1. 1  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Dialectical Behavior Therapy Presentation Materials The Behavioral Technology Transfer Group 4556 University Way NE Seattle, WA 98105 Phone 206/675-8588 Fax 206/675-8590 4556 University Way NE  Seattle, WA 98105 Phone 206/675-8588  Fax 206/675-8590 Web: www.behavioraltech.com information@behavioraltech.com Dialectical Behavior Therapy Presentation Materials The Behavioral Technology Transfer Group 4556 University Way NE Seattle, WA 98105 Phone 206/675-8588 Fax 206/675-8590 4556 University Way NE  Seattle, WA 98105 Phone 206/675-8588  Fax 206/675-8590 Web: www.behavioraltech.com information@behavioraltech.com

2. 2  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Dialectical Behavior Therapy (DBT) The Basics

3. 3  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Theory of Borderline Personality Disorder in DBT

4. 4  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG BPD is a Pervasive Disorder of the Emotion Regulation System BPD is a Pervasive Disorder of the Emotion Regulation System BPD criterion behaviors function to regulate emotions or are a natural consequence of emotion dysregulation BPD criterion behaviors function to regulate emotions or are a natural consequence of emotion dysregulation

5. 5  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Biosocial Theory of BPD Biosocial Theory of BPD Pervasive Emotion Dysregulation Biological Dysfunction in the Emotion Regulation System Invalidating Environment

6. 6  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Emotion Dysregulation Inability to Modulate Emotions Inability to Modulate Emotions Emotional Vulnerability

7. 7  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Tasks in Emotion Modulation *Decrease or Increase physiological arousal associated with emotion **Re-orient attention ***Inhibit mood-dependent action ****Organize behavior in the service of external non- mood dependent goals

8. 8  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Invalidating Environment Pervasively negates or dismisses behavior independent of the actual validity of the behavior Pervasively negates or dismisses behavior independent of the actual validity of the behavior

9. 9  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT is designed for the severe and chronic multi-diagnostic, difficult-to-treat patient with both Axis I and Axis II disorders

10. 10  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Change Core Problem Solving Problem Solving Acceptance V alidation Team Consultation Team Consultation ReciprocalReciprocal Environmental Intervention Environmental Intervention Consultation- to-the-Patient Consultation- to-the-Patient IrreverentIrreverent

11. 11  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Balance Core Strategies Dialectics VALIDATION

12. 12 Dialectical Philosophy of Treatment Dialectics As... l Persuasion l World View Dialectics As... l Persuasion l World View

13. 13  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Dialectics as Persuasion A method of logic or argumentation by disclosing the contradictions (antithesis) in an opponent’s argument (thesis) and overcoming them (synthesis).

14. 14  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Translating a Dialectical World View into Treatment Provides foundation of biosocial etiology 1.Transactional development and maintenance 2.Systemic disorder Dialectically informs treatment strategies 1.Balance of Acceptance vs. Change 2.Search for "what is left out" 3.Emphasis on speed, movement, flow Dialectically informs treatment goals 1.Emotion regulation 2.Interpersonal effectiveness 3.Mindfulness 4.Distress tolerance Provides foundation of biosocial etiology 1.Transactional development and maintenance 2.Systemic disorder Dialectically informs treatment strategies 1.Balance of Acceptance vs. Change 2.Search for "what is left out" 3.Emphasis on speed, movement, flow Dialectically informs treatment goals 1.Emotion regulation 2.Interpersonal effectiveness 3.Mindfulness 4.Distress tolerance

15. 15  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Structure the Goals of Treatment DBT Structures Treatment Goals by Levels of Disorder

16. 16  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Structure the Primary Targets of Treatment DBT arranges targets hierarchically by importance and grouped by level of patient disorder

17. 17  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Goals of Treatment by Level of Disorder Goals of Treatment by Level of Disorder Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Level 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness Level 4: Incompleteness Capacity for Joy and Freedom Capacity for Joy and Freedom Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Level 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness Level 4: Incompleteness Capacity for Joy and Freedom Capacity for Joy and Freedom

