A pilot study of dialectical behaviour therapy skills training for autistic adults.

BACKGROUND: Autism spectrum disorder (ASD) is a common and lifelong neurodevelopmental disorder with the hallmark features of social impairment and restricted and repetitive patterns of behaviour. Individuals with ASD often experience co-occurring mental health difficulties, some of which may obfuscate the ASD features themselves. Although there is a high need for mental health services for autistic adults, there are surprisingly few evidence-based treatments (EBTs) available; moreover, many mental health practitioners who are well-trained in EBTs shy away from treating autistic individuals due to lack of training in ASD. AIMS: The aim of the current study was to evaluate the feasibility and acceptability of dialectical behaviour therapy skills training (DBT-ST) in a sample of autistic adults without intellectual disability. METHOD: Sixteen adults with ASD were recruited from a treatment waiting list to enrol in this study, which included 24 weeks of DBT-ST delivered in a group setting. Feasibility and acceptability were assessed using retention and attendance data and a participant satisfaction questionnaire. RESULTS: Retention (81.3%) and attendance data (mean 87.5%) provided support for the feasibility of this intervention. Overall satisfaction ratings were high (mean 4.5 out of 5), and participants reported that they felt that DBT-ST would probably be helpful for others with ASD (mean 4.5 out of 5). CONCLUSIONS: The study findings provide preliminary evidence of (1) the feasibility of providing DBT-ST for autistic adults in community-based clinics, and (2) the perceived benefit of DBT-ST for this under-served population. Recommended modifications to the standard DBT-ST materials are discussed.

Effects of Workshop Training in the Dialectical Behavior Therapy Prolonged Exposure Protocol on Clinician Beliefs, Adoption, and Perceived Clinical Outcomes.

Although extensive efforts have been made to train clinicians in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), relatively few PTSD patients are considered appropriate for and therefore receive these treatments. The dialectical behavior therapy prolonged exposure (DBT PE) protocol was developed to expand the reach of EBPs for PTSD to suicidal patients with severe comorbidities, but methods of training clinicians to deliver this treatment have not been evaluated. We examined the impact of DBT PE workshops on clinician beliefs, adoption, and perceived patient outcomes. Clinicians (N = 266) attended 2- or 4-day workshops and completed surveys at pretraining, posttraining, and 3- and 6-month follow-ups. From pretraining to 6-month follow-up, there were significant improvements in clinician concerns regarding worsening, perceived treatment credibility, and self-efficacy that did not differ by workshop length, R2 s = .20-.45. At 6-months posttraining, 53.5% of clinicians (38.8% 2-day, 66.3% 4-day) reported using DBT PE with 241 patients. Higher posttraining ratings of self-efficacy and perceived treatment credibility predicted later DBT PE use, R2 = .28. Among adopting clinicians, 81.3% reported that, on average, their patients' PTSD improved and 66.7% reported that patients were much to very much improved on average. Most clinicians reported that their patients' comorbid problems did not worsen during DBT PE and if worsening occurred, it typically involved temporary increases in distress. Workshops may be an effective method of changing clinician beliefs and promoting the use of DBT PE in a manner that clinicians experience as effective and safe for their patients.

The Influence of Internalizing Symptoms and Emotion Dysregulation on the Association Between Witnessed Community Violence and Aggression Among Urban Adolescents.

The current cross-sectional study examined whether internalizing (i.e. anxiety and depressive) symptoms and/or emotion dysregulation moderated the association between witnessed community violence and aggressive behavior. Participants were 180 predominantly African American adolescents (62% girls; M age = 15.87 years, SD = 1.19 years) from a high school located in an urban community in the United States. Approximately 95% of adolescents reported having witnessed at least one violent act during their lifetimes, with many endorsing repeated exposure to severe acts of community violence. Results indicated that emotion dysregulation exacerbated the association between witnessed community violence and aggression. A quadratic effect of anxiety symptoms also moderated this association, such that witnessed community violence was linked to aggression at low and high, but not moderate, levels of anxiety symptoms. In contrast, a quadratic effect of depressive symptoms was uniquely related to aggression, regardless of witnessed community violence. Directions for future research and implications for practice are reviewed.

Transdiagnostic Applications of DBT for Adolescents and Adults.

Dialectical behavior therapy (DBT) is an empirically supported treatment that was originally developed for chronically suicidal adults. Since the publication of the original treatment manual, DBT has been reconceptualized as a treatment that is broadly applicable for individuals who have difficulties regulating emotion. As such, the treatment can be applied transdiagnostically. Based on the flexibility and adaptability of the treatment, several adaptations have been made to the original protocol. Considerable empirical evidence now supports the use of DBT adapted for eating disorders, substance use disorders, and posttraumatic stress disorder. Moreover, developmentally appropriate adaptations have made the treatment applicable to youth samples. The current paper is geared toward practitioners and describes the various ways in which DBT has been modified for use with various populations and age ranges.

The research-practice gap: bridging the schism between eating disorder researchers and practitioners.

