Revisiting the Self-Medication Hypothesis From a Behavioral Perspective
Arthur W. Blume, Karen B. Schmaling, G. Alan Marlatt, University of Washington
The self-medication hypothesis suggests that clients use substances as a means to reduce their psychiatric symptoms. However, substance use as a form of self-medication also can be interpreted as exacerbating symptoms. Behavioral principles may provide a useful perspective to understand this apparent contradiction. The authors investigated the relationship of types of substance use with psychiatric symptoms among 220 participants with co-occurring disorders in an acute care psychiatric unit. Participants were assessed for their use of 6 different classes of substances within 3 months of admission. Hierarchical logistic regression analyses found that particular substances were associated with each of the diagnostic categories and that the pattern of associated substances differed by diagnostic category in a way that supported both self-medication and symptom exacerbation hypotheses. Self-medication and symptom exacerbation can be defined and treated in cognitive-behavioral terms. Harm reduction strategies seem to offer great promise in this context.
Skills Training Groups on a Psychiatric Intensive Care Unit: A Guide for Group Leaders
Kenneth R. Weingardt, Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, and Robert A. Zeiss, Veterans Affairs Palo Alto Health Care System
This paper outlines a structured group intervention for use in a locked acute psychiatric intensive care environment. This intervention, described in manualized form, draws upon the empirically validated psychosocial skills training approach for the rehabilitation of individuals with chronic mental illness (cf. Liberman et al., 1993). The first section discusses general principles for conducting skills training groups in the acute psychiatric population, including practical strategies for encouraging patients to attend group, group structure, rules, and process. The second part of the paper outlines seven specific skills training modules that provide concrete, step-by-step instructions for conducting groups on such topics as anger management, communication skills, coping with mental illness, and relapse prevention. The reader is invited to critically evaluate, modify, and expand upon the materials presented in order to better serve this challenging population.
From Theory to Practice: Use of Stage of Change to Develop an STD/HIV Behavioral Intervention
Phase 2: Stage-Based Behavioral Counseling Strategies for Sexual Risk Reduction
Patricia A. Coury-Doniger, Jeffrey C. Levenkron, Peter L. McGrath, Kerry L. Knox, Marguerite A. Urban, University of Rochester
In the first 15 years of the HIV epidemic, client education alone has not resulted in sustained sexual and substance use behavior change needed for primary prevention. More recently, interventions grounded in behavioral science have demonstrated efficacy in the primary prevention of HIV and other sexually transmitted diseases (STDs). Many barriers exist however, in the implementation of research-proven behavioral interventions in real-world settings. This paper describes an adaptation of the Stages of Change/Transtheoretical Model (SOC/TTM) to develop a stage-based method of counseling that is currently being used to promote sexual and substance use behavior change for reducing the risk of acquiring STDs and HIV. This behavioral counseling intervention, named Rochester STD/HIV Behavioral Counseling (RoSHBeC), was developed for front-line providers who deliver STD/HIV prevention interventions to at-risk individuals in both clinical and community-based settings. A systematic method for assessing SOC, previously described in Coury-Doniger, Levenkron, Knox, Cowell, & Urban (1999), provides the basis for the selection of practical counseling strategies adapted from the processes of change described in the TTM. The present paper traces our efforts to develop these counseling strategies specific to sexual behaviors and illustrates their use in 12 common clinical cases (STD/HIV-prevention counseling sessions). The RoSHBeC behavioral counseling intervention can also be used to influence other health-related behaviors at the individual and group levels. The steps of RoSHBeC provide a structured psychological intervention that is grounded in behavioral science (SOC/TTM) and is practical enough to be delivered by a wide variety of providers with limited formal training in counseling and behavioral treatment methods.
