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The contribution of skills to the effectiveness of dialectical behavioral therapy
Abstract
Objective:
The present study investigated the effectiveness of dialectical behavioral therapy (DBT) and the effect of improvement in DBT skills on clinical outcomes.
Method:
Participants included 57 adults who attended a community mental health service and underwent one of two modes of DBT. Twenty-six adults had been diagnosed with borderline personality disorder (BPD) and participated in comprehensive DBT (DBT-C; including group skills training, individual therapy, and phone coaching). Thirty-one adults had BPD traits and participated in DBT skills training (DBT-S; group skills training only). In the present study, the DBT skills examined were mindfulness, emotion regulation, and interpersonal effectiveness; the clinical outcomes examined were borderline symptoms, psychological distress, and quality of life.
Results:
Six 2 × 2 analysis of covariances indicated significant improvements in psychological distress, quality of life, mindfulness, and interpersonal effectiveness (but not borderline symptoms and emotion regulation), over a 6-month period. Mode of delivery of DBT did not impact on the improvement in DBT skills and clinical outcomes over the 6-month period. Hierarchical multiple regression results indicated that improvement in DBT skills (mindfulness, emotion regulation, and interpersonal effectiveness) were associated with reductions in borderline symptoms and psychological distress, with emotion regulation the only skill uniquely associated with improvements in clinical outcomes.
Conclusions:
The results of the present study support the effectiveness of DBT and the specific role of emotion regulation for favorable clinical outcomes over a 6-month period, independent of the mode of delivery of DBT.
... DBT has shown substantial effectiveness in improving emotional regulation, reducing maladaptive behaviors, and enhancing overall psychological functioning (Bianchini et al., 2019;Lee et al., 2022). Studies have demonstrated that DBT can significantly reduce symptoms of emotional dysregulation and improve quality of life in various populations (Fnoon et al., 2021;Rezaei et al., 2019). ...
... Empathy, while beneficial in many contexts, can also become a source of stress when individuals are unable to effectively manage their emotional responses to others' distress (Omdahl & O'Donnell, 1999). DBT's interpersonal effectiveness skills are particularly relevant in this regard, as they focus on balancing one's own needs with the needs of others, thus fostering healthy and sustainable empathic responses (Lee et al., 2022). Enhancing empathy through DBT can improve interpersonal relationships and caregiving outcomes, while also preventing the negative consequences of empathic distress. ...
... Mindfulness practices help individuals become more aware of their emotional states without judgment, allowing them to manage stress more effectively. Emotional regulation strategies provide tools for identifying and altering maladaptive emotional responses, thereby preventing the accumulation of stress that leads to exhaustion (Lee et al., 2022). These mechanisms explain why participants in the DBT intervention group experienced significant improvements in their levels of emotional exhaustion. ...
The objective of this study was to evaluate the effectiveness of Dialectical Behavior Therapy (DBT) in reducing emotional exhaustion and enhancing empathy among participants. This randomized controlled trial included 30 participants, randomly assigned to either the DBT intervention group or a control group, with 15 participants in each group. The intervention group underwent eight 75-minute DBT sessions over three months, while the control group received no intervention. Emotional exhaustion and empathy were measured at baseline, post-intervention, and at a three-month follow-up using the Maslach Burnout Inventory (MBI) and the Interpersonal Reactivity Index (IRI), respectively. Data analysis was conducted using analysis of variance (ANOVA) with repeated measurements and the Bonferroni post-hoc test, with statistical analyses performed using SPSS-27. The intervention group showed a significant reduction in emotional exhaustion from a baseline mean of 45.23 (SD = 8.21) to 32.56 (SD = 7.45) post-intervention and 34.12 (SD = 7.89) at follow-up. In contrast, the control group's emotional exhaustion remained relatively stable (baseline: 44.87, SD = 7.98; post-intervention: 44.12, SD = 7.89; follow-up: 45.23, SD = 8.12). Empathy scores in the intervention group increased significantly from 52.34 (SD = 9.12) at baseline to 60.23 (SD = 8.45) post-intervention, with a slight decrease to 58.56 (SD = 8.76) at follow-up. The control group showed minimal changes in empathy (baseline: 51.67, SD = 8.89; post-intervention: 52.34, SD = 8.56; follow-up: 51.23, SD = 8.67). ANOVA results confirmed the significance of these changes (F = 31.15, p < 0.001), with Bonferroni post-hoc tests indicating significant differences between baseline and subsequent time points in the intervention group (p < 0.001). The study demonstrates that DBT is significantly effective in reducing emotional exhaustion and enhancing empathy among participants. These findings suggest that DBT can be a valuable intervention for improving psychological resilience and interpersonal effectiveness, particularly in populations at risk for burnout and empathic distress.
... Furthermore, the ability to listen carefully to others, relate to them and strive to understand their point of view is essential in order to foster create an environment where dialogue and mutual understanding can thrive, thus forming the bedrock of any mediation process (4). Other important life skills aimed at conflict management that have a bearing in mediation processes, in the legal and medicolegal settings, include the ability to solve problems effectively and sustainably, make informed decisions and manage personal emotions appropriately (5). For instance, the ability to find solutions to any given issue from scratch can help the parties involved to compromise and find common ground on which to solve their conflicts. ...
