National Education Alliance for Borderline Personality Disorder
9th Annual National Institute of Mental Health Conference
Dialectical Behavior Therapy (DBT)
State of the Art and Science
Marsha M. Linehan, Ph.D., ABPP
Martin Bohus, M.D.
Kate Comtois, Ph.D. – Linda Dimeff, Ph.D.
Anthony Dubose, Psy.D. – Alan E. Fruzzetti, Ph.D.
Melanie Harned, Ph.D. – Perry D. Hoffman, Ph.D
Kelly Koerner, Ph.D. – Katie Korslund, Ph.D
Conference presentations – Day 1
|DBT: Essential Characteristics and Clinical Outcomes|
LINEHAN, MARSHA, PHD
Professor, Department of Psychology
Director, Behavioral Research and Therapy Clinics
Borderline personality disorder (BPD) is a serious public health problem. Individuals meeting criteria for the disorder constitute up to 40% of the highest utilizers of mental health services, comprising 8 to 11% of outpatients and 14 to 20% of inpatients. Ten percent of individuals with BPD die by suicide. Clinical outcomes for treatment of other Axis I conditions are significantly compromised by the presence of BPD. Dialectical Behavior Therapy (DBT) is a comprehensive cognitive-behavioral treatment program developed at the University of Washington (UW) in the early 1980s for highly suicidal individuals and later expanded to treat those with BPD. Since then, DBT has expanded to treat individuals with other co-occurring disorders. The treatment integrates principles of behavioral science with those of Zen practice to provide a synthesis of change and acceptance both at the level of the treatment providers actions and at the level of new behaviors taught to clients. DBT was the first efficacious psychosocial intervention for BPD, as demonstrated by well-conducted randomized clinical trials (RCTs) conducted at UW. Since the original RCTs, ten RCTs demonstrating its effectiveness as well as numerous non-randomized controlled trials have been conducted around the world. This talk will briefly outline key characteristics of DBT, how DBT can be adapted for the treatment of BPD, and will review the various outcomes found in clinical trials of BPD.Objectives
|Marsha Linehan, PhD is a Professor of Psychology and adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington and is Director of the Behavioral Research and Therapy Clinics, a consortium of research projects developing new treatments and evaluating their efficacy for severely disordered and multi-diagnostic and suicidal populations. Her primary research is in the application of behavioral models to suicidal behaviors, drug abuse, and borderline personality disorder. She is also working to develop effective models for transferring science-based treatments to the clinical community.She is the past-president of both the Association for the Advancement of Behavior Therapy and of the Society of Clinical Psychology, Division 12, American Psychological Association. She is a fellow of the American Psychological Association and the American Psychopathological Association and is a diplomat of the American Board of Behavioral Psychology.She is the developer of Dialectical Behavior Therapy (DBT) a treatment originally developed for the treatment of suicidal behaviors and since expanded to treatment of borderline personality disorder and other severe and complex mental disorders, particularly those that involve serious emotion dysregulation.Dr. Linehan has written three books, including Cognitive-Behavioral Treatment for Borderline Personality Disorder and Skills Training Manual for Treating Borderline Personality Disorder.|
HOFFMAN, PERRY D., PhD
President, National Education Alliance for Borderline Personality Disorder
Families with a relative with borderline personality disorder are important to be considered when working with the individual with the disorder. Research show that family members may influence the one-year outcome of the person and their emotional involvement with the individual is a helpful factor. However, because of its severity, symptomatology, and high rates of co-occurring disorders, BPD also negatively affects family members and others in their social environment. Family members also need support, education and skills.Families have experienced a long journey going from anguish and adversity to awareness and advocacy. The presentation outlines what NEABPD’s community of family members have effected in the past 10 years, demonstrating that families matter.Objectives
