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Dialectical Behavior Therapy for Borderline Personality Disorder

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1 Dialectical Behavior Therapy for Borderline Personality Disorder
Milton Z. Brown, Ph.D. Alliant International University DBT Center of San Diego

2 A first DBT session is a lot like a first DBT class Clients and students should know what to expect and make an explicit and firm informed commitment

3 Class Participation Modeling is essential Practice is essential
TIB, like arriving late Awake – ask about nonverbal behaviors in class Awake – comment on dysfunctional behaviors DONB - problematic comments (e.g., judgment) Practice is essential in-class role-play practice awake and DONB on other in class weekly practice of DBT skills daily sitting mindfulness practice

4 Commitment Identify goals of client (or students)
Clear and thorough discussion of what therapy (or class) could involve and why Collaborative discussion of what can be done to help client (or students) meet their goals Elicit explicit and firm commitment to specific behaviors Devil’s advocate strategy highlight disadvantages of committing highlight choice: “Are you sure? You don’t have to”

5 Commitment from Patient
1. By the end of the first session commit to no suicide before the next session removing lethal means 2. By the end of the fourth session long-term commitment to not attempting suicide long-term commitment to no self-harm to work on therapy interfering behavior (target #2) to do diary card and therapy homework to engage in regular structured productive activities to work on not avoiding everything

6 Commitment to Patient 1. Commit to four sessions
to decide if you can help the client for client to decide if she will commit to therapy 2. By the end of the fourth session make a time-limited commitment (e.g., 1 year) specify progress required for you to agree to additional therapy after time period ends

7 DBT Interventions are based on Theory of BPD and Theories of Change
DBT was designed for this type of patient, not BPD Parasuicide = suicide attempts (e.g., overdose) or nonsuicidal self-injury (e.g., self-mutilation) - nonfatal intentional acute self-injury with or without intent to die, or imminent risk of harm 126 combinations of 5 of 9 criteria! DBT principles can help with treatment for these difficult patients, even if not BPD

8 Development of BPD Linehan’s Biosocial Theory
Biological and environmental factors account for BPD BPD individuals are born with emotional vulnerability BPD individuals grow up in invalidating environments Reciprocal influences between biological vulnerabilities and an invalidating environment lead to a dysfunction in the emotion regulation system. Mutual coercion (don’t repeat this!) BPD becomes noticeable in early adolescence, but begins long before that Invalidation = when the “communication of private experiences and self-generated behavior is met by erratic, inappropriate, and extreme responses” independent of the actual validity of the responses Oversimplifies Trivializes - does not take child’s communications seriously (struggle/pain/need for help) – often escalation is taken seriously though Pathologizing Punitive parenting based on aversive control (i.e., shame-based parenting) – often backs off when child escalates emotion, violence, and self-harm – mutual coercion escalation (G. Patterson) Effects of invalidating environment -worsen emotionality due to trauma -self-hate/anger/depression -failure to learn emotion regulation -suppression coping style leads to suppression rebound -increased escalation reinforced Transactional process (reciprocal influences) explains origins of problems and transactions in therapy

9 Development of BPD Linehan’s Biosocial Theory
BPD individuals grow up in invalidating environments their emotions and struggles get trivialized, disregarded, ignored, or punished (even when normal) non-extreme efforts to get help get ignored only extreme communications/behaviors taken seriously sexual abuse Why? parents are cruel (invalidated or abused as children) low empathy and skill: don’t understand child’s struggle

10 Development of BPD Linehan’s Biosocial Theory
BPD individuals learn to invalidate themselves intolerant of their own emotions and struggles (punish, suppress, and judge their emotions, even when normal) They easily “feel invalidated” by others They still influence others via extreme behaviors self-injury/suicidality to get help aggression, self-injury, and suicidality to get others to back off Punitive parenting based on aversive control (i.e., shame-based parenting) – often backs off when child escalates emotion, violence, and self-harm – mutual coercion escalation (G. Patterson) Effects of invalidating environment -worsen emotionality due to trauma -self-hate/anger/depression -failure to learn emotion regulation -suppression coping style leads to suppression rebound -increased escalation reinforced

11 Most Good Treatments Don’t Work for BPD Patients
BPD has been associated with worse outcomes in treatments of Axis I disorders such as… Major depression Anxiety disorders Eating disorders Substance abuse probably because BPD patients have low tolerance for change-focused treatments. High dropouts and poor compliance. BPD patients feel invalidated and judged. Our validation therapy had no dropouts So an effective treatment must be balanced! Also too much parasuicide and TIB

12 Why DBT was Developed? 1. BPD patients resist efforts to change them
2. BPD patients insist you help them change 3. Parasuicidal behaviors destroy therapy 4. Many behaviors interfering with therapy 5. Too hard for a single therapist to respond to crises and provide both skills training 6. Burnout and negative reactions to patients are common and often lead to iatrogenic behaviors.