Treatment of Recurrent Major Depression With Attention Training
Costas Papageorgiou, University of Manchester and North Manchester NHS Trust, and Adrian Wells, University of Manchester
This study evaluated the effectiveness of Attention Training (ATT; Wells, 1990) in the treatment of recurrent major depression. This technique is based on an information processing model of emotional disorders (Wells & Matthews, 1994) in which self-focused attention and metacognition maintain dysfunction. ATT was evaluated in a consecutive single-case series of patients referred for treatment of recurrent major depression. Patients were assigned to no-treatment baselines of 3 tot 5 weeks, administered five to eight weekly sessions of ATT, and followed up at 3, 6, and 12 months posttreatment. The effects of ATT on depression, anxiety, negative automatic thoughts, rumination, self-focused attention, and metacognition were assessed. Following ATT, all patients showed clinically significant reductions in depression and anxiety. Reductions in negative automatic thoughts, rumination, and attentional and metacognitive factors showed similar improvements. All scores fell within the normal range on completion of ATT. Treatment gains were maintained at the 12-month follow-up assessments. However, randomized controlled trials of ATT are required before firm conclusions can be drawn.
Naturalistic Evaluation of Dialectical Behavior Therapy—Oriented Treatment for Borderline Personality Disorder
Ralph M. Turner, University of the Sciences
This article reports the results of a naturalistic investigation comparing the effectiveness of a dialectical behavior therapy–oriented treatment (DBT) with a client-centered therapy control condition (CCT) for borderline personality disorder patients (BPD). Twenty-four patients diagnosed with BPD were randomly assigned to either DBT or CCT. Blinded, independent rater evaluations and a battery of patient self-report measures were completed at baseline, 6 months, and 1 year during the course of treatment. Measures of suicide attempts and self-harm episodes were collected on a weekly basis. The number of psychiatric hospitalization days per 6-month period was also measured. Outcomes showed the DBT group improved more than the CCT group on most measures. The quality of the therapeutic alliance accounted for significant variance in patients' outcomes across both treatments.
Special Section: Dialectical Behavior Therapy: Adaptations and New Applications
Introduction
Alec L. Miller, Montefiore Medical Center, Albert Einstein College of Medicine, and Jill H. Rathus, C.W. Post Campus/Long Island University
DBT was originally developed by Linehan for the treatment of chronically parasuicidal adult outpatients diagnosed with BPD. In less than a decade, this approach has transformed the way numerous practitioners conceptualize and treat patients with this disorder. In their introduction to this special section, Miller and Rathus highlight eight aspects of DBT that distinguish this therapy from standard CBT. DBT includes a flexible principle-based rather than manual-based set of interventions, the notion of a dialectical worldview, a biosocial theory of BPD, specified treatment functions and modes, the concept of stage of disorder, a hierarchy of treatment targets, an integration of acceptance and validation strategies with change strategies, and a significant emphasis on the therapeutic relationship. the authors then introduce five new applications and adaptations of DBT to different populations followed by a commentary by the originator of the treatment.
DBT for Adolescents: Dialectical Dilemmas and Secondary Treatment Targets
Jill H. Rathus, C.W. Post Campus/Long Island University, and Alec L. Miller, Montefiore Medical Center, Albert Einstein College of Medicine
The primary aim of this paper is to describe the central dialectical dilemmas the authors have observed in treating suicidal adolescents and their families using Dialectical Behavior Therapy (DBT). These dilemmas supplement those described by Linehan in standard DBT with adults. The adolescent/family dialectical dilemmas are excessive leniency vs. authoritarian control, normalizing pathological behaviors vs. pathologizing normative behaviors, and forcing autonomy vs. fostering dependence. We also discuss the corresponding treatment targets we have identified; these are aimed at achieving a synthesis between the polarities inherent in each dialectical dilemma.
