1 2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Dialectical Behavior Therapy Presentation Materials The Behavioral

12002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG

Dialectical Behavior Dialectical Behavior Therapy Presentation Therapy Presentation

Materials Materials

The Behavioral Technology Transfer GroupThe Behavioral Technology Transfer Group4556 University Way NE 4556 University Way NE Seattle, WA 98105 Seattle, WA 98105

PhonePhone 206/675-8588 206/675-8588 FaxFax 206/675-8590 206/675-8590

Web: www.behavioraltech.com [email protected]

Dialectical Behavior Dialectical Behavior Therapy Presentation Therapy Presentation

Materials Materials

The Behavioral Technology Transfer GroupThe Behavioral Technology Transfer Group4556 University Way NE 4556 University Way NE Seattle, WA 98105 Seattle, WA 98105

PhonePhone 206/675-8588 206/675-8588 FaxFax 206/675-8590 206/675-8590

Web: www.behavioraltech.com [email protected]


Dialectical Dialectical Behavior TherapyBehavior Therapy

(DBT)(DBT)

The BasicsThe Basics


Theory of Theory of Borderline Borderline

Personality Disorder Personality Disorder in DBTin DBT


BPD is a Pervasive Disorder of BPD is a Pervasive Disorder of the Emotion Regulation Systemthe Emotion Regulation System BPD is a Pervasive Disorder of BPD is a Pervasive Disorder of the Emotion Regulation Systemthe Emotion Regulation System

BPD criterion behaviors function BPD criterion behaviors function to regulate emotions orto regulate emotions or

are a natural consequence of are a natural consequence of emotion dysregulationemotion dysregulation

BPD criterion behaviors function BPD criterion behaviors function to regulate emotions orto regulate emotions or

are a natural consequence of are a natural consequence of emotion dysregulationemotion dysregulation


Biosocial Theory of BPDBiosocial Theory of BPD Biosocial Theory of BPDBiosocial Theory of BPD

Pervasive Emotion DysregulationPervasive Emotion DysregulationPervasive Emotion DysregulationPervasive Emotion Dysregulation

Biological Dysfunction in the Biological Dysfunction in the Emotion Regulation SystemEmotion Regulation System

Biological Dysfunction in the Biological Dysfunction in the Emotion Regulation SystemEmotion Regulation System

Invalidating Invalidating EnvironmentEnvironmentInvalidating Invalidating EnvironmentEnvironment


Emotion DysregulationEmotion DysregulationEmotion DysregulationEmotion Dysregulation

Inability to Inability to Modulate EmotionsModulate Emotions

Inability to Inability to Modulate EmotionsModulate Emotions

Emotional VulnerabilityEmotional VulnerabilityEmotional VulnerabilityEmotional Vulnerability


Tasks in Emotion ModulationTasks in Emotion ModulationTasks in Emotion ModulationTasks in Emotion Modulation

*Decrease or Increase physiological arousal*Decrease or Increase physiological arousal associated with emotion associated with emotion

**Re-orient attention**Re-orient attention

***Inhibit mood-dependent action***Inhibit mood-dependent action

****Organize behavior in the ****Organize behavior in the service of external non- service of external non-

mood dependent goals mood dependent goals


Invalidating EnvironmentInvalidating EnvironmentInvalidating EnvironmentInvalidating Environment

Pervasively Pervasively negates negates or or dismissesdismisses behavior behavior

independent of independent of the actual validity the actual validity

of the behaviorof the behavior

Pervasively Pervasively negates negates or or dismissesdismisses behavior behavior

independent of independent of the actual validity the actual validity

of the behaviorof the behavior


DBT DBT is designed for the is designed for the severe and severe and

chronic multi-diagnosticchronic multi-diagnostic, , difficult-to-treat patientdifficult-to-treat patient

with both Axis I with both Axis I and Axis IIand Axis II disorders disorders


ChangeChange

CoreCore

Problem Solving

Problem Solving

AcceptanceAcceptance

ValidationValidation

Team Consultation

Team Consultation

ReciprocalReciprocalReciprocalReciprocal

Environmental Intervention

Environmental Intervention

Consultation-to-the-PatientConsultation-to-the-Patient

IrreverentIrreverentIrreverentIrreverent


Balance Core StrategiesBalance Core StrategiesBalance Core StrategiesBalance Core Strategies

Dialectics

VALIDATIONVALIDATION

12

Dialectical Philosophy Dialectical Philosophy of Treatmentof Treatment

Dialectical Philosophy Dialectical Philosophy of Treatmentof Treatment

Dialectics As...Dialectics As... PersuasionPersuasion

World ViewWorld View

Dialectics As...Dialectics As... PersuasionPersuasion

World ViewWorld View


Dialectics as PersuasionDialectics as PersuasionDialectics as PersuasionDialectics as Persuasion

A method of logic or argumentation A method of logic or argumentation

by disclosing the contradictions by disclosing the contradictions

(antithesis)(antithesis) in an opponent’s in an opponent’s

argument argument (thesis)(thesis) and overcoming and overcoming

them them (synthesis)(synthesis)..

A method of logic or argumentation A method of logic or argumentation

by disclosing the contradictions by disclosing the contradictions

(antithesis)(antithesis) in an opponent’s in an opponent’s

argument argument (thesis)(thesis) and overcoming and overcoming

them them (synthesis)(synthesis)..


Translating a Dialectical World ViewTranslating a Dialectical World Viewinto Treatmentinto Treatment

Translating a Dialectical World ViewTranslating a Dialectical World Viewinto Treatmentinto Treatment

Provides foundation of biosocial etiology1. Transactional development and maintenance2. Systemic disorder

Dialectically informs treatment strategies1. Balance of Acceptance vs. Change2. Search for "what is left out"3. Emphasis on speed, movement, flow

Dialectically informs treatment goals1. Emotion regulation2. Interpersonal effectiveness3. Mindfulness4. Distress tolerance

Provides foundation of biosocial etiology1. Transactional development and maintenance2. Systemic disorder

Dialectically informs treatment strategies1. Balance of Acceptance vs. Change2. Search for "what is left out"3. Emphasis on speed, movement, flow

Dialectically informs treatment goals1. Emotion regulation2. Interpersonal effectiveness3. Mindfulness4. Distress tolerance


Structure the Structure the Goals of TreatmentGoals of Treatment

DBT Structures Treatment GoalsDBT Structures Treatment Goals by Levels of Disorder by Levels of Disorder

Structure the Structure the Goals of TreatmentGoals of Treatment

DBT Structures Treatment GoalsDBT Structures Treatment Goals by Levels of Disorder by Levels of Disorder


Structure the Structure the Primary TargetsPrimary Targets

of Treatment of Treatment

DBT arranges targets DBT arranges targets hierarchically by importance and hierarchically by importance and

grouped by level of patient grouped by level of patient disorderdisorder

Structure the Structure the Primary TargetsPrimary Targets


DBT arranges targets DBT arranges targets hierarchically by importance and hierarchically by importance and

grouped by level of patient grouped by level of patient disorderdisorder


Goals of Treatment by Level of DisorderGoals of Treatment by Level of Disorder Goals of Treatment by Level of DisorderGoals of Treatment by Level of Disorder

Dialectical SynthesisDialectical SynthesisLevel 1: Severe Behavioral DyscontrolLevel 1: Severe Behavioral Dyscontrol

Behavioral ControlBehavioral Control

Level 2: Quiet DesperationLevel 2: Quiet Desperation Emotional ExperiencingEmotional Experiencing

Level 3: Problems in LivingLevel 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness

Level 4: IncompletenessLevel 4: Incompleteness

Capacity for Joy and FreedomCapacity for Joy and Freedom

Dialectical SynthesisDialectical SynthesisLevel 1: Severe Behavioral DyscontrolLevel 1: Severe Behavioral Dyscontrol

