رفتاردرمانی دیالکتیکی: آیا روان درمانی گروهی سرپایی جایگزین موثری برای روان درمانی فردی است؟ نتایج مقدماتی

Objectives This study evaluates a 12-month-duration adapted outpatient group dialectical behavior therapy (DBT) program for patients with a borderline personality disorder in an unselected, comorbid population. If the results of this approach are comparable with the outcome rates of a standard DBT program, the group approach can have several advantages over individual treatment. One advantage is the possibility of treating more patients per therapist. Method A pre-post design was used to measure the effectiveness of an outpatient group DBT. Data from the Beck Depression Inventory II, the Symptom Checklist 90–Revised, the State-Trait Anger Inventory, the State and Trait Anxiety Inventory, of 34 female patients (mean age, 32.65 years) were collected before and after a treatment period of 1 year. Results Overall, a significant reduction (P < .05) of depressive symptoms, suicidal thoughts, anxiety, and anger was experienced by the patients. Conclusions This study is a first attempt in showing that DBT in an outpatient group setting can be effective in reducing psychiatric complaints and therefore has several advantages, such as the opportunity to treat more patients at once.

Borderline personality disorder (BPD) is a severe mental disorder that is characterized by emotional dysregulation, unstable interpersonal relations, behavioral dyscontrol, and unstable self-image [1], [2] and [3]. Borderline personality disorder is extremely disruptive for the patients and also for their families and friends. In addition, BPD puts a severe economic (financial) strain on our society, because these patients often need extensive medical and psychiatric services [4] and [5]. One of the most severe Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) symptoms of BPD is suicidal and (self) destructive behavior. Suicidal behavior includes death by suicide and intentional, nonfatal, self-injurious acts committed with or without the intent to die. In recent years, different psychotherapeutic approaches have become evidence-based treatments with regard to BPD [6], [7], [8], [9], [10] and [11]. Of these treatments, dialectical behavior therapy (DBT) is the most frequently investigated psychosocial intervention for BPD [12]. A recent meta-analysis of 16 studies, examining the efficacy and long-term effectiveness of DBT, showed that although several methodological shortcomings make it difficult to compare the different studies, a modest global effect and a moderate effect size for suicidal and self-injurious behavior were found [12]. Within the DBT trials, the studies by Linehan et al [13] and Koons et al [14], among others, also focused on the effect of DBT on the affective symptoms characteristic of borderline personality disorder. Of 28 studies in which DBT was studied and compared to other treatments, 5 studies showed significant differences between groups for depression [14], [15], [16], [17] and [18], 3 for anxiety [15], [16] and [17], and in only 1 study, significant effects for DBT on hopelessness were found [14]. Significant effects within DBT groups were found in less than half of the studies: 13 for depression, 6 for anxiety, and finally, 2 for hopelessness. Standard DBT treatment consists of skills training, in which the primary focus is to learn new skills, and individual therapy (inclusive of telephone consultation, day and night) in which the patients learn how to generalize learned skills to their daily lives. The standard treatment program lasts for 1 year. Furthermore, the program includes weekly consultation meetings for the therapists. Although this leads to the conclusion that DBT can be seen as a costly and time consuming treatment program, recent research [19] and [20] indicates that DBT does not differ in this respect from other specialized treatment programs such as structured clinical management [19]. The conclusion seems to be that good specialized treatment is expensive. DBT treatment programs, however, seem to struggle with a shortage in well trained psychotherapists. To treat more patients simultaneously, a group approach may be considered. There has been much research into the therapeutic factors in group treatments [21]. The following therapeutic factors are known: self-disclosure, interaction, interpersonal learning, acceptance, altruism, vicarious learning, installation of hope, universality, and self-responsibility [22]. The principles of DBT, then, seem to be largely consistent with the therapeutic factors of group psychotherapy. The structure of group therapy could create the opportunity to combine knowledge of group therapy with knowledge of DBT and allow the therapists to use techniques to initiate change and quickly stop destructive processes in the group. For example: in a group, patients will be confronted with the destructiveness of other group members. This gives the therapist the opportunity to help them in recognizing morbid thoughts, feelings and impulses in themselves and in others, and to learn to accept them. A soothing effect on feelings of shame and guilt can be the result. In addition, acceptance and self-acceptance are often major problems for patients with borderline personality disorder. The courage to accept the painful situation in which most borderline patients find themselves is a premier goal of DBT. Even accepting the suffering of others is often a serious problem for the borderline patient. Working in a group with like-minded people who have committed themselves not to avoid the problems that others have, coached by the therapists, contributes to self-acceptance and acceptance. Research on the effectiveness of group approaches is almost nonexistent [23]. There are a couple of studies of DBT in a group setting in the case of depressions [24] and also for eating disorders [25] but not of cases with a personality disorder. That is quite remarkable, considering the fact that already between the 1970s and the 1990s more than 700 studies have been carried out. Furhiman and Burlingame [26] demonstrated that group therapy has equally good results as individual therapy for all kinds of psychiatric pathologies/diseases in different therapeutic contexts. Tillitski and colleagues [27] conducted a meta-analysis of 23 outcome studies comparing the effectiveness of individual and group therapy within the same study and found that the formats produced large pre-post treatment gains (effect-size group = .90; effect-size individual = .76). The above information, in combination with the fact that we were able to provide our DBT services to more individuals than could otherwise receive treatment, led us to choose a group approach in this study. We hypothesize that supplying DBT in a group setting is possible, and that exchanging individual psychotherapy with group psychotherapy will result in an equal reduction of symptoms of (para)suicidal behavior, depression, anxiety and anger, compared to standard DBT in which individual therapy is applied.