18. 18  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG l Decrease Life-threatening behaviorsLife-threatening behaviors Therapy-interfering behaviorsTherapy-interfering behaviors Quality-of-life interfering behaviorsQuality-of-life interfering behaviors l Increase behavioral skills Core Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion Regulation Self-Management l Decrease Life-threatening behaviorsLife-threatening behaviors Therapy-interfering behaviorsTherapy-interfering behaviors Quality-of-life interfering behaviorsQuality-of-life interfering behaviors l Increase behavioral skills Core Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion Regulation Self-Management Stage 1 Primary Targets Dialectical Synthesis Severe Behavioral Dyscontrol Behavioral Control Stage 1 Primary Targets Dialectical Synthesis Severe Behavioral Dyscontrol Behavioral Control

19. 19 Structure the Milieu and Modes of Treatment Standard DBT is Outpatient Treatment

20. 20 STANDARD DBT is.. FLEXIBLE FLEXIBLE COMPREHENSIVE COMPREHENSIVE PRINCIPLE-DRIVEN PRINCIPLE-DRIVEN FLEXIBLE FLEXIBLE COMPREHENSIVE COMPREHENSIVE PRINCIPLE-DRIVEN PRINCIPLE-DRIVEN

21. 21  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Standard DBT Modes l Outpatient Individual Psychotherapy l Outpatient Group Skills Training l Telephone Consultation l Therapists’ Consultation Meeting l Uncontrolled Ancillary Treatments Pharmacotherapy Pharmacotherapy Acute-Inpatient Psychiatric Acute-Inpatient Psychiatric l Outpatient Individual Psychotherapy l Outpatient Group Skills Training l Telephone Consultation l Therapists’ Consultation Meeting l Uncontrolled Ancillary Treatments Pharmacotherapy Pharmacotherapy Acute-Inpatient Psychiatric Acute-Inpatient Psychiatric

22. 22  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Five Functions of Comprehensive Treatment 1. Enhance capabilities 2. Improve motivational factors 3. Assure generalization to natural environment 4. Enhance therapist capabilities and motivation to treat effectively 5. Structure the environment 1. Enhance capabilities 2. Improve motivational factors 3. Assure generalization to natural environment 4. Enhance therapist capabilities and motivation to treat effectively 5. Structure the environment

23. 23  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Goal is... The Overarching DBT Goal is...

24. 24 Treatments for BPD: PharmacotherapyPharmacotherapy Object Relations Partial HospitalizationObject Relations Partial Hospitalization DBTDBT Treatments for BPD: PharmacotherapyPharmacotherapy Object Relations Partial HospitalizationObject Relations Partial Hospitalization DBTDBT

25. 25  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Pharmacotherapy Pharmacotherapy

26. 26 Pharmacotherapy Treatments for BPD: Paul Soloff, MD Pharmacotherapy Treatments for BPD: Paul Soloff, MD Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92. Medications Algorithm & Rules – Target specific problem area Cognitive/perceptual Cognitive/perceptual Affective Affective Impulsive dyscontrol Impulsive dyscontrol – Strong empirical support – Safe – Act rapidly Pharmacotherapy Treatments for BPD: Paul Soloff, MD Pharmacotherapy Treatments for BPD: Paul Soloff, MD Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92. Medications Algorithm & Rules – Target specific problem area Cognitive/perceptual Cognitive/perceptual Affective Affective Impulsive dyscontrol Impulsive dyscontrol – Strong empirical support – Safe – Act rapidly

27. 27  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Soloff’s Medication Algorithm: Treating Cognitive/Perceptual Symptoms Soloff’s Medication Algorithm: Treating Cognitive/Perceptual Symptoms Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92. l START with low-dose typical neuroleptic l If poor/partial response, INCREASE dose. l If response still poor, RECONSIDER DIAGNOSIS. If symptoms are mood congruent, treat for affective symptoms. l If symptoms do NOT have a major mood component, SWITCH to clozapine or another atypical anti- psychotic.

28. 28  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Soloff’s Medication Algorithm: Treating Affective Symptoms Soloff’s Medication Algorithm: Treating Affective Symptoms Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92. l START with SSRI or related and antidepressant. l If response inadequate, SWITCH to different SSRI or related antidepressant. l If response still poor, AUGMENT with a benzodiazepine or a low-dose neuroleptic. l If response remains inadequate, SWITCH to MAOI. l FINALLY, add/switch to lithium or a mood stabilizer.