Behavioral ControlBehavioral Control

Level 2: Quiet DesperationLevel 2: Quiet Desperation Emotional ExperiencingEmotional Experiencing

Level 3: Problems in LivingLevel 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness

Level 4: IncompletenessLevel 4: Incompleteness

Capacity for Joy and FreedomCapacity for Joy and Freedom


DecreaseDecrease• Life-threatening behaviorsLife-threatening behaviors• Therapy-interfering behaviorsTherapy-interfering behaviors• Quality-of-life interfering behaviorsQuality-of-life interfering behaviors

IncreaseIncrease behavioral skillsbehavioral skills Core MindfulnessCore MindfulnessDistress ToleranceDistress ToleranceInterpersonal EffectivenessInterpersonal EffectivenessEmotion Regulation Emotion Regulation Self-ManagementSelf-Management

DecreaseDecrease• Life-threatening behaviorsLife-threatening behaviors• Therapy-interfering behaviorsTherapy-interfering behaviors• Quality-of-life interfering behaviorsQuality-of-life interfering behaviors

IncreaseIncrease behavioral skillsbehavioral skills Core MindfulnessCore MindfulnessDistress ToleranceDistress ToleranceInterpersonal EffectivenessInterpersonal EffectivenessEmotion Regulation Emotion Regulation Self-ManagementSelf-Management

Stage 1 Primary TargetsStage 1 Primary Targets Dialectical SynthesisDialectical Synthesis Severe Behavioral DyscontrolSevere Behavioral Dyscontrol Behavioral ControlBehavioral Control

Stage 1 Primary TargetsStage 1 Primary Targets Dialectical SynthesisDialectical Synthesis Severe Behavioral DyscontrolSevere Behavioral Dyscontrol Behavioral ControlBehavioral Control

19

StructureStructure the Milieu and Modes the Milieu and Modes


StructureStructure the Milieu and Modes the Milieu and Modes


Standard DBT is Standard DBT is Outpatient Outpatient TreatmentTreatment

Standard DBT is Standard DBT is Outpatient Outpatient TreatmentTreatment

20

STANDARD DBT isSTANDARD DBT is....STANDARD DBT isSTANDARD DBT is....

FLEXIBLEFLEXIBLE

COMPREHENSIVECOMPREHENSIVE

PRINCIPLE-DRIVENPRINCIPLE-DRIVEN

FLEXIBLEFLEXIBLE

COMPREHENSIVECOMPREHENSIVE

PRINCIPLE-DRIVENPRINCIPLE-DRIVEN


Standard DBT ModesStandard DBT ModesStandard DBT ModesStandard DBT Modes Outpatient Individual PsychotherapyOutpatient Individual Psychotherapy Outpatient Group Skills TrainingOutpatient Group Skills Training Telephone ConsultationTelephone Consultation Therapists’ Consultation MeetingTherapists’ Consultation Meeting Uncontrolled Ancillary TreatmentsUncontrolled Ancillary Treatments

• PharmacotherapyPharmacotherapy• Acute-Inpatient PsychiatricAcute-Inpatient Psychiatric

Outpatient Individual PsychotherapyOutpatient Individual Psychotherapy Outpatient Group Skills TrainingOutpatient Group Skills Training Telephone ConsultationTelephone Consultation Therapists’ Consultation MeetingTherapists’ Consultation Meeting Uncontrolled Ancillary TreatmentsUncontrolled Ancillary Treatments

• PharmacotherapyPharmacotherapy• Acute-Inpatient PsychiatricAcute-Inpatient Psychiatric


Five Functions of Five Functions of Comprehensive TreatmentComprehensive Treatment

Five Functions of Five Functions of Comprehensive TreatmentComprehensive Treatment

1.1. Enhance capabilities Enhance capabilities

2.2. Improve motivational factors Improve motivational factors

3. 3. Assure generalization to natural Assure generalization to natural environment environment

4.4. Enhance therapist capabilities and Enhance therapist capabilities and motivation to treat effectively motivation to treat effectively

5. 5. Structure the environmentStructure the environment

1.1. Enhance capabilities Enhance capabilities

2.2. Improve motivational factors Improve motivational factors

3. 3. Assure generalization to natural Assure generalization to natural environment environment

4.4. Enhance therapist capabilities and Enhance therapist capabilities and motivation to treat effectively motivation to treat effectively

5. 5. Structure the environmentStructure the environment


The Overarching

DBT GoalGoal is...is...

The Overarching

DBT GoalGoal is...is...

24

Treatments for BPD:Treatments for BPD:• Pharmacotherapy Pharmacotherapy

• Object Relations Partial Object Relations Partial Hospitalization Hospitalization

• DBTDBT

Treatments for BPD:Treatments for BPD:• Pharmacotherapy Pharmacotherapy

• Object Relations Partial Object Relations Partial Hospitalization Hospitalization

• DBTDBT


PharmacotherapyPharmacotherapy

26

Pharmacotherapy Pharmacotherapy Treatments for BPD: Treatments for BPD: Paul Soloff, MDPaul Soloff, MDSoloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.

Medications Algorithm & RulesMedications Algorithm & Rules–Target specific problem areaTarget specific problem area

•Cognitive/perceptualCognitive/perceptual•AffectiveAffective•Impulsive dyscontrolImpulsive dyscontrol

–Strong empirical supportStrong empirical support–Safe Safe –Act rapidlyAct rapidly

Pharmacotherapy Pharmacotherapy Treatments for BPD: Treatments for BPD: Paul Soloff, MDPaul Soloff, MDSoloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.

Medications Algorithm & RulesMedications Algorithm & Rules–Target specific problem areaTarget specific problem area

•Cognitive/perceptualCognitive/perceptual•AffectiveAffective•Impulsive dyscontrolImpulsive dyscontrol

–Strong empirical supportStrong empirical support–Safe Safe –Act rapidlyAct rapidly


Soloff’s Medication Soloff’s Medication Algorithm: Algorithm: Treating Cognitive/Perceptual Symptoms Treating Cognitive/Perceptual Symptoms

Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.

START with low-dose typical neurolepticSTART with low-dose typical neuroleptic

If poor/partial response, INCREASE dose.If poor/partial response, INCREASE dose.

If response still poor, RECONSIDER DIAGNOSIS. If response still poor, RECONSIDER DIAGNOSIS. If symptoms are mood congruent, treat for affective If symptoms are mood congruent, treat for affective symptoms.symptoms.

If symptoms do NOT have a major mood component, If symptoms do NOT have a major mood component, SWITCH to clozapine or another atypical anti-SWITCH to clozapine or another atypical anti-psychotic.psychotic.


Soloff’s Medication Soloff’s Medication Algorithm: Algorithm: Treating Affective SymptomsTreating Affective Symptoms


START with SSRI or related and antidepressant.START with SSRI or related and antidepressant. If response inadequate, SWITCH to different SSRI If response inadequate, SWITCH to different SSRI

or related antidepressant.or related antidepressant. If response still poor, AUGMENT with a If response still poor, AUGMENT with a

benzodiazepine or a low-dose neuroleptic.benzodiazepine or a low-dose neuroleptic. If response remains inadequate, SWITCH to If response remains inadequate, SWITCH to

MAOI.MAOI. FINALLY, add/switch to lithium or a mood FINALLY, add/switch to lithium or a mood

stabilizer.stabilizer.


Soloff’s Medication Soloff’s Medication Algorithm: Algorithm: Treating Impulsive Symptoms Treating Impulsive Symptoms


START with SSRI (if rapid response is needed, a low-START with SSRI (if rapid response is needed, a low-dose conventional neuroleptic).dose conventional neuroleptic).

If response to SSRI monotherapy inadequate, If response to SSRI monotherapy inadequate, ADD/SWITCH to low-dose neuroleptic.ADD/SWITCH to low-dose neuroleptic.