Dialectical Behavior Therapy for Domestic Violence: Rationale and Procedures
Alan E. Fruzzetti and Eric R. Levensky, University of Nevada, Reno
Domestic violence is a significant social problem with significant psychological and medical consequences for its victims and their children. In part because treatments for domestic violence are often not effective, and in part because of the hypothesized similarities between the problems of chronically aggressive men and chronically suicidal women (e.g., emotion dysregulation), a rationale for applying Dialectical Behavior Therapy (DBT) to domestic violence is provided. This new application of DBT, designed to treat aggression and violence in families, is described. Aggression assessment procedures and conceptualization issues are presented, along with a case to illustrate treatment principles and intervention strategies. Typically targeting men who batter their partners, this new application includes the four essential functions of DBT, including attending to client motivation, skill acquisition, skill generalization, and team/therapist consultation. In addition, a number of new treatment developments are presented to target reducing and eliminating aggression: validation and empathy skill training; a focus on reconditioning anger responses to be more normative (including identifying alternative emotions and their associated effective coping responses); skills training on accurate interpersonal emotional expression; and understanding the functions of aggression and teaching skills in how formerly aggressive partners can get relationship and self-management needs met skillfully. A brief overview of the other strategies and components of DBT, and how they are applied to treating domestic violence, is also provided. Particular attention is devoted to therapists maintaining a nonjudgmental stance by utilizing mindfulness practice and team consultation.
DBT With an Inpatient Forensic Population: The CMHIP Forensic Model
Robin A. McCann and Elissa M. Ball, Institute for Forensic Psychiatry, Colorado Mental Health Institute at Pueblo, and Andre Ivanoff, Columbia University
Implementation of Dialectical Behavior Therapy (DBT) in a forensic or criminal justice setting differs dramatically from standard outpatient DBT. Forensic patients are multiproblem patients with violent histories and multiple diagnoses including borderline personality disorder (BPD), antisocial personality disorder (ASPD), and concomitant Axis I psychotic or mood disorders. DBT was selected for this population because of its emphasis on treating life-threatening behaviors of patients and therapy-interfering behaviors of both patients and staff. The forensic inpatient DBT model described here includes modification of agreements, targets, skills training groups, and dialectical dilemmas. An additional skills module, the Crime Review, was developed to supplement standard DBT. Conclusions and recommendations for applying DBT in a forensic setting are presented.
Dialectical Behavior Therapy for Substance Abuse: A Pilot Application to Methamphetamine-Dependent Women With Borderline Personality Disorder
Linda Dimeff, Shireen L. Rizvi, Milton Brown, and Marsha M. Linehan, University of Washington
The primary aim of this paper is to describe key modifications made to standard Dialectical Behavior Therapy (DBT) for use with substance-dependent individuals with borderline personality disorder (BPD). Key modifications include application of dialectics to issues surrounding abstinence, a new set of substance abuse behavioral targets, a set of attachment strategies for difficult-to-engage and easily lost clients, and modification of some skills geared for substance abusing clients. Treatment outcome findings from a small 12-month uncontrolled pilot trial of DBT for methamphetamine-dependent women with BPD are presented. Of the 3 participants who commenced treatment, 2 completed treatment and were abstinent from use of all illicit drugs by 6 months; results were maintained for the duration of the assessment period 6 months later. These encouraging results suggest that DBT may hold promise for treating methamphetamine dependence.
Treatment of Elderly Depression With Personality Disorder Comorbidity Using Dialectical Behavior Therapy
Thomas R. Lynch, Duke University Medical Center and Duke University
Depression among older adults is a particularly distressing problem, not only because of high rates but also because of higher risks for suicide among this population. In addition, personality disordered depressed elderly have been shown to be less responsive to depression-specific therapies. This article reviews the rationale and treatment modifications under development for treatment of elderly depressed patients with comorbid personality disorders using Dialectical Behavior Therapy.
Commentary on Innovations in Dialectical Behavior Therapy
Marsha M. Linehan, University of Washington
The articles in this series on DBT have each identified a population of patients for whom emotion dysregulation appears to be functionally related to their presenting problems. Each paper describes how the original (and now standard) form of DBT might be modified to better fit patients with problems and/or diagnostic disorders differing from the suicidal, borderline adult women treated in the first randomized trial of DBT. Each application is designed to treat individuals with personality disorders but with varying presenting problems. The principal differences among the various applications are in the specification of additional behavioral targets to address the differing presenting problems in each population of patients. The rapid increase in new applications of DBT as exemplified in the articles presented here is exciting and suggests a value of principal-driven treatment manuals.
