Dialectical Behavior Therapy Skills Group Pilot Evaluation
Phase: NA
Conditions: Suicidal Ideation, Emotions
Sponsor: VA Connecticut Healthcare System

Cover page 
 
Study Title Dialectical Behavior Therapy Skills Group Pilot Evaluation 
 
NCT Number NCT02499406  
 
Document date: last reviewed and approved: June 4 2019 by Human Studies Subcommittee 
at VA Connecticut Health Care System 
 

 
i. 
Principal Investigator: Suzanne Decker, Ph.D. 
 
Project title:  Dialectical Behavior Therapy Skills Group Pilot Evaluation 
 
ii. 
Purpose:   
The proposed investigation is designed to evaluate the feasibility and acceptability of a group 
skills training intervention, Dialectical Behavior Therapy Skills Groups (DBT-SG). This 
intervention has been clinically piloted at VACHS as a group skills training intended to help 
Veterans learn new ways of coping and reduce emotion dysregulation.  Part I of this project will 
establish a cohort of Veterans from administrative VACHS data who have been referred to DBT-
SG to assess acceptability and feasibility and to provide descriptive data on Veterans who have 
been screened for and participated in this group to date. Part II will include prospective data 
collection from Veterans with recent suicidal ideation and emotion dysregulation who are 
referred to DBT-SG to examine feasibility, acceptability, and preliminary data on change in 
emotion dysregulation, suicidal ideation, coping skills, and mental health symptoms.  
 
Specific Aim 1: Examine feasibility and acceptability of Dialectical Behavior Therapy Skills 
Groups (DBT-SG).  
Hypothesis 1a:  DBT-SG will be feasible as indicated by skills group leader fidelity to the 
manualized skills group protocol at or above cutoff level for acceptable (Part II). 
Hypothesis 1b:  DBT-SG will be acceptable to Veterans as indicated by attendance at 50% or 
more of scheduled sessions (Part I, Part II). 
Hypothesis 1c:  DBT-SG will be acceptable to Veterans who participate as indicated by positive 
feedback on written satisfaction evaluations (Part II). 
Hypothesis 1d: DBT-SG will be acceptable to Veterans’ primary mental health providers as 
indicated by positive feedback on written satisfaction evaluations (Part II).  
 
Specific Aim 2:  Examine preliminary efficacy of DBT-SG to reduce emotion dysregulation and 
suicidal ideation, and to increase skillful coping  (Part II) 
Hypothesis 2a: DBT-SG will be associated with reduction in emotion dysregulation from pre-
treatment levels (Difficulties in Emotion Regulation Scale)  
Hypothesis 2b: DBT-SG will be associated with reduction in suicidal ideation from pre-treatment 
levels (Beck Scale for Suicidal Ideation; Suicidal Behaviors Questionnaire) 
Hypothesis 2c: DBT-SG will be associated with increased skillful coping from pre-treatment 
levels (DBT Ways of Coping Checklist) 
 
Exploratory Aim 1: Examine preliminary efficacy of DBT-SG on symptoms of PTSD (PCL-5), 
depression (BDI-II), borderline personality disorder (BSL-23), self-efficacy (GSES), pain (PEG), 
and suicidal behavior (BSBI). 
Exploratory Aim 2:  Examine preliminary efficacy of DBT-SG on impulsive behavior (Impulsive 
behaviors checklist, DSHI, BAM-C, OAS-M, and urine toxicology screens for individuals with 
substance use disorder). 
 

 
iii. 
Background:  
Suicide risk among Veterans is 66-87% greater than for the general population (McCarthy et al 
2009).  Several different mental health diagnoses and risk factors are associated with Veteran 
suicidality, suggesting that a cross-diagnostic or theory-driven approach to identifying and 
treating Veterans at risk for suicide is indicated.  Emotion dysregulation is characterized by 
unawareness of emotions, lack of strategies to modulate strong emotions, inability to control 
impulsive behavior when feeling negative emotions, and inability to pursue goals when feeling 
strong emotions (Gratz & Roemer, 2004).  Among Veterans, emotion dysregulation is 
associated with suicidality (Guerra et al., 2011; Mrnak-Meyer et al., 2011; Pietrzak et al., 
2011) and increased severity of depression and posttraumatic stress disorder (PTSD; 
Klemanski et al., 2011).  Emotion dysregulation is also associated with impulsive behaviors 
including substance abuse (Fox, Axelrod, Paliawal, Sleeper, & Sinha, 2007; Fox, Hong, & 
Sinha, 2008), suicide attempts (Miranda et al., 2013), and deliberate self-harm behavior (Gratz 
& Tull, 2010).  Individuals with emotion dysregulation are less likely to benefit from evidence-
based treatment for substance use (Berking et al., 2011). However, when individuals with 
emotion dysregulation are provided with skills-based treatment to manage emotions, reductions 
in emotion dysregulation appear to moderate their ability to reduce substance abuse (Axelrod, 
Perepletchikova, Holtzman, & Sinha, 2011). Similarly, the addition of emotion regulation skills 
training to CBT for depression has been associated with greater remission from depressive 
symptoms (Berking et al., 2013). While VA now offers evidence-based treatments for many 
specific mental health diagnoses, treatments to help Veterans reduce emotion 
dysregulation have not been systematically studied at VA. The proposed study will 
establish an administrative dataset to examine existing VACHS data on a group skills training 
treatment targeting emotion dysregulation (Part I) and conduct prospective data collection 
among Veterans participating in a group skills training treatment targeting emotion dysregulation 
(Part II) to evaluate the feasibility, acceptability, and preliminary efficacy of a group skills training 
treatment to reduce emotion dysregulation and suicidal ideation and improve coping among 
Veterans. 
Dialectical Behavior Therapy (DBT) is an evidence-based and theory-driven treatment for 
chronic suicidality in adults with chronic emotion dysregulation who are diagnosed with 
Borderline Personality Disorder (Clarkin et al., 2007; Kliem et al., 2010; Koons et al., 2001; 
Linehan et al., 1991; Linehan et al., 2006; McMain et al., 2009). DBT includes a strong focus on 
reducing emotion dyregulation by teaching individuals to understand and cope with strong 
emotions. However, comprehensive DBT is not widely available in many VA settings, including 
VACHS. DBT includes multiple components:  weekly individual DBT therapy, DBT Skills Group, 
between-session access to therapist by telephone, and therapist team consultation.  A central 
component of DBT is the DBT Skills Group, a manualized group skills training intervention that 
actively teaches participants new skills. The DBT Skills Group manual includes skills on 
managing strong emotions (emotion regulation), assertive communication and problem solving 
(interpersonal effectiveness), use of healthy coping methods to replace impulsive behaviors 
(distress tolerance), and mindfulness skills (Linehan, 1993; Linehan et al., 2006). In three large 
randomized clinical trials, skills learned during DBT Skills Groups fully mediated decreases in 