If response remains poor, ADD/SWITCH to lithium If response remains poor, ADD/SWITCH to lithium or MAOI.or MAOI.

SWITCH to carbamazepine or valproate, if no SWITCH to carbamazepine or valproate, if no response.response.

If necessary, ADD atypical neuroleptic.If necessary, ADD atypical neuroleptic.


Consensus By Experts on Consensus By Experts on Pharmacotherapy for BPDPharmacotherapy for BPD

No “magic bullet” medication for BPD No “magic bullet” medication for BPD patientspatients

Soloff’s algorithm is method of choice Soloff’s algorithm is method of choice where drugs target domain of dysfunction.where drugs target domain of dysfunction.

Pharmacotherapy alone is insufficient to Pharmacotherapy alone is insufficient to treat BPD; must be combined with treat BPD; must be combined with psychosocial treatment.psychosocial treatment.


Object RelationsObject Relations


Bateman & Fonagy’s 18-monthBateman & Fonagy’s 18-monthPartial Hospitalization Program (PHP)Partial Hospitalization Program (PHP)

PHP Treatment:PHP Treatment:• 3x/week group psychotherapy3x/week group psychotherapy• 1x/week individual psychotherapy, expressive 1x/week individual psychotherapy, expressive

therapy, and community meetingtherapy, and community meeting• 1x/month meeting with psychiatrist and case 1x/month meeting with psychiatrist and case

administratoradministratorControl: Standard Psychiatric CareControl: Standard Psychiatric Care

• 2x/month meeting with psychiatrist and 2x/month meeting with psychiatrist and visiting psychiatric nursevisiting psychiatric nurse


Bateman & Fonagy’s 18-monthBateman & Fonagy’s 18-monthPartial Hospitalization Program (PHP)Partial Hospitalization Program (PHP)

PHP<ControlPHP<Control• Frequency of suicide attempts and self-Frequency of suicide attempts and self-

mutilationmutilation• Number and duration of inpatient admissionsNumber and duration of inpatient admissions• Use of psychotropic medicationsUse of psychotropic medications• Self-report measures of depression, anxietySelf-report measures of depression, anxiety

PHP>ControlPHP>Control• Improvements on self-report measures of Improvements on self-report measures of

social and interpersonal functioningsocial and interpersonal functioning


Critique of Bateman & Fonagy’s PHPCritique of Bateman & Fonagy’s PHP

1. Methodological Confounds1. Methodological Confounds• PHP patients received considerably more treatment per PHP patients received considerably more treatment per

week (6+ hours) compared to TAU (3 hours/month).week (6+ hours) compared to TAU (3 hours/month).

2. No treatment manual currently exists2. No treatment manual currently exists limiting further investigation by others. limiting further investigation by others.

3. No studies have replicated original3. No studies have replicated original findings. findings.

4. PHP may be more expensive than DBT. 4. PHP may be more expensive than DBT. • (18 months vs. 12 months; PHP vs. outpatient).(18 months vs. 12 months; PHP vs. outpatient).


DBTDBT


DBT Randomized DBT Randomized Controlled TrialsControlled Trials

Linehan, et. al. study Linehan, et. al. study of chronically suicidal of chronically suicidal patients with BPD patients with BPD (1991, 1992, 1993, 1994).(1991, 1992, 1993, 1994).

Koons, Robins et al. Koons, Robins et al. study of BPD women study of BPD women in VA setting in VA setting (2001).(2001).

Linehan, et al. study Linehan, et al. study of drug-dependent of drug-dependent women with BPD women with BPD (1999).(1999).

Linehan, et al. study Linehan, et al. study of heroin-addicted of heroin-addicted BPD women BPD women (2002).(2002).


Randomized Controlled Trial: DBT vs. Treatment-as-Usual

With Chronically Suicidal BPD Women

(University of Washington)

Linehan, et al., 1991, 1992, 1993, 1994

Randomized Controlled Trial: DBT vs. Treatment-as-Usual

With Chronically Suicidal BPD Women

(University of Washington)

Linehan, et al., 1991, 1992, 1993, 1994


DBT < TAUDBT < TAU DBT < TAUDBT < TAU % with parasuicide% with parasuicide # parasuicides# parasuicides medical risk of parasuicidemedical risk of parasuicide treatment drop-outstreatment drop-outs psychiatric inpatient dayspsychiatric inpatient days angeranger

% with parasuicide% with parasuicide # parasuicides# parasuicides medical risk of parasuicidemedical risk of parasuicide treatment drop-outstreatment drop-outs psychiatric inpatient dayspsychiatric inpatient days angeranger

DBT > TAUDBT > TAU DBT > TAUDBT > TAU social adjustmentsocial adjustment global adjustmentglobal adjustment


DepressionDepression HopelessnessHopelessness Suicide ideationSuicide ideation

DepressionDepression HopelessnessHopelessness Suicide ideationSuicide ideation

Pre-treatment > 12-monthPre-treatment > 12-monthPre-treatment > 12-monthPre-treatment > 12-month

DBT vs. TAU: nsDBT vs. TAU: ns DBT vs. TAU: nsDBT vs. TAU: ns


Efficiency & CostsEfficiency & CostsOf DBT v. TAUOf DBT v. TAU

Cost for DBT is about 50% of TAUCost for DBT is about 50% of TAU

• Significantly fewer inpatient daysSignificantly fewer inpatient days

• Fewer and less severe parasuicidal Fewer and less severe parasuicidal behaviorsbehaviors

• Fewer emergency medical visitsFewer emergency medical visits

• Less therapy dropoutLess therapy dropout


DBT vs. Treatment-as-Usual DBT vs. Treatment-as-Usual for BPDfor BPD

(Durham VA Medical Center)(Durham VA Medical Center)

Koons, Robins, et al. , 2001Koons, Robins, et al. , 2001

DBT vs. Treatment-as-Usual DBT vs. Treatment-as-Usual for BPDfor BPD

(Durham VA Medical Center)(Durham VA Medical Center)

Koons, Robins, et al. , 2001Koons, Robins, et al. , 2001


Design: RCTDesign: RCTDesign: RCTDesign: RCT

Conditions: Dialectical Behavior Therapy (DBT)

Treatment-as-Usual (TAU)

Time Frame: 6-month treatment

Assessments: Pre-treatmentMid-treatment (3 months)

Post-treatment (6 months)

Conditions: Dialectical Behavior Therapy (DBT)

Treatment-as-Usual (TAU)

Time Frame: 6-month treatment

Assessments: Pre-treatmentMid-treatment (3 months)

Post-treatment (6 months)


SubjectsSubjectsSubjectsSubjects Women veterans, total N = 20Women veterans, total N = 20 BPD on SCID-IIBPD on SCID-II Mean Age = 35Mean Age = 35 Lifetime history of parasuicide = 75%Lifetime history of parasuicide = 75% Parasuicide within 6 months = 40%Parasuicide within 6 months = 40% Overall, a less parasuicidal, less frequently Overall, a less parasuicidal, less frequently

hospitalized group than studied in Linehan’s hospitalized group than studied in Linehan’s (1991) study.(1991) study.

Women veterans, total N = 20Women veterans, total N = 20 BPD on SCID-IIBPD on SCID-II Mean Age = 35Mean Age = 35 Lifetime history of parasuicide = 75%Lifetime history of parasuicide = 75% Parasuicide within 6 months = 40%Parasuicide within 6 months = 40% Overall, a less parasuicidal, less frequently Overall, a less parasuicidal, less frequently

hospitalized group than studied in Linehan’s hospitalized group than studied in Linehan’s (1991) study.(1991) study.