OBJECTIVE: The field of eating disorders (EDs) treatment has been beset by a marked disjunction between scientific evidence and clinical application. We describe the nature and scope of the research-practice gap in the ED field. METHOD: We draw on surveys and broader literature to better understand the research-practice gap in ED treatment and reasons for resistance to evidence-based practice. RESULTS: We identify three sources of the research-practice gap: (1) attitudinal factors, (2) differences in the definition of "evidence," and (3) cognitive factors, especially naïve realism and confirmation bias. We affirm the role of science as a safeguard against human fallibility and as a means of bridging the research-practice gap, and delineate key principles of scientific thinking for ED researchers and practitioners. DISCUSSION: We conclude with proposals for narrowing the research-practice gap in ED treatment and enhancing the quality of interventions for ED clients.

Emotion regulation difficulties in anorexia nervosa: Relationship to self-perceived sensory sensitivity.

Changes in sensation (e.g., prickly skin) are crucial constituents of emotional experience, and the intensity of perceived changes has been linked to emotional intensity and dysregulation. The current study examined the relationship between sensory sensitivity and emotion regulation among adults with anorexia nervosa (AN), a disorder characterised by disturbance in the experience of the body. Twenty-one individuals with AN, 20 individuals with AN who were weight-restored, and 23 typical controls completed self-report measures of sensory sensitivity and emotion regulation. AN participants reported heightened sensory sensitivity and greater difficulty regulating emotions relative to controls. Self-perceived sensory sensitivity was associated with greater emotion dysregulation. Weight-restored AN participants reported greater ability to regulate emotions than their currently underweight counterparts, despite heightened sensitivity. Findings suggest that hypersensitivity may be a persisting feature in AN, and that weight restoration may involve improved ability to cope with sensation.

Hope and depression and personality disorders.

Hope is a positive psychology construct that comprises goals, agency thinking, and pathways thinking and has been associated with psychological and physical well-being. This paper summarizes recent findings regarding the relationship between hope and depressive symptoms as well as hope and personality disorders and traits. Studies have shown that hope is inversely associated with negative affect when examined cross-sectionally, although the relationship between hope and depression is more complex longitudinally. Little is known about hope as it pertains to personality disorders, though more recent studies have examined the relationship between hope and personality traits such as neuroticism and extraversion; results from those studies are mixed, leaving a wide gap in the literature for future exploration.

Dialectical behavior therapy in an intensive outpatient program with a mixed-diagnostic sample.

OBJECTIVES: Intensive outpatient programs (IOPs) have become increasingly common for treating highly distressed patients, and a burgeoning number of IOPs are based on, or informed by, dialectical behavior therapy (DBT). The goal of the present study was to evaluate the effectiveness of DBT in a community mental health center IOP for patients with heterogeneous diagnoses. METHOD: Using a within-subjects design, we examined changes in depression, anxiety, mindfulness, and hope during DBT treatment in a community mental health center in the Midwestern United States. The final sample comprised 56 participants (59% female) ranging in age from 18 to 73 years, with a mean age of 36.8 years (standard deviation = 13.7). The majority of participants (80%) met criteria for a mood disorder, just over half met criteria for an anxiety disorder, and 20% met criteria for comorbid substance abuse or dependence. Over half met criteria for more than one diagnosis. Length of treatment varied based on the needs of the individual patient; treatment ranged from 2 to 16 weeks, with an average stay of 6 weeks. RESULTS: Depression and anxiety scores decreased significantly and hope scores increased significantly over the course of treatment (all p's < .001). Mindfulness scores did not increase significantly, although changes did occur in the predicted direction. In addition, the extent to which hope and mindfulness increased over the course of treatment predicted final depression and anxiety scores after controlling for baseline symptom levels. CONCLUSIONS: Results suggest that this DBT-informed intervention was effective in reducing depression and anxiety and increasing hope. Because of the move away from inpatient hospitalizations over the last few decades, it is incumbent on the field to find alternative ways to treat patients in need of more acute, intensive care. Moreover, these treatments must be cost effective, as many of these patients have limited financial resources. Group therapy formats might provide an appropriate and needed bridge for this coverage gap. The results of this study suggest that a DBT-informed IOP might be an amenable treatment for this population.

Psychometric properties of the Difficulties in Emotion Regulation Scale across demographic groups.

The Difficulties in Emotion Regulation Scale (DERS) is commonly used to assess difficulties recognizing and managing negative affect. Scores on the scale are strongly correlated with measures of psychopathology and are inversely correlated with measures of psychological well-being. Evidence supports the use of the DERS with adolescents and adults; to date, however, few studies have investigated the extent to which the psychometric properties of the DERS are consistent across demographic groups. The overarching goal of the present study was to examine the extent to which the factor structure of the DERS and the reliability and validity of DERS scores are consistent across gender and race in a diverse sample of adults. A total of 1,050 students from a medium-sized, urban university were included in the present study. Participants included 75.6% women and 24.4% men; 42.5% of participants identified as Caucasian, 40.4% as African American, and 17.1% as Asian American. Results showed that the DERS exhibits similar psychometric properties across men and women and all 3 racial groups that were included in this study. As such, the overall scale, as well as the original 6-factor solution of the DERS, can be reliably applied to individuals from the demographic groups investigated in the current study, and results can be interpreted in accordance with those from the preliminary DERS validation sample.

