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Treatment Differences in the Therapeutic Relationship and Introject During a 2-Year Randomized Controlled Trial of Dialectical Behavior Therapy Versus Nonbehavioral Psychotherapy Experts for Borderline Personality Disorder

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The present study explored the role of the therapeutic relationship and introject during the course of dialectical behavior therapy (DBT; Linehan, 1993) for the treatment of borderline personality disorder. Women meeting DSM-IV criteria for borderline personality disorder (N = 101) were randomized to receive DBT or community treatment by experts. The Structural Analysis of Social Behavior (Benjamin, 1974) was used to measure both the therapeutic relationship and introject. Relative to community treatment by experts, DBT participants reported the development of a more positive introject, including significantly greater self-affirmation, self-love, self-protection, and less self-attack, during the course of treatment and 1-year follow-up. The therapeutic relationship did not have an independent effect on intrapsychic or symptomatic outcome but did interact with treatment. DBT participants who perceived their therapist as affirming and protecting reported less frequent occurrences of nonsuicidal self-injury. The study showed positive intrapsychic change during DBT and emphasized the importance of affirmation and control in the therapeutic relationship. Results are discussed in the context of understanding the mechanisms of change in DBT.
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... Dialectic behavioural therapy (DBT), invented by Marsha Linehan in the late 1980s, is the most highly recommended therapy for these patients is focused around four major aspects: distress tolerance, emotional regulation, mindfulness and interpersonal effectiveness [12]. Mentalization-based therapy (MBT) has also been found effective in reducing psychiatric symptoms in patients with BDP [13]. Currently, no psychopharmaceutical treatments are recommended for this disorder [14]. ...
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The objective of this study was to perform a systematic review of the effectiveness of computer-driven technologies for treatment of patients suffering from BPD. A systematic literature review was conducted using the Pubmed, EMBASE, PsycNET (PsycINFO), CINAHL and Google Scholar electronic databases for the period from their inception dates until 2022. Thirty studies were selected for abstract screening. Seven studies were excluded for not meeting inclusion criteria. The remaining 23 studies were fully assessed, and 12 were excluded. Therefore, 11 studies were included in the analysis of the effectiveness of computer-driven technologies, which encompassed mobile applications, telehealth interventions, internet-based interventions, virtual reality MBT and dialogue-based integrated interventions. Computer-driven interventions are showing signs of effectiveness in the treatment of BPD symptoms. The limited number of articles found on the subject demonstrates a need for further exploration of this subject.
... Nevertheless, the presence of problematic interaction patterns seems to be an explanatory feature of client outcomes across therapy modalities. For example, research has suggested that in dialectical-behavior therapy, a treatment with a specific focus on problematic behaviors and emotion regulation (and working less directly with a relational framework), change in the quality of the person's relationship with the self, as well as with the therapist, jointly predicted reductions in self-mutilatory behavior after treatment (Bedics et al., 2012). ...
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... This dimension has been studied repeatedly over the years, from the very first small study by Shearin & Linehan [22] demonstrating that therapeutic strategies fostering a more favourable therapeutic relationship were associated with a drop in suicidal behaviour in women with BPD and a history of repeated suicidal behaviour. In a randomized trial of female patients with BPD who received either DBT or community treatment by experts, patients who received DBT reported a significantly stronger association between therapist affirmation and protection and reductions in self-harm behaviour [23] and, later in the same sample, an association between patient rated alliance and reductions in self-harm behaviour [24]. Another aspect of the therapeutic relationship was investigated by Carson-Wong et al [25] examining the association between therapists' use of validation strategies and change in J o u r n a l P r e -p r o o f patients' emotions, where the use of high levels of validation lead to increases in positive emotion and reductions in negative emotion. ...
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Background: Self‐harm (SH; intentional self‐poisoning or self‐injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults. Objectives: To assess the effects of psychosocial interventions for self‐harm (SH) compared to comparison types of care (e.g. treatment‐as‐usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH. Search methods: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). Selection criteria: We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment‐as‐usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow‐up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. Data collection and analysis: We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post‐intervention) was appraised for each intervention using the GRADE approach. Main results: We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)‐based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow‐up time points (e.g., 6‐ and 12‐months) there was some evidence that individual CBT‐based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post‐intervention assessment. On the basis of data from a single trial, mentalisation‐based therapy (MBT) reduces repetition of SH and frequency of SH by the post‐intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high‐certainty evidence). A group‐based emotion‐regulation psychotherapy may also reduce repetition of SH by the post‐intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate‐certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group‐based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At‐Risk Territories (START) and the SUicide‐PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE‐MISS) models, have any effect on repetition of SH by the post‐intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department‐based interventions. Authors' conclusions: Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow‐up time points, although no such effect was found at the post‐intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group‐based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.
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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.
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