This writing aims to convey the essential nature and features of a cultural tool based on a set of skills and capabilities generally referred to as "life skills", which allow for the proper management (in the medical and medical-forensic professional realms) of daily situations in an effective and rewarding fashion. Such a process is based on individual tools such as communication, problem solving, stress management, self-control, the ability to make timely decisions, empathy, creativity and the opportunity to work in a multidisciplinary setting. Life skills include everything the professional should rely on in order to minimize the risks of a professional error, through the acquisition of knowledge and behavioral traits which constitute the fundamental, experience-based starting point. The chief objective of this commentary is to outline the scope of a straightforward discussion by specifically defining such skills; that in turn will make it possible to identify all the technical issues to address during the medical-diagnostic assessment, also from a medico-legal perspective, in order to frame the residual life skills and evaluate the possibilities of recovery and any disabilities, based on observation and interactions with each patient aimed at weighing their psychophysical performance.
Background
Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers‐Winterling 2012).
Objectives
To assess the beneficial and harmful effects of psychological therapies for people with BPD.
Search methods
In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.
Selection criteria
Randomised controlled trials comparing different psychotherapeutic interventions with treatment‐as‐usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.
Data collection and analysis
At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.
Main results
We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation‐based treatment (MBT). The comparator interventions included treatment‐as‐usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months.
Psychotherapy versus TAU
Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) −0.52, 95% confidence interval (CI) −0.70 to −0.33; 22 trials, 1244 participants; moderate‐quality evidence. This corresponds to a mean difference (MD) of −3.6 (95% CI −4.4 to −2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is −3.0 points).
Psychotherapy may be more effective at reducing self‐harm compared to TAU (SMD −0.32, 95% CI −0.49 to −0.14; 13 trials, 616 participants; low‐quality evidence), corresponding to a MD of −0.82 (95% CI −1.25 to 0.35) on the Deliberate Self‐Harm Inventory Scale (range 0 to 34). The MIREDIF of −1.25 points was not reached.
Suicide‐related outcomes improved compared to TAU (SMD −0.34, 95% CI −0.57 to −0.11; 13 trials, 666 participants; low‐quality evidence), corresponding to a MD of −0.11 (95% CI −0.19 to −0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of −0.17 points was not reached.
Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD −0.45, 95% CI −0.68 to −0.22; 22 trials, 1314 participants; low‐quality evidence), corresponding to a MD of −2.8 (95% CI −4.25 to −1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of −4.0 points was not reached.
Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases.
A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning.
Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD −0.39, 95% CI −0.61 to −0.17; 22 trials, 1568 participants; very low‐quality evidence), corresponding to a MD of −2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of −3.0 points was not reached.
BPD‐specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data.
Psychotherapy versus waiting list or no treatment
Greater improvements in BPD symptom severity (SMD −0.49, 95% CI −0.93 to −0.05; 3 trials, 161 participants), psychosocial functioning (SMD −0.56, 95% CI −1.01 to −0.11; 5 trials, 219 participants), and depression (SMD −1.28, 95% CI −2.21 to −0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low‐quality evidence). No evidence of a difference was found for self‐harm and suicide‐related outcomes.
Individual treatment approaches
DBT and MBT have the highest numbers of primary trials, with DBT as subject of one‐third of all included trials, followed by MBT with seven RCTs.
Compared to TAU, DBT was more effective at reducing BPD severity (SMD −0.60, 95% CI −1.05 to −0.14; 3 trials, 149 participants), self‐harm (SMD −0.28, 95% CI −0.48 to −0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD −0.36, 95% CI −0.69 to −0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self‐harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD −0.58, 95% CI −1.22 to 0.05, 4 trials, 333 participants). All findings are based on low‐quality evidence. For secondary outcomes see review text.
Authors' conclusions
Our assessments showed beneficial effects on all primary outcomes in favour of BPD‐tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF‐defined cut‐off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) .
The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low‐quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self‐harm and suicide‐related outcomes.
However, compared to TAU, we observed effects in favour of DBT for BPD severity, self‐harm and psychosocial functioning and, for MBT, on self‐harm and suicidality at end of treatment, but these were all based on low‐quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.
We describe a naturally occurring, real-world comparison of outcomes following 6 months in standalone DBT skills training group for adults with Borderline Personality Disorder (BPD) without recent suicidal or severe self-harming behaviours and standard (i.e. all modes) DBT for BPD including patients with recent high-risk behaviours. 34 patients chose standalone skills over waiting for standard DBT and 54 were offered standard DBT. Dropout was higher for standalone skills than standard DBT (38.2% vs. 16.7%). No statistically or clinically significant differences were found among completers between conditions on borderline symptoms, general psychopathology, and suicide ideation. There was a moderate effect for standalone skills on hopelessness and emotion regulation difficulties which may have reflected non-equivalence of treatment groups. Significant methodological factors limit generalisability of findings which offer support for feasibility of standalone DBT skills as an effective alternative to waitlist for standard DBT for at least some patients with BPD in the community.