suicidality and anger (Neasciu, Rizvi, & Linehan, 2010), suggesting that DBT Skills Groups 
may be the most beneficial component of comprehensive DBT. Moreover, DBT Skills 
Groups as a stand-alone intervention (DBT-SG) are associated with reduced suicidality (Harley 
et al., 2007; Soler et al., 2009) and improved ability to regulate strong emotions like anger 
(Koons et al., 2006; Soler et al., 2009).   To date, no studies have investigated the 
feasibility, acceptability, and initial efficacy of DBT-SG to reduce emotion dysregulation 
and suicidal ideation among Veterans.  
The proposed study seeks to use existing VACHS data to systematically examine the feasibility 
and acceptability of a group skills training intervention to help Veterans with emotion 
dysregulation (Part I). Additional prospective data collection (Part II) will examine acceptability of 
this intervention to Veterans who participate in it (attendance, satisfaction), feasibility of 
delivering this skills training as designed (fidelity to protocol), and whether Veterans participating 
in DBT-SG experience changes in emotion dysregulation, suicidal ideation, coping skills, and 
mental health symptoms.  Data from this study will provide important initial information about the 
feasibility and acceptability of this skills training intervention in a VA setting and provide 
preliminary evidence about the potential utility of skills training approaches to assist Veterans in 
reducing emotion dysregulation and suicidal ideation and to potentially impact mental health 
outcomes.  
iv. 
Significance:  
This pilot study will provide important preliminary data about (a) the feasibility and acceptability 
of a group skills training treatment to reduce emotion dysregulation and suicidal ideation among 
Veterans, and (b) preliminary data about potential changes in emotion dysregulation, suicidal 
ideation, coping, and mental health symptoms that may be associated with participation in DBT-
SG. Although recent evidence suggests that emotion regulation skills training may be 
associated with improvements in multiple symptom domains, this has not yet been investigated 
in Veterans. Information gathered during this pilot investigation will be used to generate 
hypotheses for further research studies. If information from this pilot investigation is promising, 
further studies will be proposed to examine the efficacy of DBT-SG for Veterans with emotion 
dysregulation and suicidal ideation. Should DBT-SG for Veterans with emotion dysregulation 
prove efficacious in larger studies, the intervention can be disseminated so that Veterans with 
emotion dysregulation will have access to services targeted to their specific treatment needs. 
Findings from this study will be disseminated through presentations and publications, and used 
to support future funding applications.  
 
v. 
Research Plan:  
To achieve study objectives, an administrative cohort will be established (Part I) and recruitment 
for data collection will be conducted (Part II); see Table 1 for description.  
 
Part I:  Administrative Cohort:  DBT-SG is an existing clinical intervention that is part of 
routine clinical care for some Veterans.  We will seek a waiver of informed consent to examine 
existing data from the medical record for all Veterans who have been referred by a VACHS 
clinician for DBT-SG between 7/1/2011 and 6/30/2015. Using a data collection sheet, research 
personnel will review the chart to extract demographic information (e.g., age, race, gender, 

marital status, education), mental health diagnoses, MST, suicide high risk flag status, problems 
reported during the DBT-SG screening visit, information about participation in DBT-SG and 
other treatments (e.g., number of DBT-SG group sessions attended, number of other mental 
health treatment sessions attended), and information about symptoms from CPRS. This 
information will be used to generate descriptive data on individuals referred to and participating 
in DBT-SG, and rates of participation in DBT-SG to investigate feasibility and acceptability. A 
waiver of informed consent and waiver of HIPAA authorization are sought for collection of these 
data. 
 

