mHealth for Mental Health:
Integrating Smartphone Technology in Behavioral Healthcare
David D. Luxton, Russell A. McCann, Nigel E. Bush, Matthew C. Mishkind, and Greg M. Reger
The National Center for Telehealth & Technology, Tacoma, Washington
The rapid growth in the use of smartphones has opened a new world of opportunities for use in behavioral
health care. Mobile phone software applications (apps) are available for a variety of useful tasks to
include symptom assessment, psychoeducation, resource location, and tracking of treatment progress.
The latest two-way communication functionality of smartphones also brings new capabilities for
telemental health. There is very little information available, however, regarding the integration of
smartphone and other mobile technology into care. In this paper, we provide an overview of smartphone
use in behavioral health care and discuss options for integrating mobile technology into clinical practice.
We also discuss limitations, practical issues, and recommendations.
Keywords: smartphone, mobile device, mHealth, apps, technology
Smartphones are mobile telephones with computer functionality
that allow users to run software applications and connect to the
Internet or other data networks. This technology provides users
with the ability to engage in some activities on their phone much
in the same manner that they could with a traditional personal
computer except with the advantage and convenience of compact
size and mobility. In 2008, smartphones only made up 10% of
cellular phones used in the United States. Before the end of 2011,
however, smartphones will likely become the most commonly
used cellular phone device (Entner, 2010), and by 2013, smart-
phones are expected to overtake PCs as the most common Web
access device worldwide (“Gartner Highlights Key Predictions,”
2010). At least 300,000 software applications or apps have been
developed for smartphones (“Introducing the App,” 2010), and as
of November 2010, more than 8,000 health related apps were
available for users to download (Dolan, 2010).
Medical professionals have long been some of the earliest
adopters of personal mobile technology for assisting with the daily
routine of their practice. Portable electronic devices and special-
ized software have been utilized for health research, education,
communication, reference, and patient care from the very earliest
commercially marketed examples in the 1990s, such as the Apple
Newton (Schweitzer & Hardmeier, 1996; Stratton et al., 1998)
through the rise and decline of Palm Pilots and other personal
digital assistants (PDAs; Teall, 2009; Vishwanath, Brodsky, &
Shaha, 2009) to the current boom in multifunctional smartphones.
This article was published Online First October 31, 2011.
Editor’s Note. This is one of 19 accepted articles received in response to
an open call for submissions on Telehealth and Technology Innovations in
Professional Psychology.—MCR
DAVID D. LUXTON is a licensed clinical p.
mHealth for Mental HealthIntegrating Smartphone Technology .docx
1. mHealth for Mental Health:
Integrating Smartphone Technology in Behavioral Healthcare
David D. Luxton, Russell A. McCann, Nigel E. Bush, Matthew
C. Mishkind, and Greg M. Reger
The National Center for Telehealth & Technology, Tacoma,
Washington
The rapid growth in the use of smartphones has opened a new
world of opportunities for use in behavioral
health care. Mobile phone software applications (apps) are
available for a variety of useful tasks to
include symptom assessment, psychoeducation, resource
location, and tracking of treatment progress.
The latest two-way communication functionality of smartphones
also brings new capabilities for
telemental health. There is very little information available,
however, regarding the integration of
smartphone and other mobile technology into care. In this
paper, we provide an overview of smartphone
use in behavioral health care and discuss options for integrating
mobile technology into clinical practice.
We also discuss limitations, practical issues, and
recommendations.
Keywords: smartphone, mobile device, mHealth, apps,
technology
Smartphones are mobile telephones with computer functionality
that allow users to run software applications and connect to the
Internet or other data networks. This technology provides users
with the ability to engage in some activities on their phone
2. much
in the same manner that they could with a traditional personal
computer except with the advantage and convenience of
compact
size and mobility. In 2008, smartphones only made up 10% of
cellular phones used in the United States. Before the end of
2011,
however, smartphones will likely become the most commonly
used cellular phone device (Entner, 2010), and by 2013, smart-
phones are expected to overtake PCs as the most common Web
access device worldwide (“Gartner Highlights Key Predictions,”
2010). At least 300,000 software applications or apps have been
developed for smartphones (“Introducing the App,” 2010), and
as
of November 2010, more than 8,000 health related apps were
available for users to download (Dolan, 2010).
Medical professionals have long been some of the earliest
adopters of personal mobile technology for assisting with the
daily
routine of their practice. Portable electronic devices and
special-
ized software have been utilized for health research, education,
communication, reference, and patient care from the very
earliest
commercially marketed examples in the 1990s, such as the
Apple
Newton (Schweitzer & Hardmeier, 1996; Stratton et al., 1998)
through the rise and decline of Palm Pilots and other personal
digital assistants (PDAs; Teall, 2009; Vishwanath, Brodsky, &
Shaha, 2009) to the current boom in multifunctional
smartphones.
This article was published Online First October 31, 2011.
Editor’s Note. This is one of 19 accepted articles received in
3. response to
an open call for submissions on Telehealth and Technology
Innovations in
Professional Psychology.—MCR
DAVID D. LUXTON is a licensed clinical psychologist who
received his PhD
in clinical psychology from the University of Kansas. He is a
Research
Psychologist and Program Manager at the National Center for
Telehealth &
Technology (T2) and an Affiliate Assistant Professor of
Psychiatry and
Behavioral Sciences at the University of the Washington School
of Med-
icine in Seattle. His research and writing is focused in the areas
of military
psychological health, telehealth, and technology-based
treatments.
RUSSELL A. MCCANN received his PhD in clinical
psychology from Seattle
Pacific University. He is a post-doctoral fellow at the National
Center for
Telehealth & Technology (T2). His research interests include
the integra-
tion of technology into applied psychology, religiosity, and
determinants of
forgiveness.
NIGEL E. BUSH was awarded his PhD in psychology by the
University of
Southampton in the United Kingdom He currently is a Research
Psychol-
ogist and Program Manager at the National Center for
Telehealth &
Technology and an Affiliate Associate Professor in the
Department of
4. Psychiatry and Behavioral Sciences at the University of
Washington in
Seattle. His research focuses on the use of technology for
prevention and
treatment of psychological health issues and traumatic brain
injury in US
military service members.
MATTHEW C. MISHKIND completed his PhD in experimental
psychology
from the University of Vermont with a focus on organizational
develop-
ment and behavior. He is the Acting Chief of the Clinical
Telehealth
Division at the National Center for Telehealth & Technology
(T2). His
research and professional interests are focused on expanding the
range of
telebehavioral health care delivery options.
GREG M. REGER is a licensed clinical psychologist who
completed his PhD
in clinical psychology at Fuller Theological Seminary. He is a
former
Army psychologist and is Acting Chief of Innovative
Technology Appli-
cations Division at the National Center for Telehealth &
Technology (T2).
Dr. Reger has extensive clinical and research experience with
innovative
technologies and has published widely on the use of virtual
reality to assess
and treat psychological health concerns.
DISCLAIMER: The opinions or assertions contained herein are
the private
views of the authors and are not to be construed as official or
reflecting the
5. views of the Department of the Army or the Department of
Defense.
CORRESPONDENCE CONCERNING THIS ARTICLE should
be addressed to David
D. Luxton, PhD, National Center for Telehealth & Technology
(T2),
Defense Center of Excellence (DCoE) for Psychological Health
& Trau-
matic Brain Injury, Old Madigan Army Medical Center Bldg.
9933C,
Tacoma, WA 98431. E-mail: [email protected]
Professional Psychology: Research and Practice In the public
domain
2011, Vol. 42, No. 6, 505–512 DOI: 10.1037/a0024485
505
Smartphone tools are now found in almost every facet of
conven-
tional medicine (Johnson, 2010; Oliveira, 2010; Solomon, 2009)
with some apps such as Epocrates (Epocrates, 2011) and
MedCalc
3000 Complete (Foundation Internet, 2010) medical calculator
almost ubiquitous. Examples of medical uses cited in the
literature
range from diabetes management (Ciemins, Coon, & Sorli,
2010;
Rao, Hou, Golnik, Flaherty, & Vu, 2010), perioperative practice
(Brusco, 2010), infectious disease management (Focosi, 2008;
Oehler, Smith, & Toney, 2010), immunization management
(Kaewkungwal et al., 2010), and CPR instruction (You, Park,
Chung, & Park, 2010), to highly specialized uses in radiology
(Baerlocher, Talanow, & Baerlocher, 2010) as well as digital
imaging and bio-optical sensing (Barsam, Bhogal, Morris, &
6. Lit-
tle, 2010; Choudhri & Radvany, 2010; Jonathan & Leahy,
2010).
Although handheld mobile platforms and smartphones have
been in use within the medical community for some time, the
adoption of the technology for specific use in behavioral health
care has been slower, but is on the rise. Some recent examples
of
mobile technology use in behavioral health include assessment
of
alcohol and substance use (Bernhardt et al., 2009; Freedman,
Lester, McNamara, Milby, & Schumacher, 2006), support of in-
dividuals with a traumatic brain injury and intellectual
disability
(DePompei et al., 2008), treatment of tobacco use (Obermayer,
Riley, Asif, & Jean-Mary, 2004; Brendryn & Kraft, 2008), and
for
severe mental illness (Depp et al., 2010). Recent advancements
in
mobile device technology and the development boom of mobile
device apps, however, have opened a new world of
opportunities.