Despite research supporting the effectiveness of dialectical behavior therapy (DBT) for borderline personality disorder (BPD), few studies have examined how DBT leads to clinical change. DBT is theorized to lead to improved clinical outcomes by enhancing the capacity for emotion regulation, including improvement in skills (e.g., mindfulness and distress tolerance) for managing emotional distress and impulsive behaviors. Therefore, the aim of this study was to test whether improvements in mindfulness and distress tolerance indirectly affect the relationship between DBT skills training and clinical outcomes. The sample consists of 84 patients diagnosed with BPD who were enrolled in a randomized controlled trial comparing 20 weeks of DBT-skills group (DBT-S) to an active waitlist control. Mindfulness and distress tolerance were assessed at baseline and at the end of the 20 weeks. BPD symptoms, general psychiatric symptoms, and social adjustment were assessed at the end of 20 weeks and combined into a latent variable representing a broad assessment of general psychopathology. Relative to the waitlist control group, improvements in mindfulness and distress tolerance each independently indirectly affected the relationship between DBT-S and posttreatment general psychopathology. Findings suggest that DBT-S exerts its effects on outcomes through improvements in mindfulness and distress tolerance. These findings support the significance of mindfulness and distress tolerance in DBT-S for BPD. Limitations, future directions, and clinical implications are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
While dialectical behaviour therapy (DBT) appears efficacious in reducing suicidal and self-harming behaviour, it is unclear whether DBT reduces emotion regulation (ER) difficulties, a purported mechanism of change of treatment. This review aims to investigate and evaluate the current evidence to understand the effectiveness of DBT in improving ER difficulties. A qualitative synthesis of studies investigating the effectiveness of DBT on self-reported ER difficulties as measured by the Difficulties in Emotion Regulation Scale (DERS) was performed, identifying eligible studies using PsycINFO, PubMed, MEDLINE and EMBASE databases. Fourteen studies were identified. Current evidence indicates that DBT does not show consistent benefits relative to existing psychological treatments in improving ER difficulties. The literature is compromised by significant methodological limitations increasing risk of bias across study outcomes. Furthermore, high variability across DBT programs and a lack of investigation regarding adherence and participant engagement within interventions was observed. Further research is needed in order to conclude regarding the effectiveness of DBT in improving ER difficulties. Consistent use of active treatment conditions, greater standardisation of DBT-based interventions, in addition to further examination of participant engagement level in DBT-based interventions in the long term may assist understanding as to whether DBT improves ER difficulties.
Background
Worldwide, women are found to suffer from depression significantly more than men. This has puzzled the scientists since no biological explanation can completely resolve the matter.
Method
Extant empirical work has been conducted to solve the mystery of the issue. However, most of the research has pivoted their attention to biology. Therefore, based on the previous literature from the disciplines of medicine, psychology and sociology, the author aimed at looking and reviewing the matter critically. Specifically, the present critical review aims at conceptualising the psychological, social and cultural factors in the context of gender difference in depression.
Discussion
The work reveals that psychological variables such as women’s unique attachment patterns, relational self-construal, as well as a macro-level issue like power dynamics based on gender, and the skewed division of labour play an important role in gender difference in depression. The work also suggests that focusing solely on biological underpinnings may result in losing the entire scenario; therefore, social and cultural issues that place women in a socially disadvantaged position are equally important.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To assess the beneficial and harmful effects of psychological therapies for people with borderline personality disorder (BPD).
INTRODUCTION
87 female and 10 male adult outpatients with BPD diagnoses presenting with acute suicidal and self-harm behaviors were offered a 12-Month Intensive DBT Program delivered by an interdisciplinary team of psychotherapists, including social workers, nurses, and a psychologist.
METHODS
Clients were administered self-report measures at pre-treatment, and at 3-, 6-, and 12-month intervals in a single-group longitudinal design. Our analyses of treatment outcomes (ANOVA and Bonferroni-corrected comparisons) considered: BPD-specific symptoms, using the BSL-23 (n = 44), ZAN-BPD (n = 39), and DBT-WCCL Adaptive Skills Use and Dysfunctional Coping subscales (n = 43); transdiagnostic psychiatric symptoms, using the BSI Global Severity Index (n = 35); and quality of life, using QOLI t-scores (n = 42). We also evaluated changes in the proportions of clients who used services for mental health-related crises, visited the ER, or were admitted as inpatients.
RESULTS
Significant reductions in both BPD-specific and transdiagnostic psychiatric symptoms were found. Quality of life improved. DBT skills use notably increased and dysfunctional coping scores declined inversely. Fewer clients tended to use crisis services and visit the ER.
DISCUSSION
These results illustrate the potential for accessible, effective treatment for BPD delivered by interdisciplinary staff.
A number of statistical textbooks recommend using an analysis of covariance (ANCOVA) to control for the effects of extraneous factors that might influence the dependent measure of interest. However, it is not generally recognized that serious problems of interpretation can arise when the design contains comparisons of participants sampled from different populations (classification designs). Designs that include a comparison of younger and older adults, or a comparison of musicians and non-musicians are examples of classification designs. In such cases, estimates of differences among groups can be contaminated by differences in the covariate population means across groups. A second problem of interpretation will arise if the experimenter fails to center the covariate measures (subtracting the mean covariate score from each covariate score) whenever the design contains within-subject factors. Unless the covariate measures on the participants are centered, estimates of within-subject factors are distorted, and significant increases in Type I error rates, and/or losses in power can occur when evaluating the effects of within-subject factors. This paper: (1) alerts potential users of ANCOVA of the need to center the covariate measures when the design contains within-subject factors, and (2) indicates how they can avoid biases when one cannot assume that the expected value of the covariate measure is the same for all of the groups in a classification design.