13 The Central Dialectic Acceptance and Change
BPD clients often feel invalidated when: others focus on change (they feel blamed), but also insist that their pain ends NOW others try to get them to tolerate and accept BPD clients need to build a better life and accept life as it is feel better and tolerate emotions better Only striving for change is doomed to fail blocking emotions perpetuates suffering disappointed when change is too slow 13

14 Theory of BPD Numerous serious problems
suicidal behavior and nonsuicidal self-injury multiple disorders crisis-generating behaviors (self-sabotage) Too many therapy-interfering behaviors non-compliance strong emotional reactions to therapists therapist overwhelm, helplessness, and burnout therapists judge/blame clients 14

15 Core Problem: Emotion Dysregulation
Theory of BPD Core Problem: Emotion Dysregulation pervasive problem with emotions high sensitivity/reactivity (i.e., easily triggered) high emotional intensity slow recovery (return to baseline) inability to change emotions inability to tolerate emotions (emotion phobia) vicious circle (upward spiral) desperate attempts to escape emotions vacillate between inhibition and intrusion inhibited grieving history of invalidation for emotions self-invalidation and shame inability to control behaviors (when emotional) Impulsive behavior directly elicited by emotions or they function to reduce them 15

16 THE PROBLEM AVOIDANCE OR ESCAPE e.g., interpersonal conflict
(abandon, invalidation) EMOTION DYSREGULATION PROBLEM BEHAVIOR Alcohol & Drugs Self-injury Aggression CUE Trigger: interpersonal conflict or demands (conditioned emotional responses) Example 1: SELF-INJURY: anger/fear/SHAME, low tolerance, slippery slope, cut, internal relief, others back off, support/kindness from others --> RELIEF Example 2: AGGRESSION: ANGER/fear/shame, low tolerance, hostility, others back off --> RELIEF Escape conditioning model - The emotion relief provided by self-injury makes the behavior very resistent to change, through process of escape conditioning and negative reinforcement The individual experiences extreme anguish, engages in self-injury, and experiences emotion relief which makes the behavior even more likely to occur the next time the individual experiences similar distress. The behavior becomes habitual and automatic. why does it relieve emotions? TEMPORARY RELIEF e.g., others back off Reinforcement strengthens this whole process

17 Why Self-harm Must Stop
It is incompatible with a life-worth living 1. It is an escape behavior that removes the opportunity to learn new ways of dealing with difficult events (compare to drugs) 2. Continued sensitivity to triggers (suffering) 3. Strengthens self-hatred and shame. 4. Causes relationship and medical problems 5. I care about someone and let it continue

18 Core Problem: Avoidance
Theory of BPD Core Problem: Avoidance Denial of problems (avoiding feedback) Non-assertiveness and social avoidance Drug and alcohol abuse Self-injury, suicide attempts , and suicide Self-punishment, self-criticism (block emotions) Dissociation and emotional numbing Anger to block other (more painful) emotions Anger to divert away from sensitive interactions Hospitalization to escape stressful circumstances The chaos in their lives results from elaborate and pervasive habits of avoidance (often impulsive) – crisis-generating behaviors The SOLUTION IS THE PROBLEM (crisis generating behaviors) They have elaborate fears about “falling into the abyss” if they did not manage to avoid—unendurable suffering and unimaginable catastrophes Shame avoids anger Anger/aggression avoids depression/shame

19 The Central Treatment Dialectic
Acceptance and Change Soothing versus pushing the client Validation versus demanding This is the main dialectic in treatment Our validation treatment had no dropouts

20 The Central Treatment Dialectic
Balancing Acceptance and Change Balance therapist strategies validation and Rogerian skills CBT: problem-solving, skills, exposure, cognitive restructuring, contingency management Balance coping skills skills to change emotions and events acceptance skills are necessary since not enough change occurs and not fast enough 20

