Feasibility and initial impact of single-session internet-delivered acceptance vs change skills for emotions for stress- and trauma-related problems: a randomized controlled trial.

BACKGROUND: Current psychological trauma-focused interventions have left a gap for individuals who may not be ready for trauma-focused treatment and/or who present with other forms of clinically significant distress, such as subthreshold post-traumatic stress disorder (PTSD). Emotion regulation is a possible transdiagnostic mechanism of change that may promote and maintain some of the varied mental health problems related to trauma exposure. AIMS: This study examines the feasibility and initial impact of two brief emotion regulation skill trainings targeting different processes hypothesized to reduce trauma-related problems, compared with an active control. METHOD: Subjects (n = 156) were randomized to receive one of three brief internet-based trainings: (1) skill training on accepting emotions, (2) skill training on changing emotions, or (3) stress psychoeducation (control). Participants completed measures of emotion regulation, mindfulness, and affect intensity 24 hours pre- and immediately post-training. RESULTS: Results suggested that a brief internet-based skills training programme was feasible and acceptable, with 91.9% completing the training programme to which they were randomized. Results showed that participants in all conditions demonstrated significant decreases in emotion regulation problems over time; yet these improvements did not vary by condition. Participants in the Change condition with higher PTSD symptoms were significantly more likely to have greater increases in positive affect compared with those with lower PTSD symptoms. CONCLUSIONS: Although the three conditions did not show different outcomes, all three brief internet-delivered trainings were feasible. Results provide direction for future studies to evaluate the delivery of emotion regulation skills in individuals with trauma-related distress.

Experiences of dialectical behaviour therapy for adolescents: A qualitative analysis.

OBJECTIVES: To explore how former patients in dialectical behaviour therapy for adolescents (DBT-A) experience their treatment, and specifically if there were aspects of the treatment that they retrospectively identify as particularly meaningful, helpful or unhelpful. DESIGN: From a larger sample of 75 former DBT-A patients 19 were selected for a qualitative semi-structured interview study. METHODS: Young adults (N = 19; 18 females, one male), who as adolescents had been enrolled in DBT-A due to self-harming behaviours and features of borderline personality disorder, were interviewed up to 8 years (median 6.0; min 1.3; max 8.2) after end of treatment, at mean age 23 years (SD 2.5). Reflexive thematic analysis was implemented. RESULTS: Six key themes were revealed; (1) The need to be seen, listened to and believed in, (2) the importance of teamwork between patient and therapist, (3) the value of group and structure, (4) therapy as lifesaving and life-changing, (5) the risks of feeling misplaced and (6) the risks of abrupt endings. CONCLUSION: A trusting relationship with the therapist promoted commitment and motivation for treatment. This relationship was facilitated by the therapist showing explicit care and belief in the patient's own competence in changing their destructive behaviours. Meeting peers in group skill training offered a salient form of validation and was reported to be of particular value. The format of meeting peers and the importance of the dialectical therapeutic stance need to be studied further. Not all youth experienced DBT-A as suitable and the need for sufficient treatment dose was emphasized.

Phone consultation and burnout among providers of dialectical behaviour therapy.

Adherent dialectical behaviour therapy (DBT) includes between-session phone consultation to help clients generalize skills, solve problems during crises, and repair relationships. Despite benefits of phone consultation, it is frequently not implemented in outpatient settings. The perceived burden phone consultation places on providers is one of the most frequently cited reasons for its omission. The current study examined phone consultation in relation to providers' burnout using a cross-sectional design. We hypothesized that (1) DBT experience and support from peer consultation team members, including perceived team efficacy and shared coaching responsibilities, would be associated with lower rates of burnout and (2) higher numbers of crisis contacts and "other" contacts, but not noncrisis skills generalization contacts, would be associated with increased burnout. Participants were 65 DBT therapists who completed an anonymous survey online. Results suggest that both having more effective consultation teams and sharing phone consultation among team members were associated with decreased burnout. Additionally, more crisis contacts were found to be associated with higher burnout, whereas higher number of skills generalization calls was not. This study represents an important first step towards evaluating the impact of phone consultation on providers and highlights the importance of effective peer consultation in reducing therapist burnout.