Table 1: Study Components 
Part 
Design 
Eligibility 
Variables of Interest  
Part I 
Administrative 
data 
INCLUSION:  
(1) Veterans at VACHS who were referred 
by a VACHS clinician for DBT Skills Group 
between 7//12011 and 6/30/2015 
(2) Ages 18-65 
Demographic (e.g., age, race, 
gender, marital status, education), 
mental health diagnoses, MST, 
suicide high risk flag status, referral 
outcome, problems reported during 
the DBT-SG screening visit, 
information about participation in 
DBT-SG and other treatments (e.g., 
number of DBT-SG group sessions 
attended, number of other mental 
health treatment sessions attended); 
symptom reports including urine 
toxicology screen results during 
period of time participating in DBT-
SG  
Part II Questionnaire, 
interview, 
administrative 
data  
INCLUSION:  
(1) Veterans at VACHS who are referred or 
self-referred to DBT Skills Group  
(2) Ages 18-65 
(3) Able to understand written and spoken 
English 
(4) DERS score 105 or greater 
(5) Suicidal ideation within past 3 months 
(answer of “often, or very often” to item  
assessing past 3 months’ suicidal ideation, 
or, “sometimes” to item assessing past 3 
months suicidal ideation on SBQ and “often 
or very often” to item assessing past 4 
weeks suicidal ideation on SBQ) 
(6) Seeing an individual mental health 
provider at VACHS at least monthly 
(7) Willing to create or review a Mental 
Health Safety Plan, and stated willingness 
to use this plan to maintain safety  
(8) Consent to participate in study 
assessments 
(9) Consent to recording of group sessions 
 
EXCLUSION:  
(1) Inability to understand written or 
spoken English 
Emotion dysregulation, impulsive 
behavior, suicidal ideation, suicidal 
behavior, PTSD symptoms, 
depression symptoms, use of 
coping skills, substance use 

(2) Diagnosis of schizophrenia, 
schizoaffective disorder, bipolar I, 
antisocial personality disorder, or 
thought disorder in CPRS problem list 
and confirmed by current mental health 
provider 
 
Part II: Additional Data Collection:    
Procedures 
Recruitment:  DBT-SG is a clinical intervention that is part of routine clinical care for some 
Veterans.  Referrals to this clinical intervention are made by a Veteran’s primary mental health 
treatment provider from the VACHS Mental Health Service Line.  The PI or study staff will 
introduce this study to mental health treatment providers at VACHS psychiatric inpatient unit, 
Psychiatric Emergency Room, psychology service committee meeting, psychiatry resident or 
fellow seminars, PTSD clinic, NPSY clinic, Women’s Clinic, Substance Abuse Day Program, 
Methadone Maintenance Program,  Outpatient Substance Abuse Clinic, and mental health 
clinics at Newington Campus through attendance at clinical or administrative rounds or email, 
and will provide information about this study to VACHS Suicide Prevention Coordinators via in-
person attendance at meetings and via email.  Approved recruitment materials will be 
distributed to mental health treatment providers and Suicide Prevention Coordinators for use in 
discussing the study with Veterans. Approved flyers to identify the study to potential participants 
will be posted in clinical areas at VA Connnecticut Health Care System. When potential 
participants are self-referred, the research staff will conduct phone screening which includes a 
discussion of how often the potential participant is seeing a mental health treatment provider; if 
the potential participant is seeing a mental health treatment provider at least monthly, the 
research staff will continue phone screening and notify the mental health care provider of record 
of the potential participant’s interest in the study.  If the potential participant is not currently in 
mental health treatment or not seen at least monthly, research staff will refer the Veteran to the 
appropriate screening clinic or refer the potential participant to discuss with his or her mental 
health care provider.  The PI will conduct a brief chart review for referred or self-referred 
Veterans (see attached requests for WIC and WOA), and call referred Veterans to conduct a 
brief telephone screening to determine whether the Veteran meets screening eligibility criteria 
(interested in learning about a skills group; seeing a mental health provider monthly or more 
often; reporting suicidal ideation often or very often in past 3 months; interested in hearing more 
about a research study; see attached telephone screening protocols; see attached WWIC for 
telephone screening).   
 
Eligibility determination:  Veterans who meet screening criteria above and are interested in 
learning more about the study will be invited to attend an initial study session to review and 
complete informed consent forms. Informed consent will be obtained from participants prior to 
assessment.   After the informed consent process, questionnaires will be used to confirm study 
eligibility (DERS;  SBQ).  Veterans who do not meet study criteria will be given feedback on 
evaluation results and offered a referral to alternate treatment (e.g., participation in screening for 
an alternate DBT-SG group that is not included in Part II of this study; referral to other symptom-

specific groups at VACHS Mental Health Service Line). Veterans who meet study eligibility 
criteria will be asked to fill out further measures (see measures section) and to participate in a 
clinical interview to set goals for DBT-SG.  
 
Risk assessment and management during initial assessment session: As participants will be 
asked to complete questionnaires about suicidality, participants will be monitored for subjective 
distress and suicidal ideation during the screening session using the University of Washington 
Risk Assessment Protocol (UWRAP; attached).  The UWRAP is an assessment protocol that 
includes pre-assessment discussion, planning for coping strategies to use in the event of 
distress experienced during the assessment session, and monitoring of distress during and after 
the assessment session.  The UWRAP was developed to assess and monitor risk during 
assessment sessions with individuals with emotion dysregulation.  In addition, all Veterans who 
are screened for DBT-SG who are on the facility High Risk for Suicide list have an individualized 
safety plan in their VA medical chart. A copy of this written individualized safety plan is available 
to DBT-SG research staff.  DBT-SG research staff will review the individualized safety plan and 
work with the Veteran to improve the safety plan if desired.  If an individualized safety plan is not 
already in place, DBT-SG research staff will assist the Veteran in creating one, following VA 
clinical guidelines. DBT-SG research staff will invite the participant to take steps to reduce 
access to lethal means (e.g., planning to get rid of razors) if appropriate. Should a participant 
indicate unwillingness to use safety planning or require additional evaluation, the participant will 
be escorted to the Psychiatric Emergency Department at VACHS for further evaluation, 
assessment, and emergency treatment.  
 