21 DBT Targets Serious problem behaviors targeted immediately and directly suicidal behavior and nonsuicidal self-injury excessive hospitalization therapy-interfering behaviors Start with stabilization (coping skills) reduce life chaos (problem solving) build structure (e.g., work) distraction and emotion regulation 21

22 Principles of DBT Functions: Enhance capabilities
Improve emotion regulation Activate non-mood-dependent behavior Enhance motivation Assure generalization Structure the environment Enhance capability and motivation of therapists Enhance capabilities (esp. emotion regulation and distress tolerance) Reduce emotion vulnerabilities (e.g., habituation) Activate non-mood-dependent behavior (Jacobson behavioral activation) Enhance motivation Generalization (enhance capabilities in all relevant contexts): homework, emotion in sessions, audiotapes, phone calls, variety of skills/solutions, work real problems with therapist/therapy Treatment of the therapist – cue exposure to hostile attacks from clients, support, restructuring, validation, how to not backdown

23 DBT is a Principle-Driven Treatment
minimal use of protocols flexible use of multiple strategies based on behavioral analysis (theory of client) based on theory of BPD function supersedes form Multiple modes and strategies skills training separate from individual telephone skills coaching consultation team (therapist support) Hug therapy 23

24 DBT Strategies Individual therapy
weekly sessions (usually 60 minutes) telephone skills coaching telephone crisis management Skill training (usually group of 5-10) clients do not talk about self-injury or suicidal intent or behavior very structured didactic format not a process group Not yet known if both components are necessary Skills training probably does not need to be in a group We will focus on Individual DBT

25 DBT INTERVENES X X X X Teach how to prevent triggers
AVOIDANCE OR ESCAPE X EMOTION DYSREGULATION Regulate or tolerate distress PROBLEM BEHAVIOR Teach how to stop this behavior Teach alternative ways to avoid or distract CUE X X Reduce power of triggers and emotion vulnerabillity TEMPORARY RELIEF X Stop problem behavior or reinforcement Without escape, emotion dysregulation should improve

stimulus control AVOIDANCE OR ESCAPE X EMOTION DYSREGULATION Regulate or tolerate distress PROBLEM BEHAVIOR Stop behavior: self-management Crisis Survival Skills CUE X Non-reinforced exposure, PLEASE, increase pos events Problem solving – offer solutions, teach prob solving skills, interpersonal skills Reduce vulnerability to emotions (factors that enhance power of triggers, i.e., lower threshold) -PLEASE – take care of body: sleep, diet, exercise, illness, drugs -increase positive experiences: mastery, pleasure, positive emotions Stop problem behavior is one way to stop reinforcement of behavior and avoidance of emotion (exposure to emotions) Or stop reinforcing consequences following behavior (extinction) TEMPORARY RELIEF X Stop reinforcement (extinction) Without escape, emotion dysregulation should improve

27 Focus on Emotion Regulation
DBT Strategies Focus on Emotion Regulation Reduce emotional reactivity/sensitivity exercise, and balanced eating and sleep exposure therapy Reduce intensity of emotion episodes heavy focus on distraction early on, which is a less destructive form of avoidance Increase emotional tolerance mindfulness block avoidance Act effectively despite emotional arousal 27

28 Self-injury Intervention Options
Prevent, avoid, or solve interpersonal conflict Reduce emotional reactivity to conflict Regulate and tolerate emotions Alternative short-term escape (e.g., distraction) Behavioral control (e.g., highlight disadvantages, reduce opportunities/means) Stop relief naltrexone do not back off --these also apply to drug use and aggression Reduce emotional reactivity to cues and reduce general emotion vulnerability (e.g., PLEASE skills) Regulate and tolerate emotions – relaxation, activities, cog restruct, mindfulness, acceptance, ice Alternative short-term escape/distraction as a last resort (e.g., denial, vacation, dissociation/suppression) Stop relief - make the behavior have no benefit

29 Dialectical Behavior Therapy Treatment Strategies
Problem-solving Skills-focus* (new skills manual) Exposure and opposite action Reinforcement principles Cognitive modification Support/Validation/Acceptance Dialectical Strategies Problem-solving is often very practical – e.g., block access to lethal means (razors/pills) *change and acceptance skills; often in a group format; telephone calls from generalization Inhibit mood-dependent behaviors and structure and reinforce non-mood-dependent behaviors