29. 29  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Soloff’s Medication Algorithm: Treating Impulsive Symptoms Soloff’s Medication Algorithm: Treating Impulsive Symptoms Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92. l START with SSRI (if rapid response is needed, a low- dose conventional neuroleptic). l If response to SSRI monotherapy inadequate, ADD/SWITCH to low-dose neuroleptic. l If response remains poor, ADD/SWITCH to lithium or MAOI. l SWITCH to carbamazepine or valproate, if no response. l If necessary, ADD atypical neuroleptic.

30. 30  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Consensus By Experts on Pharmacotherapy for BPD l No “magic bullet” medication for BPD patients l Soloff’s algorithm is method of choice where drugs target domain of dysfunction. l Pharmacotherapy alone is insufficient to treat BPD; must be combined with psychosocial treatment.

31. 31  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Object Relations Object Relations

32. 32  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Bateman & Fonagy’s 18-month Partial Hospitalization Program (PHP) PHP Treatment: 3x/week group psychotherapy3x/week group psychotherapy 1x/week individual psychotherapy, expressive therapy, and community meeting1x/week individual psychotherapy, expressive therapy, and community meeting 1x/month meeting with psychiatrist and case administrator1x/month meeting with psychiatrist and case administrator Control: Standard Psychiatric Care 2x/month meeting with psychiatrist and visiting psychiatric nurse2x/month meeting with psychiatrist and visiting psychiatric nurse

33. 33  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Bateman & Fonagy’s 18-month Partial Hospitalization Program (PHP) PHP<Control Frequency of suicide attempts and self- mutilationFrequency of suicide attempts and self- mutilation Number and duration of inpatient admissionsNumber and duration of inpatient admissions Use of psychotropic medicationsUse of psychotropic medications Self-report measures of depression, anxietySelf-report measures of depression, anxietyPHP>Control Improvements on self-report measures of social and interpersonal functioningImprovements on self-report measures of social and interpersonal functioning

34. 34  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Critique of Bateman & Fonagy’s PHP 1. Methodological Confounds PHP patients received considerably more treatment per week (6+ hours) compared to TAU (3 hours/month). PHP patients received considerably more treatment per week (6+ hours) compared to TAU (3 hours/month). 2. No treatment manual currently exists limiting further investigation by others. 3. No studies have replicated original findings. 4. PHP may be more expensive than DBT. (18 months vs. 12 months; PHP vs. outpatient). (18 months vs. 12 months; PHP vs. outpatient).

35. 35  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT DBT

36. 36  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT Randomized Controlled Trials l Linehan, et. al. study of chronically suicidal patients with BPD (1991, 1992, 1993, 1994). l Koons, Robins et al. study of BPD women in VA setting (2001). l Linehan, et al. study of drug-dependent women with BPD (1999). l Linehan, et al. study of heroin-addicted BPD women (2002).

37. 37  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Randomized Controlled Trial: DBT vs. Treatment-as-Usual With Chronically Suicidal BPD Women (University of Washington) Linehan, et al., 1991, 1992, 1993, 1994

38. 38  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT < TAU l % with parasuicide l # parasuicides l medical risk of parasuicide l treatment drop-outs l psychiatric inpatient days l anger l % with parasuicide l # parasuicides l medical risk of parasuicide l treatment drop-outs l psychiatric inpatient days l anger DBT > TAU l social adjustment global adjustment global adjustment

39. 39  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG l Depression l Hopelessness l Suicide ideation l Depression l Hopelessness l Suicide ideation Pre-treatment > 12-month DBT vs. TAU: ns

40. 40  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Efficiency & Costs Of DBT v. TAU Cost for DBT is about 50% of TAU Significantly fewer inpatient daysSignificantly fewer inpatient days Fewer and less severe parasuicidal behaviorsFewer and less severe parasuicidal behaviors Fewer emergency medical visitsFewer emergency medical visits Less therapy dropoutLess therapy dropout

41. 41  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. Treatment-as-Usual for BPD (Durham VA Medical Center) Koons, Robins, et al., 2001

42. 42  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Design: RCT Conditions: Dialectical Behavior Therapy (DBT) Treatment-as-Usual (TAU) Time Frame:6-month treatment Assessments:Pre-treatment Mid-treatment (3 months) Post-treatment (6 months ) Conditions: Dialectical Behavior Therapy (DBT) Treatment-as-Usual (TAU) Time Frame:6-month treatment Assessments:Pre-treatment Mid-treatment (3 months) Post-treatment (6 months )