We conducted a search on the BlackBerry App World site
(http://
appworld.blackberry.com/webstore/) in April 2011 and found
more than 200 unique mobile phone apps specifically associated
with behavioral health. The apps cover a wide array of common
topic areas such as anxiety, depression, smoking, alcohol use,
psychosis, diet, exercise, weight loss, nutrition, parenting,
cogni-
tive performance, relationships, relaxation, sleep, spirituality,
and
general wellbeing. As can be seen in Table 1, apps for
Blackberry
and other popular smartphone platforms, such as the iPhone and
7. Android, exist for clinical assessment, symptom monitoring,
psy-
choeducation, resource location, tracking treatment progress,
skills
training, and two-way communication with providers and other
clinical resources. With this paper, we provide an overview of
smartphone technology relevant for behavioral health care and
discuss examples of its application. We also discuss primary
issues
involved when integrating this technology into clinical practice.
Smartphone Use in Clinical Practice
Smartphone apps provide useful functions that can be integrated
into conventional manualized treatments. For instance, apps de-
signed for self-assessments can help patients assess and monitor
symptoms. In the context of therapy, these assessments can be
shared with the treating clinician, tracked over time, and
presented
in a useful visual display to characterize treatment outcome.
Smartphone apps can also be programmed to respond to critical
items in self-assessments to auto-detect significant distress and,
when appropriate, offer one-touch contact to a support hotline.
The
eMoods Bipolar Mood Tracker app (Gigaram Technologies,
2011), for example, consists of a daily tracking system that
enables
users to input and keep track of subjective mood ratings in an
electronic mood journal. The app also keeps track of hours of
sleep, anxiety levels, and medication use and can generate
reports
that can be sent to a family member, caregiver, or clinician.
Some evidence-based treatments include therapist audio record-
ing of therapy sessions for patients to review later. The conve-
8. nience, portability, and excellent quality of digital audio and
video
recording on today’s smartphones make them an ideal choice for
recording sessions. The capability of apps to record and date-
stamp
homework review can help ensure treatment compliance. More-
over, the integration of calendar and phone contacts by
smartphone
apps can improve tracking of therapy appointments and can hold
therapist contact information for convenient and immediate
refer-
ence.
Apps can also include virtual coaches that provide real-time
audio and visual instruction while a patient practices a skill. For
example, clinicians often provide therapeutic skills training,
such
as relaxation breathing techniques, and sometimes audio record
in-session training for their clients so that they can practice
later at
home. Interactive or adaptive virtual training tools could coach
the
skill rehearsal to ensure successful skill acquisition. Also,
physi-
ological variables could be monitored by an app that
incorporates
gaming motivations and reinforcement for increased relaxation.
Behavioral health apps can also take advantage of the global
positioning system (GPS) functionality of many smartphones
that
locates the device, and hence the user (patient), in geographic
space. This feature can be useful for locating patients with
demen-
tia if they wander away and can help caregivers find them (Mis-
kelly, 2005). Similarly, the GPS capabilities of many
9. smartphones
could be used to increase behavioral activation. That is, the
smart-
phone can track the location of the client, such as to a busy mall
during exposure therapy.
Real-Time Two-Way Communication Capabilities
The latest generation of smartphones, such as the iPhone4 and
those running the Android operating system, have incorporated
a
video camera feature that allows synchronous and real-time
audio
and video capabilities from the palm of one’s hand. This
capability
provides real-time remote communication between patients and
providers similar to what is currently delivered by traditional
videoteleconferencing (VTC). Because smartphones are not
teth-
ered to networks at fixed geographic locations, the two-way
audio
and video capability provides new opportunities for tele-
behavioral health that is low cost, flexible, and mobile,
especially
in rural and underserved areas where clinical services are not
readily available. Although it is expected that these applications
will expand concepts of care delivery, research into the
usability
for health care delivery is scant. The National Center for Tele-
health and Technology (T2) is one organization that is leading
usability research on these smartphone functions for use among
military Service Members and health care providers. This
research
is important to demonstrate not only the capabilities of these
devices, but also whether Service Members and providers will
use
10. them, especially in more austere environments such as on
deploy-
ments overseas.
Information Resources and Psychoeducation
The smartphone platform is also an excellent and efficient
method for accessing databases or other clinical information ex-
506 LUXTON, MCCANN, BUSH, MISHKIND, AND REGER
Table 1
Examples of Behavioral Health Apps Based on Clinical Area,
Platform, and Purpose
Clinical area
App name Platform Purpose(s)
Developmental disorders
Autism Network Android Provides information, resources, and a
forum for autism
ADHD Psychopharmacology iPhone/BlackBerry/Android
Provides information on diagnosis and treatment of
ADHD
Behavior Tracker Pro iPhone/Android Tracks and graphs
behaviors
Life Skills Winner Pro Android Teaches life and social skills
Dyslexia Helper iPhone Provides treatment for dyslexia
Cognitive disorders
Dementia News Android Provides information about dementia
Alzheimer’s Info Android Provides information about
11. Alzheimer’s
Parkinson’s i-pocketcards iPhone Provides information on the
diagnosis, course, and
treatment of Parkinson’s
Geriatrics at Your Fingertips iPhone/BlackBerry Provides
information on the assessment and management
of geriatric disorders
Caregiver’s Touch iPhone Allows caregivers to store personal,
appointment, and
health information
Substance-related disorders
Blood Alcohol Tracker Android Tracks BAC
AlcoDroid Android Tracks alcohol use
Substance Abuse & Addiction Assessments iPhone Assesses
substance abuse and addiction
Cravings Manager iPhone/Blackberry Helps control cravings
12 Steps AA Companion iPhone/Android Provides the “Big
Book” and other materials for
members of AA
Psychotic disorders
Schizophrenia Psychopharmacology iPhone/BlackBerry
Provides information on diagnosis and treatment of
schizophrenia
SchizoTracker Android Tracks symptoms and triggers for
individuals with
schizophrenia
Mood disorders
eMoods Bipolar Tracker Android Tracks mood and other
12. symptoms
Mood Journal Plus iPhone/BlackBerry Tracks mood and other
symptoms
T2 Mood Tracker iPhone/Android Tracks mood and other
symptoms
Depression iPhone Provides assessments for depression
eCBT Mood iPhone Treats mood using CBT
Anxiety disorders
PTSD Coach iPhone Provides information, assessment, and
tools for
individuals with PTSD
Breath 2 Relax iPhone Teaches breathing exercises
Stop Panic & Worry Self-Help Android Uses CBT to treat
anxiety and panic
Anxiety Release Hypnosis Program BlackBerry Provides
hypnosis for anxiety
iCounselor: OCD iPhone Treats OCD using CBT
Eating disorders
Anorexia News Android Provides information on anorexia
BMI Calculator iPhone/BlackBerry Calculates BMI
Eating Disorder Assessments iPhone/Android Assesses for
eating disorders
iCounselor: Eating Disorder iPhone Treats eating disorders
using CBT
Stop Bulimia iPhone Treats bulimia using hypnosis
Sleep disorders
Sleep Bot Tracker Log Android Tracks sleep patterns
Relax and Sleep Plus Android Provides ambient sounds
designed to help individuals
sleep
SleepCyclesApp Alarm BlackBerry Helps individuals wake up
13. more refreshed by using
alarms
Sleep � iPhone Provides relaxing music to help individuals
sleep
Better Sleep iPhone Provides natural and white noise to help
individuals
sleep
Other
Lookout Mobile Security Android Provides smartphone security
Healthful Apps iPhone Provides a database of useful health apps
DSM-IV-TR iPhone Provides DSM-IV coding information
ICD-10 Search Android Search for ICD-10 codes
Psych Central iPhone/Android Provides information on
psychology
(table continues)
507SPECIAL ISSUE: INTEGRATING SMARTPHONE
TECHNOLOGY
temporaneously. Apps, such as DSM–IV–TR (Application 6,
2011)
and ICD-10 Search (Queo Sistemas, 2010), provide users with
an
efficient reference for psychiatric diagnoses. Furthermore, there
are apps available, such as Psych Central, that summarize
current
behavioral health research findings and therefore can help clini-
cians to stay up-to-date in a focused area. Apps that are already
in
use in the medical field can also be useful for behavioral health
14. providers. The Epocrates app (Epocrates, 2011), for example, is
in
use by more than one million health care providers in the United
States (“Overview,” 2011) and provides reference information
on
pharmaceuticals, dosing, contraindications, interactions and
pric-
ing information. Also, the basic Web browsing function on most
smartphones allows users to access the world of information
available on the Internet, no matter where they are located.
The audio and video functionality on smartphones also allows
for both real-time and recorded media streaming and podcasts.
Smartphones therefore offer an engaging audiovisual alternative
to
text-based psychoeducation materials. Podcasts are becoming a
very popular way for individuals to obtain behavioral health in-
formation (Dingfelder, 2010). One behavioral health podcast
web-
site, thepsychfiles.com, produces podcasts that cover a wide
vari-
ety of topics. It is estimated that 3.8 million podcasts from this
website have been downloaded worldwide (Britt, 2011).
Podcasts
are also starting to be used by some peer-reviewed journals to
disseminate information to subscribers. For example, The
Ameri-
can Journal of Psychiatry offers audio podcasts that highlight
each
issue and provide clinicians with an alternative way to learn
about
current research being done in the field. It is likely that the use
of
smartphones and other smart mobile devices for disseminating
behavioral health information will increase as the adoption of
this
15. technology grows and developers find more creative ways to use
mobile technology for this purpose.
Smartphones can also be used to provide patients with psychoe-
ducation via text messaging. Although less technologically ad-
vanced than most apps, there is evidence that text messaging
can
be an effective way to disseminate behavioral health
information
(Kim & Jeong, 2007; Kubota, Fujita, & Hatano, 2004). Texting
is
especially popular among adolescents with over 50% of adoles-
cents with cell phones sending at least 50 text messages per day
(Lenhart, Ling, Campbell, & Purcell, 2010). Because text
messag-
ing offers a relatively simple and inexpensive way to send
infor-
mation to patients, text messaging will likely continue to be
popular despite the advent of more advanced ways to
communicate
using specialized apps.