It Happened Matters More Than What Happened: Associations Between Intimate Partner Violence Abuse Type, Emotion Regulation, and Post-Traumatic Stress Symptoms.

Intimate partner violence (IPV) has varied consequences including post-traumatic stress (PTS). One proposed risk factor for PTS is escalating types of violence; however, data are mixed. Because emotion dysregulation acts as a causal mechanism across numerous problems co-occurring in survivors of IPV, this study examined its association with PTS severity versus abuse type. Regression using data from women (n = 89) seeking treatment for IPV-related distress found the following: Type of abuse was not related to emotion dysregulation and emotion dysregulation was more strongly associated with PTS than type of abuse. This suggests emotion dysregulation may be more predictive of PTS than abuse type.

Daily Self-Monitoring of Symptoms and Skills Learning in Patients With Borderline Personality Disorder Through a Mobile Phone App: Protocol for a Pragmatic Randomized Controlled Trial.

BACKGROUND: Patient self-monitoring via mobile phones during psychotherapy can enhance and provide an overview of psychotherapeutic progress by graphically displaying current and previous symptom scores, providing feedback to the patient, delivering psychoeducative material, and providing timely data to the therapist or treatment team. OBJECTIVE: This study will aim to assess the effects of using a mobile phone to self-monitor symptoms and acquire coping skills instead of using pen and paper during psychotherapy in patients with borderline personality disorder (BPD). Dialectical behavior therapy will be performed to treat BPD. The primary outcome is the mean time needed to learn coping skills directed at emotion regulation; the secondary outcome is changes in the BPD symptom score as measured by the Zanarini Rating Scale for Borderline Personality Disorder. METHODS: This study is a pragmatic, multicenter randomized controlled trial. Participants were recruited through five public general psychiatric outpatient treatment facilities in Denmark. Patients are randomly assigned, on a 1:1 basis, to either the mobile phone condition (using the Monsenso mDiary mobile app) or pen-and-paper condition. Patients will complete several self-report questionnaires on symptom severity; assessments by trained raters on BPD severity will be performed as well. Survival analysis with a shared frailty model will be used to assess the primary outcome. RESULTS: Recruitment began in June 2017 and was completed in February 2019 after 80 participants were recruited. The study ended in February 2020. It is expected that the benefits of mobile phone-based self-report compared to the pen-and-paper method will be demonstrated for skill learning speed and registration compliance. To our knowledge, this is the first trial exploring the impact of cloud-based mobile registration in BPD treatment. CONCLUSIONS: This trial will report on the effectiveness of mobile phone-based self-monitoring during psychiatric treatment. It has the potential to contribute to evidence-based clinical practice since apps are already in use clinically. TRIAL REGISTRATION: ClinicalTrials.gov NCT03191565; https://clinicaltrials.gov/ct2/show/NCT03191565. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17737.

Comparison of suicide risk and other outcomes among boys and girls who self-harm.

Little is known about sex differences in outcomes of self-harm, and there are inconclusive results concerning the association between sex, self-harm, and suicide attempts. The aim of this study was to explore sex differences in outcomes of self-harm in adolescence. In this cohort study, all individuals (0-17 years) enrolled at the child- and adolescent mental health services (CAMHS) in Stockholm between 2001 and 2015 (N = 110,072) were followed in national registers from their last contact with the CAMHS, until end of 2015. Exposure was self-harm as reason for contact, outcome measures were: alcohol-/substance use disorder, psychiatric hospitalization, non-violent or violent crime, and suicide. Differences in outcomes rates between exposed versus unexposed males, and exposed versus unexposed females, were examined using Cox regressions, expressed as hazard ratios (HR) with 95% confidence intervals (CI). Median follow-up time was 5.8 years (Q1: 2.3 years; Q3: 9.7 years). Self-harm was documented in 2.2% (N = 1241) males and 8.7% (4716) females. Exposed individuals had higher HR for all outcomes as compared with unexposed individuals of their own sex. Exposed females had more pronounced risk for drug use disorder (HR 11.2; 95% CI 9.9-12.7) compared with exposed males (HR 6.5, 95% 5.2-8.0). Both males and females who had engaged in self-harm had elevated risks for future suicide. Adjusting for socio-economic status and age at start of follow-up only marginally affected the associations. Females and males with self-harm had similarly elevated risk for suicide, and self-harm was also an important risk marker for other adverse outcomes within both sexes.