43. 43  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG SubjectsSubjects l Women veterans, total N = 20 l BPD on SCID-II l Mean Age = 35 l Lifetime history of parasuicide = 75% l Parasuicide within 6 months = 40% l Overall, a less parasuicidal, less frequently hospitalized group than studied in Linehan’s (1991) study. l Women veterans, total N = 20 l BPD on SCID-II l Mean Age = 35 l Lifetime history of parasuicide = 75% l Parasuicide within 6 months = 40% l Overall, a less parasuicidal, less frequently hospitalized group than studied in Linehan’s (1991) study.

44. 44  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT < TAU at Post-Treatment l # parasuicides (<.10) l Suicide Ideation l Depression (BDI) l Hopelessness l Anger Out l # parasuicides (<.10) l Suicide Ideation l Depression (BDI) l Hopelessness l Anger Out

45. 45  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Reduction in Mean Number of Parasuicide Acts Over Time for Each Condition Analyzed Separately Reduction in Mean Number of Parasuicide Acts Over Time for Each Condition Analyzed Separately * p<.10 Koons, Robins, et al. (1998)

46. 46  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. Treatment-as-Usual With BPD Substance Abusers (University of Washington) Linehan, Schmidt, Dimeff, Kanter, Craft, Comtois, McDavid, 1999

47. 47  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG 17 Design: RCT Conditions: DBT Treatment-as-Usual (TAU) Treatment-as-Usual (TAU) Time Frame: 1 year treatment 4 month follow-up Assessments: Pre-treatment 4 month 8 month 12 month (post-treatment) 16 month Conditions: DBT Treatment-as-Usual (TAU) Treatment-as-Usual (TAU) Time Frame: 1 year treatment 4 month follow-up Assessments: Pre-treatment 4 month 8 month 12 month (post-treatment) 16 month

48. 48  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Subjects: n=28 l BPD l SUD for opiates, cocaine, amphetamines, sedatives, hypnotics, or anxiolytics or Polysubstance Use Disorder l Female l Did not meet criteria for: Schizophrenia or other Psychotic Disorder Schizophrenia or other Psychotic Disorder Bipolar Disorder Bipolar Disorder Mental Retardation Mental Retardation l BPD l SUD for opiates, cocaine, amphetamines, sedatives, hypnotics, or anxiolytics or Polysubstance Use Disorder l Female l Did not meet criteria for: Schizophrenia or other Psychotic Disorder Schizophrenia or other Psychotic Disorder Bipolar Disorder Bipolar Disorder Mental Retardation Mental Retardation

49. 49  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Matching Variables l Age l Severity of Highest Drug Dependence l Readiness to Change Global Adjustment (Axis V, DSM-IV) Global Adjustment (Axis V, DSM-IV) l Age l Severity of Highest Drug Dependence l Readiness to Change Global Adjustment (Axis V, DSM-IV) Global Adjustment (Axis V, DSM-IV)

50. 50  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Proportion of Urinalyses DIRTY by Condition Mean Proportion Dirty Mean Proportion Dirty Time * p<.10 **p<.05 ***p<.01 * p<.10 **p<.05 ***p<.01

51. 51  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Interviewer-Assessed Proportion of DAYS USING Drugs and Alcohol by Condition Time * p<.10 **p<.05 ***p<.02 * p<.10 **p<.05 ***p<.02 Proportion of Days Using Proportion of Days Using

52. 52  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Percent Treatment Drop-Outs p<.05

53. 53  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Mean Number of Treatment Sessions During the Year by Condition Psychotherapy Sessions + Counseling with a Case Manager Individual Psychotherapy Sessions* * p<.05

54. 54  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT < TAU DBT < TAU l l Drug use DBT > TAU l l Global Adjustment (at 16-month) l l Social Adjustment (at 16-month) DBT gains continued at follow-up DBT vs. TAU: ns Parasuicide Episodes Anger DBT < TAU DBT < TAU l l Drug use DBT > TAU l l Global Adjustment (at 16-month) l l Social Adjustment (at 16-month) DBT gains continued at follow-up DBT vs. TAU: ns Parasuicide Episodes Anger