Other Smartphone Capabilities
Many smartphones have the capability to connect to external
hardware devices, such as biofeedback sensors, for monitoring
physiological signals. Biofeedback apps are a relatively new in-
troduction to mobile devices that can be used for a range of
behavioral health purposes, to include management of stress and
related health and health problems, such as headaches
(Nestoriuc,
Martin, Rief, & Andrasik, 2008), insomnia (Taylor & Roane,
2010), chronic pain (Palermo, Eccleston, Lewandowski, de C.
Williams, & Morley, 2010), and hypertension (Linden, & Mose-
ley, 2006). The PLX xWave, for example, is a portable sensor
that
16. attaches to an iPhone, iPad, or iPod Touch that can track
gamma,
delta, theta, alpha, and beta brain waves to provide
neurofeedback.
Also, at the time of writing, Apple Inc. has plans for a
“Seamlessly
Embedded Heart Rate Monitor” for the iPhone platform. The
device has an integrated sensor for detecting a user’s cardiac
activity and cardiac electrical signals. Apps providing this kind
of
physiological monitoring may provide increased fidelity,
portabil-
ity, and functionality over some traditional home-based biofeed-
back monitors.
Games are among the most frequently downloaded and used
apps on the various smartphone app markets. Increased attention
is
being given to the potential to leverage video game technologies
to
promote health-related behaviors (Papastergiou, 2009) and this
capability could also be extended to smartphone behavioral
health
apps. Furthermore, the unique capabilities of smartphones com-
pared to traditional game consoles have the potential to improve
the game experience by mixing real world behaviors with
software
performance. For example, a number of apps combine GPS,
com-
pass, and real world viewing capabilities that overlay computer
generated information and stimuli to create augmented reality
experiences. Given the number of evidence-based interventions
that include difficult real world excursions for clients, there is
high
potential for engaging behavioral health apps that provide game
motivations for desired behaviors. Apps for behavioral
17. activation,
exposure-response prevention, exercise, and in vivo exposure
could prove quite useful, however, more research is needed in
this
area.
Social support is a frequently targeted area in clinical practice
and social networking via the Internet is recognized for its
poten-
tial to provide new opportunities for social engagement and
con-
nection (Amichai-Hamburger & Furnham, 2007; Campbell,
Cum-
mings, & Hughes, 2006). Several empirical studies have
Table1 (continued)
Clinical area
App name Platform Purpose(s)
Concussion iPhone Provides information on recognizing and
diagnosing
concussions
Epocrates iPhone/Android Provides information on medications
Parenting Toolbox Android Provides parenting skills training
Socialize! iPhone Encourages social interaction
Marriage Counselor by FeelSocial iPhone Provides marital
counseling
Brain Booster BlackBerry Improves cognitive functioning
iEnforce Fitness iPhone Encourages exercise
iCBT iPhone Provides treatment using CBT
508 LUXTON, MCCANN, BUSH, MISHKIND, AND REGER
18. demonstrated the benefits of social networking sites for mental
health and well being (Ellison, Steinfield, & Lampe, 2007; Liu
&
Larose, 2008) and smartphones increase opportunities for social
networking by making social media sites more accessible. Some
of
the most popular social networking websites (e.g., Facebook,
Twitter, MySpace) have developed apps in order for users to
more
easily connect with others from their smartphone (Facebook,
2011;
Twitter, 2011; MySpace.com, 2011). These apps provide
patients
with the opportunity to connect with others without having to
sit in
front of a computer, thus increasing the potential for them to
give
and receive support regardless of time or location. Several web-
sites that provide health resources are also available on social
networking sites, such as Facebook
(http://www.facebook.com/).
For example, Afterdeployment.org is a website that provides
mil-
itary service members, Veterans, and their family members with
health resources and interventions. The site also can be found
on
Facebook where users can interact with others interested in the
information on the website and ask one another questions that
may
aid them in seeking care.
Considerations
Although there are multitudes of possibilities that smartphone
19. technology brings to behavioral health care, there are also
several
key considerations and limitations that both providers and con-
sumers of care should be aware of. In the following section, we
provide a brief overview of these considerations in order to
famil-
iarize the reader with the basic limitations and best practices
when
considering use of smartphone technology in patient care.
Usability and Acceptance Issues
Available technologies and popular preferences for using those
technologies are constantly changing. It is therefore important
for
those planning the use of smartphone technology in behavioral
health care to consider usability and acceptance by end-users.
Feedback from users, when available, can be used to assess us-
ability and preferences of particular apps. Review of published
findings from usability and feasibility testing can be useful for
determining what products may be acceptable. It is also
important
to consider that some patients will embrace use of smartphones
while others might not prefer them or be able to afford them. It
is
therefore important to have alternative options available in the
clinical tool set.
Some smartphone apps allow for end-user customization that
could help to increase ease of use and preference for using a
particular app. For example, visual appearance or choice of
male
or female voice narration can be adjusted on some apps. Content
can also be “versioned” by developers to appeal to and best fit
the
needs of various audiences. Software built into smartphones as
20. well as specialized apps can also be used to improve
accessibility
for persons with disabilities. For example, the app TalkBack
(Eyes-
Free Project, 2011) on the Android platform provides spoken
feedback that can assist persons with visual impairments.
Overall,
it is important for providers to discuss usability issues with
their
clients and consider options for customizing the tools available.
Quality Standards and Safety
The sheer number of apps available makes quality control a
significant concern. Currently, no oversight or standards for be-
havioral health via smartphone and associated apps exist. It is
possible that behavioral health apps contain inaccurate
information
or purport to provide an assessment or intervention that is not
evidence based. Therefore, it is important for those planning the
use of smartphones and behavioral health apps to be aware of
the
evidence base for their use. We also recommend that users seek
information about the developer of an app as this might provide
some insight into the quality of the app. For example, PTSD
Coach
(Department of Veterans Affairs, 2011) is an app that was
devel-
oped by the VA’s National Center for PTSD and the Department
of Defense’s National Center for Telehealth and Technology.
Users can therefore use the app with confidence regarding its
purpose, accuracy, and adherence to established treatment
guide-
lines. Overall, there is a lack of published research in this area
and
21. more data is needed to address the quality and efficacy of
behav-
ioral health associated apps that are being produced.
Patient safety should also be considered when using smart-
phones in behavioral health practice. Dropped calls and battery
failures are some of the technological problems that could
occur.
Reliance on this technology with remote high-risk patients, such
as
those who are in crisis, might place them at greater risk if the
technology fails. It is therefore important for providers to
address
these potential issues with clients and to have backup plans
estab-
lished as part of a safety plan. One the other hand, the use of
smartphones or other mobile device technology can help
providers
to stay in closer contact with high-risk patients and to gather
data
rapidly, such as from symptom or behavioral checklists. Ulti-
mately, we recommend that providers use clinical judgment to
assess risk and to consider when and for which of their clients
is
the use of this technology appropriate.
Data Security and Privacy
Data security and patient privacy must be carefully considered
when integrating smartphone technology into behavioral health
care. Some of the most common threats to data security and
patient
privacy come from unauthorized access or physical loss of the
mobile device. One of the most basic steps that should be taken
to
reduce unauthorized access to smartphones is to use the built-in
22. password protection feature on the device. The use of third
party
encryption apps can also help to secure patient information that
is
stored and transmitted on smartphones. There are also apps
avail-
able, such as Lookout Mobile Security (Lookout, 2011), which
can
be used to remotely delete data or “wipe” the smartphone in
case
the phone becomes lost.
The app software used on smartphones also poses a unique risk
to patient confidentiality. Many apps gather and send user infor-
mation back to the software developers, which can include the
individual’s username and password, contact information, age,
gender, location, phone ID, and phone number. Furthermore,
55%
of apps tested in one study were found to send some of this
information to other companies (Thurm & Kane, 2010). This
can
pose a significant risk to user confidentiality if information
were
automatically released without the user’s consent. In order to
reduce risk to patient privacy, clinicians should be aware of
what
information apps collect and how this information is used once
it
is obtained. This information should then be presented to clients
in
an informed consent procedure that clearly states the benefits
and
risks associated with use of the smartphone.
509SPECIAL ISSUE: INTEGRATING SMARTPHONE
TECHNOLOGY
23. In general, the Health Insurance Portability and Accountability
Act (HIPAA) does not apply to end-users who store or share
data
between other end users on a personal mobile device. If the user
transmits or shares protected health information with a health
care
provider (if a covered entity), however, the provider must
ensure
HIPAA compliance. Thus, it is important for behavioral health
practitioners to be cognizant of how data is stored and
transmitted
when integrating smartphones or other mobile technology into
their practice. The American Psychological Association (APA)
Practice Central site (http://www.apapracticecentral.org/)
provides
specific information regarding HIPAA requirements for
psychol-
ogists as well as information on the new The Health Information
Technology for Economic and Clinical Health Act (HITECH
Act).
Also, The Ethical Principles of Psychologists and Code of
Conduct
provides some useful guidance on the issue of client privacy
and
confidentiality. The Code states that Psychologists take
reasonable
precautions to protect confidential information obtained through
or
stored in any medium and recognize that the extent and limits of
confidentiality may be regulated by law or established by
institu-
tional rules or professional or scientific relationship. This
would
24. therefore apply to confidential information that can be
transmitted
and stored on smartphones or other mobile electronic devices.