Dialectical behavior therapy (DBT) is an empirically supported treatment for suicidal individuals. However, DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team, and little is known about which components are needed to achieve positive outcomes.
To evaluate the importance of the skills training component of DBT by comparing skills training plus case management (DBT-S), DBT individual therapy plus activities group (DBT-I), and standard DBT which includes skills training and individual therapy.
We performed a single-blind randomized clinical trial from April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up. Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a university-affiliated clinic and community settings by therapists or case managers. Outcomes were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would outperform DBT-S and DBT-I.
The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was controlled across conditions, and all treatment providers used the DBT suicide risk assessment and management protocol.
Frequency and severity of suicide attempts and NSSI episodes.
All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and reasons for living. Compared with the DBT-I group, interventions that included skills training resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = -3.5 [P < .001]) and DBT-S (t94 = -2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]).
A variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol are effective for reducing suicide attempts and NSSI episodes. Interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some areas.
clinicaltrials.gov Identifier: NCT00183651.
This study investigated, and partially aimed to replicate, important construct validity aspects and the homogeneity of trait mindfulness measures. Specifically, the study set out to examine whether a single dimension can explain the shared variance among these measures as well as the extent to which they converge with one another and in terms of their linkages to the five-factor model (FFM). Two samples completed all trait measures of the construct and one of them additionally completed a measure of the Big Five personality traits. Results showed that a single dimension explains the shared variance among measures based on the original, Eastern conceptualization of mindfulness, although not all of them seem to represent this construct comprehensively. Intercorrelations, dimensionality analysis, as well as linkages to the FFM indicated that the Eastern and Western conceptualizations, and their respective measures, reflect distinct constructs. However, the amount of variance overlap with the FFM was similar across the two conceptualizations.
BACKGROUND: Bipolar disorder (BD) is a chronic and disabling psychiatric disorder characterized by recurrent episodes of mania/hypomania and depression. Dialectical behavior therapy (DBT) techniques have been shown to effectively treat borderline personality disorder, a condition also marked by prominent affective disturbances. The utility of DBT techniques in treating BD has been largely unexplored. The purpose of this research was to conduct a pilot study of a DBT-based psychoeducational group (BDG) in treating euthymic, depressed, or hypomanic Bipolar I or II patients. METHODS: In this experiment, 26 adults with bipolar I or II were randomized to intervention or wait-list control groups and completed the Beck depression inventory II, mindfulness-based self-efficacy scale, and affective control scale at baseline and 12 weeks. The BDG intervention consisted of 12 weekly 90-min sessions which taught DBT skills, mindfulness techniques, and general BD psychoeducation. RESULTS: Using RM-ANOVA, subjects in BDG demonstrated a trend toward reduced depressive symptoms, and significant improvement in several MSES subscales indicating greater mindful awareness, and less fear toward and more control of emotional states (ACS). These findings were supported with a larger sample of patients who completed the BDG. Furthermore, group attendees had reduced emergency room visits and mental health related admissions in the six months following BDG. LIMITATIONS: The small sample size in RCT affects power to detect between group differences. How well improvements after the12-week BDG were maintained is unknown. CONCLUSIONS: There is preliminary evidence that DBT skills reduce depressive symptoms, improve affective control, and improve mindfulness self-efficacy in BD. Its application warrants further evaluation in larger studies.
The full version of the Borderline Symptom List (BSL; for clarification now labeled BSL-95) is a self-rating instrument for specific assessment of borderline-typical symptomatology. The BSL-95 items are based on criteria of the DSM-IV, the revised version of the Diagnostic Interview for Borderline Personality Disorder, and the opinions of both clinical experts and borderline patients. The BSL-95 includes 95 items. In order to reduce patient burden and assessment time, a short version with 23 items (BSL-23) was developed.
The development of the BSL-23 was based on a sample of 379 borderline patients, considering the items from the BSL-95 that had the highest levels of sensitivity to change and the highest ability to discriminate borderline patients from other patient groups. In a second step, the psychometric properties of the BSL-23 were investigated and compared with the psychometric properties of the BSL-95 in 5 different samples, including a total of 659 borderline patients.
In all of the samples, a high correlation of the sum score was found between the BSL-23 and the BSL-95 (range: 0.958-0.963). The internal consistency was high for both versions (BSL-23/Cronbach's alpha: 0.935-0.969; BSL-95/Cronbach's alpha: 0.977-0.978). Both BSL-23 and BSL-95 clearly discriminated borderline personality disorder patients from patients with an axis I diagnosis (mean effect sizes were 1.13 and 0.96 for the BSL-23 and BSL-95, respectively). In addition, comparisons before and after 3 months of dialectical behavior therapy revealed a numerically larger effect size for the BSL-23 (d = 0.47) compared to the BSL-95 (d = 0.38).