Relevant clinical information (e.g., suicidal ideation; any updates to individualized safety plan) 
will be communicated by the assessor to the Veteran’s primary mental health treatment 
provider. 
 
Data collection: Those who meet study eligibility criteria will be invited to participate in a DBT-
SG research group for approximately 26 group sessions (further details below) and to attend 
three further data collection sessions to complete surveys. These assessment sessions will 
occur at treatment midpoint (3 months), at post-treatment, and at a 3-month follow-up visit; see 
Table 2.  At each assessment session, participants will be invited to complete written surveys to 
assess emotion dysregulation, suicidal ideation and behavior, coping skills use, and mental 
health symptoms (see measures section for a complete list). An interview will be used to assess 
participation in other forms of mental health treatment. Participants’ individual mental health 
providers will be invited to complete a questionnaire about their impressions of the participant’s 
progress at treatment midpoint, post-treatment, and follow-up points. Participants who are not 
able to attend in-person data collection sessions (i.e. have moved away from area or are 
homebound) at midpoint, post-treatment, or follow-up will be offered the option of receiving and 
sending back completed surveys by mail (using a stamped self-addressed return envelope) or 
completing surveys and interviews by telephone. Written assessments will not include the 
participant’s name or other identifiers.   
 

All assessments involving assessment of suicidal ideation or behavior (SBQ, BSSI, BDI-II, Brief 
Suicide Behavior Interview) will be conducted by telephone so that appropriate risk assessment 
and management can be conducted. As in in-person assessments, participants will be invited to 
review their safety plan during telephone assessment. Prior to telephone assessment, 
participants will be asked to confirm their mailing address for mailing purposes, and so that they 
can be given telephone contact information for their local VA suicide prevention coordinator and 
nearest emergency room.   
 
Risk assessment and management during ongoing assessment sessions:  Completed 
questionnaires about suicidal ideation or risk behavior (SBQ; BSSI; Brief Suicide Behavior 
Interview; DSHI; BDI-II item 9) will be reviewed. Participants who communicate recent suicidal 
ideation or risk behavior will be interviewed individually to assess current suicidal ideation and 
intent and to assess safety. Participants will be invited to review their safety plan prior to leaving 
the assessment session.  Participants who require additional evaluation will be escorted to the 
Psychiatric Emergency Department at VACHS for further evaluation, assessment, and 
emergency treatment. In a telephone assessment, the PI will assess suicidal ideation, intent, 
plan, and preparation, and determine whether the participant requires immediate evaluation 
(e.g., in the case of suicide ideation with imminent intent, making plans to help the participant 
get to the nearest emergency room, or, calling 911 to notify emergency personnel if participant 
is unwilling to contract for safety). The local VA suicide prevention coordinator will be notified in 
the event of suicide ideation with intent for participant safety reasons.  
 
Description of intervention: DBT-SG is an existing clinical intervention at VACHS that follows a 
well-established skills training manual (Linehan, 1993; Linehan, 2014a, 2014b). The DBT-SG 
research group will follow similar procedures.  During the initial assessment session, the 
assessor will assess emotion dysregulation, provide feedback, provide information about DBT-
SG structure and guidelines, and elicit goals for DBT-SG participation from the Veteran (see 
clinical interview). The participant will be invited to complete a worksheet to detail his or her 
goals for participation and to identify areas where DBT-SG skills could potentially be useful. 
During the informed consent process, group guidelines and procedures are reviewed. A review 
of group guidelines and procedures will also occur during the first group session (see attached 
DBT Skills Group Guidelines for review during first group session, adapted from Linehan, 1993).  
DBT-SG group sessions include review of skills practiced in the past week, a brief mindfulness 
practice, review of previous week’s practice exercises (“homework”), instruction in new skills, 
and assignment of new practice exercises (“homework”) for the following session.  
 
Retention in this intervention is enhanced through telephone calls to Veterans who do not attend 
a scheduled group session and a clearly described group attendance policy that is reviewed 
during the informed consent process and during the first DBT-SG session. If a participant 
develops a pattern of missing several group sessions in a row, DBT-SG group leaders will 
contact the participant to encourage problem-solving to attend group more regularly. If a 
participant misses 3 group sessions in a row, he or she will be discharged from the group. The 
participant may continue participating in assessment if desired.  
 

DBT-SG group leader will communicate any relevant clinical information (e.g., suicidal ideation) 
to the Veteran’s primary mental health treatment provider through documentation in CPRS and 
through direct contact (i.e., a telephone call to the provider).   
 
Supervision of intervention: DBT-SG is adapted from Dialectical Behavior Therapy, which 
includes weekly peer supervision using a consultation team format.  DBT-SG group leaders will 
participate in weekly consultation team meetings to enhance fidelity to DBT-SG protocol and to 
provide support to providers working with suicidal Veterans with chronic emotion dysregulation. 
Group leaders will work to problem-solve issues that occur in DBT-SG group sessions.  This is 
consistent with how DBT-SG has been conducted as a clinical intervention at VACHS and will 
be clearly specified in the informed consent process.  
 