Additional Ethical and Policy Related Issues
In addition to confidentiality concerns, communication with
clients via smartphones or other mobile devices involves several
other ethical and policy issues. For example, although texting
and
email provide almost immediate delivery of messages, users
may
falsely expect immediate responses (Luxton, June, & Kinn,
2011).
It is therefore important to clearly specify expected response
time
with clients. It is also relevant for the practitioner to consider
potential issues with multiple relationships and boundaries
setting.
The use of texting and email between clients and practitioners
could create situations where therapeutic boundaries blur, such
as
messages during off hours or for social reasons outside of the
scope of the therapeutic relationship. The Ethical Principles of
Psychologists and Code of Conduct (APA, 2010) provides
general
guidance regarding these types of issues that should be
considered
when communicating with clients via smartphones.
It should also be acknowledged that the technological and
functional advances of smartphones do not alleviate the need for
providers to follow existing policy and local jurisdictional
require-
ments. A prime example is the need to abide by state licensure
requirements set by state psychology licensing boards (APA
25. Prac-
tice Organization, 2010). Licensure is dictated by the state in
which the patient is located and in the most simplistic form this
requires a provider to be licensed in that state or risk liability of
practicing without a valid license. There are varied nuances in
these rules and the states are not consistent in how they
interpret
guidance pertaining to cross-state health care delivery or how
they
define telehealth services. Given the complexities of telehealth
and
the potential mobility of both providers and clients, state boards
are actively pursuing updates to these regulations to both clarify
and expand the level of cross-state care allowed. It is recom-
mended that practitioners understand local jurisdictional
require-
ments as well as their own malpractice insurance before
engaging
in cross-state care.
Conclusion
Current and emerging smartphone technology offers numerous
capabilities and benefits for consumers and providers of
behavioral
health care. Advances in smartphone capabilities are
increasingly
viewed as solutions to expanding the range of health care
delivery
options. These technological advances, however, are outpacing
many policies regarding the delivery of telemental health care.
This is most evident in standard of care discussions about the
delivery of clinical telemental health care to nontraditional
loca-
tions such as mobile clinics or directly into a patient’s home.
Although these policies are designed to protect consumers and
26. providers, the real consequence is often the creation of artificial
barriers that limit the full potential of telemental health care
delivery. Luxton, Sirotin, and Mishkind (2010) conducted a
review
of telemental health studies reported in peer-reviewed journals
to
provide an overview of safety issues associated with general
telemental health care and to evaluate the safety of telemental
health care delivered to unsupervised settings. Their review pro-
vides evidence that telemental health delivered to nontraditional
locations can be safely managed. Demonstrating safety and
usabil-
ity are first steps to determining standard of care as they show
both
practicality and feasibility of delivery solutions. Once these
first
steps are met, policies to expand the widespread use of smart-
phones to deliver synchronous telemental health care can be ad-
dressed.
Although there are a number of apps available today that could
address individual components used in evidence-based
treatments,
another approach is to develop specialized apps that deliver the
full
range of capabilities required for a patient and provider to
engage
in a specific manualized treatment. Despite the establishment of
clinical practice guidelines, dissemination and implementation
of
evidence-based treatments has progressed very slowly (McHugh
&
Barlow, 2010) and it is possible that apps designed to support
specific treatments could reduce provider implementation
barriers
and barriers to patient participation. If accurate, smartphone
27. apps
that support behavioral health clinical practice may go well
beyond
increasing personal convenience by further improving the
quality
and outcomes of behavioral health care.
Future widespread use of smartphone technology in the be-
havioral health field can be expected. Our increasingly mobile,
tech-savvy, and health conscious society will demand care
delivery solutions that expand beyond traditional office-based
requirements to better fit diverse needs and lifestyles. Smart-
phone technology has the potential to make behavioral health
care more accessible, efficient, and interactive for patients and
can improve the delivery of evidence-based treatments. As we
outlined in this paper, there are many advantages of the tech-
nology as well as key issues involved when planning its inte-
gration into clinical practice. More research is needed to pro-
vide data on the usability and clinical effectiveness of
smartphone technology in the behavioral health field. Overall,
the use of smartphones and other mobile technology has many
benefits for both clients and practitioners. We recommend that
behavioral health researchers and clinicians consider the eval-
uation and use of them as part of their practice, but also keep
the
evolving privacy, ethical, and policy issues in mind.
510 LUXTON, MCCANN, BUSH, MISHKIND, AND REGER
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Received February 28, 2011
Revision received April 25, 2011
Accepted April 26, 2011 �
512 LUXTON, MCCANN, BUSH, MISHKIND, AND REGER
Sheet1Rubric for the assignmentsMaxStudentSubmitted on
time20Word count is met40Content is clear20Content is
39. relevant to the topic201000
Telehealth Issues in Consulting Psychology Practice
Thomas W. Miller University of Kentucky
Consulting psychologists have recognized the
importance of providing comprehensive consul-
tation and clinical services for consumers with
special needs. Often because of distance and
access to consultation services, remote and under-
served populations may not have the necessary
access to consultant specialists in psychology and
other disciplines. Such services are now available
through an innovative model of telehealth. Tele-
health technology and services have gained the
attention of scientists, clinicians, consultants, and
health educators in a variety of settings. Examined
are consultation case scenarios using telehealth
qualitative observations of consultants who have
used telehealth and liability issues consultants
may face using this technology. A model release of
liability is provided for consulting psychologists
who may consider its use in their consultation
practice. Case examples using telehealth appli-
cations are discussed, as are special applica-
tions for health care delivery to undeserved ru-
ral populations using telehealth technology.
Keywords: telehealth, liability, consulting,
algorithm
Telehealth is “the use of telecommunica-
tions and information technology to provide
40. access to health assessment, diagnosis, inter-
vention, consultation, supervision, education
and information across distance” (Nickelson,
1998). Several studies using telehealth tech-
nology provide case study reports of clinical
applications. Such reports are appropriate
given how recently the technologies involved
have been developed and implemented. Case
reports describe use of telehealth for conduct-
ing interviews in community mental health
clinics (Hogue, 2003; Miller, Veltkamp,
Kraus, Lane & Heister, 2003); multiple-ses-
sion evaluations for a range of disorders
(Ghosh, McLaren & Watson, 1997; Berek &
Canna, 1994); multiple session psychother-
apy including cognitive– behavioral treatment
of a child with a disruptive behavior problem;
use of telehealth in supervision, (Wood,
Miller & Hargrove, 2005); clinical supervi-
sion for allied health professions (Miller,
Burton, Sprang & Adams, 2003); psychiatric
consultations using videophones (Miller,
Veltkamp, Kraus, Lane & Heister, 1999); and
a session for children with special needs in
rural Kentucky (Miller & Miller, 1999). Such
reports as these provide early evidence of a
spectrum of potential applications for tele-
health consultation. There have been a num-
ber of services involving consulting psychol-
ogists offered in public service settings.
These services have provided a wide range of
services, including general adult and child
consultations and treatment of incarcerated
inmates. Finally, review articles of active
telehealth programs have been published
41. (Bashshur & Armstrong, 1996).
Thomas W. Miller, PhD, ABPP, is a professor in
the Department of Psychiatry, College of Medicine,
University of Kentucky in Lexington, Kentucky.
The author wishes to acknowledge the assis-
tance of Tag Heister, MLS, Deborah Kessler,
MLS, Deborah Burton, PhD Candidate, Jennifer
Trzaski, Kaysie Campbell, Michelle Chicoski,
Brenda Frommer, Richard Clayton, PhD,
Thomas Holcomb, EdD, PC. Amy Farmer, Rob
Sprang, MBA, Jennifer Gourley, Miranda Rog-
ers, Lon Hays, MD, and Otto Kaak, MD, for
their contributions to the completion of this ar-
ticle. Funding from the Center for Prevention
Research and National Institute on Drug Abuse
contract #05312 supported in part the comple-
tion of this article and publication.
Correspondence concerning this article
should be addressed to Thomas W. Miller, PhD,
ABPP, Department of Psychiatry, College of
Medicine, University of Kentucky, 3470 Blazer
Parkway, Lexington, Kentucky 40509-1810.
E-mail: [email protected]
Copyright 2006 by the American Psychological Association and
the Society of Consulting Psychology, 1065-9293/06/$12.00
DOI: 10.1037/1065-9293.58.2.82
Consulting Psychology Journal: Practice and Research, Vol. 58,
No. 2, 82–90
82
42. Consumers and practitioners in rural set-
tings have traditionally contracted indepen-
dently for specialized consultant services.
Some of the paradigmatic changes that are
being experienced in both urban and rural
settings include administrative applica-
tions, consultation models, information
systems, and evidence-based decision-
making in consultations. Summarized in
Table 1 are some of the emerging trends in
each of these categories. Most notable
among these changes are the multiple uses
of telehealth in consultation services for
psychologically related services.
Consultation Case Scenarios in
Telehealth
Case #1
A Veterans Administration psychologist
was referred a patient who had been re-
ported for incidences of child sexual abuse
by the State Department of Children and
Families. Because of the complexity of
problems and the lack of any staff special-
ized in working with perpetrators in this
rural area, the use of an innovative telecom-
munications approach was implemented to
provide multidisciplinary consultation to
the VA hospital and staff psychologist. On-
site team members included a child clinical
psychologist, an advanced practice nurse, a
clinical social worker, and a psychiatrist.
43. The team communicated with a consulting
psychologist, a specialist in treating perpe-
trators of child sexual abuse by video link
to a university-based Department of Psy-
chiatry through an inexpensive and cost-
effective model of telehealth. Through the
use of an 8x8 telemetric link, the provision
of needed interdisciplinary clinical consul-
tation and service was provided to this re-
mote site in a cost-effective and timely
manner. The telehealth services ranged
Table 1
Changing Trends in Consultation
Patterns Past trends Contemporary trends
Administrative applications Referral from medical centers,
independent practices, and
independent provider services
through consultant contracting.