3.1. Preliminary data analyses The Kolmogorov-Smirnov Z-test showed that all variables were normally distributed, with the exception of the state-anger of the STAXI. As can be seen in Table 2, the STAXI-State and STAXI-Trait showed low to moderate correlations with the other measures (r's between .00 and .55). There was a low (r = .25) to marked degree of correlation between the total score on the BDI and the other measurements, whereby the highest correlation was with state anxiety and the depression scale of the SCL-90 (.69 and .68, respectively). The intercorrelation between the SCL-90-R scales and the SCL items ranged from low (r = .07) to a marked degree (r = .78). Trait and state anxiety correlated from a low to a marked degree of correlation with the other measurements (r's ranged from .08 to .69). Table 2. Correlations between the dependent variables STAXI state STAXI trait Anxiety Phobic Anxiety Depression Somatization OCD ISP Hostility Sleeping problems Total SCL Stai trait BDI item 9 SCL item 15 SCL item 54 SCL item 59 BDI R .47⁎⁎ .02 .57*⁎ .61⁎⁎ .68⁎⁎ .44⁎ .42⁎ .53⁎⁎ .25 .36⁎ .62⁎⁎ .69⁎⁎ .63⁎⁎ .50⁎⁎ .51⁎⁎ .39⁎ .46⁎⁎ P .00 .90 .01 .00 .00 .01 .02 .00 .15 .04 .00 .00 .00 .00 .00 .02 .01 STAXI state R -.08 .40⁎ .49⁎⁎ .55⁎⁎ .34 .33 .30 .23 .36⁎ .41⁎ .45⁎⁎ .21 .14 .28 .30 .42⁎ P .68 .02 .00 .00 .05 .06 .09 .19 .04 .02 .01 .25 .43 .11 .09 .01 STAXI trait R .07 .10 .02 .42⁎ .46⁎⁎ .38⁎ .42⁎ .37⁎ .38⁎ .07 .42⁎ -.13 -.03 -.00 -.16 P .69 .57 .91 .02 .01 .03 .02 .03 .03 .73 .02 .46 .89 .98 .38 Anxiety R .60⁎⁎ .78⁎⁎ .52⁎⁎ .62⁎⁎ .59⁎⁎ .63⁎⁎ .31 .83⁎⁎ .59⁎⁎ .53⁎⁎ .25 .48⁎⁎ .76⁎⁎ .41⁎ P .00 .00 .02 .00 .00 .00 .08 .00 .00 .00 .16 .00 .00 .02 Phobic anxiety R .66⁎⁎ .62⁎⁎ .52⁎⁎ .62⁎⁎ .35⁎ .29 .67⁎⁎ .32 .29 .33 .37⁎ .27 .28 P .00 .00 .00 .00 .04 .10 .00 .07 .10 .06 .03 .12 .11 Depres-sion R .56⁎⁎ .65⁎⁎ .64⁎⁎ .53⁎⁎ .43⁎ .85⁎⁎ .46⁎⁎ .42⁎ .35⁎ .71⁎⁎ .76⁎⁎ .66⁎⁎ P .01 .00 .00 .00 .01 .00 .01 .02 .05 .00 .00 .00 Somatization R .62⁎⁎ .40⁎ .42⁎ .49⁎⁎ .70⁎⁎ .13 .44⁎ .27 .41⁎ .38⁎ .21 P .00 .02 .01 .00 .00 .49 .01 .13 .02 .03 .24 OCD R .64⁎⁎ .55⁎⁎ .46⁎⁎ .83⁎⁎ .33 .55⁎⁎ -.00 .27 .53⁎⁎ .07 P .00 .00 .01 .00 .07 .01 .99 .13 .00 .68 ISP R .60⁎⁎ .52⁎⁎ .81⁎⁎ .40⁎ .42⁎ .17 .46⁎⁎ .35⁎ .39⁎ P .00 .00 .00 .02 .02 .36 .01 .04 .02 Hostility R .37⁎ .69⁎⁎ .30 .31 .23 .40⁎ .62⁎⁎ .34⁎ P .03 .00 .09 .08 .20 .02 .00 .05 Sleeping problems R .58⁎⁎ .16 .24 .31 .51⁎⁎ .24 .37⁎ P .00 .38 .19 .08 .00 .18 .03 Total SCL R .40⁎ .60⁎⁎ .32 .56⁎⁎ .65⁎⁎ .39⁎ P .02 .00 .07 .00 .00 .02 State anxiety R .64⁎⁎ .11 .17 .38⁎ .33 P .00 .53 .36 .03 .06 Trait anxiety R .10 .08 .39⁎ .09 P .57 .66 .02 .60 BDI item9 R .68⁎⁎ .24 .54⁎⁎ P .00 .17 .00 SCL item 15 R .53⁎⁎ .73⁎⁎ P .00 .00 SCL item 54 R .50⁎⁎ P .00 Note: BDI = Beck Depression Inventory, SCL = Symptom Checklist, OCD = Obsessive Compulsive, IPS = Interpersonal sensitivity. ⁎ P < .05. ⁎⁎ P < .01. Table options The total score of the SCL-90 correlated highly with four SCL-90-R scales (r = .81 for interpersonal sensitivity, r = .83 for anxiety and obsessive-compulsive, and r = .85 for depression).