30 Levels of Validation Listen and pay attention Show you understand
paraphrase what the client said articulate the non-obvious (mind-reading) Describe how their behaviors/emotions… make sense given their past experiences make sense given their thoughts/beliefs/biology are normal or make sense now Communicate that the client is capable/valid actively “cheerlead” don’t treat them like they’re “fragile” or a mental patient Valid = true/correct, normal response to antecedents, effective for one’s goals Search for the kernel of truth Invalidate the dysfunctional DIALECTICS: V4 – makes sense historically, but not currently (although something in current environment set it off) Valid conclusions (responses), but invalid thoughts (e.g., premises are distortions) Right, but not effective Effective for short-term but not long-term goals

31 Validation What (“yes, that’s true” “of course”)
Emotional pain “makes sense” Task difficulty “It IS hard” Ultimate goals of the client Sense of out-of-control (not choice) How Verbal (explicit) validation Implicit validation acting as if the client makes sense responsiveness (taking the client seriously)

32 Functions of Validation
Increases client willingness to change Strengthens therapeutic relationship Reinforces staying in therapy Reinforces clinical progress Provides feedback to shape behavior Increases self-validation by modeling validation Increases positive expectancies (believing in client)

33 Self-Validation Get the patient to say:
“It makes perfect sense that I … because…” it is normal or make sense now of my past experiences of the brain I was born with of my thoughts/beliefs Get the patient to act as if she makes sense: non-ashamed, non-angry nonverbal behavior confident tone of voice Sexual arousal at pain + violent fantasies Abuse of child Too much faith in others and then got abused by black men and by husband

34 Marsha / Stacey Chain Analysis
From session 2 video write on white board

35 Agenda Mindfulness practice DBT Listserve Chain analysis
today regular practice DBT Listserve Chain analysis Self-validation rational-emotional role-play Observing limits

36 Problem Solving Functional analysis (chain analysis) Solution analysis
accept, tolerate, mindfulness change, regulate self vs. environment Anticipate and solve obstacles Skills acquisition (model) Rehearse – “dragging out new behavior” Commitment What will the client do differently next time? Skills acquisition: describe, model, cognitive restructuring, validation Didactic Describe recurrent patterns Highlighting consequences

37 Problem Solving Targeting
Figuring out what to focus on: Self-injury Therapy-interfering behavior Emotion regulation and skillful behavior shame and self-invalidation (judgment) anger and hostility (judgment) dissociation and avoidance In-session behavior Targeting -diary card and homework -target hierarchy -check progress in DBT skills group Impulsive behaviors Panic disorder PTSD Depression – behavioral activation

38 Understand the Problem
Do detailed behavioral analyses to discover: environmental trigger key problem emotions (and thoughts) what happened right before the start of the urge? what problem did the behavior solve? and conceptualize the problem (i.e., identify factors that interfere with solving the problem) Review the audiotape of the session

39 Understand the Problem
Identify factors that Interfere with solving the problem Lack of ability for effective behavior Effective behavior is not strong enough Thoughts, emotions, or other stronger behaviors interfere with effective behavior Skills deficit – lack of interpersonal skills, emotion regulation, distress tolerance, mindfulness, self-validation Behavior is not strong enough - Behavior is too low in response hierarchy (reinforcement) Reducing behavior is interfered with by thoughts, emotions, or other stronger behaviors -Exposure Strategies – a way to acquire/strengthen distress tolerance skills -Cognitive Restructuring – a way to acquire/strengthen cognitive skills (e.g., self-validation) -Contingency Strategies – extinction of dysfunctional behaviors (e.g., parasuicide) that compete with skillful behaviors

40 DBT Assertiveness Skill DEAR MAN GIVE FAST
Assertiveness is an effective alternative for anger and aggression helplessness (depression)

41 Therapy Interfering Behaviors (TIB)
arrives late leaves early passive or helpless not do diary card excessively talks (hard for therapist to talk) complains but does not work in session excessively angry excessively judgmental/critical of therapist EXAMPLE: client attacks/para when you do something refuse to talk about a topic if a client only wants to

42 CBT for Anger Work on anger collaboratively Problem solving
motivational interviewing style (no labels) frame the choice as “right versus effective” validate what is valid Problem solving act on anger when it helps reduce a threat Skills training Cognitive restructuring (be careful!) Exposure 42

43 Skills Training for Anger
Gently avoid (time out) postpone for a specified amount of time distraction pros and cons Relaxation Assertive communication (DEAR MAN GIVE) Empathy and explicit validation (no “should”) Get help for a “reality check” Ask a friend: “Am I over-reacting?” What am I failing to understand about other person? Is it worth the battle/loss (even if I am right)? 43

