Dialectical Behavior Therapy (DBT; Linehan, 1993, 2014) is a structured, complex and comprehensive cognitive-behavioral treatment program for patients with Borderline Personality Disorder (BPD) and severe dysfunctional behaviors (repeated suicidal attempts, self-harm behaviors, relational instability, other impulsive behaviors). Up to now, DBT proved its effectiveness in several studies: suicide attempts and dysfunctional behaviors decreased, while emotional regulation and general functioning improved. The present research aimed at assessing the effectiveness of DBT and its mechanisms of action, evaluating both outcome and process dimensions. The first part of the thesis is dedicated to the presentation of the DBT model, examining its theoretical foundations, the agreements underlying the treatment, the modalities of therapeutic program, and the strategies of intervention. The second part of the thesis is an evaluation of the effectiveness of DBT, examining the course over time of the target variables. The study is longitudinal, single-blind, with a two-arm parallel design, conducted following the international guidelines for the outcome studies on intention-to-treat samples. DBT was compared with another treatment program comparable by patient type, objectives, and complexity of interventions. The sample was comprised by 95 outpatients, assigned to groups with the minimisation procedure and assessed every three months. Since the individual variability was expected to be consistent, Hierarchical Linear Models with random effects were used. Results showed that suicidality, self-harm, emotional and behavioral dysregulation decreased in both groups after one year; unconditional growth models indicated that subjects differed in the elevation and in the rate of change. Moreover, results on the completers’ subsample suggested that the group setting and the intensity of treatment could represent specific therapeutic mechanisms. The third part of the thesis is composed by process studies with a single-case design, in the strand of the process-outcome research: the empirical evaluation of two therapeutic couples, one with a favorable outcome and one with a partial outcome, was conducted. The patients were two young women with a diagnosis of Borderline Personality Disorder, different for personality profile and dysfunctional behaviors at the beginning of treatment; they followed a DBT standard program with the same therapist, a male experienced clinician. Sessions over the first year of treatment were examined (N1 = 38; N2 = 37). The technical and the relational dimensions of the therapeutic process were assessed and examined through a macroanalytic and microanalytic perspective. Results showed that some aspects are present in both couples: namely, the adherence to the treatment model and the attitude of the therapist oriented towards collaboration. On the other hand, specificities relating to each therapeutic couple emerged. In the treatment of the patient with positive outcomes, there was a globally positive relational climate; furthermore, therapist and patient can deal even with episodes of misunderstanding. Instead, in the treatment of the patient with partial outcomes, therapist and patient struggled to find an attunement and to work in synergy, remaining trapped in problematic relational patterns and without fully achieving the therapeutic objectives previously agreed. Taken together, results confirmed the effectiveness and the complexity of DBT. More specifically, they shed light on overlaps and differences between DBT and other theoretical models, in particular interventions promoting reflective functioning. Furthermore, the importance of a collaborative relationship between therapist and patient was confirmed. Overall, results suggested that mechanisms of action in DBT can be understood only in light of the dynamics of the therapeutic process in which they occur.

La Dialectical Behavior Therapy (DBT) è un programma di trattamento cognitivo-comportamentale strutturato, complesso e ricco, messo a punto per pazienti con Disturbo Borderline di Personalità (BPD) e gravi comportamenti disfunzionali (tentativi suicidari, autolesività, instabilità relazionale, comportamenti impulsivi). DBT ha dimostrato la sua efficacia in numerosi studi: i tentativi suicidari e i comportamenti disfunzionali si sono ridotti, mentre la regolazione emotiva e il funzionamento generale dei pazienti sono migliorati. La ricerca presentata i prefigge di valutare l’efficacia e i meccanismi d’azione di DBT, esaminando sia la dimensione di outcome, sia la dimensione di processo. La prima parte dell’elaborato è dedicata alla presentazione del modello DBT. Se ne discutono i fondamenti teorici, gli accordi alla base del trattamento, le modalità del programma terapeutico e le strategie di intervento. La seconda parte dell’elaborato è una valutazione dell’efficacia di DBT, rispetto alle variabili target. Lo studio è di tipo longitudinale ed è stato condotto seguendo le linee guida internazionali. DBT è stata messa a confronto con un programma di trattamento comparabile per tipologia di pazienti, obiettivi e complessità. Il campione è composto da 95 pazienti ambulatoriali, valutati ogni tre mesi. Poiché ci si attendeva che il contributo della variabilità individuale fosse rilevante, sono stati utilizzati modelli lineari gerarchici con effetti casuali. I risultati hanno mostrato che i tentativi suicidari, i comportamenti autolesivi, la disregolazione emotiva e comportamentale sono diminuiti in entrambi i gruppi dopo un anno; i modelli hanno mostrato come i soggetti differissero nella quota di cambiamento. Inoltre, i risultati sul campione dei completer hanno suggerito che il setting di gruppo e l’intensità del trattamento potrebbero agire quali specifici meccanismi terapeutici. La terza parte dell’elaborato si compone di una serie di studi di processo con un disegno single case, inseriti nel filone della ricerca process-outcome: si tratta della valutazione di due coppie terapeutiche, una con esito favorevole ed una con esito parziale. Le pazienti erano due giovani donne con diagnosi di BPD, differenti per profilo di personalità e comportamenti disfunzionali; hanno seguito un programma DBT standard con il medesimo terapeuta, un clinico esperto. Sono state esaminate le sedute durante il primo anno di trattamento. Si sono considerate tanto la dimensione tecnica quanto quella relazionale del processo terapeutico, esaminando entrambe da una prospettiva macroanalitica e microanalitica. I risultati hanno mostrato come alcuni aspetti siano riscontrabili in ambedue le coppie terapeutiche: l’aderenza al modello di trattamento e l’atteggiamento del terapeuta orientato alla collaborazione. D’altra parte, sono emerse specificità relative alle coppie terapeutiche. Nel trattamento della paziente con esito positivo, è presente un clima relazionale globalmente positivo, terapeuta e paziente riescono ad affrontare in modo proficuo anche le incomprensioni. Invece, nel trattamento della paziente con esito parziale, terapeuta e paziente faticano a trovare una sintonizzazione e a lavorare in modo sinergico, rimanendo bloccati in dinamiche problematiche e senza riuscire a conseguire pienamente gli obiettivi prefissati. Nel loro insieme, i risultati hanno confermato l’efficacia e la complessità di DBT. Più precisamente, hanno messo in luce le sovrapposizioni e le differenze tra DBT e altri modelli teorici, in particolare con gli interventi che promuovono il funzionamento riflessivo. Inoltre, i risultati hanno confermato l’importanza di una relazione collaborativa tra terapeuta e paziente. In sintesi, è possibile concludere che i meccanismi dell’azione terapeutica in DBT possono essere compresi solo alla luce delle dinamiche del processo terapeutico entro cui si verificano.

