آموزش مهارت رفتار درمانی دیالکتیکی برای خودمسمومی آگاهانه : یک مطالعه کنترل شده با پیگیری اطلاعات 3 ماهه

Dialectical Behaviour Therapy (DBT) has been shown to be an effective treatment for deliberate self-harm (DSH) and emerging evidence suggests DBT skills training alone may be a useful adaptation of the treatment. DBT skills are presumed to reduce maladaptive efforts to regulate emotional distress, such as DSH, by teaching adaptive methods of emotion regulation. However, the impact of DBT skills training on DSH and emotion regulation remains unclear. This study examined the Living Through Distress (LTD) programme, a DBT-informed skills group provided in an inpatient setting. Eighty-two adults presenting with DSH or Borderline Personality Disorder (BPD) were offered places in LTD, in addition to their usual care. A further 21 clients on the waiting list for LTD were recruited as a treatment-as-usual (TAU) group. DSH, anxiety, depression, and emotion regulation were assessed at baseline and either post-intervention or 6 week follow-up. Greater reductions in the frequency of DSH and improvements in some aspects of emotion regulation were associated with completion of LTD, as compared with TAU. Improvements in DSH were maintained at 3 month follow-up. This suggests providing a brief intensive DBT-informed skills group may be a useful intervention for DSH.

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Results Demographic and baseline clinical characteristics With the exception of age, there were no significant differences between the LTD + TAU and TAU only groups on any of the demographic variables or study measures at baseline (see Table 1). Participants in the LTD + TAU group (M = 37.66, SD = 10.65) were significantly older than those in the TAU only group (M = 31.52, SD = 11.23; t (89) = 2.33, p = 0.02). Pearson's correlations revealed that age was not significantly associated with any of the outcome variables. Post-intervention outcomes Table 2 presents a summary of the mean pre- and post-intervention measurements for participants who completed the study, along with the results of the paired t-tests examining change over time within each group. There were no significant changes over time on any of the measures for the TAU group but significant changes over time were evidenced on several measures for the LTD + TAU group (see Table 2). Please note data presented in Table 2 refers to the completers' sample. Table 2. Pre- and post-intervention measures for the LTD + TAU and TAU groups. Scales (range) LTD + TAU TAU Pre (n = 70) Post (n = 58) Pre (n = 21) Post (n = 17) Mean SD Mean SD Mean SD Mean SD DSI 18.92 25.74 4.46 10.26** 13.94 19.63 13.25 18.49 SCL-90-R Depression (13–65) 49.90 8.96 44.31 13.07** 46.76 14.16 45.00 16.39 Anxiety (10–50) 35.38 9.18 30.64 11.35** 30.12 11.31 32.06 11.37 DERS Non-acceptance of emotions (6–30) 23.36 5.79 20.91 7.22** 22.12 7.25 22.53 7.86 Inability to engage in goal directed behaviours (5–25) 20.43 3.80 19.24 4.49 21.41 4.69 22.53 4.15 Impulse control difficulties (7–35) 19.48 6.51 18.45 6.69 19.29 6.57 19.29 6.01 Lack of emotional awareness (6–30) 19.40 5.31 18.17 4.74 20.24 7.63 19.59 5.14 Limited access to emotion regulation strategies (7–35) 30.26 7.28 28.02 8.41 31.71 6.66 33.24 5.16 Lack of emotional clarity (5–25) 16.72 4.70 14.97 4.55* 17.18 5.00 15.88 4.54 CERQ Self-blame (2–10) 7.82 2.50 6.82 2.48* 6.65 2.80 7.53 2.55 Acceptance (2–10) 6.33 2.42 6.64 2.26 6.82 2.98 6.65 2.31 Rumination (2–10) 7.30 2.19 7.04 2.08 6.82 2.45 7.12 2.15 Positive refocus (2–10) 3.46 1.86 3.73 1.73 3.76 2.86 2.71 1.26 Planning (2–10) 4.75 2.21 5.55 2.20** 4.88 2.62 4.06 2.27 Positive reappraisal (2–10) 4.66 2.43 5.71 2.18** 4.94 2.63 4.53 2.69 Putting in perspective (2–10) 4.54 2.08 5.29 1.96* 4.47 2.27 3.47 1.46 Catastrophise (2–10) 7.45 2.36 6.64 2.64* 7.35 3.26 7.88 2.71 Other-blame (2–10) 4.70 2.93 4.48 2.41 5.24 3.23 4.24 2.88 Note: Data presented in this table refers to the completers' sample. DSI = Deliberate Self-harm Inventory, SCL-90-R = Symptom Checklist-90-R, DERS = Difficulties in Emotion Regulation Scale, CERQ = Cognitive Emotion Regulation Questionnaire. t-test * < .05, ** < .001. Table options Differences between the LTD + TAU and TAU groups on DSH, Anxiety, and Depression were examined using three one-way ANCOVAs, controlling for pre-treatment scores on these measures. Within the ITT sample, there was a significant between-group difference