RevisioningRevisioning & & Recapturing E.B.P:Recapturing E.B.P:

Scott D. Miller, Ph.D.

Behavior Therapy (DBT) as ExampleDialectical

http://www.medterms.com/script/main/art.asp?articlekey=34212http://www.apa.org/divisions/div12/cppi.htmlhttp://www.mhreform.org/policy/ebs.htm

Dialectical Behavior Therapy (DBT):

•Defined as, “a mode of treatment designed for people with borderline personality disorder (BPD)”;

•Aims to help people to validate their emotions and behaviors, examine the negative impact of emotions and behaviors on their lives, and make a conscious effort to bring about positive change.

•Currently identified by professional organizations, funding bodies, and government agencies as an “evidence-based,”“empirically-supported,” “best practice.”

http://www.apa.org/divisions/div12/cppi.htmlhttp://www.mhreform.org/policy/ebs.htm

•Recommend that “consumers seek out that have been studied and show to be beneficial in controlled studies”;•Empirically supported therapies meet several “stringent” criteria:

•Controlled (randomization, manuals, equality in delivery);•Results better than no treatment;•Results equal to an alternative treatment;•More than one study by more than one researcher or team.

http://depts.washington.edu/brtc/sharing/publications/research-and-articles-on-dialectical-behavior-therapy

•Currently 15 studies published on DBT (1991-2006);•Nine of the fifteen qualify as “randomized clinical trials” (RCT);

•Three of the nine RCT’s were conducted by researchers other than the developer.

DBT:DBT:What do the data say?

•All of these studies but one compared the approach to “treatment as usual” or wait-list control;

•The one study compared DBT to an approach that “proscribed use of cognitive-behavioral change techniques or any overt suggestion of new behaviors or advice about what to do.” (p. 16)

•An example…

DBT:DBT:What do the data say?

Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13-26.

Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.

•NIMH funded study of DBT:• Compared DBT to services offered by “community-nominated” treatment experts;

DBT:DBT:What do the data say?

Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.

• Community experts:•Received no training, supervision, or consultation;•No control of type, amount, or quality of services . •Provided significantly less direct service than DBT therapists.

•DBT therapists:•Received 45 hours of specialized training;•Pre- and during-study supervision.•Gave 38 more hours of contact dedicated to keeping people out of the hospital

DBT:DBT:What do the data say?

“When individuals, based on their extensive experience and reputation, are nominated by their peers as experts, their actual performance is…found to be unexceptional…”.

Ericsson, K.A. (2006). The influence of expertise and deliberate practice on the development of expert performance. In K.A. Ericcson, N. Charness, P.J. Feltovich, & R.R. Hoffman (eds.). The Cambridge Handbook of Expertise and Expert Performance (pp. 683-704). New York: Cambridge University Press.

VariVari--ability between Therapists:ability between Therapists:What do the data say?

Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.

DBT:DBT:What do the data say?

Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.

DBT:DBT:What do the data say?

http://www.nrepp.samhsa.gov/programfulldetails.asp?PROGRAM_ID=72

BPD = 157

25.9 v. 35.6%18-45Mean = 31.7

81.5% WhiteBPD = 100% Female1 semi-direct comparison

8.5TOTALAllegiance

52/4911.5% v. 28.6%18-45Mean = 29

86% White3.8% BlackAsian 1.9% Other 5.8%

100% FemaleCommunity nominated experts

YesLinnehan et al. 2006BPD

17/17Not reported66-80Mean = 66

85% White9% Black6% Hispanic

85% Female15% Male

Medication v. Meds plus DBT(significantly higher dose)

Partial (n = 4)

Lynch et al. 2003Depression

14/152/14 (14%) v. 1/15 (7%)18-54Mean = 34

87% White13% Unspecified

100% FemaleWait list controlYesSafer et al. 2001Bulimia

22/224/22 (18%) v. 6/22 (27%)

Mean = 5094% White6% Unspecified

100% FemaleWait list controlYesTelch et al. 2001Binge Eating

31/2714/31 (45%) v. 20/27 (74%)

Mean = 37.5Not reported100% FemaleTreatment as usual (significantly lower dose)

YesVan den Bosch et al 2002Verheul et al. 2003BPD/Drug

14/143/14 (21%) v. 2/14 (14%)

31-4675% White25% Black

100% femaleTreatment as usual (significantly lower dose)

YesKoons et al. 2001BPD

11/124/11 (36%) v. 0/1228-43Mean = 36

87% White12% Unspecified

100% femaleDBT plus 12 stepsYesLinnehan et al. 2002BPD/Drug

12/165/12 (41.6%) 1 death v. 0D.O. in TAU dropped out prior to treatment

18-45Mean = 30

78% White11% Unspecified7% Black4% Hispanic

100% femaleTreatment as usual (significantly lower dose)DBT received 2X as much therapy

YesLinnehan et al. 1999BDP/Drug

13/133/13 (23%)1 suicide v. 0

18-45Mean = 26

Not reported100% FemaleTreatment as usual(Dosing not reported)

YesLinnehan et al. 1994BPD

24/244/24 (16.7%) v. 6/12 (50%)1 Suicide

18-45Not reported100% femaleTreatment as usual (Dosing not reported)

YesLinnehan et al. 1991BPD

ParticipantsDrop out rate (DBT/other)

AgeRace & EthnicityGenderComparisionGroup

RCTStudy

1. Extremely small and restricted sample (n = 157; 100% female, 81% White);

2. Allegiance effects in 7/9 studies;3. No real direct comparisons with another bonafide

therapy;4. Inequalities in dose and intensity of services;5. No control over known confounds and contributors

(especially, therapist and alliance effects).

DBT:DBT:What can we conclude?

What Works in Therapy:Direct Comparisons & Allegiance Effects

What Works in Therapy:Direct Comparisons & Allegiance EffectsDirect Comparisons & Allegiance Effects

Miller, S.D., Wampold, B.E., & Varhely, K. (2008). Direct comparisons of treatment modalities for youth disorders: A meta-analysis. Psychotherapy Research, 18(1), 5-14

•Meta-analysis of all studies published between 1980-2006 comparing bona fide treatments for children with ADHD, conduct disorder, anxiety, or depression:

•No difference in outcome between approaches intended to be therapeutic;

•Researcher allegiance accounted for 100% of variance in effects.

What Works in Therapy:Alliance & Therapist Effects

What Works in Therapy:Alliance & Therapist EffectsAlliance & Therapist Effects

Researchers found SFT superior to TFP in work with borderline-diagnosed clients:

•Significant differences in outcome between therapists;

•Alliance significant predictor of retention and improvement, independent of outcome;

•“In the more semistructured and long-term treatment of Axis II disorders, the development and maintenance of the therapeutic alliance constitutes a central issue of therapy and may constitute a central curing mechanism.”

Spinhoven, P. et al. (2007). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75(1), 104-115.

Smoke and MirrorsReal World Applications

DBT for “BPD”• In a large CMHC serving

SPMI clients: Of 382 eligible by dx, only 25 (6.5%) thought it was for them; 25% of those dropped out before program started; another 25% dropped out…is it worth the cost?

Haynes, M. (2006). Real world applications of evidence based practice. Heart and Soul of Change 3. Bar Harbor, ME.

Doing

Better

Therapy

= D.B.T.

DBT:DBT:What can we conclude?

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