Dialectical Behavior Therapy for Men With Borderline Personality Disorder and Antisocial Behavior: A Clinical Trial.

In addition to suicidal behaviors, men with borderline personality disorder (BPD) often display antisocial behavior that could impair contacts with mental health services. While research has established effective treatments for women with BPD, this is not yet the case for men. The authors evaluated 12 months of dialectical behavior therapy (DBT) for 30 men with BPD and antisocial behavior, using a within-group design with repeated measurements. The authors found moderate to strong, statistically significant pre-to posttreatment reductions of several dysfunctional behaviors, including self-harm, verbal and physical aggression, and criminal offending (rate ratios 0.17-0.39). Symptoms of BPD and depression were also substantially decreased. The dropout rate was 30%, and completing participants reported high satisfaction with treatment and maintained their improvements at 1-year follow-up. The authors conclude that DBT could be an effective treatment alternative for men with BPD and antisocial behavior, and it merits future studies with more rigorous design.

Family Connections in different settings and intensities for underserved and geographically isolated families: a non-randomised comparison study.

BACKGROUND: Family Connections (FC) is a multi-family skills training program for relatives of individuals with borderline personality disorder (BPD) and related difficulties, typically offered once per week for 12-14 weeks. Families with loved ones receiving residential Dialectical Behaviour Therapy DBT (DBT-R) in a different community, or those with multiple caregiving demands may have difficulty participating in weekly standard FC (FC-S). The aims of this paper are to: 1) Evaluate the results of the FC-S approach compared with an intensified weekend FC model developed for family members whose relatives are in DBT-R (FC-R); 2) Evaluate outcomes of FC-R for families with loved ones returning home from DBT-R, as little is known about how this population fares. METHODS: Data were collected at pre-treatment (T1), post-treatment (T2), and at six-to-seven-month follow-up (T3) in this non-randomized comparison study. A total of 82 family members participated, 34 of whom completed the FC-S program and 48 of whom completed the FC-R program. The evaluation was based upon outcomes derived from a standard battery used in FC research, analyzed by time and treatment setting. A composite score to evaluate family distress was generated. Two-way mixed multivariate analyses of variance (MANOVA) were employed to evaluate time (pre-versus-post versus follow-up) and group (FC-S versus FC-R). RESULTS: Scores on measures of mental health difficulties (General Severity Index), sense of burden (Burden Assessment Scale), and Global Family Functioning showed improvement over time. Having a loved one return home from DBT-R was associated with worsening on the GSI and the BAS at post-test. Notably, this deterioration was not found at follow-up. CONCLUSIONS: Little is known about families with loved ones receiving DBT-R other than the fact that their loved ones had not responded to previous services, which suggests greater complexity and chronicity. Because the family members receiving the weekend intensive FC-R version of FC demonstrated improvement, preliminary support exists for service providers to use the weekend intensive FC-R model as a time-and-cost efficient option whenever barriers exist to participating in weekly FC-S. Our findings also suggest that booster sessions may be indicated for families receiving loved ones home from DBT-R programs.

Restrictive eating and nonsuicidal self-injury in a nonclinical sample: Co-occurrence and associations with emotion dysregulation and interpersonal problems.