Consultants establish networks and
alliances; psychologists contracting
through integrated delivery system
of service providers by telehealth
models and technology.
Consultation models Provider-focused, psychologists are
individual providers/specialists.
They provide services on an
independent basis without
integrating multidisciplinary
input.
Client-focused, consumer-focused
44. clinical models, psychologists, and
team of providers and specialists
provide service systems integrating
treatment planning, implementation
and evaluation.
Information systems Paper, fax, and clinical records,
provider developed record
systems, local accessibility
record.
Interactive television consultation,
electronic health records, on-line
support systems, E-mail, electronic
files, and information exchange for
comprehensive and integrated
clinical care.
Evidence-based decision
making in consultation
Few incentives for prevention-based
initiatives or for health promotion
and prevention in programs in
health, nutrition, exercise,
addictive disorders. Interactive
Video emotional and behavior
telehealth models in disorders,
attention deficit, intervention
services to hyperactivity disorders
and community centers.
Prevention-oriented healthy lifestyles/
wellness and healthcare promotion,
clients receive accurate information
through telehealth, screening based
45. on evidence-based decision-making.
83Consulting Psychology Journal: Practice and Research
Spring 2006
from continuing education on perpetrator
treatment, consultation about each of the
referred perpetrators to a clinical diagnostic
evaluation, a multidisciplinary team treat-
ment plan, and subsequent implementation
of the treatment plan involving weekly tele-
health supervision for treatment staff at the
remote VA site, family relations and sub-
sequent contact and follow-up involving
the ongoing communication and monitor-
ing of the home and family situation.
Case #2
A state hospital-based psychologist was
referred an inpatient case involving a court-
ordered evaluation for a cult member and
criminal activity. In the course of the
emerging presence of this cult, the super-
intendent of the school system in which the
cult activity was occurring recognized the
need for professional assistance in manag-
ing the situation and sought clinical consul-
tation services. The case involved several
high school teenagers described as mem-
bers of a “vampire cult.” They were
charged with first-degree murder in the
bludgeoning deaths of the parents of a cult
member. Through telehealth technology,
46. clinical specialists in the treatment of cults,
the sociology of cults, and multidisci-
plinary telehealth held a series of consulta-
tions to the hospital and school system.
Telehealth consultations provided the
school personnel in this rural community
with the education expertise and assistance
necessary to manage and provide an under-
standing as to how school personnel should
consider dealing in with cult members in
the school system.
Many of the necessary consultations were
accomplished by using portable video tele-
phone equipment that utilized long distance
telephone lines. The set-top videophone is
designed for clinical use. This set-top
videophone integrates a digital video cam-
era, a high-performance modem, and a
powerful video processing system using a
portable video communications processor.
Case #3
A psychologist in an outpatient commu-
nity mental health center and clinic in a
rural Midwestern setting was presented
with a clinical case of a differential diag-
nosis and treatment planning involving a
12-year-old child with Attention Deficit
Hyperactivity Disorder (ADHD). A multi-
disciplinary clinical consultation using tele-
health technology was conducted. Partici-
pating professionals were a clinical psychi-
atrist, special educator, speech language
pathologist, and school psychologist. The
47. multidisciplinary consultation using tele-
health technology was accomplished by
using the set-top videophone. This consul-
tation provided interaction opportunities
among school personnel, medical and
health-related professionals that assisted
in the differential diagnosis and treatment
planning for the psychologist in the rural
outpatient clinic setting. A model algo-
rithm practice guideline is offered in Fig-
ure 1. This summarizes the steps a con-
sultant should consider in the delivery of
consultation services.
Qualitative Observations With
Telehealth Technology
Current technology used in providing
telehealth clinical services involves the
Polycom system. This is an improvement in
technology over the earlier systems, both of
which transmit through normal phone lines.
The limitations of the earlier system are
such that the video image is married by
frequent disruption whenever any move-
ment occurs in the camera. This makes it
such that as long as the person is sitting
completely still, their image is relatively
intact, but as soon as they move, or make
any facial gestures, the image becomes a
blur. The Polycom system is an improve-
ment in that it compresses much more in-
formation in a shorter amount of time, thus
allowing for a much greater resolution in
84 Consulting Psychology Journal: Practice and Research
48. Spring 2006
video quality. This allows for every move-
ment of the face and body to be seen.
Much of the diagnostic qualities of a clin-
ical evaluation involves observing behavior.
Any system must allow one to observe not
only gross motor behaviors, but also subtle
nonverbal communication that one normally
uses in facial expression and body language.
It is the information that we receive from this
nonverbal body language that comprises an
important element in a clinical evaluation. As
technology improves to increase the visual
resolution through telephone lines with im-
proved information compression software
and hardware, the technical limitations of
telehealth will be virtually eliminated. There
is still the limitation of not being physically
present with the client, and this perhaps will
never be bridged by telehealth technology.
This was not always a hindrance to the eval-
Figure 1. Model algorithm for use of telehealth.
85Consulting Psychology Journal: Practice and Research
Spring 2006
uation. It was mainly noticeable at times
when poignant subjects were broached and
49. the consultants’ ability to confer empathy
through body language was limited.
One interesting phenomenon that occurs
with telehealth equipment is that there usu-
ally is approximately a 1 to 2 second delay
in the video and audio information. This
creates an interesting situation, such that if
someone pauses while answering a ques-
tion and then when another question or
comment is made, if that person also starts
to talk at that the same time, there will
actually be a break in the audio information
as your information confronts the audio
information coming from the other site.
This information coming in from the other
site will often interrupt what the other per-
son had just started to say, and therefore
both parties will pause in a somewhat em-
barrassed moment waiting to see who re-
ally wants to talk first. Over time, this has
led some consultants using telehealth tech-
nology to allow for much longer pauses
after a person finishes a statement to see if
they are going to continue with their conver-
sation, or whether they are ready for another
question or comment from the clinician.
Style and pattern of conversation be-
comes another qualitative issue. Two
groups of communicators along these lines
are realized. The first population tends to
go from sentence to sentence rather rapidly,
therefore making it somewhat easier for the
clinician to know when they have stopped.
There is a second group of people who
50. seem to pause 2 seconds between major
statements or major subjects naturally. It is
this 2 second pause that is the most difficult
to judge, because the interviewer is left
with the immediate decision of whether
they are ready for the interviewer to ask
another question. Another interesting con-
sequence of the audio format of telehealth
exchanges is that it can sometimes be dif-
ficult to hear the parents over a very bois-
terous child or in couples therapy when one
person speaks over another. Since the in-
formation is only conferred by a single
microphone, which gathers sound from the
whole room, the competition involved can
be quite difficult to clarify.
In a normal evaluation setting, often the
consultant will have the client sitting close
to them and the child playing off in the
distance, so that although they may be loud,
it is easier to pay attention to what the
parent is saying. In my own telehealth prac-
tice, after approximately 30 – 45 minutes, it
may be necessary to take their child out of
the room while finishing the session with the
parent. At the same time, this system allows
for excellent diagnostic information, since
when the child is loud, the mother also is
having trouble hearing what the consultant is
saying, and what they choose to do with this
situation can be quite diagnostically helpful.
Finally, consultants who work with chil-
dren have a natural playfulness they em-
51. ploy with children. There are some intrigu-
ing aspects to the telehealth. One of these is
the zoom function of the camera, which can
easily be found on most remote controls for
the camera which the clinician can then
change, impacting facial expression on the
face on the camera screen.
With children, this has the tendency to
see how they can focus and how they in-
teract with people. They often will be most
intrigued and ask for repetitions of a phe-
nomenon. Growling and keeping an angry
face permits the clinician to zoom in on the
face and increase the loudness of my growl
watching how children then want me to
repeat this, as well as watching how they
regulate the emotion of fear has been quite
diagnostic. Some children will cower and
cling to their parent, yet at the same time
knowing that it is pretend, ask for more,
enjoying the excitement of the scary situa-
tion. Other children will respond aggres-
sively taking on their own monster roar and
even sometimes swinging at the screen or
hitting the microphone in retaliation.
Some consultants use the telehealth
equipment to show close-ups of various
86 Consulting Psychology Journal: Practice and Research
Spring 2006
stimuli or thematic apperception cards.
52. This is used early on in the interview, usu-
ally to develop some rapport with the pa-
tient since often they start the session in a
very restricted affect, being either over-
whelmed by the technology or scared about
the fact that they are in some hospital and
know that they are going to be evaluated
for their behavior. Showing these cards
over the telehealth network places the card
in full large view of the child, and often
they will be fascinated by the cards and
provide clinical relevant responses helpful
in diagnosis.
Reflections on the Utility of Telehealth
Technology
The telehealth applications have been
specifically directed at consultations that
are requested by clinicians working in a
rural community. Some of the clients seen
are at least 2 to 5 hours away from the
nearest specialist. They are referred usually
by family practitioners. The great utility of
telehealth then occurs in the fact that these
people are receiving consultation that is
usually not available to them and therefore
allows their clients to have a full evaluation
and consultation with a consulting psychol-
ogist who has the specific expertise that is
beneficial to the rural client and practitioner.