55. 55  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. Comprehensive Validation (1 Year) with BPD Heroin Addicts University of Washington Linehan, Dimeff, Reynolds, Comtois, McDavid, & Kivlahan

56. 56  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Subjects: n=23 l BPD on SCID II and PDE l Met criteria for Heroin Dependence l 18-45 Years l Female l Did not meet criteria for: Schizophrenia or other Psychotic Disorder Schizophrenia or other Psychotic Disorder Bipolar Disorder Bipolar Disorder Mental Retardation Mental Retardation l BPD on SCID II and PDE l Met criteria for Heroin Dependence l 18-45 Years l Female l Did not meet criteria for: Schizophrenia or other Psychotic Disorder Schizophrenia or other Psychotic Disorder Bipolar Disorder Bipolar Disorder Mental Retardation Mental Retardation

57. 57  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Matching Variables l Age l Cocaine Dependence l Anti-Social Personality Disorder Global Assessment of Functioning (GAF) Global Assessment of Functioning (GAF) l Age l Cocaine Dependence l Anti-Social Personality Disorder Global Assessment of Functioning (GAF) Global Assessment of Functioning (GAF)

58. 58  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Design: RCT Conditions: Dialectical Behavior Therapy (DBT) Comprehensive Validation Comprehensive Validation Therapy(CVT) Time Frame: 12 month treatment 4 month follow-up Assessments:Pre-treatment 4 month 4 month 8 month 8 month 12 month (post) 16 month 16 month Conditions: Dialectical Behavior Therapy (DBT) Comprehensive Validation Comprehensive Validation Therapy(CVT) Time Frame: 12 month treatment 4 month follow-up Assessments:Pre-treatment 4 month 4 month 8 month 8 month 12 month (post) 16 month 16 month

59. 59  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Treatment Conditions l Individual Therapy l Group Skills Training l Homework Review l Phone Coaching l Therapist Consult Meeting l Drug-Replacement l Individual Therapy l NA 12&12 Group l NA 12&12 Sponsor l Crisis Intervention l Therapist Consult Meeting l Drug-Replacement l Individual Therapy l Group Skills Training l Homework Review l Phone Coaching l Therapist Consult Meeting l Drug-Replacement l Individual Therapy l NA 12&12 Group l NA 12&12 Sponsor l Crisis Intervention l Therapist Consult Meeting l Drug-Replacement DBTDBT CVT CVT

60. 60  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG AssessmentsAssessments Urinalysis (3 times weekly)Urinalysis (3 times weekly) Substance Abuse History Interview (SAHI)Substance Abuse History Interview (SAHI) Urinalysis (3 times weekly)Urinalysis (3 times weekly) Substance Abuse History Interview (SAHI)Substance Abuse History Interview (SAHI)

61. 61  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT CVT+12S Opiate Use Across Year % Positive WeeksWeeks

62. 62  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Percent Treatment Drop-Outs p<.05

63. 63  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. CVT+12S: ns l Drug Use, Self-Report l Brief Symptom Inventory l Global Adjustment l Social Adjustment l Drug Use, Self-Report l Brief Symptom Inventory l Global Adjustment l Social Adjustment Pre-treatment > 12-month

64. 64  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Integrating DBT into Community Mental Health The Mental Health Center of Greater Manchester, New Hampshire Recipients of the 1998 Gold Award American Psychiatric Association Psychiatric Services, 49, 1338-1340

65. 65  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG The Mental Health Center of Greater Manchester, New Hampshire l Provided comprehensive DBT in outpatient setting. l Pre-post data collected for first 14 patients receiving DBT. l Team received intensive 10-day training in DBT over six month period of time.

66. 66  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Treatment Costs Cut by More than Half From $645,000 to $273,000 l 77% decrease in hospital days, from 479 to 85 days. l 76% decrease in partial hospital days, from 173 to 42 days. l 56% decrease in crisis beds, from 170 to 73 beds. l 80% decrease in face- to-face contact with emergency services, from 61 to 12 days. l Significant increase in outpatient services, from 438 days to 1,387 days.

67. 67  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Non-Randomized Studies On DBT l Stanley, Ivanoff et. al. Study of Suicidal, Self- Mutilators (1998). l Miller & Rathus study of DBT for Suicidal Adoelscents (1996). l McCann & Ball study of DBT for Forensic Inpatients (1996). l Bohus et al. Study of DBT inpatient treatment (2001). l Trupin et al. Study of incarcerated youth (2002).