on DSH, F (1, 89) = 4.53, p = 0.04, Cohen's d = .27. Examination of mean scores indicated a lower frequency of DSH (M = 9.41, SD = 28.48) for the LTD + TAU group than the TAU group (M = 14.44, SD = 18.75) at post-intervention. There were non-statistically significant differences between the groups on Anxiety, F (1, 100) = 3.32, p = 0.07, and Depression, F (1, 100) = 0.18, p = 0.67. With regard to DSH, 49% of participants in the LTD + TAU group showed a reduction in self-harm of 75% or greater, 12% showed a reduction of between 50% and 75%, and 4% showed a reduction of 15%–30%. The remaining 19% reported either no change or increases in the frequency of DSH. Those who reported no change had reported low frequencies of DSH prior to the intervention (<2 incidents in 6 weeks) and those who reported increases in DSH had low overall scores (<2 incidents per week post-intervention). Of note, 16% of participants had reported no incidents of DSH at baseline so no improvement in DSH was possible in this proportion of the sample.1 A MANCOVA was conducted to examine differences between the LTD + TAU and TAU groups on the emotion regulation scales (i.e. DERS and CERQ), controlling for the baseline measurements on these scales. Within the ITT sample, there was a significant multivariate effect across groups, Wilks' λ = .686, F (15, 70) = 2.14, p = 0.02, partial eta squared = 0.31. Power to detect the effect was .94. Significant main effects were obtained for (a) Inability to Engage in Goal-Directed Behaviour, F (1, 84) = 5.65, p = 0.02, Cohen's d = 0.62, power = .65, (b) Limited Access to Emotion Regulation Strategies, F (1, 84) = 6.84, p = 0.01, Cohen's d = 0.55, power = .73, (c) Positive Refocus, F (1, 84) = 7.27, p < 0.01, Cohen's d = 0.50, power = .76 (d) Planning, F (1, 84) = 7.08, p < 0.01, Cohen's d = 0.55, power = .75, and (e) Putting in Perspective, F (1, 84) = 9.52, p < 0.01, Cohen's d = .74, power = .86. Pre–post difference scores were calculated for DSH and the five emotion regulation subscales of interest (i.e. Inability to Engage in Goal-Directed Behaviour, Limited Access to Emotion Regulation Strategies, Positive Refocus, Planning, Putting in Perspective). Pearson's correlation coefficients were then computed to explore relationships between the difference scores of DSH and the difference scores of the five emotion regulation subscales. There were positive correlations between DSH and ‘Inability to Engage in Goal-Directed Behaviour’ (r = 0.07), ‘Limited Access to Emotion Regulation Strategies’ (r = 0.17), and ‘Putting in Perspective’ (r = 0.06). There were negative correlations between DSH and Positive Refocus (r = 0.05) and Planning (r = 0.23). The correlation between DSH and Planning was statistically significant (p = 0.03). 3 month follow-up Forty percent of participants who completed the DSH measure post-intervention also completed it at 3-month follow-up. No statistically significant differences were found between those who completed the 3 month follow-up assessments (n = 20) and those who did not (n = 28) on baseline assessments or socio-demographic and clinical variables. Furthermore, there were no statistically significant differences in the frequency of DSH at post-intervention between those who later completed the follow-up (M = 5.84, SD = 18.14) and those who did not complete follow-up (M = 9.25, SD = 29.66; F (1, 83) = .29, p = .59, d = 0.11). This indicates the follow-up assessments were not more likely to have been completed by participants who reported lower frequencies of DSH immediately after the intervention. 2 The repeated-measures ANOVA showed a significant main effect for time, F (2, 28) = 5.65, p = 0.01, ηp2=.29ηp2=.29 (large effect). Post hoc tests revealed a significant decrease between baseline (M = 23.33, SD = 29.01) and post-intervention (M = 9.33, SD = 22.98; p = 0.03) and between baseline and 3 month follow-up (M = 2.53, SD = 5.11; p = 0.01). Of note, the analyses were repeated on the data from the completers' sample and similar results were obtained for the post-intervention outcomes. There was a statistically significant difference between the groups on frequency of DSH and non-statistically significant differences between the groups on anxiety and depression. Similar results were also found for the emotion regulation measures within the completer's sample, with the exception that an additional main effect was found on the ‘Catastrophise’ subscale.