information about the treatment program of dialectical behaviour therapy and about Borderline Personality Disorder), followed by the commitment question i.e. whether the participants were willing (and able) to participate in all sessions of the skills training part of the training. The content of the next six meetings was structured as follows: the start of the session consisted of a mindfulness exercise given by one of the trainers, followed by an overview of the content of that session and last week’s theory was summarized. This summary was followed by discussing the homework assignments by patients and their relatives and after a short intermission finally new theory was discussed and practiced (including role plays in the group). The theory of the third, fourth, fifth and sixth meetings was respectively mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. The last two meetings of the training consisted of evaluating all the DBT skills previously discussed. At the end of the last meeting there was an evaluation of how to continue practicing the DBT skills in the future.
All patients participated in an intensified adapted DBT program, which consisted of 3 months residential DBT plus 6 months of outpatient DBT. (24) In residential DBT, support staff were present during office hours to help the patients apply DBT skills. Different program parts were added to the standard DBT program like daily mindfulness classes, daily meetings about living together as a group, weekly drama therapy, weekly group sessions on validation skills and chain analyses and every other week the network training was given. Therefore, the network training was also a part of the 3 months residential DBT program. Patients could choose who they wanted to participate with in the DBT network training. In clinical practice, this meant that mothers, fathers, partners, friends and siblings were invited in person by the patients to join the DBT network training with them.
As mentioned before at the end of the second meeting, all participants were asked for commitment to continue training in the skill modules. Commitment not only consisted of participating in the remaining meetings, but also the willingness to practice the skills material and practice homework assignments together (both network member and patient).
At the start of the first network training session everyone was asked to fill in the PC scale. At the end of the last network-training session, everyone was asked again to fill in the PC scale.
Data collection took place during the years that residential DBT was provided by the Jelgersma Centre. In the last part of this period, the study of the effectivity of residential DBT treatment took place (24) but the collection of data of the network training was not included in the study protocol. The scientific commission and the board of GGZ Rivierduinen agreed to support the execution of the data collection.
Statistical analyses are performed by SPSS for windows version 22. The impact of the DBT network training is determined by paired sample t-tests. Scores of the perceived criticism scale before and after following the DBT network training were compared. All tests where two-tailed tests and alpha was set at .05. To determine the size of the effect, Cohen’s d is calculated. The formula d = t/√n is used because of the within-subject design. (25)