Response: Expanding Applications of Dialectical Behavior Therapy: Prospects and Pitfalls
Clive J. Robins, Duke University Medical Center and Duke University
The papers in this series describe creative adaptations of DBT for several populations. This commentary describes what I perceive as some of the strengths of DBT that suggest its potential for multiproblem patients as well as concerns about the possibility of clinical dissemination outpacing controlled data, potential obstacles to dissemination of effective DBT due to insufficient training, staffing, and financial resources, and the need to consider which aspects of DBT are needed to treat a given population both effectively and cost-efficiently.
COGNITIVE BEHAVIORAL CASE CONFERENCE
The Case of Katrina
Anna Samoilov, Harvard Medical School, and Marvin R. Goldfried, SUNY at Stony Brook
The case of Katrina, a 25-year-old, married woman with a history of multiple psychiatric hospitalizations due to recurrent, impulsive suicide attempts, pervasive suicidal ideation, depression, and intrusive memories of sexual abuse, was presented to six experienced clinicians of various theoretical backgrounds. Regardless of the diagnostic label they assigned to the case or their theoretical orientation, the clinicians largely agreed on two levels of interventions: (a) the use of dialectical behavior therapy (DBT) and situational analysis in combination with other cognitive behavior therapies (CBTs) and interpersonal and behavioral interventions to address Katrina's current problems; and (b) interventions focused on Katrina's in-session behaviors and the use of the therapeutic relationship to provide Katrina with an opportunity to learn new, more adaptive coping skills in a safe and accepting environment.
Response Paper: The Integrative Stage Model Approach to the Case of Katrina
Kenneth Chase, Harvard Medical School
The Integrative Stage Model (ISM) is applied to Katrina, a trauma survivor suffering primarily from chronic posttraumatic stress disorder and associated long-standing interpersonal and affect regulation difficulties, which often result in self-injurious behavior. The ISM is a long-term, integrative, feminist-oriented stage approach focused on self-care/safety, interpersonal functioning, and trauma processing. An interpersonal/process-oriented approach is used to facilitate the development of trust and to work on the patient's interpersonal difficulties. Directive approaches are utilized within this context to preserve the patient's safety, to challenge her nonadaptive cognitive distortions, to increase the patient's coping skills, to educate her about her disorders and treatment, to process traumas, and to translate insights and understanding in therapy to action outside of session.
Response Paper: A Cognitive-Behavioral Analysis of a Patient With Borderline Personality Disorder
Gerald C. Davison, University of Southern California
Comments are made on case material from a patient likely to be diagnosable as borderline personality disorder. The author offers an analysis of the case as one reflecting emotional dysregulation and the complex interpersonal consequences of lack of control over turbulent storms of negative emotionality. A tentative treatment plan is outlined that involves a dialectical cognitive behavioral approach aimed at reducing emotional sensitivity and enabling the patient to cope better with her hitherto uncontrollable and frightening emotional lability and self-destructive behavior. Critical observations are offered on the risks of inferring childhood sexual and physical abuse from reports by clients who were treated by therapists whose theoretical or political orientation lead them to assume the presence of abuse in the past histories of people like those with borderline personality disorder.
