Thursday, September 07, 2006

Marsha Marsha Marsha

If you're interested in treatment of Borderline Personality Disorder, you really should read the latest article in the Archives of General Psychiatry (abstract included below). What is not mentioned in the abstract is that the DBT therapists received 45 hours of training in DBT. They also received mandatory weekly supervision during the course of the study. Oh, and during the study, DBT provided both individual and group therapy, whereas the so-called expert treatment consisted of only individual sessions. However, in a move of remarkable statistical legerdemain, the authors add in the additional treatment sessions that the "expert"-treated clients received in inpatient settings to note that there was no significant difference in treatment time between groups.

That's clever. Give one group of therapists extensive training in treating BPD with a sensible treatment model and then have the other group receive no formal training and likely no supervision -- the article is not clear about the amount of supervision received by the "experts". While on a roll, give the DBT clients extra group treatment not received by the "expert"-treated clients. When the confounds of less treatment time up front and lesser-trained (and likely less confident) therapists creep up, the "expert"-treated folks end up in more inpatient treatment. This is one of those studies that really backs up what the common factors camp has been saying for ages -- studies that show one therapy is better than another are generally fraught with numerous confounds, leaving us to only logically conclude that therapists who are especially well-trained and perform a high intensity therapy beat lesser-trained therapists providing a low-intensity treatment. This article will likely ring through the academic clinical psychology circles as a loud endorsement of DBT's specific efficacy for BPD, which is unfortunately inaccurate.

Don't get me wrong. I like DBT. It is based on a sensible model and has strong empirical support. However, whether it is any more efficacious than an equally intensive treatment performed by equally well-trained therapists is still essentially unaddressed.

The abstract is yours to peruse below...

Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder

Marsha M. Linehan, PhD; Katherine Anne Comtois, PhD; Angela M. Murray, MA, MSW; Milton Z. Brown, PhD; Robert J. Gallop, PhD; Heidi L. Heard, PhD; Kathryn E. Korslund, PhD; Darren A. Tutek, MS; Sarah K. Reynolds, PhD; Noam Lindenboim, MS

Arch Gen Psychiatry. 2006;63:757-766.

Context Dialectical behavior therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder with well-documented efficacy.

Objective To evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non–behavioral psychotherapy experts.

Design One-year randomized controlled trial, plus 1 year of posttreatment follow-up.

Setting University outpatient clinic and community practice.

Participants One hundred one clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria, matched to condition on age, suicide attempt history, negative prognostic indication, and number of lifetime intentional self-injuries and psychiatric hospitalizations.

Intervention One year of DBT or 1 year of community treatment by experts (developed to maximize internal validity by controlling for therapist sex, availability, expertise, allegiance, training and experience, consultation availability, and institutional prestige).

Main Outcome Measures Trimester assessments of suicidal behaviors, emergency services use, and general psychological functioning. Measures were selected based on previous outcome studies of DBT. Outcome variables were evaluated by blinded assessors.

Results Dialectical behavior therapy was associated with better outcomes in the intent-to-treat analysis than community treatment by experts in most target areas during the 2-year treatment and follow-up period. Subjects receiving DBT were half as likely to make a suicide attempt (hazard ratio, 2.66; P = .005), required less hospitalization for suicide ideation (F1,92=7.3; P = .004), and had lower medical risk (F1,50=3.2; P = .04) across all suicide attempts and self-injurious acts combined. Subjects receiving DBT were less likely to drop out of treatment (hazard ratio, 3.2; P<.001) and had fewer psychiatric hospitalizations (F1,92=6.0; P = .007) and psychiatric emergency department visits (F1,92=2.9; P = .04).

Conclusions Our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.


Spitting said...

*Applauds* Thank you for a great post :)

CL Psych said...

Thank you for the friendly review! You've certainly got an interesting blog yourself. I'll have to read it a bit more when I have more time. Cheers!