- Title
- A randomised clinical trial of dialectical behaviour therapy and conversational model for the treatment of borderline personality disorder: a hybrid efficacy-effectiveness study in a public sector mental health service in Australia
- Creator
- Walton, Carla Joy
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2019
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Borderline Personality Disorder (BPD) is a disabling mental disorder that is associated with a high degree of suffering for the individual. Large-scale studies have shown pervasive social and functional impairment. It is associated with intensive use of mental health services and is recognised as a challenging disorder for clinicians to treat. There was previously little hope about the capacity for BPD to be successfully treated. In the past 20 years, there has been considerable progress in psychotherapeutic treatments developed and evaluated for BPD. Psychotherapy, rather than psychiatric medication is the indicated treatment for BPD. There are a number of psychotherapies that have been developed specifically for the treatment of adults with a diagnosis of BPD, with Dialectical Behaviour Therapy (DBT) being the therapy with the greatest evidence base. However, the outcome research for BPD is in its infancy. There are a number of limitations in the existing randomised studies. Many have small sample sizes; apart from DBT, most treatment models have only been evaluated in one or two studies and the majority of studies have been conducted by treatment developers or investigators who are strongly allegiant to one particular model of therapy. DBT has been evaluated in a number of efficacy studies but few effectiveness studies. It has rarely been compared against another active treatment for BPD. Other therapies for BPD, such as the Conversational Model (CM), a psychodynamic therapy, show promising results. However, CM has not been investigated in a randomised trial, nor has it been evaluated against another evidence-based treatment for BPD. This thesis describes the methodology and outcomes of a randomised clinical trial (RCT) conducted in a public sector mental health service comparing DBT and CM in the treatment of suicidal and non-suicidal self-injurious behaviour and depression severity among persons with BPD. The methodology of the trial is described in Chapter 2. Persons with a diagnosis of BPD and recent suicidal and non-suicidal self-injury were randomised to receive either DBT or CM for 14 months. Outcomes were evaluated at baseline, mid-treatment (7 months) and post-treatment (14 months). Chapter 3 discusses the development and evaluation of an adherence measure for CM. The tool was found to have good inter-rater reliability on items and to clearly discriminate between the two treatments. Outcomes from the RCT are discussed in Chapter 4. Both treatments showed significant improvement over time across the 14 months of therapy in suicidal and non-suicidal self-injury and depression scores. There were no significant differences between the treatment models in reduction of suicidal and non-suicidal self-injury. However, DBT was associated with significantly greater reductions in depression scores compared to CM. The pattern of results was similar with the secondary outcomes such that scores on BPD severity, dissociation, interpersonal problems, sense of self, mindfulness capacity and difficulties in emotion regulation all significantly improved with both treatments. At the differential level, DBT was associated with significantly better improvement in mindfulness capacity and emotion regulation. Chapter 5 reports on the findings of the RCT, in relation to the working alliance. The therapeutic alliance in DBT and CM was compared for therapist-rated and client-rated alliance overall, as well as distinct components of the alliance in the sub-scales of task, goal, and bond. There was a significant treatment effect overall for client-rated goals, which were significantly greater in DBT than CM. Therapist-rated goals were also significantly greater in DBT than CM in a time by treatment interaction effect. Chapter 6 reports on changes at the individual level, beyond the aggregated results by treatment group reported in Chapters 4 and 5. The majority of participants improved in terms of their suicidal and non-suicidal self-injury, severity of BPD symptoms, depression scores, and dissociation scores. Despite this improvement in severity of symptoms, only 38% of the sample no longer met criteria for BPD after 14 months of treatment. The majority of participants fell in the ‘unchanged’ category on interpersonal problems, sense of self and mindfulness capacity. The final chapter of this thesis synthesises the main findings of the preceding six chapters. This research adds to the accumulating body of knowledge of psychotherapeutic treatment of BPD and supports the use of both DBT and CM as effective treatments in routine clinical settings, with some additional benefits for DBT for persons with co-morbid depression. Future research directions are identified and discussed.
- Subject
- borderline personality disorder; dialectical behaviour therapy; conversational model; randomised clinical trial; psychotherapy; public sector; treatment
- Identifier
- http://hdl.handle.net/1959.13/1395562
- Identifier
- uon:33901
- Rights
- Copyright 2019 Carla Joy Walton
- Language
- eng
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Thesis | 2 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 317 KB | Adobe Acrobat PDF | View Details Download |