Search

BACKGROUND The Family Connections™ (FC) program is a 12-week support and skill-training program for caregivers of youth with mental health challenges. The intervention was originally developed with a focus on borderline personality disorder (BPD). It is important to understand the experiences of caregivers in such interventions, as well as its applicability beyond BPD, for the purposes of evaluation and ongoing program improvement. OBJECTIVE To explore and analyse the experiences of caregivers of youth with diverse mental health challenges and who participated in FC. DESIGN Semi-structured interviews with thirteen FC-participating caregivers of youth with mental health challenges. RESULTS Thematic analysis uncovered three major themes regarding caregivers' experience with FC: (a) FC increased the caregivers' ability to manage their youth's mental health challenges; (b) participating in FC impacted their intra- and interpersonal spheres; and (c) improvements to the program were proposed. Following participation in FC, caregivers felt they learned a new approach to understanding themselves, their youth and mental health, and were better able to manage their youth's mental health challenges. DISCUSSION AND CONCLUSION FC is a promising intervention for caregivers of youth with mental health challenges, beyond the traditional BPD focus. The intervention has the potential to provide broad-based benefits for caregivers and should be considered for implementation and scale-up across youth- and caregiver-serving organizations. Potential areas of intervention flexibility and improvement are discussed. PATIENT/PUBLIC CONTRIBUTION Caregivers were involved in the program development and facilitation of FC. A person with lived experience was involved with the analysis.

Emotional and interpersonal instability are core features of borderline personality disorder (BPD) and can pose a challenge for the therapeutic relationship. In dialectical behavior therapy (DBT) for BPD, ruptures in the therapeutic alliance are considered through a behavioral lens that examines the client's relational learning history, the function and context of the rupture, as well as the patterns of emotional processing difficulties that underlie interpersonal conflict. In this article, we use the case of Rachel to illustrate how alliance-focused approach can be integrated with DBT case formulation to enhance treatment planning and the successful negotiation of alliance ruptures.

Despite research supporting the effectiveness of dialectical behavior therapy (DBT) for borderline personality disorder (BPD), few studies have examined how DBT leads to clinical change. DBT is theorized to lead to improved clinical outcomes by enhancing the capacity for emotion regulation, including improvement in skills (e.g., mindfulness and distress tolerance) for managing emotional distress and impulsive behaviors. Therefore, the aim of this study was to test whether improvements in mindfulness and distress tolerance indirectly affect the relationship between DBT skills training and clinical outcomes. The sample consists of 84 patients diagnosed with BPD who were enrolled in a randomized controlled trial comparing 20 weeks of DBT-skills group (DBT-S) to an active waitlist control. Mindfulness and distress tolerance were assessed at baseline and at the end of the 20 weeks. BPD symptoms, general psychiatric symptoms, and social adjustment were assessed at the end of 20 weeks and combined into a latent variable representing a broad assessment of general psychopathology. Relative to the waitlist control group, improvements in mindfulness and distress tolerance each independently indirectly affected the relationship between DBT-S and posttreatment general psychopathology. Findings suggest that DBT-S exerts its effects on outcomes through improvements in mindfulness and distress tolerance. These findings support the significance of mindfulness and distress tolerance in DBT-S for BPD. Limitations, future directions, and clinical implications are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Case formulation, a method of personalizing brand-name psychotherapies for individual clients, is considered essential to the effective implementation of dialectical behaviour therapy (DBT). Despite the development and utilization of a case formulation being a core competency for certification in DBT practice, many clinicians lack training on how to do so. This chapter presents the underlying theoretical framework of case formulation in DBT and describes the steps and elements involved. Each of the steps is illustrated through the presentation of a case study in which case formulation is used to guide the treatment of a client diagnosed with borderline personality disorder.

The aim of this study was to determine the influence of posttraumatic stress disorder (PTSD) on treatment outcomes in patients with borderline personality disorder (BPD). Participants were 180 individuals diagnosed with BPD enrolled in a randomized controlled trial that compared the clinical and cost effectiveness of dialectical behavior therapy (DBT) and general psychiatric management (GPM). Multilevel linear models and generalized linear models were used to compare clinical outcomes of BPD patients with and without PTSD. BPD patients with comorbid PTSD reported significantly higher levels of global psychological distress at baseline and end of treatment compared to their non-PTSD counterparts. Both groups evidenced comparable rates of change on suicide attempts and non-suicidal self-injury (NSSI), global psychological distress, and BPD symptoms over the course of treatment and post-treatment follow-up. DBT and GPM were effective for BPD patients with and without PTSD across a broad range of outcomes.