Noticeable in some clients are some
amount of apprehension at first in using the
telehealth equipment. In rural settings,
there are some families that may not even
53. have a telephone or a TV in their house-
hold, although this is a small minority. Tak-
ing these families and placing them in front
of telehealth technologies from the latest
part of the 20th century can be quite over-
whelming. Often clinicians notice that the
children warm up rather quickly, whereas
the mother or father tend to hesitate in
answering and will often ask a question
several times if they are being heard. Uni-
formly, at the end of an hour of a telehealth
session, the parents will express great grat-
itude, usually along the lines that this was
the first time that they have actually under-
stood, or someone explained what their
child’s diagnosis was, or that they were
relieved to find out that there were actually
medications or counseling services that
would help their child improve.
Another aspect of serving as a consul-
tant to clinicians in a rural community is
that the clinician tends to restrict the clini-
cal note to only the essential information
required. Given that these clinicians prob-
ably have to see 50 – 60 patients in a day, a
lengthy four-page note would be useless for
them, and they would probably gravitate
only to the plan. Notes are kept to less than
one page, and use a bulleted presentation
with specific behaviors emphasized, the di-
agnosis, and a very simple concise plan.
The feedback received from clinicians that
have ordered the consults is that they are
greatly appreciative of the telehealth option,
54. especially given the isolation and large re-
sponsibility they often undertake in being the
only provider in these communities.
Liability in Telehealth
A critical factor involves liability for
telehealth clinical services. Telehealth lia-
bility for consultation services involves two
potential types of telehealth liability that
consultants must recognize and address.
These include liability for negligence or
abandonment. Consultants may run the risk
of liability for negligence whenever they
provide telehealth services. Consultants
must address the following areas and real-
ize that proof must exist before one is lia-
ble. To prove liability for negligence, con-
sumers must show that the consultant owes
the consumer a duty of reasonable care.
Has reasonable care been provided? Con-
sultants breached their duty of reasonable
care to patients when the consultant failed
to do something or provide some service
that they should have provided and did not
in fact provide in the course of using tele-
health medicine. Agencies can breach their
duty to patients in either of the following
87Consulting Psychology Journal: Practice and Research
Spring 2006
ways: Agency staff members do something
that they should not do. As a result of
55. failure to provide reasonable care, consult-
ants’ breach of duty may cause injury or
damage to the consumer. The best way to
define “caused” is in terms of “but for.” But
for the consultants’ breach of duty, the con-
sumer would not have been injured or dam-
aged. To prove injury or damage, the con-
sumer must show damage or extreme and
outrageous conduct on the part of the con-
sultant. Extreme and outrageous conduct is
behavior that would be disturbing, inappro-
priate or cannot be tolerated. Liability may
also result when consultants, primary care-
givers, and/or patients do not thoroughly
Figure 2. Release of liability model.
88 Consulting Psychology Journal: Practice and Research
Spring 2006
understand how to operate the equipment
used in providing telehealth services. It is
essential that successful training in the use
of the equipment to the consultant and con-
sumer is assured.
Risk management strategies should ed-
ucate consultants and consumers about
telehealth equipment. Who will provide
training, what mechanisms are used to eval-
uate the effectiveness of training, and how
to document deficits in knowledge follow-
ing completion of initial training.
56. Another concern with respect to liability
involves liability for abandonment. Aban-
donment may occur when the consultant
would unilaterally terminate the relation-
ship with a client or the relationship was
terminated without reasonable notice, and
termination occurred when further attention
was needed. Consultants using telehealth
technology continuously monitor the cli-
ents’ ability to participate in telehealth ac-
tivities and confirm their understanding of
their responsibilities in the use of telehealth
equipment. A model disclaimer is offered
in Figure 2.
In summary, a consulting psychologist
using telehealth in the course of their prac-
tice, should employ a practice guideline for
its use, effectively asses risk management,
understand liability in the use of telehealth
and consider a disclaimer. These are critical
steps that must be addressed in each con-
sultation. There remain several concerns
about the use of telehealth technology in
the delivery of direct patient care services
and in consultation services. What remains
clear is that the value of utilizing telehealth
Figure 2 (continued)
89Consulting Psychology Journal: Practice and Research
Spring 2006
57. technology where services to patients re-
quires specialized services not available in
such underserved, rural, or distant sites, this
medium of care provides access for patients
and clients. There are persistent questions,
which continue to emerge and serve as a
sounding board for consulting psycholo-
gists who are using telehealth in their prac-
tice. This is a period of opportunities to
consider different levels and models of
consultation services through the use of
such telehealth technology. The current
models provide systems based on improved
knowledge and technology which will ulti-
mately provide an improved quality of life
to many underserved consumers.
References
Bashshur, R., & Armstrong, P. (1996). Tele-
medicine: A new mode for the delivery of
health care. Inquiry, l13, 233–244.
Berek, B., & Canna, M. (1994). Telemedicine
on the move: Health care heads down the
information superhighway. Hospital Tech-
nology Series, 13, 1– 65.
Ghosh, G. J., McLaren, P. M., & Watson, J. P.
(1997). Evaluating the alliance in video-link
teletherapy. Journal of Telehealth, 3, 33–35.
Hogue, E. (2003). Telehealth and risk manage-
ment in home health. Home Healthcare
Nurse, 21, 699 –703.
58. Miller, T. W., Burton, D., Sprang, R., & Adams,
J. (2003). A model for clinical supervision in
allied health. The Internet Journal of Allied
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Miller, T. W., & Miller, J. M. (1999). Telemedi-
cine: New directions for health care delivery
in Kentucky schools. Journal of the Ken-
tucky Medical Association, 94, 163–167.
Miller, T. W., Veltkamp, L. J., Kraus, R. F.,
Lane, T., & Heister, T. (1999). An adoles-
cent vampire cult in rural america. Child
Psychiatry and Human Development, 29,
209 –219.
Nickelson, D. (1998). Behavioral telehealth:
Emerging practice, research, and policy op-
portunities. Behavioral Sciences and the
Law, 14, 443– 457.
U.S. Department of Health and Human Services
(1997). Exploratory evaluation of rural ap-
plications of telemedicine. Retrieved (date),
from http://www.ntia.doc.gov.
Wood, J., Miller, T. W., & Hargrove, S. (2005).
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90 Consulting Psychology Journal: Practice and Research
Spring 2006
59. 22
Borderline Personality
Disorder
JOEL R. SNEED, ERIC A. FERTUCK, DORA
KANELLOPOULOS, AND MICHELLE E. CULANG-REINLIEB
OVERVIEW OF DISORDER
The origin of borderline personality disorder
(BPD) dates back to the original use of the term
borderline as delineating a group of patients
who were neither neurotic nor psychotic
(Stern, 1938). While early descriptions clari-
fied similarities and differences between the
phenomenology of BPD and other disorders, it
was the advent of DSM-III criteria that
allowed for reliable diagnosis and the facili-
tation of research into the disorder (Fertuck,
Lenzenweger, Clarkin, Hoermann, & Stanley,
60. 2006). BPD is currently defined by frantic
efforts to avoid abandonment, unstable inter-
personal relationships, emotional lability,
intense and inappropriate anger, impulsivity
that is self-destructive (including drug use,
indiscriminant sexual relations, and suicidal
and parasuicidal behavior), stress-related dis-
sociation and paranoia, and chronic feelings of
emptiness (American Psychiatric Association,
2000). Recurrent suicidal behaviors, along
with self-mutilation (i.e., cutting, burning,
etc.), are often referred to as parasuicidal and
are defined as nonfatal, intentional self-injuri-
ous behaviors with intent to cause bodily harm
or risk death (Linehan, 1993a).
The burden and suffering caused by BPD
is profound. BPD is associated with an up to
10% rate of completed suicide (Black, Blum,
61. Pfohl, & Hale, 2004), which is similar to the
rate for major depression and schizophrenia,
and 400 times greater than the suicide rate of
the general population. Nonsuicidal self-injury
(Simeon et al., 1992), intense and chronic
emotional pain (Stiglmayr et al., 2005), and
chronic physical illnesses (Frankenburg &
Zanarini, 2004) are also prevalent.
The symptoms characteristic of BPD have
been categorized in several ways. For
example, Linehan (1993a) argued that the
DSM-IV criteria can be reorganized according
to five domains of dysregulation: emotional
(the primary disturbance), interpersonal, cog-
nitive, behavioral, and self. Others have sug-
gested that the symptoms fall along three
primary dimensions: interpersonal and identity
disturbance, emotional instability, and impul-
62. sive and aggressive behaviors (Sanislow,
Grilo, & McGlashan, 2000). While individuals
with BPD may vary in the severity of these
features, they are highly intercorrelated in
BPD, and cohere into a unitary syndrome
(Clifton & Pilkonis, 2007).
In clinical settings, nearly three quarters of
those diagnosed with BPD are female (Swartz
et al., 1989); however, epidemiological studies
of representative community samples indicate
an equal sex ratio (Lenzenweger, Lane,
c22 18 April 2012; 14:9:55
507
Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based
practice in clinical psychology : Adult disorders. Retrieved
from http://ebookcentral.proquest.com
Created from ashford-ebooks on 2019-11-15 12:11:20.
C
op
yr
ig
64. ht
s
re
se
rv
ed
.