Disordered eating frequently co-occurs with nonsuicidal self-injury (NSSI), and evidence suggests that the co-occurrence of these behaviors is associated with heightened emotion dysregulation. However, little is known about the relationship between restrictive eating and NSSI, and the significance of their co-occurrence. This study examined cross-sectional associations between self-reported restrictive eating, NSSI, and putative mechanisms of emotion regulation and interpersonal problems in a non-clinical sample of undergraduate students (N = 98, 80.6% female), using the Dietary Restriction Screener (Haynos & Fruzzetti, 2015), Deliberate Self-Harm Inventory (Gratz, 2001), Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2006), and Inventory of Interpersonal Problems-Personality Disorders-25 (Kim & Pilkonis, 1999). Hierarchical logistic regression analyses indicated that restrictive eating was associated with NSSI above and beyond the influence of binge eating, purging, and relevant covariates (B = 2.04, p < 0.001). In addition, multivariate analyses of variance revealed that the co-occurrence of restrictive eating and NSSI was associated with greater difficulties accessing and implementing effective, rather than impulsive, emotion regulation strategies when distressed than either behavior alone (p < 0.001). Findings highlight the seriousness of restrictive eating even within a nonclinical sample, as it is associated with heightened probability of NSSI and clinical severity among those who engage in co-morbid NSSI. Healthcare providers are encouraged to screen for NSSI among individuals with restrictive eating. In addition, a focus on improving emotion regulation and interpersonal skills may enhance prevention and intervention efforts for individuals with co-occurring restrictive eating and NSSI behaviors.

Restrictive eating is associated with emotion regulation difficulties in a non-clinical sample.

The relationship between emotion regulation difficulties and restrictive eating has not been established in non-clinical samples. In this study, undergraduates (n = 98) provided information regarding general and specific emotion regulation difficulties on the Difficulties in Emotion Regulation Scale (DERS) and whether they had engaged in recent restrictive eating. Generalized linear models were used to determine if individuals endorsing versus denying recent restrictive eating differed on emotion regulation problems. Results indicated that individuals endorsing restrictive eating had elevated DERS Total (p < .001), Goals (p = .001), Impulse (p < .001), and Strategies (p < .001) scores. Results remained primarily unchanged after controlling for the related construct of dietary restraint. Findings indicate that endorsement of restrictive eating among non-clinical individuals is uniquely associated with emotion regulation deficits, especially those reflecting emotional under-control. Interventions targeting emotion regulation may enhance prevention and treatment of restrictive eating across severity.

Pain patients' experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome.

BACKGROUND AND AIMS: Validating and invalidating responses play an important role in communication with pain patients, for example regarding emotion regulation and adherence to treatment. However, it is unclear how patients' perceptions of validation and invalidation relate to patient characteristics and treatment outcome. The aim of this study was to investigate the occurrence of subgroups based on pain patients' perceptions of validation and invalidation from their physicians. The stability of these perceptions and differences between subgroups regarding pain, pain interference, negative affectivity and treatment outcome were also explored. METHODS: A total of 108 pain patients answered questionnaires regarding perceived validation and invalidation, pain severity, pain interference, and negative affectivity before and after pain rehabilitation treatment. Two cluster analyses using perceived validation and invalidation were performed, one on pre-scores and one on post-scores. The stability of patient perceptions from pre- to post-treatment was investigated, and clusters were compared on pain severity, pain interference, and negative affectivity. Finally, the connection between perceived validation and invalidation and treatment outcome was explored. RESULTS: Three clusters emerged both before and after treatment: (1) low validation and heightened invalidation, (2) moderate validation and invalidation, and (3) high validation and low invalidation. Perceptions of validation and invalidation were generally stable over time, although there were individuals whose perceptions changed. When compared to the other two clusters, the low validation/heightened invalidation cluster displayed significantly higher levels of pain interference and negative affectivity post-treatment but not pre-treatment. The whole sample significantly improved on pain interference and depression, but treatment outcome was independent of cluster. Unexpectedly, differences between clusters on pain interference and negative affectivity were only found post-treatment. This appeared to be due to the pre- and post-heightened invalidation clusters not containing the same individuals. Therefore, additional analyses were conducted to investigate the individuals who changed clusters. Results showed that patients scoring high on negative affectivity ended up in the heightened invalidation cluster post-treatment. CONCLUSIONS: Taken together, most patients felt understood when communicating with their rehabilitation physician. However, a smaller group of patients experienced the opposite: low levels of validation and heightened levels of invalidation. This group stood out as more problematic, reporting greater pain interference and negative affectivity when compared to the other groups after treatment. Patient perceptions were typically stable over time, but some individuals changed cluster, and these movements seemed to be related to negative affectivity and pain interference. These results do not support a connection between perceived validation and invalidation from physicians (meeting the patients pre- and post-treatment) and treatment outcome. Overall, our results suggest that there is a connection between negative affectivity and pain interference in the patients, and perceived validation and invalidation from the physicians. IMPLICATIONS: In clinical practice, it is important to pay attention to comorbid psychological problems and level of pain interference, since these factors may negatively influence effective communication. A focus on decreasing invalidating responses and/or increasing validating responses might be particularly important for patients with high levels of psychological problems and pain interference.