|Perry D. Hoffman, Ph.D. is the President and a co-founder of the National Education Alliance for Borderline Personality Disorder (www.borderlinepersonalitydisorder.org). She has several grants from the National Institute of Mental Health with a focus on families who have a relative with borderline personality disorder. Dr. Hoffman is co-designer of the 12-week psycho-education course for families, Family Connections, which is available in many locations both in the United States as well as other countries. She is co editor, with John G. Gunderson, MD, of the book Understanding and Treating Borderline Personality Disorder: A Guide for Professionals and Family Member and co editor of Borderline Personality Disorder: Meeting the Challenges to Successful Treatment. Dr. Hoffman, who is intensively trained in Dialectical Behavior Therapy (DBT), has been the director of several DBT treatment programs in the New York area and now is in private practice in New York City and Westchester County, NY.|
|Dialectical Behavior Therapy Treatment Fidelity: Clinical and Research Implications|
KORSLUND, KATHRYN E., PhD, ABPP
University of Washington
Dialectical Behavior Therapy (DBT) is a comprehensive, principle driven, cognitive-behavioral treatment designed for the complex and difficult to treat patient. To date, DBT is the most researched treatment for Borderline Personality Disorder with nine randomized controlled trials, seven controlled trials, and at least seventeen uncontrolled trials demonstrating its efficacy across a wide range of clinical targets and settings. DBT has been widely disseminated and enthusiastically embraced by clients and clinicians alike. But, what is actually being delivered outside the confines of a research study? There is no agreed upon requirement for research or clinical practice in terms of monitoring intervention delivery in psychotherapy. Yet, several studies have demonstrated better outcomes for consumers when evidence-based practice includes the use of a validated treatment fidelity scale. This presentation will discuss the concepts of treatment fidelity as relevant to DBT researchers, clinicians, consumers and third party stakeholders including a review of the DBT – gold standard- measure for therapy monitoring and the relationship between treatment fidelity and DBT proficiency credentialing.Objectives
|Kathryn Korslund, Ph.D., ABPP is a Research Scientist in the Department of Psychology at the University of Washington and the Associate Director of the Behavioral Research and Therapy Clinics. She is a co-investigator with Dr. Marsha Linehan on several federally funded clinical research studies evaluating the efficacy of behavioral treatments for suicidal behavior, substance dependence, and borderline personality disorder and with Dr. Melanie Harned on her NIMH funded study to develop an exposure-based protocol to be added to DBT for treatment of co-occurring PTSD in suicidal and self-injuring BPD women. Dr. Korslund is a Diplomate of the American Board of Professional Psychology and a Fellow of the American Academy of Cognitive and Behavioral Psychology. She is a recognized expert on Dialectical Behavior Therapy (DBT) therapy and DBT fidelity monitoring, and is co-chair of the International DBT Program Accreditation and Therapist Certification Workgroup.|
|Being Mindful of Emotion to Validate Self and Other|
KOERNER, KELLY, PhD
Creative Director & CEO,
Evidence-Based Practice Institute
At a given moment, multiple emotions may be firing, some at strength, some weaker. When we offer each other strongly worded and emotionally evocative validation the validation can direct our attention and trigger an adaptive emotion, changing our perception, sensing, remembering, and action urges with that newly triggered emotion. By doing so, more flexible, adaptive responding may become immediately possible. In this presentation we look at the natural adaptive function of emotion and examine how mindfulness of our own and others’ emotion can lead to validation of self and others.Objectives
By the conclusion of the presentation participants will be able to:
|Kelly Koerner, PhD, is Clinical Faculty at the University of Washington and is Creative Director of the Evidence-Based Practice Institute, a social enterprise that helps practitioners learn and use evidence-based mental health care practices. She is an expert clinician, clinical supervisor and trainer in Dialectical Behavior Therapy (DBT) with specialized training in many other evidence based treatments. She has served as: Chair of the Training Committee for Acceptance and Commitment Therapy; Director of Training for Marsha Linehan’s research investigating the efficacy of DBT for suicidal and drug abusing individuals with borderline personality disorder; Creative Director at Behavioral Tech Research where she developed e-learning and other technology based methods to disseminate evidence-based practices; and co-founder and first CEO of Behavioral Tech, a company that provides training in DBT. Her publications include: Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings (2007) and the forthcoming, DBT in Action: Individual psychotherapy. She also maintains a private practice in Seattle and provides case consultation and training for dialectical behavior therapy teams and individual therapists.|
|Processes of Change in DBT: What Happens In, and Out, of the Session|
ALAN E. FRUZZETTI, PhD
Associate Professor and Director,
Dialectical Behavior Therapy and Research Program,
University of Nevada
Although dozens of controlled studies have established the efficacy of Dialectical Behavior Therapy for disorders related to emotion dysregulation, the essential processes of change are not as clearly understood. In this presentation, different aspects of the change process will be highlighted, including in-session therapist and client behaviors, and immediate changes in client behavior outside the session, that all influence eventual treatment outcome for clients with borderline personality disorder and recent suicidality. Data will be woven throughout to illustrate some important in-session changes (specifically, therapist validation of client primary vs. secondary emotion) and immediate changes in client behaviors that predict outcome (mediators of outcome, including emotion regulation and family functioning). The clinical implications of these findings will be discussed.Objectives
|Alan E. Fruzzetti, Ph.D., is Associate Professor of Psychology and Director of the Dialectical Behavior Therapy and Research Program at the University of Nevada, Reno. He received his B.A. from Brown University and M.S. & Ph.D. from the University of Washington in Seattle. His research focuses on the interplay between severe psychopathology and interpersonal processes (including couple and family interactions and therapist-client interactions) and the development of effective individual and family treatments for these problems. Dr. Fruzzetti is Research Director and a Member of the Board of Directors of the National Education Alliance for Borderline Personality Disorder, and is the co-creator of the NEABPD Family Connections program. He has been providing DBT as a clinician since 1987 and as a supervisor and clinic director since 1992, and has created multiple DBT applications for individuals, couples, parents, and families. He maintains a clinical practice with individuals and families, and has provided extensive training in the United States, Europe, and Australia in DBT.|
Moderator: ALAN E. FRUZZETTI, PhD
Conference presentations – Day 2
|Residential DBT program for patients with borderline personality disorder and PTSD after childhood sexual abuse a controlled randomized trial|
PROF. MARTIN BOHUS, MD
Chair Psychosomatic Medicine and Psychotherapy,
University of Heidelberg
Director Clinic of Psychosomatic Medicine and Psychotherapy,
Central Institute of Mental Healt
We modified standard dialectical behavior therapy (DBT) to meet the specific needs of adult patients experiencing borderline personality disorder (BPD) plus therapy resistant PTSD related to childhood sexual abuse. We evaluated the effects of DBT-PTSD.Method: 80 women meeting DSM-IV for BPD and co-occuring PTSD related to CSA were randomised to either a waitlist condition (WL) or a three month residential DBT-PTSD program. Patients were assessed prior to randomisation (t1), post treatment (t2, 3 months post randomisation), at 6 weeks and 3 months post discharge (t3, t4; 4.5 months and 6 months post randomisation). Assessments included Clinician Administered PTSD Scale (CAPS), Posttraumatic Diagnostic Scale (PDS), Beck Depression Inventory (BDI), SCL90R, and Borderline Symptom List (BSL).
Results: Group Comparisons at t1 and t3 revealed significant response and remission for the DBT-PTSD group. Manovas revealed significant time x group interactions, showing a significantly greater reduction of symptomatology in CAPS, PDS, and BDI for DBT-PTSD as compared to WL. Cohen,s d (t1 vs. t4, CAPS) was 1.4 for DBT-PTSD and 0.19 for the WL.Conclusions: Data suggest that DBT-PTSD has high promise for reducing severe and chronic PTSD and comorbid psychopathology related to CSA.
Key words: PTSD, Dialectical Behavior Therapy.