DBT < TAU at Post-TreatmentDBT < TAU at Post-Treatment DBT < TAU at Post-TreatmentDBT < TAU at Post-Treatment

# parasuicides (<.10)# parasuicides (<.10)

Suicide IdeationSuicide Ideation

Depression (BDI)Depression (BDI)

HopelessnessHopelessness

Anger OutAnger Out

# parasuicides (<.10)# parasuicides (<.10)

Suicide IdeationSuicide Ideation

Depression (BDI)Depression (BDI)


Anger OutAnger Out


Reduction in Mean Number of Reduction in Mean Number of Parasuicide Acts Over Time for Each Parasuicide Acts Over Time for Each

Condition Analyzed SeparatelyCondition Analyzed Separately

5.1

0.65

1.61.1

0.4

1

0

1

2

3

4

5

6

Mean Number

Pre-Treatment Mid-Treatment Post-Treatment

Time

DBT*

TAU

* p<.10* p<.10

Koons, Robins, et al. (1998)


DBT vs. Treatment-as-UsualDBT vs. Treatment-as-UsualWith BPD Substance AbusersWith BPD Substance Abusers

(University of Washington)(University of Washington)

Linehan, Schmidt, Dimeff, Kanter, Craft, Linehan, Schmidt, Dimeff, Kanter, Craft, Comtois, McDavid, 1999Comtois, McDavid, 1999

DBT vs. Treatment-as-UsualDBT vs. Treatment-as-UsualWith BPD Substance AbusersWith BPD Substance Abusers

(University of Washington)(University of Washington)

Linehan, Schmidt, Dimeff, Kanter, Craft, Linehan, Schmidt, Dimeff, Kanter, Craft, Comtois, McDavid, 1999Comtois, McDavid, 1999


17

Design: RCTDesign: RCTDesign: RCTDesign: RCTConditionsConditions:: DBTDBT

Treatment-as-Usual (TAU)Treatment-as-Usual (TAU)

Time FrameTime Frame:: 1 year treatment1 year treatment 4 month follow-up4 month follow-up

AssessmentsAssessments:: Pre-treatmentPre-treatment4 month4 month8 month8 month12 month 12 month (post-treatment)(post-treatment)

16 month16 month

ConditionsConditions:: DBTDBT Treatment-as-Usual (TAU)Treatment-as-Usual (TAU)

Time FrameTime Frame:: 1 year treatment1 year treatment 4 month follow-up4 month follow-up

AssessmentsAssessments:: Pre-treatmentPre-treatment4 month4 month8 month8 month12 month 12 month (post-treatment)(post-treatment)

16 month16 month


Subjects: n=28Subjects: n=28Subjects: n=28Subjects: n=28 BPDBPD

SUD for opiates, cocaine, amphetamines, SUD for opiates, cocaine, amphetamines, sedatives, hypnotics, or anxiolytics sedatives, hypnotics, or anxiolytics oror Polysubstance Use DisorderPolysubstance Use Disorder

FemaleFemale Did not meet criteria for:Did not meet criteria for:

• Schizophrenia or other Psychotic DisorderSchizophrenia or other Psychotic Disorder• Bipolar DisorderBipolar Disorder• Mental RetardationMental Retardation

BPDBPD

SUD for opiates, cocaine, amphetamines, SUD for opiates, cocaine, amphetamines, sedatives, hypnotics, or anxiolytics sedatives, hypnotics, or anxiolytics oror Polysubstance Use DisorderPolysubstance Use Disorder

FemaleFemale Did not meet criteria for:Did not meet criteria for:

• Schizophrenia or other Psychotic DisorderSchizophrenia or other Psychotic Disorder• Bipolar DisorderBipolar Disorder• Mental RetardationMental Retardation


Matching VariablesMatching VariablesMatching VariablesMatching Variables

AgeAge

Severity of Highest Drug Severity of Highest Drug DependenceDependence

Readiness to ChangeReadiness to Change

Global Adjustment (Axis V, Global Adjustment (Axis V, DSM-IV)DSM-IV)

AgeAge

Severity of Highest Drug Severity of Highest Drug DependenceDependence

Readiness to ChangeReadiness to Change

Global Adjustment (Axis V, Global Adjustment (Axis V, DSM-IV)DSM-IV)


Proportion of Urinalyses Proportion of Urinalyses DIRTYDIRTY by Conditionby Condition

Proportion of Urinalyses Proportion of Urinalyses DIRTYDIRTY by Conditionby Condition

47.640.1

33.5

57.1

47.545.5

70.466.4 66

84.3

0

10

20

30

40

50

60

70

80

90

100

Pre-tx 4- Month***

8- Month*

12- Month

16-Month**

DBT

TAU

Mean Proportion

Dirty

Mean Proportion

Dirty

TimeTime* p<.10**p<.05***p<.01

* p<.10**p<.05***p<.01


Interviewer-Assessed Proportion of Interviewer-Assessed Proportion of DAYS DAYS USINGUSING Drugs and Alcohol by Condition Drugs and Alcohol by Condition

Interviewer-Assessed Proportion of Interviewer-Assessed Proportion of DAYS DAYS USINGUSING Drugs and Alcohol by Condition Drugs and Alcohol by Condition

611

2118

71

68 54

4438 40

0

10

20

30

40

50

60

70

80

Pre-tx 4- Month***

8- Month**

12- Month*

16- Month***

DBT

TAU

TimeTime

* p<.10**p<.05***p<.02

* p<.10**p<.05***p<.02

Proportion of Days

Using

Proportion of Days

Using


Percent Treatment Drop-OutsPercent Treatment Drop-OutsPercent Treatment Drop-OutsPercent Treatment Drop-Outs

42

81

0

50

100

DBT

TAUp<.05


Mean Number of Treatment Sessions Mean Number of Treatment Sessions During the Year by ConditionDuring the Year by Condition

Mean Number of Treatment Sessions Mean Number of Treatment Sessions During the Year by ConditionDuring the Year by Condition

42.4

16.6

43.1

31.6

DBT

TAU

Psychotherapy Sessions +

Counseling with a Case Manager

Individual Psychotherapy

Sessions*

* p<.05* p<.05


DBT < TAUDBT < TAU Drug use

DBT > TAUDBT > TAU Global Adjustment (at 16-month) Social Adjustment (at 16-month)

DBT gains continued at follow-up

DBT vs. TAU: nsDBT vs. TAU: ns•Parasuicide Episodes• Anger

DBT < TAUDBT < TAU Drug use

DBT > TAUDBT > TAU Global Adjustment (at 16-month) Social Adjustment (at 16-month)

DBT gains continued at follow-up

DBT vs. TAU: nsDBT vs. TAU: ns•Parasuicide Episodes• Anger


DBT vs. Comprehensive Validation DBT vs. Comprehensive Validation (1 Year)(1 Year)

with BPD Heroin Addictswith BPD Heroin Addicts

University of WashingtonUniversity of Washington

Linehan, Dimeff, Reynolds, Comtois, Linehan, Dimeff, Reynolds, Comtois, McDavid, & KivlahanMcDavid, & Kivlahan

DBT vs. Comprehensive Validation DBT vs. Comprehensive Validation (1 Year)(1 Year)

with BPD Heroin Addictswith BPD Heroin Addicts

University of WashingtonUniversity of Washington

Linehan, Dimeff, Reynolds, Comtois, Linehan, Dimeff, Reynolds, Comtois, McDavid, & KivlahanMcDavid, & Kivlahan


Subjects: n=23Subjects: n=23Subjects: n=23Subjects: n=23

BPD on SCID II and PDEBPD on SCID II and PDE Met criteria for Heroin DependenceMet criteria for Heroin Dependence 18-45 Years18-45 Years FemaleFemale

Did not meet criteria for:Did not meet criteria for:• Schizophrenia or other Psychotic DisorderSchizophrenia or other Psychotic Disorder• Bipolar DisorderBipolar Disorder• Mental RetardationMental Retardation