44 Cognitive Restructuring for Anger
Empathic interpretations of others notice “shoulds” external attributions (current causes) benefit of the doubt times client’s intent has been misunderstood historical causes Ask rather than assume Humor Acceptance and forgiveness 44

45 Exposure for Anger Thoroughly assess triggers In vivo exposure
role-play verbal barbs homework Imaginal exposure client can write a script in advance Opposite action validation opposite thinking? DMV in vivo homework example pg. 194 45

46 Responding to Anger in Session
Discourage simple venting/catharsis Link behavior to clients goals Refuse to talk about anger-inducing situations when not productive Validate/apologize/repair to the extent that therapist made a mistake. Do not avoid the issues that prompt the anger if they are reasonable to deal with do not back down or appease 46

47 In-Session TIB Protocol Problematic Behavior Excess
EXTINCTION: block behaviors “that’s ineffective” (broken record technique) return to the trigger or first emotion Validate or use humor/irreverence Comment on the therapy interactions (process) Illusion of choice in absence of alternatives Elicit collaboration (turn the tables) EXTINCTION: Do not respond (at all!) EXAMPLE: client attacks/para when you do something refuse to talk about a topic if a client only wants to complain but not work

48 TIB Protocol Problematic Behavior Excess
Other Consequences Correction-Overcorrection (repair) Negative judgment from therapist Vacation from therapy Therapy termination

49 “Boundaries” in DBT = Observing Limits
Hold natural rather than arbitrary limits Keep your sanity Model and reinforce effective interpersonal behavior Reinforce independent coping

50 Common Contingencies in DBT
Observing limits “drag out new behavior” “talk it to death” (miss out on other topics) fill out diary card in session; make it useful schedule phone calls (not contingent on problems) withdraw warmth (or slightly aversive tone) minimize impact of hospitalization 24 hour rule Client refuses to collaborate -confront (learn when to let go, but come back to it later) -illusion of choice in the absence of alternatives -change topic quickly (if client chose topic) -end session early Improvement on DBT targets -control agenda -increased (decreased) length or duration of contacts (sessions or calls) -more warmth, soothing, validation, reassurance Recent parasuicidal behavior -do not increase positive behaviors -avoid heart-to-hearts -withdraw warmth (slight aversive) Client gets suicidal to get into hospital -teach client to get admitted without suicidal behavior -have client submit a hospital contingency plan to avoid reinforcement (don't make it too nice) -help client get out soon Suicide threats in session: judgments, threats (call family) Extreme pervasive hopeless thinking (can't work on anything else): assess, orient to, and block avoidance Highlighting consequences -things might be worse after dead -I don't care about dead people -I won't attend you're funeral -I'll tell everybody you killed yourself for revenge

51 Contingency Management: Dragging Out New Behavior
Redo dysfunctional in-session behaviors “Hold the patient hostage" until they emit an adaptive behavior shaping of successive approximations modeling, encouragement, validation Persist like “water over rocks (nagging) Redo dysfunctional in-session behaviors (but could also be arbitrary rehearsal of solutions) shaping -"setting the bar" too low (vs. too high) Build relationship to reinforce new behavior in session (excitement+hope+satisfaction) -make therapy time-limited so therapist can use therapy as a contingency refuse to talk about a topic if a client only wants to complain but not work

52 Rational-Emotional Role-Play
1. Assess nuances of the intricate web of negative thoughts lingering present rational thoughts to counter negative instruct client to thoroughly discredit rational thoughts model to client how to counter tricky negative thoughts 2. Have client rehearse rational thoughts play role of Devil’s advocate (speak neg. thoughts) prompt client to counter negative thoughts 52

53 Four Skills Modules Mindfulness Distress Tolerance Emotion Regulation
surviving crises accepting reality Emotion Regulation reduce vulnerability reduce emotion episodes Interpersonal Effectiveness assertiveness INADVERTENT REINFORCEMENT – following dysfunctional behavior… - adding/extending sessions/calls or end early - diverting/changing topics (e.g., heart-to-heart) - hospitalizing for suicidality - more warmth/soothing or validation - backing off (after hostile threats or suicide threats/hopelessness talk) DO NOT REINFORCE DYSFUNCTIONAL BEHAVIOR!! OVERALL, do not give more when they are worse, INSTEAD more when improvements - no payoffs for dys. Behavior - not get out of something/avoid - do not collude with avoidance If negative reinforcement (avoidance), persist! Do not back off (extinction burst) - naltrexone (block internal reinforcement?) If positive reinforcement, do not increase support/kindness (extinction burst) - give noncontingent “reinforcement” - reinforce adaptive behaviors Punish dys behaviors Build relationship to reinforce new behavior in session (excitement+hope+satisfaction) -make therapy time-limited so therapist can use therapy as a contingency SRS - Longer therapy sessions when she does exposure