An experimental analysis of the affect regulation model of binge eating.

There is research suggesting that binge eating may serve an affect regulation function. However, experimental evidence supporting this model in adults is sparse and studies have been mixed regarding whether negative affect impacts objective energy intake. This study examined the impact of a real-time interpersonal stressor on laboratory test meal intake between individuals endorsing recent objective binge eating (≥1×/week) and those denying disordered eating. Generalized linear modeling was used to compare individuals with recent binge eating (BE group; n = 52) to those denying recent eating pathology (HC group; n = 51) on test meal intake following a stressor (stressful condition) or neutral stimulus (non-stressful condition). Moderated mediation analyses were used to examine whether negative affect mediated the impact of condition on intake differently between BE and HC groups. The BE group did not have significantly higher energy intake than the HC group in the stressful verses non-stressful condition. However, the BE group was more likely to engage in extreme intake (i.e., over- or under-consumption) than the HC group in the stressful versus non-stressful condition (p = 0.02). Changes in negative affect did not significantly mediate the relationship between condition and intake extremes for the BE group. The results indicate that both over- and under-consumption are triggered by stress among individuals with recent binge eating. Continued research investigating both binge eating and restriction as a means of affect regulation in binge-eating samples is encouraged.

Emotion regulation training to reduce problematic dietary restriction: An experimental analysis.

Evidence suggests that emotion regulation may be a process relevant to problematic dietary restriction. However, emotion regulation has not been evaluated as an intervention target across a range of restriction severity. This study utilized an experimental design to examine whether targeting emotion regulation reduced problematic dietary restriction. Within a self-identified restrictive sample (n = 72), the effects of an emotion regulation condition (i.e., emotion regulation training) were compared to those of a control condition (i.e., nutrition information training) on dietary restriction indices (i.e., effort to reduce intake on a progressive ratio task, work towards an alternate reinforcer on a progressive ratio task, intake by dietary recall) following a stressor. Exploratory analyses of potential moderators (i.e., restraint, BMI, binge eating and purging status, emotion regulation difficulties) were conducted to examine whether these factors affected the impact of training on dietary restriction. No significant main effects of condition were detected on any outcome measure. However, results were moderated by BMI status. Participants with lower BMIs exerted less effort towards dietary restriction following the emotion regulation condition versus the control condition (p = 0.02). Results suggest that targeting emotion regulation may help to reduce problematic dietary restriction among lower weight individuals.

Effects of dialectical behavior therapy skills training on outcomes for mental health staff in a child and adolescent residential setting.

Training in Dialectical Behavior Therapy (DBT) skills coaching is desirable for staff in psychiatric settings, due to the efficacy of DBT in treating difficult patient populations. In such settings, training resources are typically limited, and staff turnover is high, necessitating brief training. This study evaluated the effects of a brief training in DBT skills coaching for nursing staff working in a child and adolescent psychiatric residential program. Nursing staff (n = 22) completed assessments of DBT skill knowledge, burnout, and stigma towards patients with borderline personality disorder (BPD) before and after a six-week DBT skills coaching training. Repeated measure ANOVAs were conducted to examine changes on all measures from pre- to post- treatment and hierarchical linear regressions to examine relationships between pre- training DBT knowledge, burnout, and BPD stigma and these same measures post-training. The brief DBT skill coaching training significantly increased DBT knowledge (p = .007) and decreased staff personal (p = .02) and work (p = .03) burnout and stigma towards BPD patients (p = .02). Burnout indices and BPD stigma were highly correlated at both time points (p < .001); however, while pre-training BPD stigma significantly predicted post-training client burnout (p = .04), pre-training burnout did not predict post-training BPD stigma. These findings suggest that brief training of psychiatric nursing staff in DBT skills and coaching techniques can result in significant benefits, including reduced staff burnout and stigma toward patients with BPD-related problems, and that reducing BPD stigma may particularly promote lower burnout.