Response Paper: Radical Behavioral Help for Katrina
Robert J. Kohlenberg, University of Washington, and Mavis Tsai, Independent Practice, Seattle, Washington
Our treatment plan for Katrina is guided by the principles of functional anaIytic psychotherapy (FAP; Kohlenberg & Tsai, 1991), an approach derived from radical behaviorism. The fundamental assumption is that we and our clients act the way we do because of the contingencies of reinforcement we have experienced in past relationships. It then follows that clinical improvements, which are acts of the client, also involve contingencies of reinforcement that occur in the relationship between the client and therapist. Thus, our treatment of Katrina emphasizes the use of the client-therapist interaction as an in-vivo learning opportunity. It is for this reason that FAP views a caring, genuine, sensitive, and emotional client-therapist relationship as the most important element in the change process. We describe a FAP case conceptualization form designed to help the therapist achieve a curative therapeutic relationship. Our case conceptualization of Katrina includes an account of how Katrina's history resulted in her current daily life problems, identification of Katrina's cognitive phenomena that might be related to her current problems, and most importantly the prediction of how Katrina's clinically relevant behavior—daily life problems, dysfunctional thinking, and improvements—might occur during the session within the therapist-client relationship.
Response Paper: A Dialectical Behavioral Formulation: The Case of Katrina
Shelley McMain, Centre for Addiction and Mental Health and University of Toronto
Katrina is a 25-year-old woman who presents with multiple problems, among them chronic suicidal behavior. Clients like Katrina, who impress diagnostically with a Borderline Personality Disorder, are particularly suited to Dialectical Behavior Therapy (DBT). It is an appropriate approach because it was developed in the context of working with such individuals, and is one of the few treatments for this population for which there is outcome data to support its efficacy. A DBT approach helps the therapist identify the range of a client's problems and organize problems in order of priority. Treatment interventions, which are premised on a biosocial theory of the etiology and maintenance of a client's difficulties, are guided by a stage theory of treatment. The behavioral patterns that characterize borderline individuals and that often become obstacles to progress are an important focus of treatment. An overview of a DBT approach and the application of DBT formulation to the case of Katrina is presented.
Response Paper: The Case of Katrina: Skating on Thin Ice
James P. McCullough, Jr., Virginia Commonwealth University
The treatment of Katrina, a chronically depressed 25-year-old female who presented with a comorbid PTSD disorder, is discussed. The cognitive behavioral analysis system of psychotherapy (CBASP; McCullough, in press) is used to treat the psychopathology. Inhibiting the patient's tendency to leave therapy prematurely constitutes the first task of therapy. The next phase of treatment illustrates how the PTSD symptoms will be addressed. The final stage of treatment explains how the clinician will treat the chronic depressive disorder. The patient will remain on anxiolytic and antidepressant medication throughout.
Response Paper: A Prescriptive Eclectic Approach With Ms. Katrina
John C. Norcross and Nancy A. Caldwell, University of Scranton
This article illustrates a prescriptive eclectic approach with Ms. Katrina, a complex and challenging woman, by demonstrating the process of customizing psychological treatments and therapeutic relationships to her specific needs as defined by a multitude of diagnostic and particularly nondiagnostic considerations. Given the wealth of clinical and historical information provided, we would initially concentrate on assessing Ms. Katrina?s objectives, preferences, and resources while cultivating a validating and collaborative alliance. We would then systematically select and implement a series of cascading, iterative treatment decisions: setting, intensity, format, strategies, somatic treatments, and therapeutic relationships. Three priorities in this case are the coordination of an intense, integrative treatment involving multiple modalities, formats, and clinicians, the need to actively enlist Ms. Katrina's participation and strengths in her psychotherapy, and the centrality of therapist self-care when treating angst-inducing disorders.
Summary: The Case of Katrina
Anna Samoilov, Harvard Medical School, and Marvin R. Goldfried, SUNY at Stony Brook
Building on their unique theoretical and clinical backgrounds, the respondents presented curiously convergent views on the case of Katrina. The response papers highlighted Katrina's underlying deficit in affect regulation and the interaction between biological vulnerability and environmental stress as possible etiological factors in her illness. Most respondents suggested two main levels of interventions: skill-building interventions (e.g., dialectical behavior therapy) to facilitate more adaptive coping style, and interventions with a focus on Katrina?s in-session behaviors and therapeutic relationship.