Why Ineffective Psychotherapies Appear to Work: A Taxonomy of Causes of Spurious Therapeutic Effectiveness.

The past 40 years have generated numerous insights regarding errors in human reasoning. Arguably, clinical practice is the domain of applied psychology in which acknowledging and mitigating these errors is most crucial. We address one such set of errors here, namely, the tendency of some psychologists and other mental health professionals to assume that they can rely on informal clinical observations to infer whether treatments are effective. We delineate four broad, underlying cognitive impediments to accurately evaluating improvement in psychotherapy-naive realism, confirmation bias, illusory causation, and the illusion of control. We then describe 26 causes of spurious therapeutic effectiveness (CSTEs), organized into a taxonomy of three overarching categories: (a) the perception of client change in its actual absence, (b) misinterpretations of actual client change stemming from extratherapeutic factors, and (c) misinterpretations of actual client change stemming from nonspecific treatment factors. These inferential errors can lead clinicians, clients, and researchers to misperceive useless or even harmful psychotherapies as effective. We (a) examine how methodological safeguards help to control for different CSTEs, (b) delineate fruitful directions for research on CSTEs, and (c) consider the implications of CSTEs for everyday clinical practice. An enhanced appreciation of the inferential problems posed by CSTEs may narrow the science-practice gap and foster a heightened appreciation of the need for the methodological safeguards afforded by evidence-based practice.

Why many clinical psychologists are resistant to evidence-based practice: root causes and constructive remedies.

Psychotherapists are taught that when a client expresses resistance repeatedly, they must understand and address its underlying sources. Yet proponents of evidence-based practice (EBP) have routinely ignored the root causes of many clinical psychologists' reservations concerning the use of scientific evidence to inform clinical practice. As a consequence, much of the resistance to EBP persists, potentially widening the already large scientist-practitioner gap. Following a review of survey data on psychologists' attitudes toward EBP, we examine six sources underpinning resistance toward EBP in clinical psychology and allied domains: (a) naïve realism, which can lead clinicians to conclude erroneously that client change is due to an intervention itself rather than to a host of competing explanations; (b) deep-seated misconceptions regarding human nature (e.g., mistaken beliefs regarding the causal primacy of early experiences) that can hinder the adoption of evidence-based treatments; (c) statistical misunderstandings regarding the application of group probabilities to individuals; (d) erroneous apportioning of the burden of proof on skeptics rather than proponents of untested therapies; (e) widespread mischaracterizations of what EBP entails; and (f) pragmatic, educational, and attitudinal obstacles, such as the discomfort of many practitioners with evaluating the increasingly technical psychotherapy outcome literature. We advance educational proposals for articulating the importance of EBP to the forthcoming generation of clinical practitioners and researchers, and constructive remedies for addressing clinical psychologists' objections to EBP.

The role of hope in engaging in healthy behaviors among college students.

OBJECTIVES: To examine hope in relation to alcohol use, binge drinking, smoking, exercise, and limiting of dietary fat among college students. METHODS: Undergraduate students (N=2265) completed an online survey. RESULTS: Lower hope scores were related to binge drinking and smoking in the past month and more frequent drinking and binge drinking, controlling for sociodemographics. Higher hope scores were related to greater likelihood of and more frequent exercising and fat limitation in the past month. CONCLUSIONS: Interventions to improve college student health behaviors should target hope.

Balancing psychological assessments: including strengths and hope in client reports.

Borrowing from B. A. Wright's (1991) suggestions, a balanced approach is advocated for gathering information and writing the subsequent report. Specifically, it is suggested that the clinician attend to four aspects of an interviewee: (a) the strengths in the client's psychological makeup, (b) the weaknesses in the client's psychological makeup, (c) the strengths in the client's environment, and (d) the weaknesses in the client's environment. Additionally, using hope theory (C. R. Snyder, 1994) as a framework, the importance of including information about client goals, along with the routes to those goals (pathways thinking) and the motivation to use those pathways (agency thinking), is described. Furthermore, the implications of using this framework in conducting a diagnostic interview and writing the ensuing report are provided. Finally, the advantages of including human strengths to achieve a balanced interview and report are discussed.

Reconciling the rift: improving clinical psychology graduate training in the twenty-first century.

Most graduate programs in clinical psychology adhere to and reportedly are satisfied with the scientist-practitioner model of training. In the present commentary, I take the position that this model must be updated to reconcile the rift that currently exists between the scientists and the practitioners within the field. A return to scientific rigor within the field is espoused, and suggestions of ways to improve both undergraduate and graduate curricula are made.