The results indicate that the BSL-23 is an efficient and convenient self-rating instrument that displays good psychometric properties comparable to those of the BSL-95. The BSL-23 also demonstrated sensitivity to the effects of therapy.
We constructed a set of circumplex scales for the Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988). Initial scale construction used all 127 items from this instrument in two samples of university undergraduates (n = 197; n = 273). Cross-sample stability of item locations plotted against the first two principal components was high. A final set of eight 8-item circumplex scales was derived from the combined sample (n = 470) and cross-validated in a third university sample (n = 974). Finally, we examined the structural convergence of the IIP circumplex scales with an established measure of interpersonal dispositions, the Revised Interpersonal Adjective Scales (IAS-R; Wiggins, Trapnell, & Phillips, 1988). Although both circumplex instruments were derived independently, they shared a common Circular space. Implications of these results are discussed with reference to current research methods for the study of interpersonal behavior.
Previous reports demonstrating quality-of-life impairment in anxiety and affective disorders have relied upon epidemiological samples or relatively small clinical studies. Administration of the same quality-of-life scale, the Quality of Life Enjoyment and Satisfaction Questionnaire, to subjects entering multiple large-scale trials for depression and anxiety disorders allowed us to compare the impact of these disorders on quality of life.
Baseline Quality of Life Enjoyment and Satisfaction Questionnaire, demographic, and clinical data from 11 treatment trials, including studies of major depressive disorder, chronic/double depression, dysthymic disorder, panic disorder, obsessive-compulsive disorder (OCD), social phobia, premenstrual dysphoric disorder, and posttraumatic stress disorder (PTSD) were analyzed.
The proportion of patients with clinically severe impairment (two or more standard deviations below the community norm) in quality of life varied with different diagnoses: major depressive disorder (63%), chronic/double depression (85%), dysthymic disorder (56%), panic disorder (20%), OCD (26%), social phobia (21%), premenstrual dysphoric disorder (31%), and PTSD (59%). Regression analyses conducted for each disorder suggested that illness-specific symptom scales were significantly associated with baseline quality of life but explained only a small to modest proportion of the variance in Quality of Life Enjoyment and Satisfaction Questionnaire scores.
Subjects with affective or anxiety disorders who enter clinical trials have significant quality-of-life impairment, although the degree of dysfunction varies. Diagnostic-specific symptom measures explained only a small proportion of the variance in quality of life, suggesting that an individual's perception of quality of life is an additional factor that should be part of a complete assessment.
The authors examine the facet structure of mindfulness using five recently developed mindfulness questionnaires. Two large samples of undergraduate students completed mindfulness questionnaires and measures of other constructs. Psychometric properties of the mindfulness questionnaires were examined, including internal consistency and convergent and discriminant relationships with other variables. Factor analyses of the combined pool of items from the mindfulness questionnaires suggested that collectively they contain five clear, interpretable facets of mindfulness. Hierarchical confirmatory factor analyses suggested that at least four of the identified factors are components of an overall mindfulness construct and that the factor structure of mindfulness may vary with meditation experience. Mindfulness facets were shown to be differentially correlated in expected ways with several other constructs and to have incremental validity in the prediction of psychological symptoms. Findings suggest that conceptualizing mindfulness as a multifaceted construct is helpful in understanding its components and its relationships with other variables.
This study assessed the construct validity of the circumplex model of the Inventory of Interpersonal Problems (IIP-C) in Norwegian clinical and nonclinical samples. Structure was examined by evaluating the fit of the circumplex model to data obtained by the IIP-C. Observer-rated personality disorder criteria (DSM-IV, Axis II) were used as external correlates. The reliability of the IIP-C scales was acceptable and in the same range as in the original version. A multisample analysis strategy did not support an invariant circumplex model across the 2 groups. However, the estimated structures reflected mostly the same circular pattern of a quasi-circumplex model in the 2 groups. Departures from the ideal model were of negligible practical significance. The validity results examining personality disorder correlates of the IIP-C generally conformed to predictions, providing direct evidence for agreement between self-report and expert judgments of interpersonal problems.
A core aspect of Dialectical Behaviour Therapy (DBT) is the acquisition and use of DBT skills to replace maladaptive behaviours. However, it is unclear whether DBT skill use is associated with differential reductions in psychological distress across individuals with varying severities of borderline personality disorder (BPD) symptoms. In the current study, moderated mediation analyses were conducted to examine the relationships among DBT skill use and attitudes towards skill use, pre-treatment BPD symptom severity and changes in psychological distress over the course of a 12-week DBT-informed program in a sample of outpatients with mixed psychopathology (N = 102), including a minority with BPD (N = 16). It was predicted that (i) self-reported use of the four types of DBT skills (mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness) and (ii) patient attitudes towards these skills (confidence and perceived effectiveness) would be associated with greater improvements in psychological distress in individuals with higher levels of BPD symptoms compared to individuals with lower levels of BPD symptoms. Results supported this hypothesis, indicating that self-reported DBT skill use and attitudes towards DBT skills are associated with differential patterns of reductions in psychological distress.
Objective
We examined the relationship between mindfulness skills acquisition and symptom reduction.
Method
Participants were adults (n = 35) with a diagnosis of borderline personality disorder (BPD) who completed a 20‐week dialectical behaviour therapy (DBT) skills training group program in a community mental health setting. We used the Five Facet Mindfulness Questionnaire, which measures five dimensions of mindfulness: observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience.