BPD on SCID II and PDEBPD on SCID II and PDE Met criteria for Heroin DependenceMet criteria for Heroin Dependence 18-45 Years18-45 Years FemaleFemale

Did not meet criteria for:Did not meet criteria for:• Schizophrenia or other Psychotic DisorderSchizophrenia or other Psychotic Disorder• Bipolar DisorderBipolar Disorder• Mental RetardationMental Retardation


Matching VariablesMatching VariablesMatching VariablesMatching Variables

AgeAge

Cocaine DependenceCocaine Dependence

Anti-Social Personality DisorderAnti-Social Personality Disorder

Global Assessment of Functioning Global Assessment of Functioning (GAF)(GAF)

AgeAge

Cocaine DependenceCocaine Dependence

Anti-Social Personality DisorderAnti-Social Personality Disorder

Global Assessment of Functioning Global Assessment of Functioning (GAF)(GAF)


Design: RCTDesign: RCTDesign: RCTDesign: RCTConditionsConditions:: Dialectical Behavior Therapy Dialectical Behavior Therapy

(DBT)(DBT) Comprehensive Validation Comprehensive Validation

TherapyTherapy (CVT)(CVT)

Time FrameTime Frame:: 12 month treatment12 month treatment 4 month follow-up4 month follow-up

AssessmentsAssessments:: Pre-treatmentPre-treatment 4 month4 month 8 month 8 month

12 month (post)12 month (post) 16 month16 month

ConditionsConditions:: Dialectical Behavior Therapy Dialectical Behavior Therapy (DBT)(DBT)

Comprehensive Validation Comprehensive Validation TherapyTherapy (CVT)(CVT)

Time FrameTime Frame:: 12 month treatment12 month treatment 4 month follow-up4 month follow-up

AssessmentsAssessments:: Pre-treatmentPre-treatment 4 month4 month 8 month 8 month

12 month (post)12 month (post) 16 month16 month


Treatment ConditionsTreatment ConditionsTreatment ConditionsTreatment Conditions Individual TherapyIndividual Therapy Group Skills TrainingGroup Skills Training Homework ReviewHomework Review Phone CoachingPhone Coaching Therapist Consult MeetingTherapist Consult Meeting Drug-ReplacementDrug-Replacement

Individual TherapyIndividual Therapy NA 12&12 GroupNA 12&12 Group NA 12&12 SponsorNA 12&12 Sponsor Crisis InterventionCrisis Intervention Therapist Consult MeetingTherapist Consult Meeting Drug-ReplacementDrug-Replacement

Individual TherapyIndividual Therapy Group Skills TrainingGroup Skills Training Homework ReviewHomework Review Phone CoachingPhone Coaching Therapist Consult MeetingTherapist Consult Meeting Drug-ReplacementDrug-Replacement

Individual TherapyIndividual Therapy NA 12&12 GroupNA 12&12 Group NA 12&12 SponsorNA 12&12 Sponsor Crisis InterventionCrisis Intervention Therapist Consult MeetingTherapist Consult Meeting Drug-ReplacementDrug-Replacement

DBTDBTDBTDBT

CVTCVT CVTCVT


AssessmentsAssessmentsAssessmentsAssessments

• Urinalysis (3 times weekly)Urinalysis (3 times weekly)

• Substance Abuse History Substance Abuse History Interview (SAHI)Interview (SAHI)

• Urinalysis (3 times weekly)Urinalysis (3 times weekly)

• Substance Abuse History Substance Abuse History Interview (SAHI)Interview (SAHI)


DBT

CVT+12S

Opiate Use Across YearOpiate Use Across YearOpiate Use Across YearOpiate Use Across Year%

%

Po

siti

veP

osi

tive

%

% P

osi

tive

Po

siti

ve

WeeksWeeksWeeksWeeks


Percent Treatment Drop-OutsPercent Treatment Drop-OutsPercent Treatment Drop-OutsPercent Treatment Drop-Outs

36%

0%

0%5%

10%

15%20%

25%30%

35%40%

Condition

DBT

CVT

p<.05


DBT vs. CVT+12S: nsDBT vs. CVT+12S: nsDBT vs. CVT+12S: nsDBT vs. CVT+12S: ns

Drug Use, Self-ReportDrug Use, Self-Report Brief Symptom InventoryBrief Symptom Inventory Global AdjustmentGlobal Adjustment Social AdjustmentSocial Adjustment

Drug Use, Self-ReportDrug Use, Self-Report Brief Symptom InventoryBrief Symptom Inventory Global AdjustmentGlobal Adjustment Social AdjustmentSocial Adjustment

Pre-treatment > 12-monthPre-treatment > 12-monthPre-treatment > 12-monthPre-treatment > 12-month


Integrating DBT into Integrating DBT into Community Mental HealthCommunity Mental Health

The Mental Health Center of Greater The Mental Health Center of Greater Manchester, New HampshireManchester, New Hampshire

Recipients of the 1998 Gold AwardRecipients of the 1998 Gold AwardAmerican Psychiatric AssociationAmerican Psychiatric Association

Psychiatric ServicesPsychiatric Services, , 4949, 1338-1340, 1338-1340


The Mental Health Center of Greater The Mental Health Center of Greater Manchester, New HampshireManchester, New Hampshire

Provided comprehensive DBT in outpatient Provided comprehensive DBT in outpatient setting.setting.

Pre-post data collected for first 14 patients Pre-post data collected for first 14 patients receiving DBT.receiving DBT.

Team received intensive 10-day training in Team received intensive 10-day training in DBT over six month period of time.DBT over six month period of time.


Treatment Costs Cut by More than HalfTreatment Costs Cut by More than HalfFrom $645,000 to $273,000From $645,000 to $273,000

77% decrease in 77% decrease in hospital days, from 479 hospital days, from 479 to 85 days.to 85 days.

76% decrease in partial 76% decrease in partial hospital days, from 173 hospital days, from 173 to 42 days.to 42 days.

56% decrease in crisis 56% decrease in crisis beds, from 170 to 73 beds, from 170 to 73 beds.beds.

80% decrease in face-80% decrease in face-to-face contact with to-face contact with emergency services, emergency services, from 61 to 12 days.from 61 to 12 days.

Significant increase in Significant increase in outpatient services, outpatient services, from 438 days to 1,387 from 438 days to 1,387 days.days.


Non-Randomized Studies On DBTNon-Randomized Studies On DBT Stanley, Ivanoff et. al. Stanley, Ivanoff et. al.

Study of Suicidal, Self-Study of Suicidal, Self-Mutilators Mutilators (1998).(1998).

Miller & Rathus study of Miller & Rathus study of DBT for Suicidal DBT for Suicidal AdoelscentsAdoelscents (1996).(1996).

McCann & Ball study of McCann & Ball study of DBT for Forensic DBT for Forensic InpatientsInpatients (1996). (1996).

Bohus et al. Study of Bohus et al. Study of DBT inpatient treatment DBT inpatient treatment (2001).(2001).

Trupin et al. Study of Trupin et al. Study of incarcerated youth incarcerated youth (2002).(2002).


