Readings for Professionals on Dialectical Behavior Therapy and other Mindfulness Oriented Approaches

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Published Abstracts from Randomized Controlled Trials

Evans, K., Tyrer, P., Catalan, J., Schmidt, U., Davidson, K., Dent, J., Tata, P., Thornton, S., Barber, J., & Thompson, S. (1999). Manual-Assisted Cognitive-Behavior Therapy (MACT): A randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm. Psychological Medicine, 29, 19-25.

Investigated the effectiveness of a new manual-based treatment for recurrent deliberate self-harm that varied from bibliotherapy (6 self-help booklets) alone to 6 sessions of cognitive therapy linked to the booklets, which contained elements of dialectical behavior therapy. Thirty-four patients, aged 16-50 yrs, seen after an episode of deliberate self-harm, with personality disturbance within the flamboyant cluster and a previous parasuicide episode within the past 12 months, were randomly assigned to treatment with MACT (18 Ss) or treatment as usual (TAU;16Ss). Assessments of clinical symptoms and social function were made at baseline and repeated at 6 months. The number and rate of all parasuicide attempts, time to next episode and costs of care were also determined. Thirty-two patients (18MACT; 14 TAU) were seen at follow-up and 10 patients in each group (56% MACT and 71% TAU) had a suicidal act during the 6 months. The rate of suicidal acts per month was lower with MACT (median 0.17/mo MACT; 0.37/mo TAU) and self-rated depressive symptoms also improved. The treatment involved a mean of 2.7 sessions and the observed average cost of care was 46% less with MACT. Results suggest that this new form of cognitive-behavior therapy is promising in its efficacy and feasible in clinical practice.

 

 

Linehan, M.M., Dimeff, Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L. Korslund, K.E., Tutek, D.A., Reynolds, S.K., Lindenboim, N. (2002). Two-year randomized trial  +  follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry.

CONTEXT: Dialectical Behavior Therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder (BPD) with well-documented efficacy. OBJECTIVES: Evaluate the hypothesis that unique aspects of DBT are more efficacious in comparison to treatment offered by non-behavioral expert psychotherapists. DESIGN: One year randomized controlled trial plus one-year post-treatment follow-up. SETTING: University outpatient clinic and community practice. PARTICIPANTS: 101, clinically referred women with recent suicidal and self-injurious behaviors DSM-IV BPD criteria matched to condition on number of lifetime intentional self-injuries and psychiatric hospitalizations, suicide attempt history, age, and negative prognostic indication. INTERVENTION: One year of DBT or Community Treatment-By-Experts (CTBE). The CTBE condition was developed to maximize internal validity by controlling therapist availability, expertise, allegiance, gender, training and experience, consultation, availability, and institutional prestige. MAIN OUTCOME MEASURES: Trimester assessments of suicidal behaviors, emergency services usage, and general psychological functioning. Measures were selected on previous outcome studies of DBT. Assessment and outcome variables were blinded assessors. RESULTS: DBT had better outcomes on intent-to-treat analysis than CTBE in most target areas over the two-year treatment and follow-up period. DBT subjects were half as likely to make a suicide attempt (p=0.39) across all suicide attempts and self-injurious acts combined. DBT subjects were less likely to drop out of treatment (p<.001), had few psychiatric emergency room visits (p=0.43) and fewer psychiatric hospitalizations (p=.007). Subjects in both conditions showed statistically significant improvement over time on above measures as well as depression, reasons for living, and suicide ideation. CONCLUSION: Findings replicate previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy.

 

Linehan, M.M., Schmidt, H., Dimeff. L.A., Craft, J.C., Kanter, J., & Comtios, K.A. (1999). Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug-dependence. American Journal on Addictions, 8, 279-292.

A randomized clinical trial was conducted to evaluate whether Dialectical Behavior Therapy (DBT), an effective cognitive-behavioral treatment for suicidal individuals with borderline personality disorder (BPD), would also be effective for drug-dependent women with BPD when compared with treatment-as-usual (TAU) in the community. Subjects were randomly assigned to either DBT or TAU for a year of treatment. Subjects were assessed at 4, 8, and 12 months, and at a 16-month follow-up. Subjects assigned to DBT had significantly greater reductions in drug abuse measured both by structured interviews and urinalyses throughout the treatment year and at follow-up than did subjects assigned to TAU. DBT also maintained subjects in treatment better than did TAU, and subjects assigned to DBT had significantly greater gains in global and social adjustment at follow-up than did subjects assigned to TAU. DBT has been shown to be more effective than treatment-as-usual in treating drug abuse in this study, providing more support for DBT as an effective treatment for severely dysfunctional BPD patients across a range of presenting problems.

 

 

Safer, D.L., Telch, C.F. & Agras, W.S. (2001). Dialectical Behavior Therapy for Bulimia Nervosa. American Journal of Psychiatry, 158, 632-634.