Results
Linear mixed model results suggested that increases in some mindfulness facets, especially in acting with awareness and nonjudging of inner experience were more strongly related to changes during treatment including reductions in BPD symptomology, depression, and distress with increases in nonjudging also predicting a reduction in the hospital use.
Conclusions
These results suggest the usefulness of emphasising mindfulness skills that develop awareness and encourage a nonjudgmental stance.
Limited literature suggests that there may be age-related differences in borderline personality disorder (BPD) symptom expression. The present study used item response theory (IRT) methods to examine whether there are age differences in the likelihood of endorsing DSM-IV symptoms of BPD, when equating for levels of BPD symptom severity. Data were drawn from a nationally representative survey of adults in the US (n = 34,653), the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). We found that 7 out of the 9 DSM-IV symptoms of BPD were age invariant. However, there were statistically and clinically significant differences between the oldest and youngest age groups in two BPD symptoms: oldest adult women were less likely to report suicidal/self-harm behavior than the youngest adult women across levels of BPD severity and unstable/intense interpersonal relationships discriminated BPD severity better in the youngest age group compared to the oldest age group in both genders. Overall, our findings indicate substantial age-related differences in BPD symptom expression. Mental health care providers should be alert to these two age-related differences in BPD symptom expression when making assessment and treatment decisions across adult age groups.
Gender bias in the diagnosis and assessment of borderline personality disorder (BPD) has been the subject of much controversy in the psychological research literature. Evidence regarding differential prevalence rates and diagnostic rates in clinical settings between genders has been mixed, and measurement bias is one potential explanation for these mixed findings. A total of 340 participants were recruited from a Midwestern university and four outpatient community mental health clinics. They were administered two structured clinical interviews for BPD that were then evaluated for measurement invariance. Both the SCID-II BPD scale and the PDI-IV BPD scale were found to be measurement invariant between genders. No significant differences were found on the SCID-II BPD scale in diagnosis or overall number of criteria endorsed. However, in the rates of endorsement of individual criteria, differences were found in the unstable relationships item.
Background: Little is known about the “active ingredients” of psychological therapy for Borderline Personality Disorder (BPD) despite a growing evidence base documenting its clinical effectiveness. This information can be used by clinicians to inform service planning and care pathways.
Aims: The aim of this study was to review published empirical research investigating the potential mechanisms underlying therapeutic change in Dialectical Behaviour Therapy (DBT) and Cognitive Behaviour Therapy (CBT) for BPD.
Method: A thorough search of the PsychInfo, CINAHL Plus, PubMed, MEDLINE and EMBASE databases revealed research into potential mechanisms of change.
Results: A total of 52 abstracts were reviewed. After a full text screen of the most relevant studies, 14 met inclusion criteria. Twelve examined DBT and two CBT. Mechanisms of change identified broadly fell into three categories: emotion regulation/self-control, skills use and therapeutic alliance/investment in treatment. Outcomes measured included general mental health diagnoses (e.g. anxiety, depression) and BPD-specific symptoms (e.g. self-harm/suicidality, impulsivity, substance misuse, anger).
Conclusion: Further empirically robust research is required to test hypotheses about the influence of the proposed mechanisms on therapeutic change in psychological therapies for BPD.
Objective:
Evidence-based therapies for borderline personality disorder (BPD) are lengthy and scarce. Data on brief interventions are limited, and their role in the treatment of BPD is unclear. Our aim was therefore to evaluate the clinical effectiveness of brief dialectical behaviour therapy (DBT) skills training as an adjunctive intervention for high suicide risk in patients with BPD.
Method:
Eighty-four out-patients were randomized to 20 weeks of DBT skills (n = 42) or a waitlist (WL; n = 42). The primary outcome was frequency of suicidal or non-suicidal self-injurious (NSSI) episodes. Assessments were conducted at baseline 10, 20 and 32 weeks.
Results:
DBT participants showed greater reductions than the WL participants on suicidal and NSSI behaviours between baseline and 32 weeks (P < 0.0001). DBT participants showed greater improvements than controls on measures of anger, distress tolerance and emotion regulation at 32 weeks.
Conclusions:
This abbreviated intervention is a viable option that may be a useful adjunctive intervention for the treatment of high-risk behaviour associated with the acute phase of BPD.
The Book is the Italian Edition of M-M: Linehan DBT skills training manual pp.900
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.
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The Affective Control Scale (ACS) is a widely used measure of fear of emotion. Although the scale as a whole has good utility and predictive validity, there is little work on the specificity of the subscales of the ACS, which measure fear of anxiety, anger, depressed mood and positive mood. In the present study, we investigated the unique relations between fear of specific emotions and the everyday experience of those emotions. We sampled 120 undergraduate students and tracked their emotional experiences over the course of a week using ecological momentary assessments. We found evidence for specificity in the predictive validity of the subscales. After controlling for common variance across the subscales, fear of anger, anxiety, and depressed mood uniquely predicted greater daily experience of the corresponding emotion. These data also support the notion that those who fear specific emotions tend to experience more of those emotions in everyday life.