Loranger, & Kessler, 2007; Torgerson, Krin-
glen, & Cramer, 2001). Population prevalence
estimates for BPD range from 0.3% to 1.6%
(Lenzenweger et al., 2007), which is compa-
rable to other major psychiatric disorders, such
as schizophrenia. Given these associations, it
is not surprising that BPD is associated with
extensive health-care utilization (Bender
et al., 2001). It is estimated that approximately
11% of psychiatric outpatients and 19% of
psychiatric inpatients meet criteria for BPD
(Marshall & Serin, 1997). There is also a
65. substantial co-occurrence between BPD and
other Axis I disorders, such as major depres-
sion (Joyce et al., 2003; Stanley & Wilson,
2006), substance abuse (Trull, Sher, Minks-
Brown, Durbin, & Burr, 2000; Wilson et al.,
2006), anxiety disorders (Skodol et al., 2002),
posttraumatic stress disorder (Heffernan &
Cloitre, 2000; Landecker, 1992), eating dis-
orders (Zanarini, Frankenburg, Hennen,
Reich, & Silk, 2004), and—to a lesser
degree—bipolar mood disorder (Atre-Vaidya
& Hussain, 1999; Deltito et al., 2001;
Gunderson et al., 2006; Henry et al., 2001;
Paris, Gunderson, & Weinberg, 2007). Suicide
attempts increase dramatically in borderline
patients with co-occurring major depression
and substance abuse (Fertuck, Makhija,
& Stanley, 2007; Jacobs, Brewer, & Klein-
66. Benheim, 1999; Tanney, 2000).
Traditionally, clinicians have considered
BPD a difficult-to-treat condition with a
negative long-term prognosis (Stern, 1938;
Stone, Hurt, & Stone, 1987); however, a more
recent meta-analysis suggests that psycho-
therapeutic treatment for BPD is associated
with a sevenfold greater rate of recovery
compared to the natural history of the disorder
(Perry, Banon, & Ianni, 1999). In addition,
the long-term prognosis for individuals with
BPD appears more positive than previously
appreciated (Lenzenweger, 2008; Zanarini,
Frankenburg, Hennen, & Silk, 2003). Impor-
tantly, in the last two decades, clinicians
and researchers have developed and evalu-
ated targeted, BPD-specific psychosocial and
pharmaceutical treatment options that have
67. preliminary support from randomized con-
trolled trials (RCTs). Consequently, many
clinicians now express a cautious but founded
optimism for the efficacy of psychosocial
treatments for BPD (Gabbard, 2007).
The aim of this chapter is to review and
summarize empirically supported psycho-
social treatments for BPD. In addition, we
delineate the emerging trends and challenges
for the future of empirically supported treat-
ment including multimodal, integrative
treatments, treatment mechanism research,
and patient–treatment matching by BPD
subtypes and stage of recovery.
EMPIRICALLY SUPPORTED
TREATMENTS
We will use the principles established by the
American Psychological Association (Levant,
68. 2005) on Evidence-Based Practice in Psy-
chology (EBPP) to evaluate whether a given
treatment has been demonstrated to be effec-
tive. According to the Policy Statement on
Evidence-Based Practice in Psychology
(EBPP), “The purpose of EBPP is to promote
effective psychological practice and enhance
public health by applying empirically sup-
ported principles of psychological assessment,
case formulation, therapeutic relationship, and
intervention” (p. 5). This statement was
inspired by the debate and controversy over the
original criteria put forth by Division 12 of the
APA to rigorously define empirically validated
treatments (Chambless & Hollon, 1998). The
original definition has two levels: well estab-
lished and probably efficacious. To be well
established, a treatment must have support
71. rv
ed
.
require thatthe treatmenthavea well-articulated
manual and that the diagnostic characteristics
of the patient group samples be clearly specified
by DSM-IV criteria.
CONSENSUS PANEL
RECOMMENDATIONS
The American Psychiatric Association pub-
lished guidelines in 2001 for the treatment
of BPD that advocate for a combined psy-
chotherapy and targeted pharmacotherapy
approach with psychotherapy being the
primary treatment component and pharma-
cotherapy the adjunctive component (Oldham,
2005). Although the majority of RCTs involve
treatment of BPD with DBT, the updated
72. guidelines noted a number of new manualized
psychotherapy approaches being examined in
open treatment trials. Since the publication of
the update, several RCTs have been published
that we have reviewed (see the following).
Augmenting psychotropic agents, such as
SSRIs, atypical antipsychotics, and mood
stabilizers, are also recommended to treat
targeted symptoms such as affective dysregu-
lation, cognitive-perceptual disturbances, or
impulse dyscontrol in BPD.
There are now several psychosocial treat-
ments for BPD with varying empirical support
from RCTs (see Table 22.1). In the following
section, we summarize the nature and research
support for the most established approaches.
The section is divided into treatments that
are comprehensive and treatments that are
73. adjunctive.
COMPREHENSIVE TREATMENTS
Dialectical Behavior Therapy
Dialectical behavior therapy (Linehan, 1993a)
is a flexible, cognitive behavioral treat-
ment characterized by weekly individual
sessions, weekly skills training groups, and
telephone coaching to help generalize newly
learned skills beyond therapy sessions. The
central focus of DBT is on the dialectical
tension between accepting the patient’s
emotional experience and effecting adaptive
change through the use of chain analyses,
self-monitoring diaries, and contingency
management, particularly with respect to life-
threatening and therapy-interfering behaviors.
It also emphasizes education, role playing, and
problem solving strategies. DBT’s focus on
74. mindfulness, dialectics, and the therapeutic
relationship distinguish it from standard CBT.
According to the theoretical underpinnings
of DBT, the emotional dysregulation that
typifies BPD has its etiology in the interaction
between biology and environment. The bio-
logical underpinnings of emotional dysregu-
lation are high sensitivity and high reactivity
to painful affect, as well as a slow return to
emotional baseline after arousal. As a result,
borderline patients are primed for high emo-
tional reactivity because the biological con-
comitants of negative affectivity are still
active and have not returned to premorbid
levels. In conjunction with biological vulner-
ability, borderline patients are often subjected
to invalidating environments. Typical features
of the invalidating environment are being
75. exposed to caregivers or significant others
who: (a) respond erratically and inappropri-
ately to private emotional experiences, (b) are
insensitive to people’s emotional states,
(c) have a tendency to over- or underreact to
emotional experiences, (d) emphasize control
over negative emotions, and (e) have a ten-
dency to trivialize painful experiences and/
or attribute such experiences to negative
traits, such as lack of motivation or disci-
pline. It is theorized that the interaction
between emotional vulnerability and invali-
dating environments results in not being able
to label and modulate emotions, tolerate
emotional or interpersonal distress, or trust
private experiences as valid.
According to DBT, parasuicidal behaviors
that have been traditionally thought of as
78. BPD (N ¼ 38; ages 16 to 65)
MBT in partial
hospitalization (N ¼ 19)
versus TAU (N ¼ 19)
18 months MBT showed greater decreases in self-mutilation,
suicide attempts,
anxiety, depression, and severity of symptom reports than TAU.
Reduction in hospital admissions and length of stay for MBT
group
in last 6 months of study; in the TAU group, there was an
increase
in the same time period.
Bateman and Fonagy (2008) Follow-up of patients with
BPD in partial hospitalization
setting from 1999 study
(N ¼ 38; ages 16 to 65)
MBT group received
additional 18 months of
outpatient treatment versus
TAU
5-year
79. postdischarge
follow-up
Fewer MBT patients met criteria for BPD compared to TAU.
MBT
patients had less use of services and medication had longer
duration
of employment than TAU.
Blum et al. (2008) BPD patients with no
previous participation in
STEPPS (N ¼ 124; Mean
age ¼ 31.5; SD ¼ 9.5)
STEPPS þ TAU (N ¼ 65)
versus TAU (N ¼ 59)
20 weeks Differences in affective, cognitive, impulsive,
affective, and
interpersonal domains of Zanarini Rating Scale for BPD as well
as
improvements in global functioning favoring the STEPPS group.
Clarkin, Levy, Lenzenweger,
and Kernberg (2007)
Patients with BPD (N ¼ 90;
80. ages 18 to 50)
TFP (N ¼ 23); DBT (N ¼ 17);
and ST (N ¼ 22)
1 year TFP and DBT were significantly associated with
improvement in
suicidality. TFP and ST were associated with improvement in
anger. TFP was associated with improvement in Barratt Factor 2
Impulsivity as well as irritability, verbal assault, and direct
assault.
ST was predictive of improvement in Barratt Factor 3
Impulsivity.
Davidson et al. (2006) Patients with BPD who had
received emergency
psychiatric services in past
year (N ¼ 106; ages 18 to 65)
CBT þ TAU (N ¼ 54) versus
TAU only (N ¼ 52)
1 year treatment;
1 year follow-up
No differences between the groups in suicidal acts, inpatient, or
emergency hospitalization. There was a statistically significant
81. difference in the mean number of suicide acts (small effect size)
as
well as lower anxiety and BPRS distress favoring CBT at the
end of
2 years.
Giesen-Bloo et al. (2006) Patients with BPD (N ¼ 86;
ages 18 to 60)
TFP (N ¼ 42) versus SFT
(N ¼ 44)
3 years Both treatments related to significant increases in
quality of life,
reduction in all BPD symptoms, and reduction in general
psychopathologic dysfunction. SFT group had greater reduction
in
BPD symptoms, general psychopathology than TFP. Higher
dropout rate for TFP than SFT.
Gregory et al. (2008) Patients with BPD and active
alcohol abuse/dependence
(N ¼ 30; ages 18 to 45)
DDP (N ¼ 15) versus TAU
(N ¼ 15)
82. 12–18 months Significant improvement in parasuicide, alcohol
misuse, and
institutional care over time for DDP but not for TAU.
Koons et al. (2001) Women with BPD recruited
from a VA clinic (N ¼ 20;
ages 21 to 46)
DBT (N ¼ 10) versus TAU
(N ¼ 10)
6 months DBT patients had greater reductions in suicidal
ideation,
depression, hopelessness, and anger compared to TAU at
posttreatment.
c
2
2
1
8
A
p
ril
2
0
1
2
;
1
84. ages 18 to 50)
TFP (N ¼ 31) versus SPT
(N ¼ 30) versus DBT
(N ¼ 29)
1 year Reflective function, attachment coherence, and security
of
attachment had a significantly greater increase over the year of
treatment for the TFP group versus the other two therapy
groups.