54 "you can't say goodbye to something until you say hello to it"
No-where to Now-here Be Loving and Openhearted with My Emotions

55 Skills for Reducing Emotions
Distraction activities with focused attention self-soothing Intense exercise TIP Relaxation progressive muscle relaxation slow diaphragmatic breathing HRV biofeedback Temperature ice cubes in hands* face in ice water (whole body dunk)

56 Relaxation Training Progressive Muscle Relaxation Slow breathing
breathe from the diaphragm 5-6 breaths per minute (4 sec in, 6 sec out) exhale longer than inhale maximize HRV 56

57 Skills for Persistent Worry
Focus on physical sensations Imagery desensitization vs. coping imagery Check the facts (relax or solve problem) Acceptance with the mind (“what is IS” “makes sense” “everything is as it should be”) with body (relax muscles; breathe slowly) with face (half-smile) through acceptance actions (act “as if”) Imagine accepting Fully accept for one moment

58 Skills for Reducing Behavior
Pros/Cons of new behavior Mindfulness of current emotion/urge Postpone behavior for a specific small amount of time (fully commit) Distract, relax, or self-soothe Postpone behavior again Do the behavior in slow motion Do the behavior in a very different way Add a negative consequence for behavior

59 Skills for Increasing Behavior
To get opposite action: Pros/Cons of new behavior Mindfulness of current emotion/urge Break overwhelming tasks into small pieces and do first step something always better than nothing Problem solve; Build mastery

60 DBT Treatment Outcomes
DBT has better outcomes than TAU/TBE on: suicidal behavior (self-injury) psychiatric admissions and ER treatment retention angry behavior global functioning All treatments show improvement on: suicide ideation depressed mood trait anger DBT maintained its superior outcomes when compared to only those TAU subjects who received stable individual psychotherapy during the treatment year and when number of psychotherapy hours and number of telephone contacts were controlled. Outcome results were weaker but generally maintained during a one-year follow-up. Suicide ideation and depression decreased

61 DBT Treatment Outcomes
Linehan DBT Replication Study Tx Year FU Year DBT TBE DBT TBE Suicide Attempt 23% 47% Psych ER 43% 58% 23% 30% Psych Inpatient 20% 49% 23% 24% NIMH3 - N=101; Same reductions in emotions, but less experiential avoidance -during follow-up yr, 1/4 of DBT and TBE had at least 1 psych ER, and 1/4 of DBT and TBE had at least 1 hospitalization 2 parasuicide BPD studies (Linehan) N=44, N=101 2 drug BPD studies (Linehan) TAU, CVTS 2 BPD studies in other labs (Koons, Verheul) better TAU 1 study of DBT-oriented therapy (Turner) vs. client-centered therapy 2 RCTs of DBT for eating disorders 1 RCT of DBT for geriatric depression

62 DBT Treatment Outcomes
UW Replication Study Effects of DBT are not simply due to: session attendance getting good therapy (TBE) therapist commitment and confidence Expert therapists are better than treatment as usual NIMH3 - N=101; Same reductions in emotions, but less experiential avoidance -during follow-up yr, 1/4 of DBT and TBE had at least 1 psych ER, and 1/4 of DBT and TBE had at least 1 hospitalization 2 parasuicide BPD studies (Linehan) N=44, N=101 2 drug BPD studies (Linehan) TAU, CVTS 2 BPD studies in other labs (Koons, Verheul) better TAU 1 study of DBT-oriented therapy (Turner) vs. client-centered therapy 2 RCTs of DBT for eating disorders 1 RCT of DBT for geriatric depression

63 Is DBT feasible in the Real World?
Research patients have severe problems and multiple diagnoses Treatment can provide a cost savings sessions 3 hrs/wk + phone calls Is treatment is too hard for average therapists to learn competently? ongoing evaluation, consultation, and training is worth the cost Many settings/clients require adaptations little is known about core change process 63

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