One of the fastest growing areas within psychology is the field of emotion regulation. However, enthusiasm for this topic continues to outstrip conceptual clarity, and there remains considerable uncertainty as to what is even meant by “emotion regulation.” The goal of this review is to examine the current status and future prospects of this rapidly growing field. In the first section, I define emotion and emotion regulation and distinguish both from related constructs. In the second section, I use the process model of emotion regulation to selectively review evidence that different regulation strategies have different consequences. In the third section, I introduce the extended process model of emotion regulation; this model considers emotion regulation to be one type of valuation, and distinguishes three emotion regulation stages (identification, selection, implementation). In the final section, I consider five key growth points for the field of emotion regulation.
This study evaluated the validity of the interpersonal model of binge-eating disorder (BED) psychopathology in a clinical sample of women with BED. Data from a cross-sectional sample of 255 women with BED were examined for the direct effects of interpersonal problems on BED symptoms and psychopathology, and indirect effects mediated by negative affect. Structural equation modelling analyses demonstrated that higher levels of interpersonal problems were associated with greater negative affect, and greater negative affect was associated with higher frequency of BED symptoms and psychopathology. There was a significant indirect effect of interpersonal problems on BED symptoms and psychopathology mediated through negative affect. Interpersonal problems may lead to greater BED symptoms and psychopathology, and this relationship may be partially explained by elevated negative affect. The results of the study are the first to provide support for the interpersonal model of BED symptoms and psychopathology in a clinical sample of women. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.
Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.
Objective
Dialectical behavior therapy (DBT) skills training is currently being administered as stand-alone treatment across a variety of clinical settings, serving diverse client populations. However, there is little empirical support for this use.Method
In this systematic review, we identified 17 trials employing a treatment that included DBT skills training in the absence of the other DBT modalities.ResultsWhile the literature reviewed provides preliminary evidence of the utility of DBT skills training to address a range of mental health and behavioral problems, methodological limitations of published studies preclude us from drawing strong conclusions about the efficacy of skills training as a stand-alone treatment.Conclusion
We present an overview of the implementation of DBT skills training across clinical settings and populations. We found preliminary evidence supporting the use of DBT skills training as a method of addressing a range of behaviors. We provide recommendations for future research.
Objective
Difficulties with emotions are common across mood and anxiety disorders. Dialectical behavior therapy skills training (DBT-ST) reduces emotion dysregulation in borderline personality disorder (BPD). Preliminary evidence suggests that use of DBT skills mediates changes seen in BPD treatments. Therefore, we assessed DBT-ST as a stand-alone, transdiagnostic treatment for emotion dysregulation and DBT skills use as a mediator of outcome.
Method
Forty-four anxious and/or depressed, non-BPD adults with high emotion dysregulation were randomized to 16 weeks of either DBT-ST or an activities-based support group (ASG). Participants completed measures of emotion dysregulation, DBT skills use, and psychopathology every 2 months through 2 months posttreatment.
Results
Longitudinal analyses indicated that DBT-ST was superior to ASG in decreasing emotion dysregulation (d = 1.86), increasing skills use (d = 1.02), and decreasing anxiety (d = 1.37), but not depression (d = 0.73). Skills use mediated these differential changes. Participants found DBT-ST acceptable. 32% of DBT-ST and 59% of ASG participants dropped treatment. 59% of DBT-ST and 50% of ASG participants complied with the research protocol to avoid ancillary psychotherapy and/or medication changes.
Conclusion
DBT-ST is a promising treatment for emotion dysregulation for depressed and anxious transdiagnostic adults, although more assessment of feasibility is needed.
Abstract This exploratory study examined specific emotion processes and cognitive problem-solving processes in individuals with borderline personality disorder (BPD), and assessed the relationship of these changes to treatment outcome. Emotion and cognitive problem-solving processes were assessed using the Toronto Alexithymia Scale, the Linguistic Inquiry Word Count, the Derogatis Affect Balance Scale, and the Problem Solving Inventory. Participants who showed greater improvements in affect balance, problem solving, and the ability to identify and describe emotions showed greater improvements on treatment outcome, with affect balance remaining statistically significant under the most conservative conditions. The results provide preliminary evidence to support the theory that specific improvements in emotion and cognitive processes are associated with positive treatment outcomes (symptom distress, interpersonal functioning) in BPD. The implications for treatment are discussed.
The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and its short form (Q-LES-Q-SF) are among the most frequently used outcome measures in psychiatry research. The aim of this study was to analyse the measurement properties of the Q-LES-Q-SF for quality of life assessments in the clinical settings. Fifty-seven adults with a psychiatric diagnosis participated. Psychometric evaluation included descriptive analysis, internal consistency, test-retest reliability, validity, sensitivity and responsiveness analysis. The amount of missing data was 5.3%, while no floor or ceiling effects were observed. The internal consistency and test-retest coefficients were 0.9 and 0.93, respectfully. Almost all items significantly correlated to the total score and other measures used in the study, with the correlations ranging 0.41-0.81. Finally, the responsiveness parameters indicated the Q-LES-Q-SF is 80% sensitive and 100% specific measure. This preliminary analysis of the Q-LES-Q-SF demonstrated that it could produce reliable and valid clinical assessments of quality of life.