Documentation of intervention: Information about participants’ attendance at and participation in 
DBT-SG (completion of homework, skills practiced, and notes about any unusual clinical 
presentation such as suicidal ideation) and any telephone calls made to the participant will be 
documented in the participant’s medical record via a CPRS progress note. The participant’s 
primary mental health treatment provider will be added as an additional signer to the note. This 
is consistent with how DBT-SG has been conducted as a clinical intervention at VACHS and 
allows the participant’s primary mental health treatment provider to remain informed about the 
participant’s participation in DBT-SG.  This will be clearly specified in the informed consent 
process.  
 
Risk assessment and management during treatment sessions:  Participants will have an 
established Mental Health Safety Plan prior to entering DBT-SG group. In each weekly group 
session, participants will be asked to fill out a Skills Group Check-In Sheet to assess current 
symptoms and willingness to use safety plans. Participants who indicate high suicidal ideation 
or indicate unwillingness to use their suicide safety plan will be briefly assessed and reminded 
to use their Mental Health Safety Plan; if needed, participants will be escorted to the Psychiatric 
Emergency Department at VACHS for further evaluation, assessment, and emergency 
treatment. DBT-SG group leader will communicate any relevant clinical information (e.g., 
suicidal ideation) to the Veteran’s primary mental health treatment provider.  
 
Session recording and fidelity: Feasibility of DBT-SG will be determined in part by monitoring 
group leader fidelity to DBT-SG protocol. During DBT-SG sessions, a group leader will complete 
a checklist of items to encourage fidelity to protocol. Audio or videotaping of DBT-SG sessions 
is necessary to ensure fidelity of these sessions. Recordings will be conducted on a VA-
approved device. Participants who decline to participate in session recording will be referred for 
alternate treatment.  DBT-SG leader will conduct the session recording and will upload 
recording files after each session to the secure VA server behind the VA firewall 
(\\vhaconfpc2\research\investigators\vhacondeckes). Recording files will be deleted from the 
recording device after uploading to the secure VA server behind the VA firewall. Recordings will 
be stored as secure electronic files behind the VA firewall. The device used for session 
recording will be locked in Bldg 35 Room 42 when not in use. Only approved research 
personnel will have access to the recordings. Recordings will be used for on-site supervision by 

DBT-SG leader and fidelity ratings conducted using the established DBT Adherence Rating 
Scale.  A portion of session recordings will be rated by the co-developer of the DBT Adherence 
Rating Scale, Kathryn Korslund, PhD, ABPP, at the University of Washington, the site of DBT 
treatment development. Dr. Korslund will rate sessions using the DBT Adherence Rating Scale. 
Session recordings will be sent to University of Washington on encrypted CDs via UPS, or 
personal transport in a locked briefcase by the PI.  Encrypted CDs with session recordings will 
be returned to VACHS after rating is completed, using UPS, or personal transport in a locked 
briefcase by the PI. Once returned, encrypted CDs will be stored in a locked filing cabinet in 
locked research office (Building 35 office 42). 
 
 
Table 2:  Part II:  Assessment visit schedule for additional data collection 
Procedures 
Approximate 
number of 
months after 
beginning 
DBT-SG 
Procedures and Assessments  
Informed 
consent process 
for study; 
Screening 
assessment 
0: Prior to 
participation in 
DBT-SG  
Consent process.  UWRAP; review MH Safety Plan; 
DERS;  SBQ.   
Provide feedback on eligibility.   If eligible,   CI, DBT-
WCCL; BSSI; Brief Suicide Behavior Interview – Initial; 
DSHI; PCL-5, BDI-II; BSL-23; BAM; TSR-A’ PEG, OASM; 
GSES 
Mid treatment 
assessment 
3  
DERS; BSSI; SBQ;  Brief Suicide Behavior Interview – 
Follow-Up; DBT-WCCL; DSHI; PCL-5, BDI-II; BSL-23; 
BAM; CSS; Tx Provider SS; TSR-A; PEG, OASM; GSES; 
SSA 
Post- treatment 
assessment 
6  
DERS; BSSI; SBQ;  Brief Suicide Behavior Interview – 
Follow-Up; DBT-WCCL; DSHI; PCL-5, BDI-II; BSL-23; 
BAM; CSS; Tx Provider SS; TSR-A; PEG, OASM; GSES; 
SSA 
Follow up 
assessment 
9  
DERS; BSSI; SBQ;  Brief Suicide Behavior Interview – 
Follow-Up; DBT-WCCL; DSHI; PCL-5, BDI-II; BSL-23; 
BAM; Tx Provider SS; TSR-A; PEG, OASM; GSES; SSA 
 

Risk Management Protocol for Screening (see attached measures, Table 3): 
University of Washington Risk Assessment Protocol (UWRAP): The risk assessment protocol is 
a structured method for assessing and managing suicide risk in research trials or clinical 
screening interviews (Reynolds et al., 2006). This protocol starts before other assessment 
measures are administered by assessing stress, self-harm ideation, suicidal intent, and urges 
for drug/alcohol use. Specific coping plans for any increase in these outcomes are agreed upon 
between the participant and assessor before any further assessment is conducted, and if, risk is 
particularly high, assessment stops. This allows the assessor and client to have a series of pre-
planned coping activities in the event that the participant becomes more distressed or 
experiences an increase in risk.  The risk assessment protocol concludes at the end of the 
assessment interview with a re-assessment of stress, urges to self-harm, intent for suicide, and 
urges for drug/alcohol use. The assessor compares post-interview ratings to pre-interview 
ratings to determine whether significant changes have occurred and whether further suicide risk 
assessment is warranted. Interventions are selected based on level of suicide risk and may 
range from use of a mood induction activity and reassessment to escorting the client to the 
Emergency Room.   
 