The aim of this exploratory study was to investigate alliance rupture and resolution processes in the early sessions of a sample of clients who underwent 1 year of standard dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Participants were three recovered and three unrecovered clients drawn from the DBT arm of a randomized controlled trial that compared the clinical and cost-effectiveness of DBT and general psychiatric management. Alliance rupture and resolution processes were coded using the observer-based Rupture Resolution Rating Scale. Unrecovered clients evidenced a higher frequency of withdrawal ruptures than recovered clients. Withdrawal ruptures tended to persist for unrecovered clients despite the degree of resolution in the prior session, unlike for recovered clients, for whom the probability of withdrawal ruptures decreased as the degree of resolution increased. This study suggests that alliance rupture and resolution processes in early treatment differ between recovered and unrecovered clients in DBT for BPD.

A positive therapeutic relationship is widely recognized as an important factor that contributes to the effectiveness of clinical outcomes in psychotherapy for borderline personality disorder (BPD). All psychotherapy approaches for the treatment of BPD emphasize the importance of the relationship, yet with BPD clients, a positive relationship is often slow to develop, inconsistent, and difficult to maintain. The interpersonal sensitivity and reactivity that characterize borderline pathology often evokes countertherapeutic reactions in psychotherapists. Therapist contributions to the interaction frequently impede the development and maintenance of a positive relationship. This paper outlines 5 strategies that are common across psychotherapies for BPD for cultivating a positive therapeutic relationship: (a) cultivating emotional awareness, (b) structuring treatment, (c) being responsive, (d) supervision or team involvement, and (e) exploring ruptures. We discuss how these strategies serve to increase the effectiveness of treatment with individuals with BPD by decreasing intense emotional arousal and reactivity of both the client and the therapist.

This study examined suicide and self-harm trajectories in 180 individuals with BPD receiving dialectical behavior therapy or general psychiatric management in a randomized controlled trial. Suicide and self-harm behaviors were assessed at baseline, every four months throughout treatment, and every 6 months over 2 years of follow-up. Latent class growth mixture modeling identified suicide and self-harm trajectories. Multinomial logistic regression analyses examined baseline patient characteristics. Three latent subgroups were identified. The largest responded rapidly to treatment and sustained a favorable response post-discharge. The second progressed slowly during treatment but achieved and maintained a favorable response. A third subgroup showed a rapid favorable response during treatment, however symptoms returned to near baseline levels post-discharge. This third subgroup had higher baseline depression, emergency department visits, and unemployment. BPD patients with high baseline health care utilization, depression, and unemployment may benefit from modifications to treatment specifically targeting these issues.

Research on processes and mechanisms of change aim to explain how and why an intervention leads to change. Despite some theoretical and empirical progress in understanding processes and mechanisms of change in Dialectical Behaviour Therapy (DBT), this remains an understudied area in the DBT literature. This chapter considers how DBT conceptualizes the etiology and maintenance of dysfunction, and how active ingredients in DBT treatment produce client change. It proposes four key mechanisms of change that have been a focus of scientific efforts in DBT research: (1) increased awareness and acceptance of emotion; (2) increased attentional control; (3) increased ability to modulate emotion; and (4) increased use of adaptive coping skills. Next, it reviews the research evidence to support these putative mechanisms of change. Finally, it discusses clinical implications of this research, and propose recommendations for future research on mechanisms of change in DBT.

Recent studies suggest that it is not simply the expression of emotion or emotional arousal in session that is important, but rather it is the reflective processing of emergent, adaptive emotions, arising in the context of personal storytelling and/or Emotion-Focused Therapy (EFT) interventions, that is associated with change.To enhance narrative-emotion integration specifically in EFT, Angus and Greenberg originally identified a set of eight clinically derived narrative-emotion integration markers were originally identified for the implementation of process-guiding therapeutic responses. Further evaluation and testing by the Angus Narrative-Emotion Marker Lab resulted in the identification of 10 empirically validated Narrative-Emotion Process (N-EP) markers that are included in the Narrative-Emotion Process Coding System Version 2.0 (NEPCS 2.0).Based on empirical research findings, individual markers are clustered into Problem (e.g., stuckness in repetitive story patterns, over-controlled or dysregulated emotion, lack of reflectivity), Transition (e.g., reflective, access to adaptive emotions and new emotional plotlines, heightened narrative and emotion integration), and Change (e.g., new story outcomes and self-narrative discovery, and co-construction and re-conceptualization) subgroups. To date, research using the NEPCS 2.0 has investigated the proportion and pattern of narrative-emotion markers in Emotion-Focused, Client-Centered, and Cognitive Therapy for Major Depression, Motivational Interviewing plus Cognitive Behavioral Therapy for Generalized Anxiety Disorder, and EFT for Complex Trauma. Results have consistently identified significantly higher proportions of N-EP Transition and Change markers, and productive shifts, in mid- and late phase sessions, for clients who achieved recovery by treatment termination.Recovery is consistently associated with client storytelling that is emotionally engaged, reflective, and evidencing new story outcomes and self-narrative change. Implications for future research, practice and training are discussed.