|Prof. Dr. Martin Bohus is Chair in Psychosomatics and Psychotherapy, University of Heidelberg, and Director, Dept. of Psychosomatics and Psychotherapy, Central Institute of Mental Health, Mannheim. He holds memberships in the Deutsche Gesellschaft for Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN; board member), European Society for the Study of Personality Disorders (ESSPD; vice president); German Association for DBT (DDBT; president), Association for Research in Personality Disorders (ARPD; board member). Honors and awards include the Established Investigator Award. Borderline Personality Disorder Research Foundation, New York and Research Award International Society for the Investigation and Teaching of Dialectical Behavioral Therapy, Boston; Psychotherapy Award of the German Association of Psychiatry, Psychotherapy and Neurology; Outstanding Research Award International Society for the Investigation and Teaching of Dialectical Behavioral Therapy, Washington; Hamburg Award for Personality Disorders: German Association for Personality Disorders. Research interests are pain processing in patients with psychiatric disorders, psychopathology of Borderline Personality Disorders, PTSD, Social Phobia, treatment development. Prof Bohus has been awarded major grants in Germany and the US including Borderline Personality Foundation, NY and National Institute of Drug Abuse, and has188 publications in journals such as: Nature, Lancet, Archives of General Psychiatry, American Journal of Psychiatry, Biological Psychiatry.|
|Treating PTSD in Suicidal and Self-Injuring Clients with Borderline Personality Disorder |
MELANIE S. HARNED, PhD
Research Scientist, Department of Psychology,
University of Washington, Seattle, WA
A number of randomized controlled trials have documented the efficacy of Dialectical Behavior Therapy (DBT) in treating individuals with borderline personality disorder (BPD), and it is now widely used in clinical practices around the world. While DBT has been shown to be highly effective in reducing suicidal and non-suicidal self-injury, it is less effective in treating PTSD, a comorbid diagnosis that is prevalent in BPD patients. Conversely, existing PTSD treatments typically exclude suicidal and self-injuring patients, making it difficult to determine the generalizability of these treatments to high-risk individuals with BPD. This presentation will describe a newly developed PTSD protocol (adapted from Prolonged Exposure therapy) that can be added to standard DBT to treat PTSD among suicidal and/or self-injuring individuals with BPD. Pilot data on this combined DBT + PTSD protocol treatment indicates that it can be implemented safely in this high-risk population, and that it is associated with significant improvements in PTSD and other trauma-related problems. Emphasis will be placed on how to determine whether clients are ready to begin PTSD treatment and describing the structure and procedures of the PTSD protocol.Learning Objectives
Harned, M. S. & Linehan, M. M. (2008). Integrating Dialectical Behavior Therapy and Prolonged Exposure to treat co-occurring borderline personality disorder and PTSD: Two case studies. Cognitive and Behavioral Practice, 15(3), 263-276.
Linehan, M.M. (1993). Cognitive behavioral treatment for borderline personality disorder. New York: Guilford Press.
|Melanie S. Harned, Ph.D. is a Research Scientist in the Department of Psychology at the University of Washington and is the Research Director of Dr. Marsha Linehan’s clinic. She is currently Principal Investigator of an NIMH funded study to develop a PTSD protocol that can be added to Dialectical Behavior Therapy to treat co-occurring PTSD in suicidal and self-injuring clients with borderline personality disorder. She is also a Co-Investigator with Dr. Linehan on her NIMH and NIDA funded research. Dr. Harned also works as a Research Scientist at Behavioral Tech Research, Inc. and is Principal Investigator on several studies focused on developing effective methods for disseminating exposure-based treatments to community mental health settings.|
|Running an empirically supported treatment center: Administration, training, supervision, and fidelity|
ANTHONY P. DUBOSE, Psy.D.
President, Evidence Based Treatment Centers of Seattle, PLLC
In 2001 a group of research therapists began discussions about starting a center in Seattle that would demonstrate that treatments developed in the university setting could be implemented in the private sector. There was specific interest in demonstrating fidelity to DBT, providing a place for training, and creating a work environment that embodied the principles of a DBT consultation team. The result was that the DBT Center of Seattle opened in July of 2002 and has since evolved into the Evidence Based Treatment Centers of Seattle, PLLC (EBTCS). EBTCS now involves multiple centers, each focused on providing specific empirically supported treatments. This presentation will discuss the lessons learned from that venture, and will provide an outline of the organizational structure, staffing model, postdoctoral fellowship programs, and methods used to evaluate services provided at EBTCS. The models and procedures used at EBTCS will also be compared to other models, with rationales given for the choice of those implemented at EBTCS.Objectives