Surveys (see attached measures, Table 3): 
i. Difficulties in Emotion Regulation Scale (DERS): This 36-item self-report measure assesses 
acceptance of emotional responses, ability to pursue goal-directed behavior when feeling 
negative emotions, impulse control when feeling negative emotions, access to strategies to 
manage emotions, emotional clarity, and emotional awareness (Gratz & Roemer, 2004). The 
six subscales demonstrate good internal consistency (Cronbach’s α.80-.89) and the scale 
correlates significantly with other measures of emotion regulation.  
ii. Beck Scale for Suicide Ideation (BSSI): Participants will be asked to rate past-week suicidal 
ideation (self-destructive thoughts or wishes) on this 21-item self-report measure (Beck, 
Steer, & Ranieri, 1988). This scale shows high internal consistency (Cronbach’s α 0.93) and 
has a score range of 0-38.   
iii. Suicide Behavior Questionnaire (revised; SBQ): This 30-item self-report measure assesses 
suicidal ideation, suicidal behavior, suicidal threats, and likelihood of future suicidal ideation 
and behavior (Addis & Linehan, 1989). Scores on this measure will be used to establish a 
baseline for suicidal ideation and behavior in the 90 days prior to DBT-SG and to assess 
suicidal ideation and behavior during and after participation in DBT-SG.  
iv. Brief Suicide Behavior Interview (Initial and Follow-up versions).  This interview adapted 
from a well-established suicide interview (Linehan Suicide Attempt Self-Injury Assessment 
Interview) assesses suicidal behavior, medical attention seeking, and attempt lethality in the 
lifetime, 9, 6, and 3 months before the intervention, and at 3 month intervals during and after 
the intervention. This will be used to generate descriptive data and to note any changes in 
the number of suicide attempts, ER presentations, or lethality of suicidal behavior.  
v. DBT Ways of Coping Checklist (DBT-WCCL). This 59-item self-report measure assesses 
methods of coping with distress (Neasciu, Rizvi, Vitaliano, Lynch, & Linehan, 2010). Two 
subscales include effective methods of coping (i.e., DBT-SG skills), and ineffective methods 
of coping (e.g., avoiding problems, blaming others). The scale shows excellent internal 

consistency (Cronbach’s α 0.92-0.96) and acceptable test-rest reliability for individuals not 
exposed to DBT-SG (0.71). 
vi. Deliberate Self-Harm Inventory (DSHI). This 17- item self-report measure assessing the 
presence or absence of deliberate self-harm behaviors over a predetermined period of time. 
This assessment has demonstrated good internal consistency (Cronbach’s α .85, Gratz, 
2001; .81, Fliege et al., 2006) and adequate test-retest reliability (phi .68, Gratz, 2001; r = 
.91, Fliege et al., 2006).   
vii. PTSD Checklist (PCL-5). The PCL is a 20-item self-report measure of posttraumatic stress 
disorder (PTSD) symptomatology (Weathers, Litz, Keane, Palmieri, Marx, & Schnurr, 2013). 
This instrument is widely used in VA settings as a measure of PTSD symptom severity and 
change over time.  
viii. Borderline Symptom List-23 (BSL-23) with Impulsive Behavior Checklist. This 23-item self-
report measure assesses symptoms of Borderline Personality Disorder. It has excellent 
internal consistency (Cronbach’s α 0.94-0.97), discriminates individuals with Borderline 
Personality Disorder from individuals with other psychiatric disorders, and shows sensitivity 
to change in individuals treated with DBT (Bohus et al., 2009). 
ix. Beck Depression Inventory-II (BDI-II).  This 21-item self-report measure of depression 
severity is routinely used in VA clinical care and shows good internal consistency 
(Cronbach’s α .91; Beck, Steer, & Brown, 1996).  
x. Brief Addiction Monitor (BAM). This 17-item self-report measure asks the respondent about 
substance use and other impulsive behavior, interpersonal conflict, in the last 30 days.  
Test-retest reliability for three factor-analytically derived factors (recovery protection, 
substance use and risk, physical and psychological problems) is excellent. The measure is 
sensitive to change over time in Veterans participating in substance use treatment (Cacciola 
et al., 2012).  
xi. Skills Group Check-In Sheet (SGCS). A screening form administered during DBT-SG 
sessions to assess safety and willingness to use safety plans will be collected for ongoing 
monitoring.   
xii. Client Satisfaction Survey (CSS). A survey measure created for this study will assess DBT-
SG acceptability by assessing Veteran subjects’ satisfaction with DBT-SG.  
xiii. Treatment Provider Satisfaction Survey (TPSS). A survey measure adapted for this study 
from the Therapist Interview (Linehan & Heard, 1987) will assess DBT-SG acceptability by 
assessing the satisfaction of the Veteran’s primary mental health treatment provider with 
DBT-SG.  
xiv. General Self-Efficacy Scale (GSES). This ten-item scale assesses the respondent’s general 
sense of self-efficacy and has norms available for comparison (Shwarzer & Jerusalem, 
1995). Preliminary data on DBT interventions suggests that self-efficacy may increase 
during treatment and may mediate treatment outcome (Barnicot, personal communication, 
2014). 
xv. PEG. This four-item scale assesses the presence of chronic pain (item 1) and the level of 
pain severity, impact on life enjoyment, and interference of with life activities (Krebs et al., 
2009). This scale is widely used in pain research including research with Veterans.  
xvi. Overt Aggression Scale – Modified (self-report version; OAS-M). This self-report measure 
assesses aggression and irritability. The measure shows adequate test-retest reliability and 