A central component of Dialectical Behavior Therapy (DBT) is the teaching of specific behavioral skills with the aim of helping individuals with Borderline Personality Disorder (BPD) replace maladaptive behaviors with skillful behavior. Although existing evidence indirectly supports this proposed mechanism of action, no study to date has directly tested it. Therefore, we examined the skills use of 108 women with BPD participating in one of three randomized control trials throughout one year of treatment and four months of follow-up. Using a hierarchical linear modeling approach we found that although all participants reported using some DBT skills before treatment started, participants treated with DBT reported using three times more skills at the end of treatment than participants treated with a control treatment. Significant mediation effects also indicated that DBT skills use fully mediated the decrease in suicide attempts and depression and the increase in control of anger over time. DBT skills use also partially mediated the decrease of nonsuicidal self-injury over time. Anger suppression and expression were not mediated. This study is the first to clearly support the skills deficit model for BPD by indicating that increasing skills use is a mechanism of change for suicidal behavior, depression, and anger control.
Skills training is a crucial mode of treatment in dialectical behavioral therapy (DBT; Linehan, 1993b), yet a psychometrically sound measure of DBT skills use does not exist. We adapted the Revised Ways of Coping Checklist (RWCCL; Vitaliano, Russo, Carr, Maiuro, & Becker, 1985) to create the DBT Ways of Coping Checklist (DBT-WCCL). Using factor analysis procedures, two subscales emerged: one assessing coping via DBT skills, the DBT Skills Subscale (DSS), and one assessing coping via dysfunctional means, the Dysfunctional Coping Subscale (DCS). Principal component, internal consistency, test-retest reliability, and content validity analyses suggested that the scale has good to excellent psychometric properties. In addition, the DSS successfully discriminated patients who received skills training during 4 months of treatment from patients who did not. Moderators of skills use are also discussed. The DBT-WCCL appears to be a promising new measure of DBT skills use.
The psychometric properties of the Depression Anxiety Stress Scales (DASS) were evaluated in a normal sample of N = 717 who were also administered the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). The DASS was shown to possess satisfactory psychometric properties, and the factor structure was substantiated both by exploratory and confirmatory factor analysis. In comparison to the BDI and BAI, the DASS scales showed greater separation in factor loadings. The DASS Anxiety scale correlated 0.81 with the BAI, and the DASS Depression scale correlated 0.74 with the BDI. Factor analyses suggested that the BDI differs from the DASS Depression scale primarily in that the BDI includes items such as weight loss, insomnia, somatic preoccupation and irritability, which fail to discriminate between depression and other affective states. The factor structure of the combined BDI and BAI items was virtually identical to that reported by Beck for a sample of diagnosed depressed and anxious patients, supporting the view that these clinical states are more severe expressions of the same states that may be discerned in normals. Implications of the results for the conceptualisation of depression, anxiety and tension/stress are considered, and the utility of the DASS scales in discriminating between these constructs is discussed.
The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) is a self-report measure designed to enable investigators to easily obtain sensitive measures of the degree of enjoyment and satisfaction experienced by subjects in various areas of daily functioning. The summary scores were found to be reliable and valid measures of these dimensions in a group of depressed outpatients. The Q-LES-Q measures were related to, but not redundant with, measures of overall severity of illness or severity of depression within this sample. These findings suggest that the Q-LES-Q measures may be sensitive to important differences among depressed patients that are not detected by the measures usually employed.
Proposed in this paper is an expansion of the concept of fear of fear to include fear of other emotions (anger, depression, and positive emotions). In Study 1, initial evidence of the reliability and validity of a questionnaire designed to measure this construct, the Affective Control Scale, is provided. In Study 2, an analogue experiment of susceptibility to panic disorder was conducted. The ability of fear of anger, depression, and positive emotions to predict fear of laboratory-induced bodily sensations in a population with no history of panic attacks was demonstrated.
Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Within the last few years, several adaptations to specific settings have been developed. This study aims to evaluate a three-month DBT inpatient treatment program. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment (i.e. four weeks after discharge for the DBT group). Pre-post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson's criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features. Stability of the recovery after one month following discharge, however, was not evaluated and requires further study.
The psychometric properties of the Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond, 1995a) were examined in depressed psychiatric hospital samples.
Three studies administered the DASS and other symptom measures at admission and discharge to consecutive adult hospital patients with a primary diagnosis of depression. Study 3 aimed to address problems with the DASS by extending the response options.
Study 1 found that the DASS had good reliability and validity, was moderately sensitive to change, but the Depression Scale exhibited a ceiling effect. In Study 2, confirmatory factor analysis supported a three-factor structure and the DASS continued to demonstrate good psychometric properties, but the ceiling effect was replicated. Study 3 found that by extending the response scale to include an additional option, the factor structure of the instrument as a whole was maintained, the sensitivity to treatment was increased, but the ceiling effect was only marginally reduced.
The psychometric properties of the DASS were sound in clinically depressed samples, but the Depression Scale exhibited a ceiling effect that could not be resolved with minor changes to the scale. Suggestions for revisions of the DASS are made.
Quality of Life Enjoyment and Satisfaction Questionnaire: A new measure
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Quality of Life Enjoyment and Satisfaction Questionnaire: A new measure
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