DBT vs. Treatment-as-Usual DBT vs. Treatment-as-Usual for Suicidal and for Suicidal and

Self-Mutilating BehaviorSelf-Mutilating Behavior

(New York State Psychiatric Institute(New York State Psychiatric Institute& Columbia University)& Columbia University)

Stanley, B., Ivanoff, A., Brodsky, B., & Oppenheim, Stanley, B., Ivanoff, A., Brodsky, B., & Oppenheim, S. (1998S. (1998))

DBT vs. Treatment-as-Usual DBT vs. Treatment-as-Usual for Suicidal and for Suicidal and

Self-Mutilating BehaviorSelf-Mutilating Behavior

(New York State Psychiatric Institute(New York State Psychiatric Institute& Columbia University)& Columbia University)

Stanley, B., Ivanoff, A., Brodsky, B., & Oppenheim, Stanley, B., Ivanoff, A., Brodsky, B., & Oppenheim, S. (1998S. (1998))


Design: Matched ControlDesign: Matched ControlDesign: Matched ControlDesign: Matched ControlConditionsConditions:: Dialectical Behavior Therapy Dialectical Behavior Therapy

(DBT)(DBT) Treatment-as-Usual (TAU)Treatment-as-Usual (TAU)

Time FrameTime Frame:: 6-month treatment6-month treatment

AssessmentsAssessments::Pre-treatmentPre-treatmentMid-treatment (3 months)Mid-treatment (3 months)Post-treatmentPost-treatment

ConditionsConditions:: Dialectical Behavior Therapy Dialectical Behavior Therapy (DBT)(DBT)

Treatment-as-Usual (TAU)Treatment-as-Usual (TAU)

Time FrameTime Frame:: 6-month treatment6-month treatment

AssessmentsAssessments::Pre-treatmentPre-treatmentMid-treatment (3 months)Mid-treatment (3 months)Post-treatmentPost-treatment


Subjects: n = 30Subjects: n = 30Subjects: n = 30Subjects: n = 30

BPDBPD FemalesFemales ParasuicidalParasuicidal The baseline mean number of suicide The baseline mean number of suicide

attempts did not differ between DBT attempts did not differ between DBT

and TAUand TAU

BPDBPD FemalesFemales ParasuicidalParasuicidal The baseline mean number of suicide The baseline mean number of suicide

attempts did not differ between DBT attempts did not differ between DBT

and TAUand TAU


DBT < TAUDBT < TAU

DBT < TAUDBT < TAU

• Self-mutilationSelf-mutilation• Suicide ideationSuicide ideation• Suicidal urgesSuicidal urges• Urges to self-mutilateUrges to self-mutilate

• Self-mutilationSelf-mutilation• Suicide ideationSuicide ideation• Suicidal urgesSuicidal urges• Urges to self-mutilateUrges to self-mutilate

(Neither group had a suicide attempt.)

(Neither group had a suicide attempt.)


DBT = TAUDBT = TAU DBT = TAUDBT = TAU

DepressionDepression


Global AdjustmentGlobal Adjustment

DepressionDepression


Global AdjustmentGlobal Adjustment


DDBT vs. Treatment-as-UsualBT vs. Treatment-as-Usualfor Suicidal Adolescents for Suicidal Adolescents

The Albert Einstein College of Medicine/The Albert Einstein College of Medicine/Montefiore Medical CenterMontefiore Medical Center

Miller, A. L. & Rathus, J. H. (1996)Miller, A. L. & Rathus, J. H. (1996)

DDBT vs. Treatment-as-UsualBT vs. Treatment-as-Usualfor Suicidal Adolescents for Suicidal Adolescents

The Albert Einstein College of Medicine/The Albert Einstein College of Medicine/Montefiore Medical CenterMontefiore Medical Center

Miller, A. L. & Rathus, J. H. (1996)Miller, A. L. & Rathus, J. H. (1996)


Design: Parallel Control GroupDesign: Parallel Control GroupDesign: Parallel Control GroupDesign: Parallel Control Group

ConditionsConditions:: DBT for AdolescentsDBT for Adolescents Treatment-as-Treatment-as-Usual Usual

Time FrameTime Frame:: 12 week treatment12 week treatment

AssessmentsAssessments:: Pre-treatmentPre-treatment

Post-treatment (12 wk)Post-treatment (12 wk)

ConditionsConditions:: DBT for AdolescentsDBT for Adolescents Treatment-as-Treatment-as-Usual Usual

Time FrameTime Frame:: 12 week treatment12 week treatment


Post-treatment (12 wk)Post-treatment (12 wk)


Subjects: n=111 (DBT=29, TAU=82)Subjects: n=111 (DBT=29, TAU=82)Subjects: n=111 (DBT=29, TAU=82)Subjects: n=111 (DBT=29, TAU=82)

Referrals to the Adolescent Depression and Referrals to the Adolescent Depression and Suicide Program, 78% female and 22% Suicide Program, 78% female and 22% malemale

Age range 12-19 yearsAge range 12-19 years

68% Hispanic, 17% African American, 68% Hispanic, 17% African American, 8% Caucasian, 1% Asian, 6% other8% Caucasian, 1% Asian, 6% other

Referrals to the Adolescent Depression and Referrals to the Adolescent Depression and Suicide Program, 78% female and 22% Suicide Program, 78% female and 22% malemale

Age range 12-19 yearsAge range 12-19 years

68% Hispanic, 17% African American, 68% Hispanic, 17% African American, 8% Caucasian, 1% Asian, 6% other8% Caucasian, 1% Asian, 6% other


Subjects: Assignment to ConditionSubjects: Assignment to ConditionSubjects: Assignment to ConditionSubjects: Assignment to Condition

Subjects were assigned to DBT if they Subjects were assigned to DBT if they met the following criteria:met the following criteria:

Subjects were assigned to DBT if they Subjects were assigned to DBT if they met the following criteria:met the following criteria: Either made a suicide attempt within the Either made a suicide attempt within the

last 16 weeks OR reported current last 16 weeks OR reported current suicidal ideation suicidal ideation

Met diagnostic criteria for BPD or Met diagnostic criteria for BPD or borderline personality features (as borderline personality features (as measured by the SCID-II)measured by the SCID-II)

Either made a suicide attempt within the Either made a suicide attempt within the last 16 weeks OR reported current last 16 weeks OR reported current suicidal ideation suicidal ideation

Met diagnostic criteria for BPD or Met diagnostic criteria for BPD or borderline personality features (as borderline personality features (as measured by the SCID-II)measured by the SCID-II)


DBT < TAUDBT < TAUDBT < TAUDBT < TAU

• Treatment drop-outTreatment drop-out• Inpatient psychiatric daysInpatient psychiatric days

• Treatment drop-outTreatment drop-out• Inpatient psychiatric daysInpatient psychiatric days

DBT = TAUDBT = TAUDBT = TAUDBT = TAU

• Suicide AttemptsSuicide Attempts

• Suicide AttemptsSuicide Attempts


Treatment Drop-out: DBT vs.. Treatment Drop-out: DBT vs.. TAUTAU

Treatment Drop-out: DBT vs.. Treatment Drop-out: DBT vs.. TAUTAU

38

60

0

20

40

60

80

100

Per

cen

t D

rop

-ou

t

DBT

TAU

* p=.04* p=.04


Psychiatric Hospitalizations Psychiatric Hospitalizations During Treatment: DBT vs. TAUDuring Treatment: DBT vs. TAU

Psychiatric Hospitalizations Psychiatric Hospitalizations During Treatment: DBT vs. TAUDuring Treatment: DBT vs. TAU

0

13

0

5

10

15

Per

cen

t H

osp

ital

ized

DBT

TAU

* p=.04* p=.04


DBT=TAU: Suicide AttemptsDBT=TAU: Suicide AttemptsDBT=TAU: Suicide AttemptsDBT=TAU: Suicide AttemptsDBT>TAU at pre-treatment:DBT>TAU at pre-treatment:

•Number of Axis I disorders Number of Axis I disorders •ImpulsivityImpulsivity•Number of prior hospitalizationsNumber of prior hospitalizations

The fact that DBT subjects were The fact that DBT subjects were notnot more suicidal during treatment than more suicidal during treatment than TAU is noteworthyTAU is noteworthy..

DBT>TAU at pre-treatment:DBT>TAU at pre-treatment:•Number of Axis I disorders Number of Axis I disorders •ImpulsivityImpulsivity•Number of prior hospitalizationsNumber of prior hospitalizations

The fact that DBT subjects were The fact that DBT subjects were notnot more suicidal during treatment than more suicidal during treatment than TAU is noteworthyTAU is noteworthy..


