Skills use and common treatment processes in dialectical behaviour therapy for borderline personality disorder

Background and Objectives Dialectical behaviour therapy (DBT) trains participants to use behavioural skills for managing their emotions. The study aimed to evaluate whether skills use is associated with positive treatment outcomes independently of treatment processes that are common across different therapeutic models. Method Use of the DBT skills and three common treatment processes (therapeutic alliance, treatment credibility and self-efficacy) were assessed every 2 months for a year in 70 individuals with borderline personality disorder receiving DBT. Mixed-multilevel modelling was used to determine the association of these factors with frequency of self-harm and with treatment dropout. Results Participants who used the skills less often at any timepoint were more likely to drop out of DBT in the subsequent two months, independently of their self-efficacy, therapeutic alliance or perceived treatment credibility. More frequent use of the DBT skills and higher self-efficacy were each independently associated with less frequent concurrent self-harm. Treatment credibility and the alliance were not independently associated with self-harm or treatment dropout. Limitations The skills use measure could not be applied to a control group who did not receive DBT. The sample size was insufficient for structural equation modelling. Conclusion Practising the DBT skills and building an increased sense of self-efficacy may be important and partially independent treatment processes in dialectical behaviour therapy. However, the direction of the association between these variables and self-harm requires further evaluation

Assertive Anger Mediates Effects of Dialectical Behaviour-informed Skills Training for Borderline Personality Disorder: A Randomized Controlled Trial.

Dialectical behaviour therapy (DBT)-informed skills training for borderline personality disorder (BPD) aims at the development of specific emotion regulation skills in patients, particularly with regard to the regulation of problematic anger. While the effects of dialectical behaviour skills training have been shown, their processes of change are rarely examined. Neacsiu, Rizvi and Linehan (2010) found that patient's self-reported use of emotion regulation skills was a mediator of therapeutic change in these treatments; however, they found no effect for problematic anger. From an integrative perspective on anger (Pascual-Leone & Greenberg, 2007; Pascual-Leone & Paivio, 2013), there are several forms of anger, varying in their degree of therapeutic productivity. The present add-on randomized controlled trial included n = 41 patients with BPD (n = 21 DBT-informed skills training versus n = 20 treatment as usual). The first study examined the outcome of the DBT-informed skills training encompassing basic components of training in mindfulness, distress tolerance, interpersonal effectiveness and emotion regulation. Results showed that symptom reduction was significantly greater in the DBT-informed skills training, compared with the treatment as usual. The second study used process assessment, for which all patient completers underwent a 50-min-long psychological interview both early and late in treatment, which was rated using the Classification of Affective Meaning States. DBT-informed skills training produced increased levels of primary 'assertive' anger, as compared with the treatment as usual, whereas no effect was found for 'rejecting' secondary anger. Most importantly, we showed that changes in assertive anger mediated the reported symptom reduction, in particular in patient's social roles. We discuss these results in the context of underlying mechanisms of change in DBT skills group treatments, in particular towards developing more productive forms of anger in this patient population. Copyright © 2015 John Wiley & Sons, Ltd. A 20-session dialectical behaviour therapy (DBT)-informed skills training is a promising adjunct intervention for patients with borderline personality disorder, in particular for reducing problems related to social role. Increases in assertive anger mediate the effects of DBT-informed skills training, whereas rejecting anger remains unchanged over the course of treatment. Short-term objectives for intervention might involve the specific increase of assertive anger in BPD, by using DBT-informed skills training; long-term objectives for intervention might involve a specific decrease of rejecting anger in BPD

The Role of Coping Change in Borderline Personality Disorder: A Process-Outcome Analysis on Dialectical-Behaviour Skills Training.

Difficulty in emotion regulation is a hallmark feature of patients with borderline personality disorder (BPD). Skills training concepts based on dialectical-behaviour therapy (DBT) are common and effective treatment options for specifically addressing lacking skills in emotion regulation. However, so far it is unclear which aspects of coping change over the course of DBT skills training and if these coping strategies predict symptom change. The present process-outcome analysis, based on a randomized controlled study, aims at investigating these questions, by referring to a general conception of coping and by using an observer-rated approach to assess coping strategies directly in the therapy sessions. In total, n = 31 patients with BPD underwent two individual clinical interview assessments (pre- and post-study intervention; half of the patients underwent DBT skills training, half were in a wait-list control). All individual assessment sessions were transcribed and analysed using the Coping Action Pattern Rating Scale. Outcome was assessed pre- and post-intervention using the Outcome Questionnaire-45.2 and the Borderline Symptom List 23. The results showed increase in overall coping functioning in patients who underwent the DBT skills training, compared with the controls, and specific increases in relatedness coping where the stress is appraised as challenge, along with specific decreases in autonomy coping where the stress is appraised as threat. These changes predicted changes in general distress and borderline symptomatology. The results are interpreted within a general framework aiming at understanding the psychological effects of treatments for BPD, in particular effects related to coping. Effective emotion regulation strategies may therefore be important candidates as potential change mechanisms in treatments for BPD. Copyright © 2016 John Wiley & Sons, Ltd. It seems important for clinicians to assess the quality of coping strategies as they occur within the session facing a patient with borderline personality disorder. Clinicians may foster the emergence of support-seeking and self-reliance coping strategies in order to increase the effectiveness of therapy. Clinicians may monitor closely the patient's use of ineffective emotion regulation strategies, in particular opposition and submission, with the aim of reducing them early in therapy

Psychosocial interventions for self-harm in adults

Background: Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm. Objectives: To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH. Search methods: The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). Selection criteria: We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services. Data collection and analysis: We used Cochrane's standard methodological procedures

Process and impact of dialectical behaviour therapy: a systematic review of perceptions of clients with a diagnosis of borderline personality disorder

Purpose: To identify, appraise and synthesise findings from qualitative studies of individuals diagnosed with Borderline Personality Disorder who have experienced Dialectical Behaviour Therapy, to gain further understanding of their perceptions of the process and impact of therapy. Methods: We conducted a comprehensive systematic search of the literature from several online databases, and appraised them using an adapted version of the Critical Appraisal Skills Programme tool. A meta-ethnographic approach was used to synthesise the data. Results: Seven studies met the criteria to be included and their quality subsequently appraised. Four main themes were identified through the synthesis process: Life before DBT; the relationships that support change; developing self-efficacy; a shift in perspectives. Conclusions: The findings of the synthesis highlight the importance of a number of key factors in the process of DBT, and the impact that the therapy has both on day to day life and on individuals’ identity

A Treatment Mechanism for Emotion Dysregulation Across Mood and Anxiety Disorders

Thesis (Ph.D.)--University of Washington, 2012