Dbt Handouts 2009

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As any clinician knows, every year witnesses the introduction of new treatment models. Invariably, the developers and proponents claim superior effectivess of the approach over existing treatments. In the last decade or so, such claims, and the publication of randomized clinical trials, has enabled some to assume the designation of an "evidence-based practice" or "empirically supported treatment." Training, continuing education, funding, and policy changes follow.

Published in: Health & Medicine

Dbt Handouts 2009

  1. 1. Revisioning & Recapturing E.B.P: Dialectical Behavior Therapy (DBT) as Example Scott D. Miller, Ph.D.
  2. 2. Dialectical Behavior Therapy (DBT): •Defined as, “a mode of treatment designed for people with borderline personality disorder (BPD)”; •Aims to help people to validate their emotions and behaviors, examine the negative impact of emotions and behaviors on their lives, and make a conscious effort to bring about positive change. •Currently identified by professional organizations, funding bodies, and government agencies as an “evidence-based,” “empirically-supported,” “best practice.” http://www.medterms.com/script/main/art.asp?articlekey=34212 http://www.apa.org/divisions/div12/cppi.html http://www.mhreform.org/policy/ebs.htm
  3. 3. •Recommend that “consumers seek out that have been studied and show to be beneficial in controlled studies”; •Empirically supported therapies meet several “stringent” criteria: •Controlled (randomization, manuals, equality in delivery); •Results better than no treatment; •Results equal to an alternative treatment; •More than one study by more than one researcher or team. http://www.apa.org/divisions/div12/cppi.html http://www.mhreform.org/policy/ebs.htm
  4. 4. DBT: What do the data say? •Currently 15 studies published on DBT (1991-2006); •Nine of the fifteen qualify as “randomized clinical trials” (RCT); •Three of the nine RCT’s were conducted by researchers other than the developer. http://depts.washington.edu/brtc/sharing/publications/research-and- articles-on-dialectical-behavior-therapy
  5. 5. DBT: What do the data say? •All of these studies but one compared the approach to “treatment as usual” or wait-list control; •The one study compared DBT to an approach that “proscribed use of cognitive-behavioral change techniques or any overt suggestion of new behaviors or advice about what to do.” (p. 16) •An example… Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13-26.
  6. 6. DBT: What do the data say? •NIMH funded study of DBT: • Compared DBT to services offered by “community- nominated” treatment experts; Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.
  7. 7. DBT: What do the data say? •DBT therapists: •Received 45 hours of specialized training; •Pre- and during-study supervision. •Gave 38 more hours of contact dedicated to keeping people out of the hospital • Community experts: •Received no training, supervision, or consultation; •No control of type, amount, or quality of services . •Provided significantly less direct service than DBT therapists. Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.
  8. 8. Vari-ability between Therapists: What do the data say? “When individuals, based on their extensive experience and reputation, are nominated by their peers as experts, their actual performance is…found to be unexceptional…”. Ericsson, K.A. (2006). The influence of expertise and deliberate practice on the development of expert performance. In K.A. Ericcson, N. Charness, P.J. Feltovich, & R.R. Hoffman (eds.). The Cambridge Handbook of Expertise and Expert Performance (pp. 683-704). New York: Cambridge University Press.
  9. 9. DBT: What do the data say? Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.
  10. 10. DBT: What do the data say? Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.
  11. 11. Study RCT Comparision Gender Race & Ethnicity Age Drop out rate Participants Group (DBT/other) Linnehan et al. Yes Treatment as usual 100% female Not reported 18-45 4/24 (16.7%) v. 6/12 24/24 1991 (Dosing not (50%) BPD reported) 1 Suicide Linnehan et al. Yes Treatment as usual 100% Female Not reported 18-45 3/13 (23%) 13/13 1994 (Dosing not Mean = 26 1 suicide v. 0 BPD reported) Linnehan et al. Yes Treatment as usual 100% female 78% White 18-45 5/12 (41.6%) 12/16 1999 (significantly lower 11% Unspecified Mean = 30 1 death v. 0 BDP/Drug dose) 7% Black D.O. in TAU dropped DBT received 2X 4% Hispanic out prior to treatment as much therapy Linnehan et al. Yes DBT plus 12 steps 100% female 87% White 28-43 4/11 (36%) v. 0/12 11/12 2002 12% Unspecified Mean = 36 BPD/Drug Koons et al. 2001 Yes Treatment as usual 100% female 75% White 31-46 3/14 (21%) v. 2/14 14/14 BPD (significantly lower 25% Black (14%) dose) Van den Bosch et Yes Treatment as usual 100% Female Not reported Mean = 37.5 14/31 (45%) v. 20/27 31/27 al 2002 (significantly lower (74%) Verheul et al. 2003 dose) BPD/Drug Telch et al. 2001 Yes Wait list control 100% Female 94% White Mean = 50 4/22 (18%) v. 6/22 22/22 Binge Eating 6% Unspecified (27%) Safer et al. 2001 Yes Wait list control 100% Female 87% White 18-54 2/14 (14%) v. 1/15 (7%) 14/15 Bulimia 13% Unspecified Mean = 34 Lynch et al. 2003 Partial (n Medication v. Meds 85% Female 85% White 66-80 Not reported 17/17 Depression = 4) plus DBT 15% Male 9% Black Mean = 66 (significantly higher 6% Hispanic dose) Linnehan et al. Yes Community 100% Female 86% White 18-45 11.5% v. 28.6% 52/49 2006 nominated experts 3.8% Black Mean = 29 BPD Asian 1.9% Other 5.8% TOTAL 8.5 1 semi- BPD = 100% Female 81.5% White 18-45 25.9 v. 35.6% Allegiance direct Mean = 31.7 BPD = comparison http://www.nrepp.samhsa.gov/programfulldetails.asp?PROGRAM_ID=72 157
  12. 12. DBT: What can we conclude? 1. Extremely small and restricted sample (n = 157; 100% female, 81% White); 2. Allegiance effects in 7/9 studies; 3. No real direct comparisons with another bonafide therapy; 4. Inequalities in dose and intensity of services; 5. No control over known confounds and contributors (especially, therapist and alliance effects).
  13. 13. What Works in Therapy: Direct Comparisons & Allegiance Effects Direct Comparisons & Allegiance Effects •Meta-analysis of all studies published between 1980-2006 comparing bona fide treatments for children with ADHD, conduct disorder, anxiety, or depression: •No difference in outcome between approaches intended to be therapeutic; •Researcher allegiance accounted for 100% of variance in effects. Miller, S.D., Wampold, B.E., & Varhely, K. (2008). Direct comparisons of treatment modalities for youth disorders: A meta-analysis. Psychotherapy Research, 18(1), 5-14
  14. 14. What Works in Therapy: Alliance & Therapist Effects Researchers found SFT superior to TFP in work with borderline-diagnosed clients: •Significant differences in outcome between therapists; •Alliance significant predictor of retention and improvement, independent of outcome; •“In the more semistructured and long- term treatment of Axis II disorders, the development and maintenance of the therapeutic alliance constitutes a central issue of therapy and may constitute a central curing mechanism.” Spinhoven, P. et al. (2007). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75(1), 104-115.
  15. 15. Smoke and Mirrors Real World Applications DBT for “BPD” • In a large CMHC serving SPMI clients: Of 382 eligible by dx, only 25 (6.5%) thought it was for them; 25% of those dropped out before program started; another 25% dropped out…is it worth the cost? Haynes, M. (2006). Real world applications of evidence based practice. Heart and Soul of Change 3. Bar Harbor, ME.
  16. 16. DBT: What can we conclude? Doing ~ Better = D.B.T. Therapy

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