Suicide Attempts: DBT vs. TAUSuicide Attempts: DBT vs. TAUSuicide Attempts: DBT vs. TAUSuicide Attempts: DBT vs. TAU

0

9

0

2

4

6

8

10

Per

cen

t w

ith

A

ttem

pt

DBT

TAU

Miller, A. L., & Rathus, J. H. (1996)

*ns*ns


DBT vs. Treatment-as-UsualDBT vs. Treatment-as-Usualfor Forensic Inpatientsfor Forensic Inpatients

Institute for Forensic PsychiatryInstitute for Forensic PsychiatryColorado Mental Health Institute at PuebloColorado Mental Health Institute at Pueblo

McCann & Ball, 1996McCann & Ball, 1996

DBT vs. Treatment-as-UsualDBT vs. Treatment-as-Usualfor Forensic Inpatientsfor Forensic Inpatients

Institute for Forensic PsychiatryInstitute for Forensic PsychiatryColorado Mental Health Institute at PuebloColorado Mental Health Institute at Pueblo

McCann & Ball, 1996McCann & Ball, 1996


Design: LongitudinalDesign: LongitudinalDesign: LongitudinalDesign: Longitudinal

Conditions: Dialectical Behavior Therapy (DBT; n=21)

Treatment-as-Usual (TAU; n=14)

Time Frame: 20 month treatment

Assessments: Pre-treatmentPost-treatment

Conditions: Dialectical Behavior Therapy (DBT; n=21)

Treatment-as-Usual (TAU; n=14)

Time Frame: 20 month treatment

Assessments: Pre-treatmentPost-treatment


Subjects: (35 male, 11 female)Subjects: (35 male, 11 female)Subjects: (35 male, 11 female)Subjects: (35 male, 11 female)

Patients on intermediate and medium Patients on intermediate and medium security forensic wards security forensic wards

Age range 37.6 yearsAge range 37.6 years

BPD = 50%; ASPD= 33%; 45% either BPD = 50%; ASPD= 33%; 45% either schizophrenic or bi-polarschizophrenic or bi-polar

Patients on intermediate and medium Patients on intermediate and medium security forensic wards security forensic wards

Age range 37.6 yearsAge range 37.6 years

BPD = 50%; ASPD= 33%; 45% either BPD = 50%; ASPD= 33%; 45% either schizophrenic or bi-polarschizophrenic or bi-polar


DBT: Pre < postDBT: Pre < postDBT: Pre < postDBT: Pre < post

Depressed and hostile moodDepressed and hostile mood Paranoia, Paranoia, Psychotic behaviors, Psychotic behaviors, Maladaptive interpersonal coping stylesMaladaptive interpersonal coping styles Staff burn-out (trend)Staff burn-out (trend)

TAU: Pre = postTAU: Pre = post

Depressed and hostile moodDepressed and hostile mood Paranoia, Paranoia, Psychotic behaviors, Psychotic behaviors, Maladaptive interpersonal coping stylesMaladaptive interpersonal coping styles Staff burn-out (trend)Staff burn-out (trend)

TAU: Pre = postTAU: Pre = post

McCann & Ball

86

Evaluation of DBT-Inpatient Evaluation of DBT-Inpatient TreatmentTreatment

Evaluation of DBT-Inpatient Evaluation of DBT-Inpatient TreatmentTreatment

University of Freiburg, GermanyUniversity of Freiburg, Germany

Bohus, Bohus, Haaf, Stiglmayr, Pohl, Bohme, & Linehan 2001

University of Freiburg, GermanyUniversity of Freiburg, Germany

Bohus, Bohus, Haaf, Stiglmayr, Pohl, Bohme, & Linehan 2001


DBT vs. TAU-Waiting List DBT vs. TAU-Waiting List a Controlled Studya Controlled Study

Inclusion: BPD: SCID II; DIB-R>7Inclusion: BPD: SCID II; DIB-R>7 Exclusion: lifetime schizophrenia, Exclusion: lifetime schizophrenia,

bipolar I, current substance abusebipolar I, current substance abuse Measure points: Measure points:

pre: admission pre: admission

post: 1 month after dischargepost: 1 month after discharge

Inclusion: BPD: SCID II; DIB-R>7Inclusion: BPD: SCID II; DIB-R>7 Exclusion: lifetime schizophrenia, Exclusion: lifetime schizophrenia,

bipolar I, current substance abusebipolar I, current substance abuse Measure points: Measure points:

pre: admission pre: admission

post: 1 month after dischargepost: 1 month after discharge


DBT vs. TAU - Waiting ListDBT vs. TAU - Waiting List

DBTDBT n=31n=31 age=29.1age=29.1 mean DSM-IV 6.81 mean DSM-IV 6.81 Comorbidities:Comorbidities:

• Anxiety disorder 77%Anxiety disorder 77%• Eating disorder 50%Eating disorder 50%• Depressive Depressive

Disorder 80%Disorder 80%

DBTDBT n=31n=31 age=29.1age=29.1 mean DSM-IV 6.81 mean DSM-IV 6.81 Comorbidities:Comorbidities:



TAU - Waiting ListTAU - Waiting List n=19n=19 age=29.5age=29.5 mean DSM-IV 7.63mean DSM-IV 7.63 Comorbidities:Comorbidities:



TAU - Waiting ListTAU - Waiting List n=19n=19 age=29.5age=29.5 mean DSM-IV 7.63mean DSM-IV 7.63 Comorbidities:Comorbidities:




Pre-post comparison and group vs. Pre-post comparison and group vs. time differences: Depressiontime differences: Depression

BDI HAMD

0

5

10

15

20

25

TAU-Waiting List Treatment

**

normal range

**

0

5

10

15

20

25

30

35

40

TAU-Waiting List DBT

**

**

normal range

TAU DBT


Pre-post comparison and group vs. Pre-post comparison and group vs. time differences: Anxietytime differences: Anxiety

STAI HAMA

0

5

10

15

20

25

30


**

normal range

**

40

45

50

55

60

65

70

75

80


**

**

normal range

TAU DBT


Pre-post comparison and group vs. Pre-post comparison and group vs. time differences: SCL-90-Rtime differences: SCL-90-R

GSI PSDI

1,0

1,2

1,4

1,6

1,8

2,0

2,2

2,4

2,6

2,8

3,0

TAU-Waiting List

**

Treatment

**

normal range

0,0

0,5

1,0

1,5

2,0

2,5


**

**

normal range

TAU DBT


Pre-post comparison and group vs. time Pre-post comparison and group vs. time differences: Dissociationdifferences: Dissociation

DES

0

5

10

15

20

25

30

35

40


**

normal range

*TAU DBT


Pre-post comparison and group vs. Pre-post comparison and group vs. time differences: Angertime differences: Anger

STAXI

1

2

3

4

5

6

7

8

9


normal range

TAU DBT


Pre-post comparison and group vs. time Pre-post comparison and group vs. time differences: Social Integrationdifferences: Social Integration

GAF

0

10

20

30

40

50

60

70

80

90

100


normal range

**

**TAU DBT


Effect Sizes TAU-DBTEffect Sizes TAU-DBT

0,0

0,5

1,0

1,5

GAF SCL-90-R(GSI)

SCL-90-R(PSDI)

DES BDI HAMD STAI HAMA STAXI

TAU-Waiting-List n=19

Treatment n=31

small

medium

large


Responder criteriaResponder criteria

Every patient who had values above Every patient who had values above the the median in at least 5 of 9 pre-post-median in at least 5 of 9 pre-post-differencesdifferences (dissociation, GAF, (dissociation, GAF, HAMA, STAI, BDI, HAMD, STAXI, HAMA, STAI, BDI, HAMD, STAXI, SCL-GSI, SCL-Intensity) was SCL-GSI, SCL-Intensity) was allocated to the responder-groupallocated to the responder-group


Responder criteriaResponder criteria

Discriminant Analysis: All of the 9 Discriminant Analysis: All of the 9 variables accounted significantly for variables accounted significantly for the classification into responder- and the classification into responder- and non-responder-groups and are non-responder-groups and are responsible for 71.8% of the variance responsible for 71.8% of the variance between the groups (Fbetween the groups (F8,208,20=6.35, =6.35, p=.000***).p=.000***).