68. 68  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. Treatment-as-Usual for Suicidal and Self-Mutilating Behavior (New York State Psychiatric Institute & Columbia University) Stanley, B., Ivanoff, A., Brodsky, B., & Oppenheim, S. (1998)

69. 69  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Design: Matched Control Conditions: Dialectical Behavior Therapy (DBT) Treatment-as-Usual (TAU) Treatment-as-Usual (TAU) Time Frame: 6-month treatment Assessments: Pre-treatment Mid-treatment (3 months) Post-treatment Conditions: Dialectical Behavior Therapy (DBT) Treatment-as-Usual (TAU) Treatment-as-Usual (TAU) Time Frame: 6-month treatment Assessments: Pre-treatment Mid-treatment (3 months) Post-treatment

70. 70  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Subjects: n = 30 l BPD l Females l Parasuicidal l The baseline mean number of suicide attempts did not differ between DBT and TAU l BPD l Females l Parasuicidal l The baseline mean number of suicide attempts did not differ between DBT and TAU

71. 71  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT < TAU DBT < TAU Self-mutilation Self-mutilation Suicide ideation Suicide ideation Suicidal urges Suicidal urges Urges to self-mutilate Urges to self-mutilate Self-mutilation Self-mutilation Suicide ideation Suicide ideation Suicidal urges Suicidal urges Urges to self-mutilate Urges to self-mutilate (Neither group had a suicide attempt.) (Neither group had a suicide attempt.)

72. 72  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT = TAU l Depression l Hopelessness l Global Adjustment l Depression l Hopelessness l Global Adjustment

73. 73  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. Treatment-as-Usual for Suicidal Adolescents The Albert Einstein College of Medicine/ Montefiore Medical Center Miller, A. L. & Rathus, J. H. (1996)

74. 74  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Design: Parallel Control Group Conditions: DBT for Adolescents Treatment-as-Usual Time Frame:12 week treatment Assessments:Pre-treatment Post-treatment (12 wk) Post-treatment (12 wk) Conditions: DBT for Adolescents Treatment-as-Usual Time Frame:12 week treatment Assessments:Pre-treatment Post-treatment (12 wk) Post-treatment (12 wk)

75. 75  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Subjects: n=111 (DBT=29, TAU=82) l Referrals to the Adolescent Depression and Suicide Program, 78% female and 22% male l Age range 12-19 years l 68% Hispanic, 17% African American, 8% Caucasian, 1% Asian, 6% other l Referrals to the Adolescent Depression and Suicide Program, 78% female and 22% male l Age range 12-19 years l 68% Hispanic, 17% African American, 8% Caucasian, 1% Asian, 6% other

76. 76  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Subjects: Assignment to Condition Subjects were assigned to DBT if they met the following criteria: l Either made a suicide attempt within the last 16 weeks OR reported current suicidal ideation l Met diagnostic criteria for BPD or borderline personality features (as measured by the SCID-II) l Either made a suicide attempt within the last 16 weeks OR reported current suicidal ideation l Met diagnostic criteria for BPD or borderline personality features (as measured by the SCID-II)

77. 77  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT < TAU Treatment drop-out Treatment drop-out Inpatient psychiatric days Inpatient psychiatric days Treatment drop-out Treatment drop-out Inpatient psychiatric days Inpatient psychiatric days DBT = TAU Suicide Attempts Suicide Attempts

78. 78  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Treatment Drop-out: DBT vs.. TAU * p=.04

79. 79  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Psychiatric Hospitalizations During Treatment: DBT vs. TAU * p=.04

80. 80  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT=TAU: Suicide Attempts DBT>TAU at pre-treatment: Number of Axis I disordersNumber of Axis I disorders ImpulsivityImpulsivity Number of prior hospitalizationsNumber of prior hospitalizations The fact that DBT subjects were not more suicidal during treatment than TAU is noteworthy. DBT>TAU at pre-treatment: Number of Axis I disordersNumber of Axis I disorders ImpulsivityImpulsivity Number of prior hospitalizationsNumber of prior hospitalizations The fact that DBT subjects were not more suicidal during treatment than TAU is noteworthy.