|Anthony P. DuBose, Psy.D. is a Founding Member and the President of the Evidence Based Treatment Centers of Seattle, PLLC. Dr. DuBose received a doctoral degree in clinical psychology from Pacific University of Oregon, and is licensed as a psychologist in the state of Washington. His interest in suicidal and self-injurious behaviors developed while serving as the director of an inpatient adolescent psychiatry program at the Child Study and Treatment Center, in Lakewood, WA. He is a recognized expert in Dialectical Behavior Therapy, and has trained and consulted internationally in the treatment of borderline personality disorder, substance use disorders, and suicidal and self-injurious behaviors in adults and adolescents. He holds appointments in the University of Washington Department of Psychiatry and Behavioral Sciences and the Department of Psychology. He is currently collaborating with Marsha Linehan, Ph.D., ABPP, on the implementation of an adolescent treatment development clinic in the Behavioral Research and Therapy Clinics at the University of Washington. He has a particular interest in implementation of evidence-based practices in systems.|
|DBT-ACES: Achieving Recovery from Psychiatric Disability |
KATE COMTOIS, PHD, MPH
Associate Professor, Department of Psychiatry and Behavioral Sciences,
Adjunct Associate Professor, Department of Psychology
The DBT-Accepting the Challenges of Exiting the System (DBT-ACES) advanced year of DBT has been designed specifically for psychiatrically disabled individuals with severe borderline personality disorder to assist them to achieve recovery as recommended in the President’s New Freedom Commission on Mental Health. This program was developed by a DBT team in a community mental health center to help patients leave public mental health system for living wage employment. DBT-ACES is an advanced year of DBT treatment that is provided following the successful completion of standard DBT for those who want to work and leave public mental health. This presentation will review the factors underlying psychiatric disability, especially as it related to borderline personality disorder, and describe the history and conceptual approach of DBT-ACES as a response to them. The main treatment DBT strategies used in DBT-ACES will be described. DBT-ACES adaptations of DBT will be highlighted and the initial data showing its feasibility presented.Objectives
|Kate Comtois is Associate Professor in the Department of Psychiatry and Behavioral Sciences and Adjunct Associate Professor in the Department of Psychology at the University of Washington. She received her Ph.D. in clinical/community psychology from the University of Maryland in 1992. Dr. Comtois conducts research evaluating treatment services provided prior to or following suicidal behavior and dissemination of evidence-based practices in large health systems. She is currently completing two feasibility and treatment development studies of treatments for acute and chronically suicidal patients adapting existing treatments to the public mental health setting. Dr. Comtois is clinical director of the Dialectical Behavior Therapy clinic at Harborview Mental Health Services and the UW DBT Residency Training program. She has received awards for her teaching from the UW School of Medicine, UW Postdoctoral Association, from the International Society for Innovation and Training in DBT for her contribution to the science of DBT, and from King County for her DBT clinic as the best direct service mental health or substance abuse program in the county in 2000. In addition, Dr. Comtois provides training in DBT across the United States, Canada, Australia, and the United Kingdom.|
|Dialectical Behavior Therapy for Substance Abusers: A brief retrospective |
LINDA A. DIMEFF, PhD
Vice President/Chief Scientific Officer,
Behavioral Tech Research, Inc.
Substance use disorders (SUD) co-occurring with borderline personality disorder (BPD) affects up to 6% of the population and poses serious and complex public health problems. Dialectical behavior therapy (DBT) is an efficacious treatment for individuals with BPD and SUD. This presentation will provide a retrospective review of the development of this DBT adaptation, the specific modifications made to DBT, and the research conducted to date on its efficacy. We will review the early clinical observations made by Linehan and her colleagues that influenced the initial modifications made to DBT, including the Path to Clear Mind behavioral targets for substance abuse, strategies to facilitate attachment, the use of replacement medications, SUD-specific skills, dialectical abstinence, and the role of family in treatment. Subsequent refinements made to the treatment, based on lessons learned over time, will also be presented. Finally, we will look to the future of what next steps might look like in the evaluation of DBT for BPD-SUD patients.
|Linda Dimeff, Ph.D. is Vice President and Chief Scientific Officer for Behavioral Tech Research, Inc., an organization devoted to the dissemination of empirically supported therapies (EST). She holds an appointment as clinical faculty in the Department of Psychology at the University of Washington. Dr. Dimeff was the chief collaborator to Dr. Linehan in the development of DBT for substance dependent individuals with BPD. She is the primary editor of Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings. Over the years, she has written numerous theoretical and empirical papers in the areas of addictive behaviors, DBT, and dissemination. Her more recent work has focused on leveraging technology to facilitate the widespread implementation of DBT and other EST.|