Background Concurrent mental health and substance use disorders among youth are associated with functional impairment in developmentally salient domains, yet research on prevention and intervention for this vulnerable population is sparse. This paper describes the rationale and design of the Research and Action for Teens study, an initiative designed to strengthen the evidence base for prevention, screening, treatment and service delivery for youth concurrent mental health and substance use concerns. Methods Four sub-studies were developed: (1) a cohort study examining the emergence of mental health and substance use concerns from early to mid-adolescence; (2) a screening and diagnosis study validating screening tools with a diagnostic interview; (3) a treatment study examining the feasibility and effectiveness of dialectical behaviour therapy skills training interventions for youth and family members; and (4) a systems study implementing cross-sectoral collaborative networks of youth-serving agencies using a common screening tool. Results Multiple stakeholders, including service providers from youth-serving agencies across sectors, consumer groups and family members participated in an initial consultation, and in the implementation of 4 sub-studies. Conclusions Collaboration with community stakeholders across sectors and disciplines throughout the research process is challenging but feasible, and is important for the production of applicable knowledge across the continuum of care.

This study aimed to further understand how narrative flexibility contributes to therapeutic outcome in brief psychotherapy for depression utilizing the Narrative-Emotion Process Coding System (NEPCS), an observational measure that identifies specific markers of narrative and emotion integration in therapy sessions.The present study investigated narrative flexibility by examining the contribution of NEPCS shifting (i.e., movement between NEPCS markers) in early, middle, and late sessions of client-centred therapy (CCT), emotion-focused therapy (EFT), and cognitive therapy (CT) and treatment outcome (recovered versus unchanged at the therapy termination). A logistic regression, with Wald tests of parameter estimates and pairwise comparisons, was used to test the study hypotheses.Results demonstrated that for recovered clients, the probability of shifting over the course of a therapy session was constant, whereas the probability of shifting declined for unchanged clients as the session progressed. There was also evidence that longer duration of time spent in any single NEPCS marker was negatively associated with shifting for both recovered and unchanged clients, although the effect was stronger for unchanged clients.The results provided preliminary support for the contribution of narrative flexibility to treatment outcomes in EFT, CCT, and CT treatments of depression.

While the individual contributions of narrative and emotion processes to psychotherapy outcome have been the focus of recent interest in psychotherapy research literature, the empirical analysis of narrative and emotion integration has rarely been addressed. The Narrative-Emotion Processes Coding System (NEPCS) was developed to provide researchers with a systematic method for identifying specific narrative and emotion process markers, for application to therapy session videos.The present study examined the relationship between NEPCS-derived problem markers (same old storytelling, empty storytelling, unstoried emotion, abstract storytelling) and change markers (competing plotlines storytelling, inchoate storytelling, unexpected outcome storytelling, and discovery storytelling), and treatment outcome (recovered versus unchanged at therapy termination) and stage of therapy (early, middle, late) in brief emotion-focused (EFT), client-centred (CCT), and cognitive (CT) therapies for depression.Hierarchical linear modelling analyses demonstrated a significant Outcome effect for inchoate storytelling (p = .037) and discovery storytelling (p = .002), a Stage × Outcome effect for abstract storytelling (p = .05), and a Stage × Outcome × Treatment effect for competing plotlines storytelling (p = .001). There was also a significant Stage × Outcome effect for NEPCS problem markers (p = .007) and change markers (p = .03).The results provide preliminary support for the importance of assessing the contribution of narrative-emotion processes to efficacious treatment outcomes in EFT, CCT, and CT treatments of depression.

Clinically depressed individuals have consistently been shown to demonstrate a bias for overgeneral autobiographical memory (ABM) disclosure, a strategy used to protect against the access of intense, primary emotions that may accompany specific memories. The present study examined how ABM specificity in client narratives was related to expressed emotional arousal in brief emotion-focused and client-centred psychotherapy for depression. Emotion episodes identified in two early-, two middle-, and two late-therapy transcripts drawn from 34 clients from the York I Depression Study were rated for degree of ABM specificity and expressed emotional arousal. A hierarchical linear modelling analysis demonstrated that greater ABM specificity was associated with higher expressed emotional arousal for clients who were no longer depressed at therapy termination.

Overgeneral autobiographical memory (ABM) disclosure has been established as a key cognitive marker of clinical depression in experimental research studies. To determine the ecological validity of these findings for psychotherapy treatments of depression, the present study investigated the relationship between change in level of depression and ABM specificity in the context of early, middle, and late therapy session transcripts selected from 34 clients undergoing emotion-focused therapy and client-centered therapy in the York I Depression Study. A hierarchical linear modeling analysis demonstrated that clients disclosed significantly more specific ABMs over the course of therapy. There were no differences in ABM specificity between treatment groups. There was also no evidence that increased specificity differentiated between recovered and unchanged clients at treatment termination.