81. 81  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Suicide Attempts: DBT vs. TAU Miller, A. L., & Rathus, J. H. (1996) *ns

82. 82  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. Treatment-as-Usual for Forensic Inpatients Institute for Forensic Psychiatry Colorado Mental Health Institute at Pueblo McCann & Ball, 1996

83. 83  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Design: Longitudinal Conditions: Dialectical Behavior Therapy (DBT; n=21) Treatment-as-Usual (TAU; n=14) Time Frame:20 month treatment Assessments:Pre-treatment Post-treatment Conditions: Dialectical Behavior Therapy (DBT; n=21) Treatment-as-Usual (TAU; n=14) Time Frame:20 month treatment Assessments:Pre-treatment Post-treatment

84. 84  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Subjects: (35 male, 11 female) l Patients on intermediate and medium security forensic wards l Age range 37.6 years l BPD = 50%; ASPD= 33%; 45% either schizophrenic or bi-polar l Patients on intermediate and medium security forensic wards l Age range 37.6 years l BPD = 50%; ASPD= 33%; 45% either schizophrenic or bi-polar

85. 85  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT: Pre < post l Depressed and hostile mood l Paranoia, l Psychotic behaviors, l Maladaptive interpersonal coping styles l Staff burn-out (trend) TAU: Pre = post TAU: Pre = post l Depressed and hostile mood l Paranoia, l Psychotic behaviors, l Maladaptive interpersonal coping styles l Staff burn-out (trend) TAU: Pre = post TAU: Pre = post McCann & Ball

86. 86 Evaluation of DBT-Inpatient Treatment University of Freiburg, Germany Bohus, Bohus, Haaf, Stiglmayr, Pohl, Bohme, & Linehan 2001 University of Freiburg, Germany Bohus, Bohus, Haaf, Stiglmayr, Pohl, Bohme, & Linehan 2001

87. 87  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. TAU-Waiting List a Controlled Study l Inclusion: BPD: SCID II; DIB-R>7 l Exclusion: lifetime schizophrenia, bipolar I, current substance abuse l Measure points: pre: admission post: 1 month after discharge pre: admission post: 1 month after discharge l Inclusion: BPD: SCID II; DIB-R>7 l Exclusion: lifetime schizophrenia, bipolar I, current substance abuse l Measure points: pre: admission post: 1 month after discharge pre: admission post: 1 month after discharge

88. 88  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. TAU - Waiting List DBT l n=31 l age=29.1 l mean DSM-IV 6.81 l Comorbidities: Anxiety disorder 77%Anxiety disorder 77% Eating disorder 50%Eating disorder 50% Depressive Disorder 80%Depressive Disorder 80%DBT l n=31 l age=29.1 l mean DSM-IV 6.81 l Comorbidities: Anxiety disorder 77%Anxiety disorder 77% Eating disorder 50%Eating disorder 50% Depressive Disorder 80%Depressive Disorder 80% TAU - Waiting List l n=19 l age=29.5 l mean DSM-IV 7.63 l Comorbidities: Anxiety disorder 76%Anxiety disorder 76% Eating disorder 41%Eating disorder 41% Depressive Disorder 82%Depressive Disorder 82% TAU - Waiting List l n=19 l age=29.5 l mean DSM-IV 7.63 l Comorbidities: Anxiety disorder 76%Anxiety disorder 76% Eating disorder 41%Eating disorder 41% Depressive Disorder 82%Depressive Disorder 82%

89. 89  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Pre-post comparison and group vs. time differences: Depression BDIHAMD TAUDBT

90. 90  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Pre-post comparison and group vs. time differences: Anxiety STAIHAMA TAUDBT

91. 91  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Pre-post comparison and group vs. time differences: SCL-90-R GSIPSDI TAUDBT

92. 92  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Pre-post comparison and group vs. time differences: Dissociation DES TAUDBT

93. 93  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Pre-post comparison and group vs. time differences: Anger STAXI TAUDBT

94. 94  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Pre-post comparison and group vs. time differences: Social Integration GAF TAUDBT

95. 95  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Effect Sizes TAU-DBT small medium large

96. 96  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Responder criteria l Every patient who had values above the median in at least 5 of 9 pre-post- differences (dissociation, GAF, HAMA, STAI, BDI, HAMD, STAXI, SCL-GSI, SCL-Intensity) was allocated to the responder-group

97. 97  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Responder criteria l Discriminant Analysis: All of the 9 variables accounted significantly for the classification into responder- and non-responder-groups and are responsible for 71.8% of the variance between the groups (F 8,20 =6.35, p=.000***).

