Quality of Research
Review Date: October 2006
Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Bohus, M., Haaf, B., Simms, T., Limberger, M. F., Schmahl, C., Unckel, C., et al. (2004). Effectiveness of inpatient dialectical behavior therapy for borderline personality disorder: A controlled trial. Behaviour Research and Therapy, 42, 487-499. Study 2Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064. Study 3Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (n.d.). Dialectical behavior therapy versus treatment-by-experts for suicidal individuals with borderline personality disorder: One year treatment and one year follow-up. Unpublished manuscript. Study 4Linehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A., Welch, S. S., Heagerty, P., et al. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-Step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67, 13-26. Study 5Linehan, M. M., Heard, H. L., & Armstrong, H. E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971-974. Study 6Linehan, M. M., Schmidt, H., III, Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addictions, 8, 279-292. Study 7Linehan, M. M., Tutek, D. A., Heard, H. L., & Armstrong, H. E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151, 1771-1776. Study 8Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158, 632-634. Study 9Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1061-1065. Study 10Turner, R. M. (2000). Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder. Cognitive and Behavioral Practice, 7, 413-419. Study 11van den Bosch, L. M., Verheul, R., Schippers, G. M., & van den Brink, W. (2002). Dialectical behavior therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27, 911-923. Study 12Verheul, R., van den Bosch, L. M., Koeter, M. W., De Ridder, M. A., Stijnen, T., & van den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. British Journal of Psychiatry, 182, 135-140.
Supplementary Materials Dialectical behavior therapy: Efficacy, effectiveness & feasibility [Handout]
Dimeff, L., Koerner, K., & Linehan, M. M. (2002). Summary of research on dialectical behavior therapy. Seattle, WA: Behavioral Tech, LLC.
Letters to the editor. (1993). Archives of General Psychiatry, 50, 157-158.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford.
Robins, C. J., & Chapman, A. L. (2004). Dialectical behavior therapy: Current status, recent developments, and future directions. Journal of Personality Disorders, 18, 73-89.
Outcomes
Outcome 1: Suicide attempts |
Description of Measures
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Suicide attempts were measured by the Parasuicide History Interview (now called the Suicide Attempt Self-Injury Interview, or SASII), a semistructured interview administered by blind assessors.
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Key Findings
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After 1 year of care during a randomized controlled trial, 23.1% of DBT participants reported suicide attempts, compared with 46.7% of recipients of alternative expert treatment (p = .005).
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Studies Measuring Outcome
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Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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3.7
(0.0-4.0 scale)
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Outcome 2: Nonsuicidal self-injury (parasuicidal history) |
Description of Measures
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Nonsuicidial self-injury (parasuicidal history) or NSSI refers to deliberate self-harm, such as self-mutilation or drug overdose, in which suicide is not intended. This outcome was measured by blind assessors using the Parasuicide History Interview (now called the Suicide Attempt Self-Injury Interview, or SASII).
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Key Findings
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Multiple evaluations, including randomized controlled trials and independent studies, confirmed that patients completing 1 year of DBT experienced less nonsuicidal self-injury than patients awaiting care or receiving alternative treatment (p < .05). In one evaluation, DBT patients averaged 0.55 incidents during the previous month compared with 9.33 incidents in a treatment-as-usual group (p < .05). In two other evaluations, DBT participants experienced incidents of nonsuicidal self-injury with a frequency comparable to that of recipients of alternative professional treatment.
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Studies Measuring Outcome
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Study 1, Study 2, Study 3, Study 5, Study 6, Study 10, Study 11, Study 12
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Study Designs
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Experimental
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Quality of Research Rating
|
3.3
(0.0-4.0 scale)
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Outcome 3: Psychosocial adjustment |
Description of Measures
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Psychosocial adjustment was measured by standardized self-reports and blind assessor reports. Measures included the Social Adjustment Scale and Longitudinal Interview Follow-Up Evaluation, Global Assessment Scale, Hamilton Rating Scale for Depression, State-Trait Anger Expression Inventory, and self-reports on targeted behaviors, among others.
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Key Findings
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Seven randomized controlled trials found that 1 year of DBT improved at least some measures of psychological, social, or global adjustment, when compared with results for patients awaiting care or receiving alternative treatment (p < .05 across multiple measures). Two evaluations found sustained effects 16 and 18 months after treatment, respectively. One evaluation noted reduced anger among DBT participants 24 months after treatment.
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Studies Measuring Outcome
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Study 1, Study 3, Study 4, Study 5, Study 6, Study 7, Study 10
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Study Designs
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Experimental
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Quality of Research Rating
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3.4
(0.0-4.0 scale)
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Outcome 4: Treatment retention |
Description of Measures
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Treatment retention was measured by clinicians' records of attendance.
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Key Findings
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In multiple evaluations, DBT participants remained in treatment longer than patients receiving treatment as usual or alternative treatment (p < .002). DBT retention rates ranged from 63% to 100%, depending on the evaluation format, while retention rates for comparative treatment in the same studies ranged from 23% to 73%.
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Studies Measuring Outcome
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Study 2, Study 3, Study 6, Study 12
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Study Designs
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Experimental
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Quality of Research Rating
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3.4
(0.0-4.0 scale)
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Outcome 5: Drug use |
Description of Measures
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Drug use was measured by urine samples and structured clinical interviews. Interviews included the Timeline Followback Interview, administered by blind assessors.
