تمرین مهارت ها در مناظرهای رفتار درمانی برای معیارهای نشست خودکشی زنان برای اختلال شخصیت مرزی

Abstract Dialectical Behavior Therapy (DBT) is an evidence-based practice for borderline personality disorder (BPD) and suicidal behavior that has been replicated with a variety of populations. Patients’ practice of behavioral skills taught in the group skills training component of DBT may be partly responsible for the positive treatment outcomes according to the skills deficit model of BPD that underlies DBT. This study was designed to examine the type and frequency of skills practiced by DBT patients. Participants were 49 women, who met criteria for BPD and current and chronic suicidal behavior, receiving 1 year of standard DBT as part of a clinical trial. Skills were recorded on the daily diary cards completed by participants each week and reviewed by their individual therapists. Results indicated that the majority of participants reported practicing skills most days throughout treatment. Crisis survival and mindfulness skills were practiced most frequently in our sample. Hierarchical linear modeling demonstrated that skills practice increased as a function of time in therapy. Directions for future research are discussed.

Results Treatment Retention and Compliance with Diary Cards The average length of DBT treatment for this sample was 49 (SD = 10) weeks. 1 As a whole, compliance with the self-monitoring diary card was very high. The average number of diary cards per participant in the study was 41 (SD = 15), accounting for 84% of the time in the study. Similarly, the median number of days with nonblank cards was 280 (IQR = 104 - 343; 82%), and the median number of days with completely blank cards was 21 (IQR = 7-82; 6.1%). Amount and Frequency of Skills Practice Summing across all skills, the average daily number of skills practiced per person was 4.96 (SD = 3.64). The large standard deviations reflect large variability of skills practice in our sample. Participants reported practicing at least one skill 78% (SD = 24) of the days in therapy. The median proportion of days with at least one skill practiced was .87 (IQR = .69 to .95). Table 1 displays the proportion of days each particular skill was practiced per participant, averaged across days in treatment. There was a considerable range among the skills, with “distraction” being practiced 43% of the days and “self-respect effectiveness” being practiced 13% of the days. To analyze whether any one skill or type of skill was practiced more days than another (i.e., practice preference), MMANOVA was conducted comparing each of the 19 skills with each other. The omnibus test was significant, F(18, 46) = 10.79, p < .001, indicating skills were not practiced equally in our sample. Since participants entered the study at different times, but the order of skills teaching was invariant (interpersonal effectiveness, emotion regulation, and distress tolerance), we added a variable indicating the first module a client practiced. Exploratory contrasts were calculated among the individual skills (see Table 1). Results indicate that there is a significant skill practice preference even when analyses controlled for the first skills module practiced (with the exception of mindfulness skills, for which no adequate control was possible). Participants practiced distracting, self-soothing, observing, and “wise mind” most frequently and interpersonal skills least often. We next computed contrasts between the four skills modules. Significant differences for modules are also reported in Table 2. There were no interaction effects between the order that the skills were taught and the rate of practice of different modules, or overall practice (p = .147). In other words, the fact that in this study participants entered their skills training at different times and started with different modules did not significantly influence the frequency of their skills practice or the type of skills they practiced. Skills Practice as a Function of Time Daily ratings across the weeks were averaged, and the weekly average of the number of skills practiced was used as the dependent variable in our HLM analyses. This is a useful indicator of practice since it is affected by the consistency of practice as well as the variety of skills practiced. We first assessed whether there was a significant increase in the number of skills practiced over the entire year in therapy. As can be seen in Fig. 1, the number of skills practiced per day increased over the year (slope estimate = .090, SE = .016, t = 5.49, p < .01), indicating that over the entire year the mean number of skills practiced per day increased by .09 skills per week. In order to control for the fact that it takes approximately 6 months to complete all the skills modules taught in DBT, we divided the year into the first half and the second half of the treatment. During the first half of the treatment, the slope estimate was .16 (SE = .024, t = 6.79, p < .01). Therefore, an increase in 1 week of treatment corresponds to an increase of .16 in the mean number of skills practiced per day. During the second 6 months in treatment, the rate of increase in skills practice was smaller. The value for the fixed effect of the slope was .049 (SE = .020, t = 2.44, p = .019). As can be seen, the rate of increase of skills use is three times higher in the first 6 months (.16) than in the second half of treatment (.049). Random effects of both intercepts and slopes were significant in all of our models, where the Wald Z statistic ranged from 2.76 to 4.79 (all p < .01). These findings suggest that participants varied considerably in both their initial practice and the pattern of skills practice over time. Image for figure Figure 1 Figure 1.