98. 98  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG GAF TAUDBTRespondersNon-Responders

99. 99  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Therapy Response: Effect sizes

100. 100  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Predictor Variables (Discriminant Analysis) Clinical variables: l Frequency of comorbid axis I disorders l Frequency and days of lifetime hospitalizations l Frequency of lifetime suicide attempts Current or lifetime diagnosis of comorbid anxiety disordercomorbid anxiety disorder eating disordereating disorder depressiondepression Clinical variables: l Frequency of comorbid axis I disorders l Frequency and days of lifetime hospitalizations l Frequency of lifetime suicide attempts Current or lifetime diagnosis of comorbid anxiety disordercomorbid anxiety disorder eating disordereating disorder depressiondepression

101. 101  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Predictor Variables (Discriminant Analysis) Diagnostic variables: l value of the DIB-R criterias l number of met DSM-IV criterias l severity of pre-assessment symptoms Diagnostic variables: l value of the DIB-R criterias l number of met DSM-IV criterias l severity of pre-assessment symptoms

102. 102  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Predictor Variables (Discriminant Analysis) Social variables: l employment l psychological or psychosocial stress at beginning of therapy l age l quality of family relationships l quality of leisure activities l global contentment with social aspects of one’s life Social variables: l employment l psychological or psychosocial stress at beginning of therapy l age l quality of family relationships l quality of leisure activities l global contentment with social aspects of one’s life

103. 103  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT Skills Training vs. No Skills One Year: Out-patient (Linehan et al.) l DBT skills training + individual non- DBT psychotherapy (DBT Skills) vs. l Individual non-DBT psychotherapy only (NO DBT Skills) DBT Skills = No DBT Skills: all measuresDBT Skills = No DBT Skills: all measures l DBT skills training + individual non- DBT psychotherapy (DBT Skills) vs. l Individual non-DBT psychotherapy only (NO DBT Skills) DBT Skills = No DBT Skills: all measuresDBT Skills = No DBT Skills: all measures

104. 104  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG DBT vs. Treatment-as-Usual for Incarcerated Juvenile Offenders Echo Glen Children’s Center Trupin, Stewart, Boesky, McClung, Beach

105. 105  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Design: Parallel Control Group Conditions: DBT: Staff trained > 80 hrs. (n=22) DBT: Staff trained 16 hrs. (n=15) DBT: Staff trained 16 hrs. (n=15) Time Frame:10 months Assessments:Pre-treatment Post-treatment Conditions: DBT: Staff trained > 80 hrs. (n=22) DBT: Staff trained 16 hrs. (n=15) DBT: Staff trained 16 hrs. (n=15) Time Frame:10 months Assessments:Pre-treatment Post-treatment

106. 106  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Subject Demographic Characteristics l Female, adolescent offenders incarcerated on general and mental health cottages l Age: M=15 yrs. l % Axis I disorders: 76% l Number prior offenses: M=5.5 l Female, adolescent offenders incarcerated on general and mental health cottages l Age: M=15 yrs. l % Axis I disorders: 76% l Number prior offenses: M=5.5

107. 107  2002 The Behavioral Technology Transfer Group (BTTG) Slides Provided Courtesy of BTTG Significant Changes l DBT 80 hrs. training Reduced severe behavior problems (parasuicide, aggression, class disruptions)Reduced severe behavior problems (parasuicide, aggression, class disruptions) Reduced staff use of punitive actions (compared to previous year)Reduced staff use of punitive actions (compared to previous year) l DBT 16 hrs. training No reduction in behavior problemsNo reduction in behavior problems Increased staff use of punitive actionsIncreased staff use of punitive actions l DBT 80 hrs. training Reduced severe behavior problems (parasuicide, aggression, class disruptions)Reduced severe behavior problems (parasuicide, aggression, class disruptions) Reduced staff use of punitive actions (compared to previous year)Reduced staff use of punitive actions (compared to previous year) l DBT 16 hrs. training No reduction in behavior problemsNo reduction in behavior problems Increased staff use of punitive actionsIncreased staff use of punitive actions