GAFGAF

0

10

20

30

40

50

60

70

80

90

100

TAU-Waiting List Treatment non-respondersresponders

normal range

** ** *

TAU DBT Responders Non-Responders


Therapy Response: Effect sizesTherapy Response: Effect sizes

0,0

0,5

1,0

1,5

2,0

2,5

3,0

GAF SCL-90-R(GSI)

SCL-90-R(PSDI)

DES BDI HAMD STAI HAMA STAXI

TAU-Waiting-List n=19Treatment n=31Responder n= 16Non-Responder n=15


Predictor VariablesPredictor Variables(Discriminant Analysis)(Discriminant Analysis)

Clinical variables: Clinical variables: Frequency of comorbid axis I disordersFrequency of comorbid axis I disorders Frequency and days of lifetime Frequency and days of lifetime

hospitalizations hospitalizations Frequency of lifetime suicide attemptsFrequency of lifetime suicide attempts

Current or lifetime diagnosis of Current or lifetime diagnosis of • comorbid anxiety disorder comorbid anxiety disorder • eating disordereating disorder• depressiondepression

Clinical variables: Clinical variables: Frequency of comorbid axis I disordersFrequency of comorbid axis I disorders Frequency and days of lifetime Frequency and days of lifetime

hospitalizations hospitalizations Frequency of lifetime suicide attemptsFrequency of lifetime suicide attempts

Current or lifetime diagnosis of Current or lifetime diagnosis of • comorbid anxiety disorder comorbid anxiety disorder • eating disordereating disorder• depressiondepression


Predictor VariablesPredictor Variables(Discriminant Analysis)(Discriminant Analysis)

Diagnostic variables: Diagnostic variables: value of the DIB-R criterias value of the DIB-R criterias number of met DSM-IV criteriasnumber of met DSM-IV criterias severity of pre-assessment symptomsseverity of pre-assessment symptoms

Diagnostic variables: Diagnostic variables: value of the DIB-R criterias value of the DIB-R criterias number of met DSM-IV criteriasnumber of met DSM-IV criterias severity of pre-assessment symptomsseverity of pre-assessment symptoms


Predictor Variables Predictor Variables (Discriminant Analysis)(Discriminant Analysis)

Social variables:Social variables: employment employment psychological or psychosocial stress at beginning of psychological or psychosocial stress at beginning of

therapy therapy age age quality of family relationshipsquality of family relationships quality of leisure activitiesquality of leisure activities global contentment with social aspects of one’s lifeglobal contentment with social aspects of one’s life

Social variables:Social variables: employment employment psychological or psychosocial stress at beginning of psychological or psychosocial stress at beginning of

therapy therapy age age quality of family relationshipsquality of family relationships quality of leisure activitiesquality of leisure activities global contentment with social aspects of one’s lifeglobal contentment with social aspects of one’s life


DBT Skills Training vs. No SkillsDBT Skills Training vs. No SkillsOne Year: Out-patient (Linehan et al.)One Year: Out-patient (Linehan et al.)

DBT Skills Training vs. No SkillsDBT Skills Training vs. No SkillsOne Year: Out-patient (Linehan et al.)One Year: Out-patient (Linehan et al.)

DBT skills training + individual non-DBT skills training + individual non-DBT psychotherapy (DBT Skills) DBT psychotherapy (DBT Skills) vs.vs.

Individual non-DBT psychotherapy Individual non-DBT psychotherapy only (NO DBT Skills)only (NO DBT Skills)

• DBT Skills = No DBT Skills: all DBT Skills = No DBT Skills: all measuresmeasures

DBT skills training + individual non-DBT skills training + individual non-DBT psychotherapy (DBT Skills) DBT psychotherapy (DBT Skills) vs.vs.

Individual non-DBT psychotherapy Individual non-DBT psychotherapy only (NO DBT Skills)only (NO DBT Skills)

• DBT Skills = No DBT Skills: all DBT Skills = No DBT Skills: all measuresmeasures


DBT vs. Treatment-as-UsualDBT vs. Treatment-as-Usualfor Incarcerated Juvenile for Incarcerated Juvenile

Offenders Offenders Echo Glen Children’s Center Echo Glen Children’s Center

Trupin, Stewart, Boesky, McClung, BeachTrupin, Stewart, Boesky, McClung, Beach

DBT vs. Treatment-as-UsualDBT vs. Treatment-as-Usualfor Incarcerated Juvenile for Incarcerated Juvenile

Offenders Offenders Echo Glen Children’s Center Echo Glen Children’s Center

Trupin, Stewart, Boesky, McClung, BeachTrupin, Stewart, Boesky, McClung, Beach


Design: Parallel Control GroupDesign: Parallel Control GroupDesign: Parallel Control GroupDesign: Parallel Control Group

ConditionsConditions:: DBT: Staff trained > 80 hrs. DBT: Staff trained > 80 hrs. (n=22)(n=22)

DBT: Staff trained 16 hrs. DBT: Staff trained 16 hrs. (n=15)(n=15)

Time FrameTime Frame:: 10 months10 months


Post-treatment Post-treatment

ConditionsConditions:: DBT: Staff trained > 80 hrs. DBT: Staff trained > 80 hrs. (n=22)(n=22)

DBT: Staff trained 16 hrs. DBT: Staff trained 16 hrs. (n=15)(n=15)

Time FrameTime Frame:: 10 months10 months


Post-treatment Post-treatment


Subject Demographic CharacteristicsSubject Demographic CharacteristicsSubject Demographic CharacteristicsSubject Demographic Characteristics Female, adolescent offenders Female, adolescent offenders

incarcerated on general and mental incarcerated on general and mental health cottages health cottages

Age: M=15 yrs.Age: M=15 yrs. % Axis I disorders: 76%% Axis I disorders: 76% Number prior offenses: M=5.5Number prior offenses: M=5.5

Female, adolescent offenders Female, adolescent offenders incarcerated on general and mental incarcerated on general and mental health cottages health cottages

Age: M=15 yrs.Age: M=15 yrs. % Axis I disorders: 76%% Axis I disorders: 76% Number prior offenses: M=5.5Number prior offenses: M=5.5


Significant ChangesSignificant Changes

DBT 80 hrs. trainingDBT 80 hrs. training• Reduced severe behavior problems Reduced severe behavior problems

(parasuicide, aggression, class (parasuicide, aggression, class disruptions)disruptions)

• Reduced staff use of punitive actions Reduced staff use of punitive actions (compared to previous year) (compared to previous year)

DBT 16 hrs. trainingDBT 16 hrs. training• No reduction in behavior problemsNo reduction in behavior problems• Increased staff use of punitive actionsIncreased staff use of punitive actions

DBT 80 hrs. trainingDBT 80 hrs. training• Reduced severe behavior problems Reduced severe behavior problems

(parasuicide, aggression, class (parasuicide, aggression, class disruptions)disruptions)

• Reduced staff use of punitive actions Reduced staff use of punitive actions (compared to previous year) (compared to previous year)

DBT 16 hrs. trainingDBT 16 hrs. training• No reduction in behavior problemsNo reduction in behavior problems• Increased staff use of punitive actionsIncreased staff use of punitive actions

Documents

1 2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Dialectical Behavior Therapy Presentation Materials The Behavioral