Initial evaluation of a single-item screener to assess problematic dietary restriction.

PURPOSE: Existing measures to assess restrictive eating conflate both problematic and healthy restrictive practices, and perceived restriction without reduced caloric intake. In this study, we devised and tested the utility of a single-item screener, the Dietary Restriction Screener (DRS), to assess problematic restriction. METHODS: 94 individuals completed the DRS and measures assessing eating disorder symptoms, preoccupations, and rituals. Participants were given access to an ad libitum single-item test snack. Linear regressions were conducted to evaluate whether the DRS predicted eating disorder symptoms and snack intake after controlling for relevant covariates and a commonly used restraint scale. RESULTS: The DRS significantly predicted eating disorder symptoms (p < 0.001), preoccupations (p < 0.001), rituals (p = 0.001), and snack intake (p = 0.017) above covariates and an existing restraint scale. CONCLUSIONS: The DRS may offer added utility in predicting problematic dietary restriction over existing measures and is beneficial due to its brevity and low burden.

I see you're in pain - The effects of partner validation on emotions in people with chronic pain.

Background and aims Chronic pain not only affects the person in pain, but can also have a negative impact on relationships with loved ones. Research shows that chronic pain is associated with difficulties in marital relationships, which in turn is related to a variety of negative outcomes such as psychological distress and conflict within the family. This suggests that couples where chronic physical pain is present also struggle with emotional pain and relationship problems, and thus targeting relationship skills and interpersonal functioning might be helpful for these couples. Although studies in this area are promising, their numbers are few. In the present study, validation as a way of communicating is suggested for handling emotional expression in interpersonal interactions. Validation communicates understanding and acceptance of the other person's experience, and it has been shown to have a down-regulating effect on negative emotions. It has previously been demonstrated to be important for these couples. However, the feasibility and effects of increasing partner validation in these couples are unknown. Therefore, the aim of the present study was to investigate if a brief training session in validation for spouses would result in more validating and fewer invalidating responses towards their partners with pain, and to investigate if changes in these behavioural responses were associated with changes in emotion and pain level in the partner with pain. Methods Participants were 20 couples where at least one partner reported chronic pain. The study employed a within-groups design in which spouses of people with pain received validation training (without their partner's knowledge), and their validating and invalidating responses were rated pre- and post-intervention using a reliable observational scale. Also, positive and negative affect and subjective pain level in the persons with pain were rated pre- and post-intervention. Results Results showed that the validation training was associated with increased validating and decreased invalidating responses in the partners. Their spouses with chronic pain reported a decrease in negative affect from pre- to post-training. Conclusions Our results indicate that the partner or closest family member, after brief validation training, increased validating responses and decreased invalidating responses towards the person with pain, which had an immediate positive impact on emotions in the other person. Implications This study suggests that using validation in interpersonal interactions is a promising tool for couples where chronic pain is present.

Emotion regulation difficulties in anorexia nervosa before and after inpatient weight restoration.

OBJECTIVE: This study examined: (1) changes in emotion regulation difficulties in underweight inpatients with anorexia nervosa (AN) following weight restoration, (2) differences in emotion regulation between AN subtypes at acute and weight-restored stages of illness. METHOD: Repeated measure analyses of variance examined changes in scores on the Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, J Psychopathol Behav Assess, 26, 41-54, 2004) and other clinical variables in a group of inpatients with AN from hospital admission (N = 65) to weight restoration (N = 51). Correlations between BMI and DERS scores at both time points were examined. Emotion regulation difficulties were compared between individuals with AN, restricting type (AN-R) and AN, binge/purge type (AN-BP) at both time points using multivariate analysis of covariance. RESULTS: All clinical variables, except for the DERS, significantly improved with weight restoration (p < .001). There were no associations between BMI and DERS prior to or after weight restoration and AN subtypes did not significantly differ in emotion regulation difficulties. DISCUSSION: Unlike other clinical variables, emotion regulation difficulties in AN did not improve with weight restoration. In addition, both subtypes of AN appear to have similar difficulties with emotion regulation. The treatment of AN might be enhanced by focusing on improving emotion regulation abilities.