face validity (McCloskey & Coccaro, 2003). In prior studies on DBT, this measure has 
demonstrated reduction over time (Linehan et al., 2008). 
xvii. Skills Satisfaction Assessment (SSA). A survey measure created for this study will assess 
the perceived utility of each skill.  This survey measure will present the names and brief 
descriptions of each skill and ask the respondent to rate how useful the skill is for its 
intended purpose (e.g., how useful are each of these skills to help you manage strong 
emotions?). 
 
Interviews (see attached measures, Table 3): 
xviii. Treatment Services Review - Adapted (TSR-A). An interview measure assessing 
participation in treatment in the 3 months prior to each assessment will be adapted for this 
study from the Treatment Services Review (McLellan, 1992).  
xix. Clinical interview (CI). An interview will be conducted during the initial assessment visit to 
review DBT-SG theory and review participants’ goals for DBT-SG.  
 
Session Rating Scales (see attached measures, Table 3): 
i. 
Dialectical Behavior Therapy Skills Group Self-Rating Checklist (DBT-SG-SRC). A checklist 
of session items will be completed during DBT-SG sessions to encourage adherence to the 
protocol and used in clinical supervision.  A percent of items completed correctly will be 
calculated for sessions overall.  
ii. 
Dialectical Behavior Therapy Adherence Rating Scale (DBTARS). A rating scale will be 
used to rate taped sessions to determine whether DBT-SG is being delivered as designed, 
with fidelity to the model.  The Dialectical Behavior Therapy Adherence Rating Scale 
(Linehan & Korslund, 2003) rates the adherence of skills group providers on DBT 
strategies. Inter-rater reliability for scale items ranges 0.78-0.83. Using the scale 
developer’s cutoff score of 3.9 out of a total of 5 possible points, this scale will be used to 
determine whether DBT-SG sessions are being provided as designed.  
iii. 
Weekly Participation Report Form (WPRF). This form will be filled out by study staff for 
each session to monitor attendance, homework completion, diary card completion, and 
notes about participation.  
 
 
 

Table 3: Measures  
Hypoth 
Domain 
Measure 
Admin schedule 
1 
Feasibility: self-rating 
checklist 
DBT-SG-SRC 
Weekly during session by clinician 
1 
Feasibility: adherence 
rating scale 
DBTARS 
-- 
1 
Acceptability (client) 
WPRF 
Weekly during session by clinician 
1 
Acceptability (client) 
SSA 
Mid-Tx; Post-Tx; Follow-Up 
1 
Acceptability (client) 
CSS 
Mid-Tx; Post-Tx; Follow-Up 
1 
Acceptability (provider) 
TPSS 
Mid-Tx; Post-Tx; Follow-Up 
2a 
Suicidal ideation – past 3 
months  
SBQ 
Initial; Mid-Tx; Post-Tx; Follow-Up 
2a 
Suicidal ideation – past 
week 
BSSI 
Initial; Mid-Tx; Post-Tx; Follow-Up 
2a 
Suicidal ideation – current 
CSI-w 
Weekly during session 
2b 
Emotion dysregulation 
DERS  
Initial; Mid-Tx; Post-Tx; Follow-Up 
2c 
Coping 
DBT-WCCL 
Initial; Mid-Tx; Post-Tx; Follow-Up 
Expl. 1 
Depression 
BDI-II 
Initial; Mid-Tx; Post-Tx; Follow-Up 
 
PTSD 
PCL-5 
Initial; Mid-Tx; Post-Tx; Follow-Up 
 
Borderline PD symptoms  
BSL-23 
Initial; Mid-Tx; Post-Tx; Follow-Up 
 
Self-efficacy 
GSES 
Initial; Mid-Tx; Post-Tx; Follow-Up 
 
Chronic pain 
PEG 
Initial; Mid-Tx; Post-Tx; Follow-Up 
 
Suicidal behavior – lifetime 
and past 3 months 
BSBI  
Initial; Mid-Tx; Post-Tx; Follow-Up 
Expl. 2 
Non-suicidal self-injury 
DSHI 
Initial; Mid-Tx; Post-Tx; Follow-Up 
 
Substance use 
BAM 
Initial; Mid-Tx; Post-Tx; Follow-Up 
 
Aggressive behavior 
OASM 
Initial; Mid-Tx; Post-Tx; Follow-Up 
-- 
Treatment participation 
TSR-A 
Initial; Mid-Tx; Post-Tx; Follow-Up 
-- 
Clinical interview 
CI 
Initial 
 
Analytic Plan 

Part I: Descriptive analyses: Descriptive statistics (frequency, percent, mean, mode, standard 
deviation) will be used to describe the demographic and mental health status of individuals 
referred for DBT-SG.  Numbers of participants starting, completing, and prematurely terminating 
DBT-SG will be generated. Acceptability of treatment will be examined by calculating the 
percent of DBT-SG sessions attended (number of sessions attended divided by number of 
sessions expected to attend) among those who participate in DBT-SG. Participation in other 
treatments will also be examined (e.g., mean and modal number of individual and group mental 
health sessions attended during participation in DBT-SG).  
 