(2019). The complexity of therapeutic action in DBT: preliminary studies on process and outcome. (Tesi di dottorato, Università degli Studi di Milano-Bicocca, 2019).

The complexity of therapeutic action in DBT: preliminary studies on process and outcome

RODER, EMANUELA
2019

Abstract

Dialectical Behavior Therapy (DBT; Linehan, 1993, 2014) is a structured, complex and comprehensive cognitive-behavioral treatment program for patients with Borderline Personality Disorder (BPD) and severe dysfunctional behaviors (repeated suicidal attempts, self-harm behaviors, relational instability, other impulsive behaviors). Up to now, DBT proved its effectiveness in several studies: suicide attempts and dysfunctional behaviors decreased, while emotional regulation and general functioning improved. The present research aimed at assessing the effectiveness of DBT and its mechanisms of action, evaluating both outcome and process dimensions. The first part of the thesis is dedicated to the presentation of the DBT model, examining its theoretical foundations, the agreements underlying the treatment, the modalities of therapeutic program, and the strategies of intervention. The second part of the thesis is an evaluation of the effectiveness of DBT, examining the course over time of the target variables. The study is longitudinal, single-blind, with a two-arm parallel design, conducted following the international guidelines for the outcome studies on intention-to-treat samples. DBT was compared with another treatment program comparable by patient type, objectives, and complexity of interventions. The sample was comprised by 95 outpatients, assigned to groups with the minimisation procedure and assessed every three months. Since the individual variability was expected to be consistent, Hierarchical Linear Models with random effects were used. Results showed that suicidality, self-harm, emotional and behavioral dysregulation decreased in both groups after one year; unconditional growth models indicated that subjects differed in the elevation and in the rate of change. Moreover, results on the completers’ subsample suggested that the group setting and the intensity of treatment could represent specific therapeutic mechanisms. The third part of the thesis is composed by process studies with a single-case design, in the strand of the process-outcome research: the empirical evaluation of two therapeutic couples, one with a favorable outcome and one with a partial outcome, was conducted. The patients were two young women with a diagnosis of Borderline Personality Disorder, different for personality profile and dysfunctional behaviors at the beginning of treatment; they followed a DBT standard program with the same therapist, a male experienced clinician. Sessions over the first year of treatment were examined (N1 = 38; N2 = 37). The technical and the relational dimensions of the therapeutic process were assessed and examined through a macroanalytic and microanalytic perspective. Results showed that some aspects are present in both couples: namely, the adherence to the treatment model and the attitude of the therapist oriented towards collaboration. On the other hand, specificities relating to each therapeutic couple emerged. In the treatment of the patient with positive outcomes, there was a globally positive relational climate; furthermore, therapist and patient can deal even with episodes of misunderstanding. Instead, in the treatment of the patient with partial outcomes, therapist and patient struggled to find an attunement and to work in synergy, remaining trapped in problematic relational patterns and without fully achieving the therapeutic objectives previously agreed. Taken together, results confirmed the effectiveness and the complexity of DBT. More specifically, they shed light on overlaps and differences between DBT and other theoretical models, in particular interventions promoting reflective functioning. Furthermore, the importance of a collaborative relationship between therapist and patient was confirmed. Overall, results suggested that mechanisms of action in DBT can be understood only in light of the dynamics of the therapeutic process in which they occur.
PAROLIN, LAURA ANTONIA LUCIA
BPD; DBT; Ricerca psicoterapia; Ricerca efficacia; Ricerca processo
BPD; DBT; Psychother. research; Effectiveness resear; Ricerca processo
M-PSI/07 - PSICOLOGIA DINAMICA
English
21-gen-2019
PSICOLOGIA, LINGUISTICA E NEUROSCIENZE COGNITIVE - 77R
31
2017/2018
open
(2019). The complexity of therapeutic action in DBT: preliminary studies on process and outcome. (Tesi di dottorato, Università degli Studi di Milano-Bicocca, 2019).
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/10281/241311
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