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Key Findings
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In a randomized controlled trial, DBT participants were significantly more likely than alternative-treatment recipients to have drug-free urine screens 4 months after completing a year-long course of treatment; effect size was medium (Cohen's d = 0.75). In another evaluation, most DBT participants continued to reduce their use of opiate drugs over the course of 1 year of treatment, while alternative-treatment recipients typically increased their use during the last 4 months of treatment (p < .05).
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Studies Measuring Outcome
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Study 4, Study 6, Study 11
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Study Designs
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Experimental
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Quality of Research Rating
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3.3
(0.0-4.0 scale)
|
Outcome 6: Symptoms of eating disorders |
Description of Measures
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Symptoms of eating disorders were measured by the Eating Disorders Examination, which diagnoses disorders and measures number of days and episodes of binge eating, and the Binge Eating Scale, which measures severity of eating disorder.
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Key Findings
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DBT participants reported significantly less binging or purging behavior than patients awaiting treatment (p < .05). In one evaluation, 89% of DBT participants were free of purge behavior, compared with 12.5% of patients awaiting care (p < .001).
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Studies Measuring Outcome
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Study 8, Study 9
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Study Designs
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Experimental
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Quality of Research Rating
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3.2
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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18-25 (Young adult) 26-55 (Adult)
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100% Female
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Data not reported/available
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Study 2
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18-25 (Young adult) 26-55 (Adult)
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100% Female
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Data not reported/available
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Study 3
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18-25 (Young adult) 26-55 (Adult)
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100% Female
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87% White 6% Race/ethnicity unspecified 4% Black or African American 2% Asian 1% American Indian or Alaska Native
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Study 4
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18-25 (Young adult) 26-55 (Adult)
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100% Female
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66% White 26% Black or African American 4% Race/ethnicity unspecified
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Study 5
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18-25 (Young adult) 26-55 (Adult)
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100% Female
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Data not reported/available
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Study 6
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18-25 (Young adult) 26-55 (Adult)
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100% Female
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78% White 11% Race/ethnicity unspecified 7% Black or African American 4% Hispanic or Latino
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Study 7
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18-25 (Young adult) 26-55 (Adult)
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100% Female
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Data not reported/available
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Study 8
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18-25 (Young adult) 26-55 (Adult)
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100% Female
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87.1% White 12.9% Race/ethnicity unspecified
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Study 9
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18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
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100% Female
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94% White 6% Race/ethnicity unspecified
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Study 10
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18-25 (Young adult) 26-55 (Adult)
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79.2% Female 20.8% Male
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79.2% White 16.7% Black or African American 4.2% Asian
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Study 11
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26-55 (Adult)
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100% Female
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Data not reported/available
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Study 12
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26-55 (Adult)
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100% Female
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Data not reported/available
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Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: Suicide attempts
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3.8
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3.8
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4.0
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3.5
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3.0
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4.0
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3.7
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2: Nonsuicidal self-injury (parasuicidal history)
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3.8
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3.8
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3.3
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2.9
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2.6
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3.7
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3.3
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3: Psychosocial adjustment
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4.0
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4.0
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3.0
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3.2
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2.7
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3.7
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3.4
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4: Treatment retention
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4.0
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4.0
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3.7
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2.5
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2.7
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3.8
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3.4
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5: Drug use
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3.6
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3.6
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3.5
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2.8
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2.8
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3.5
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3.3
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6: Symptoms of eating disorders
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3.6
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3.6
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3.0
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2.3
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2.8
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4.0
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3.2
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Study Strengths In general, study designs were of high quality. The conservative approach used to address attrition was well founded.
Study Weaknesses Although the treatment is manualized, it is unclear how adherence was monitored and how deficiencies were addressed. It is also unclear how the research team addressed issues with missing data.
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Readiness for Dissemination
Review Date: October 2006
Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford.
Linehan, M., & Behavioral Tech, LLC. (2006). Advanced topics in Dialectical Behavior Therapy with special emphasis on adolescents: Two-day training. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). Coping with chaos: Dialectical Behavior Therapy for the multiply disordered client. One-day training. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). Coping with chaos: Dialectical Behavior Therapy for the multiply disordered client. Two-day training. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). Dialectical Behavior Therapy applied to substance abuse. Two-day training. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). Dialectical Behavior Therapy 5-day foundational training. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). Dialectical Behavior Therapy intensive training course. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). How to be a skills trainer in Dialectical Behavior Therapy. Two-day workshop. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). Introduction to individual psychotherapy in Dialectical Behavior Therapy. Two-day workshop. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). Skills training in Dialectical Behavior Therapy. Two-day training. Seattle, WA: Authors.
Linehan, M., & Behavioral Tech, LLC. (2006). Treating the multiply disordered suicidal client. Two-day training. Seattle, WA: Authors.
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
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Training and Support
Resources
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Quality Assurance
Procedures
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Overall
Rating
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4.0
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3.0
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2.5
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3.2
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Dissemination Strengths An excellent range of materials is available to directly assist implementation. Materials describe the intervention as it is applied to a variety of problems. Training materials are comprehensive and vary appropriately with the topic. Online peer supervision is available. Practical and intervention-specific measures for intervention fidelity and outcomes are provided to support quality assurance.
Dissemination Weaknesses Very little information is provided on how trainers are trained and selected. Little information is provided to describe how a treatment team is formed and how it functions over time, and very little attention is paid to implementation issues for administrators. There is no description of when and by whom data is collected and reported. No information is provided describing the uses of the data for improving treatment processes or program outcomes.
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