Part II: Descriptive statistics (frequency, percent, mean, mode, standard deviation) will be used 
to describe the demographic and mental health status of individuals participating in screening 
for DBT-SG and participating in DBT-SG.  Numbers of participants starting, completing, and 
prematurely terminating DBT-SG will be generated to examine feasibility. Acceptability of 
treatment will be examined by calculating the percent of DBT-SG sessions attended (number of 
sessions attended divided by number of sessions expected to attend) and completion of 
homework among those who participate in DBT-SG. Participation in other treatments will also 
be examined (e.g., mean and modal number of individual and other group mental health 
sessions attended during participation in DBT-SG). Descriptive statistics (mean, mode, standard 
deviation) will be used to describe participant and provider satisfaction with DBT-SG.  
Descriptive statistics (mean, standard deviation) will be calculated on adherence scores on the 
DBT-SG-SRC and DBT Adherence Rating Scale to determine whether the mean adherence 
rating is at or above the acceptable level.   
Descriptive statistics will be used to describe emotion dysregulation, suicidal ideation, coping, 
satisfaction with the intervention, satisfaction with each skill, and mental health symptoms at 
each assessment time point. After data screening for linearity and normality, and transformation 
as needed, one-way repeated measures analyses of variance or general linear mixed model will 
be used to examine any changes over time in emotion dysregulation (DERS), depressive 
symptoms (BDI-II), coping (DBT-WCCL), suicidal ideation (BSSI, SBQ, CSI-w), self-efficacy 
(GSES), pain (PEG), suicidal behavior (BSBI), and impulsive behavior (BAM, DSHI, Impulsive 
Behavior Checklist, OAS-M).  Comparison of suicidal ideation in the three months before 
treatment, at treatment mid-point, post-treatment, and follow-up point (SBQ) will occur using 
one-way repeated measures ANOVA or general linear mixed model. Paired sample t-tests 
examining pre- and post-treatment values for each variable will also be conducted. Corrections 
for multiple comparisons will be used as appropriate. The reliable change index, a measure of 
clinically significant change determined by the absolute magnitude of change divided by the 
standard error of the difference between two test scores (Jacobson & Truax, 1991), may also be 
used to compare pre- and post-DBT-SG scores to determine the number of participants 
improved on each variable.  
 
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Summary of amendments reviewed and approved by VACHS IRB: 
Staff additions approved 11/20/14:  Lorig Kachadourian, Natalie Hung, Jennifer Presnall-
Shvorin, Lauren Sippel, Christopher Cryan, Kathryn Hefner  
Instrument changes approved 12/4/14:  minor modifications to language SBQ, BSSI, DBT Skills 
Group Self-Rating Checklist, Treatment Provider Satisfaction Survey, Client Satisfaction Survey;   
Addition of General Self Efficacy Scale, OAS-M (aggression measure), PEG (chronic pain 
measure) to baseline, 3, 6, 9 month assessments;  Addition of Skills Satisfaction Survey at 3, 6, 
and 9 month assessments;  Deletion of weekly Client Satisfaction Survey measure that 
assessed satisfaction with skills immediately after they were taught and thus prior to participants 
having an opportunity to practice skills.  
Recruitment changes approved 1/22/15:  addition of advertisements to potential participants and 
clinicians; modified WIC and WOA to reflect that chart review will occur for self-referred potential 
participants; additional telephone screening script;  modified inclusion criteria to report of "often 
or very often" to item assessing suicidal ideation in past 3 months, or, report of "sometimes" to 
item assessing suicidal ideation in past 3 months and report of "often or very often" to item 
assessing suicidal ideation in past 4 weeks.   
Protocol changes approved 6/18/15:  modifications to advertisements and telephone screening 
protocols; addition of Brief Suicide Behavior Interview (initial and follow-up); update of chart 
review data collection sheet to include military service data and to account for individuals who 
had multiple referrals; recruitment at additional staff and clinic meetings; addition of weekly 
participation report form.  
Staff deletions approved 8/3/15:  Lorig Kachadourian, Natalie Hung, Jennifer Presnall-Shvorin 
removed from protocol;   Staff additions approved 8/3/15:  Jennifer Doran, Candice Presseau, 
Laura Watkins added to protocol;  expansion in duties for Kathryn Hefner  
Protocol change approved 2/4/2016: Modification to allow data collection by mail or telephone 
for mid-treatment, end-treatment, and follow-up for individuals. Data about suicidal ideation is 
collected over the telephone by the PI. Prior to telephone assessment, information for nearest 
suicide prevention coordinator and emergency room is located and provided to the participant.  
Staff change approved 10/5/2016:  Addition of staff member Kathleen Taylor, PhD 
Protocol change approved 10/26/2016:  Moving PI's office and storage of study materials to 
building 35, room 42. 
Staff change approved 7/18/17: Remove Kathleen Taylor, PhD; Laura Watkins, PhD; Jennifer 
Doran, PhD from protocol; add Steve Martino, PhD to protocol 
Staff change approved 10/19/17: Add Mehmet Sofuoglu, MD, PhD to protocol