OBJECTIVE: The effects of Dialectical Behavior Therapy adapted for the treatment of binge/purge behaviors were examined. METHOD: Thirty-one women (averaging at least one binge/purge episode per week) were randomly assigned to 20 weeks of Dialectical Behavior Therapy or 20 weeks of a waiting-list comparison condition. The manual-based Dialectical Behavior Therapy focused on training in emotion regulation skills. RESULTS: An intent-to-treat analysis showed highly significant decreases in binge/purge behavior with Dialectical Behavior Therapy compared to the waiting-list condition. No significant group differences were found on any of the secondary measures. CONCLUSIONS: The use of Dialectical Behavior Therapy adapted for treatment of bulimia nervosa was associated with a promising decrease in binge/purge behaviors.

 

Telch, C.F., Agras, W.S., & Linehan, M.M. (2001). Dialectical Behavior Therapy for Binge Eating Disorder. Journal of Consulting and Clinical Psychology, 69(6), 1061-1065.

The study evaluated the use of Dialectical Behavior Therapy (DBT) adapted for binge eating disorder (BED). Forty-four women with BED were randomly assigned to group DBT or a wait-list control condition and administered the Eating Disorder Examination in addition to measures of weight, mood, and affect regulation at baseline and post-treatment. Treated women evidenced significant improvement on measures of binge eating and eating pathology compared to controls, and 89% of the women receiving DBT had stopped binge eating by the end of the treatment. Abstinence rates were reduced to 56% at the six-month follow-up. Overall, the findings on the measures of weight, mood, and affect regulation were not significant. These results support further research into DBT as a treatment of BED.

 

Van den Bosch, L.M.C., Verheul, R., Schippers, G.M., & van den Brink, W. (2002). Dialectical Behavior Therapy of Borderline Patients With and Without Substance Use Problems: Implementation and long term effects. Addictive Behaviors. 27(6): 911-923.

OBJECTIVE: The aim of this article is to examine whether standard Dialectical Behavior Therapy (DBT) (1) can be successfully implemented in a mixed population of borderline patients with or without comorbid substance abuse (SA), (2) is equally efficacious in reducing borderline symptomatology among those with and those without comorbid SA, and (3) is efficacious in reducing the severity of the substance use problems. METHOD: The implementation of DBT is examined qualitatively. The impact of comorbid SA on its efficacy, as well as on its efficacy in terms of reducing SA is investigated in a randomized clinical trial comparing DBT with treatment-as-usual (TAU) in 58 female borderline patients with (n=31) and without (n=27) SA. RESULTS: Standard DBT can be applied in a group of borderline patients with and without comorbid SA. Major implementation problems did not occur. DBT resulted in greater reductions of severe borderline symptoms than TAU, and this effect was not modified by the presence of comorbid SA. Standard DBT, as it was delivered in our study, however, is not more efficacious than TAU in reducing substance use problems. We propose that, rather than developing separate treatment programs for dual diagnosis patients, DBT should be “multitargeted.” This means that therapists ought to be trained in addressing a range of severe manifestations of personality pathology in the impulse control spectrum, including suicidal and self-damaging behaviors, binge eating, and SA.

 

 

Books and Articles Relevant to Clinical Practice

 

Foa, E. B. & Rothbaum, B. O. (2001). Treating the Trauma of Rape: Cognitive Behavioral Therapy for post-traumatic stress disorder.Guilford Press: New York.

 

Greco, L.A., & Hayes, S.C.  (2008).  Acceptance & Mindfulness Treatments for Children and Adolescents: A practitioner’s guide.  Oakland, CA.: New Harginger Press.

 

Hayes, S.C. Follette, V.M., & Linehan, M.M. (eds.) (2004). Mindfulness and Acceptance: Expanding the cognitive behavioral tradition.New York: The Guilford Press.

 

Linehan, M.M. (1993). Cognitive Behavioral Treatment for Borderline Personality Disorder. New York: Guilford Publications.

 

Linehan, M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.

 

McKay, M., Wood, J., and Brantley J. (2007).  The Dialectical Behavior Therapy Skills Workbook – Practical DBT Excercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance. Oakland, CA: New Harbinger Publications, Inc.

 

Miller, A.L., Rathus, J.H. & Linehan, M.M. (2006). Dialectical Behavior Therapy with Suicidal Adolescents. New York: Guilford Publications.

 

Segal, Z., Williams, J.M., Teasdale, J.D. (2001) Mindfulness-Based Cognitive Therapy for Depression: A new approach to preventing relapse.New York: Guilford Press.

 

Swales, M. A., & Heard, H. L. (2009). Dialectical behaviour therapy: distinctive features. London: Routledge.

 

Online Resources

 

For Clinicians:

Behavioral Tech

http://behavioraltech.org

 

Institute for Girls’ Development

http://www.instituteforgirlsdevelopment.com/

 

For Clients:

Official Behavioral Tech Site for Consumers

http://behavioraltech.org/resources/tools_consumers.cfm

 

Institute for Girls’ Development

http://www.instituteforgirlsdevelopment.com/

 

DBT Self Help Resources

http://www.dbtselfhelp.com