There were no significant changes across groups for resolution
of
loss or trauma.
Linehan, Armstrong, Suarez,
Allmon, and Heard (1991)
Chronically parasuicidal
women with BPD recruited
from outpatient clinic
(N ¼ 44; ages 18 to 45)
DBT (N ¼ 22) versus TAU
(N ¼ 22)
1 year DBT patients had significant reductions in parasuicidal
behavior,
85. were significantly more likely to start and to complete
treatment,
stayed in treatment longer, and had significantly fewer inpatient
hospital days compared to TAU. Findings were maintained
throughout the posttreatment follow-up year.
Linehan, Heard, and
Armstrong (1993)
Women with BPD and at least
two instances of parasuicidal
behavior (N ¼ 39; ages 18 to
45)
DBT (N ¼ 19) versus TAU
(N ¼ 20)
1 year Parasuicide repeat rate and the likelihood of any
psychiatric
hospitalization were lower for DBT versus TAU completers;
this
difference remained during the 12–18 month follow-up period.
During the follow-up year, DBT patients reported significantly
better Global Assessment Scale scores and employment
86. performance than TAU.
Linehan, Tutek, Heard, and
Armstrong (1994)
Women with BPD (N ¼ 26;
ages 18 to 45)
DBT (N ¼ 13) versus TAU
(N ¼ 13)
1 year DBT was more effective than TAU in the community in
improving
interpersonal and general adjustment in women with BPD. DBT
patients rated selves better on trait anger scores and on overall
social adjustment posttreatment.
Linehan et al. (1999) Women with BPD and
substance use disorder
(N ¼ 28; ages 18 to 45)
DBT (N ¼ 12) modified for
substance abuse versus TAU
(N ¼ 16)
1 year Significant reduction in substance abuse, improvements
in social
and global adjustment, and greater retention rates for DBT
87. versus
TAU. Improvements in social and global adjustment greater for
DBT versus TAU at follow-up. Greater adherence of therapists
to
DBT treatment manual resulted in better outcomes.
Linehan et al. (2002) Heroin-dependent women
with BPD (N ¼ 23; ages 18 to
45).
DBT (N ¼ 11) modified for
substance users versus
CVT þ 12S (N ¼ 12). Both
groups also received opiate
agonist therapy.
1 year Both treatments when combined with opiate agonist
treatment were
effective in reducing opiate use and maintaining the reduction
to
4-month posttreatment. CVT þ 12S had greater retention rate
than
DBT. DBT group was more accurate in self-recording opiate
use.
Linehan et al. (2006) Women with BPD (N ¼ 103;
ages 18 to 45)
88. DBT (N ¼ 52) versus CBTE
(N ¼ 49)
1 year DBT group had half the rate of suicide attempts, was
more effective
at reducing emergency room visits, and inpatient psychiatric
care
for suicide ideation compared to the CTBE group. DBT was
more
than twice as effective as CTBE in keeping subjects in
treatment.
(Continued)
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90. Linehan, McDavid, Brown,
Sayrs, and Gallop (2008)
Women with BPD and high
levels of irritability and anger
(N ¼ 24; ages 18 to 60)
DBT þ placebo (N ¼ 12)
versus DBT þ olanzapine
(N ¼ 12)
6 months Irritability, aggression, and self-injurious behavior
improved
significantly during treatment for both conditions. Irritability
and
aggression tended to decrease more rapidly for olanzapine,
while
self-inflicted injury tended to decrease more placebo group.
Spinhoven, Giesen-Bloo,
van Dyck, Kooiman, and
Arntz (2007)
Patients with BPD (N ¼ 78;
ages 18 to 60)
SFT (N ¼ 44) versus TFP
91. (N ¼ 34)
3 years The quality of the therapeutic alliance increased for
patients for
both SFT and TFP but therapist frustration decreased for SFT
while
it increased for TFP. Compared to SFT significantly more
patients
in TFP dropped out early.
Turner (2000) Patients with BPD (N ¼ 24;
Mean age ¼ 22)
DBT (N ¼ 12) with no
separate skills group versus
CCT (N ¼ 12)
1 year DBT group showed a greater reduction in global mental
health
functioning, self-harm behaviors, and hospitalization days at
both
6 and 12 months. DBT had lower impulsivity than CCT at 12
months.
Van den Bosch, Koeter,
Stijnen, Verheul, and van
den Brink (2005)
92. Women with BPD with and
without substance abuse
(N ¼ 58; ages 18 to 45)
DBT (N ¼ 27) versus TAU
(N ¼ 31)
6-month follow-up DBT had a significantly greater decrease in
impulsive and self-
mutilating behavior and alcohol consumption than TAU. The
treatment effects were sustained for the 6-month period after
termination of treatment.
Van Den Bosch, Verheul,
Schippers, and van den
Brink (2002)
Women with BPD with and
without substance abuse
(N ¼ 58; ages of 18 to 45)
DBT (N ¼ 27) versus TAU
(N ¼ 31)
1 year Substance abuse was not effectively targeted by either
treatment.
93. DBT had greater retention rate and showed greater reductions of
self-mutilating behavior and self-damaging impulsive acts than
TAU. Beneficial effect of DBT on self-mutilating behaviors was
greater for those patients that had higher baseline behaviors.
Verheul et al. (2003) Women with BPD (N ¼ 64;
ages 18 to 70)
DBT (N ¼ 31) versus TAU
(N ¼ 33)
1 year DBT had a decrease in self-mutilating behaviors and a
greater
retention rate than TAU. Impact of DBT was more pronounced
for
participants who reported higher baseline frequencies of self-
mutilating behaviors.
Weinberg, Gunderson,
Hennen, and Cutter (2006)
Women with BPD (N ¼ 30;
ages 18 to 40)
MACT þ TAU (N ¼ 15)
versus TAU (N ¼ 15).
6 to 8 weeks The MACT group had significantly greater
94. decrease in frequency
and severity of deliberate self-harm (DSH) at both 6–8 weeks
and at
the 6-month follow-up. No significant differences between
groups
were observed for suicidal ideation and time to repeat DSH.
Note: MBT ¼ Mentalization-Based Therapy; TAU ¼ Treatment
As Usual; STEPPS ¼ Systems Training for Emotional
Predictability and Problem Solving; TFP ¼ Transference
Focused Psychotherapy; DBT ¼ Dialectical Behavioral Therapy;
ST ¼ Supportive Therapy; CBT ¼ Cognitive Behavior Therapy;
SFT ¼ Schema Focused Therapy; DDP ¼ Dynamic
Deconstructive Psychotherapy; MPSP ¼ Modified
Psychodynamic Supportive Psychotherapy; CVT ¼
Comprehensive Validation Therapy; CBTE ¼ Community-Based
Treatment by
Experts; CCT ¼ Client Centered Therapy; MACT ¼ Manual-
Assisted Cognitive Therapy
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96. manipulative and controlling are reframed
as maladaptive attempts at problem solving
and emotion regulation. Linehan argued
that a dialectical perspective looks for the
wisdom or the adaptiveness of the parasuicidal
gesture; that is, although the gesture is
dysfunctional, it has been shaped by an
environment that actively teaches emotional
invalidation. As such, this model posits that
parasuicidal gestures serve self-regulatory
functions and also serve to elicit responses in
significant others who have not responded
appropriately to the patient’s emotional
needs. According to Linehan (1993a), what
maybe viewed as dysfunctional, distorted, and
destructive, may actually be adaptive, accu-
rate, and constructive.
97. Weekly skills training groups (Linehan,
1993b) aim to replace the maladaptive prob-
lem-solving strategies characteristic of BPD
patients with more constructive and adaptive
strategies that help the patient build a life
worth living. The four areas of skills training
include core mindfulness, interpersonal effec-
tiveness, emotion regulation, and distress
tolerance. Mindfulness strategies integrate
Zen meditation practices and epitomize the
acceptance versus change dialectic, which lies
at the heart of DBT. The core mindfulness
module distinguishes between rational mind,
emotion mind, and wise mind. The wise mind
represents an integration of rational and emo-
tion mind and can be thought of as the indi-
vidual’s intuition. Mindfulness exercises form
the core of the module and aim to decrease
98. impulsivity and allow for the implementation
of more adaptive strategies learned in the other
modules. The interpersonal module provides
strategies and techniques for dealing with and
negotiating difficult interpersonal interactions
based on a clear understanding of the priorities
in a given situation. Emotion regulation
provides the patient with an organizing
framework for understanding emotions, and
exercises that aim to enhance the capacity to
label and understand the antecedents, conse-
quences, and function of emotional expression.
Finally, distress tolerance aims to provide the
patient with various crisis strategies in order to
prevent maladaptive coping that historically
has hindered the individual from living a
meaningful and productive life.
Randomized clinical trials of DBT. We
99. identified 11 RCTs of DBT in patients meeting
criteria for BPD. Eight of these studies were
with patients meeting BPD criteria alone
whereas three examined the efficacy of DBT in
BPD patients meeting criteria for comorbid
substance abuse or dependence. Following, we
summarize their main findings.
Linehan et al. (1991) randomized 44 women
aged 18 to 45 years with BPD to either DBT
(N ¼ 22) or to treatment as usual (TAU)
(N ¼ 22) for 12 months. The DBT program
was comprehensive and included individual
psychotherapy, 150-minute group skills train-
ing including training in interpersonal skills,
distress tolerance/reality acceptance skills, and
emotion regulation skills. Patients were
exposed to all skills teaching twice within this
12-month trial. The TAU patients were given
alternative therapy referrals from which they