Dialectical behavior therapy training to reduce clinical burnout in a public behavioral health system.

There is a risk of experiencing clinical burnout among therapists providing treatment to clients with borderline personality disorder (BPD), a complex, costly and difficult-to-treat psychiatric disorder. Dialectical behavior therapy (DBT) is an evidence-based treatment of BPD that has been widely disseminated. There is only one published study that has examined pre and post scores of burnout among clinicians who receive training in DBT, and none that have taken place within a public behavioral health system in the United States where resources for community-based agencies are limited and demands are high. The current study examined the rates of burnout among therapists treating clients with BPD within a large, urban public behavioral health system. The study included a sample of nine clinicians and showed significantly decreased scores of burnout after participants attended a series of DBT trainings over a period of 13 months. There were several key limitations to internal validity including the lack of a control group. Similar evaluations of training outcomes are needed to address the widespread occurrence of burnout among community-based clinicians providing treatment to clients with BPD in order to enhance the quality of patient care.

A hybrid emotion-focused exposure treatment for chronic pain: A feasibility study.

Background and aims Exposure in vivo for patients with fear-related chronic pain has a strong theoretical base as well as empirical support. However, the treatment does not work for every patient and overall the effect size is only moderate, underscoring the need for improved treatments. One possible way forward might be to integrate an emotion regulation approach since emotions are potent during exposure and because distressing emotions may both interfere with exposure procedures and patient motivation to engage in exposure. To this end, we proposed to incorporate an emotion-regulation focus into the standard exposure in vivo procedure, and delivered in the framework of achieving relevant personal goals. The aim of this study then was to test the feasibility of the method as well as to describe its effects. Method We tested a hybrid treatment combining an emotion-regulation approach informed by Dialectical Behaviour Therapy (DBT) with a traditional exposure protocol in a controlled, single-subject design where each of the six participants served as its own control. In this design participants first make ratings to establish a baseline from which results during treatment and the five month follow-up may then be compared. To achieve comparisons, participants completed diary booklets containing a variety of standardized measures including pain catastrophizing, pain intensity, acceptance, and function. Results Compared to baseline, all subjects improved on key variables, including catastrophizing, acceptance, and negative affect, at both post treatment and follow up. For 5 of the 6 subjects considerable gains were also made for pain intensity and physical function. Criteria were established for each measure to help determine whether the improvements were clinically significant. Five of the six participants had consistent results showing clinically significant improvements across all the measures. The sixth participant had mixed results demonstrating improvements on several variables, but not on pain intensity or function. Conclusions This emotion-regulation hybrid exposure intervention resulted in considerable improvements for the participants. The results of this study underscore the potential utility of addressing emotions in the treatment of chronic pain. Further, they support the idea that targeting emotional stimuli and using emotion regulation skills in conjunction with usual exposure may be important for obtaining the best results. Finally, we found that this treatment is feasible to provide and may be an important addition to usual exposure. However, since we did not directly compare this hybrid treatment with other treatments, additional research is needed before firm conclusions can be made. Implications Addressing emotional distress in the treatment of patients suffering chronic pain appears to be quite relevant. Emotion regulation skills, employed together with exposure in vivo, hold the promise of being useful tools for achieving better results for patients suffering fear-related and emotionally distressing chronic pain.

Barriers and solutions to implementing dialectical behavior therapy in a public behavioral health system.

Dialectical behavior therapy (DBT) is an evidence-based treatment that is considered to be the standard of care in treating individuals with BPD, however there have been few published studies to identify the challenges and solutions for implementing DBT in community-based settings. The current study identified the barriers and solutions within a system-wide roll-out of DBT within a large, urban public health system encompassing both mental health and substance abuse treatment settings. Qualitative interviews were conducted with 19 clinicians receiving DBT training over a period of 13 months. A content analysis revealed three themes that were identified as challenges to the DBT implementation process including program development and recruitment of patients, a lack of administrative support or organizational investment in DBT, and time commitment of DBT. In order to transfer DBT into a public behavioral health system, investment from both clinic- and system-level administrators is required. Strategies to prevent drift, such as incorporating a train-the-trainer model, are discussed.