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Paper 1: High-risk behaviours (HRB) are understood to serve a function of regulating emotions in the absence of other adaptive coping strategies. Engagement in multiple HRBs during adolescence is known to contribute to increased risk of suicide and psychopathology. Dialectical Behaviour Therapy for adolescents (DBT-A) has received attention for treating HRB in adolescents over recent years. Previous reviews have either provided a narrow focus on one HRB in isolation, and/or have focused broadly on several interventions’ effectiveness in treating HRBs. This systematic review aimed to synthesise the literature across six databases, exploring the effectiveness of DBT-A (including both individual and group DBT sessions) on a range of HRBs in various settings. Eleven papers met the search criteria and were included within the review. A narrative synthesis of the findings provided evidence for DBT-A reducing a range of HRBs in comparison to control conditions, with particular benefits for suicidal ideation and self-harm. Improvements in self-harm were more likely to be maintained over follow-up, whereas between-group differences in other HRBs were often lost over time. Studies varied considerably in quality, treatment length, frequency, and intensity. The implications for future research and practice are discussed. Paper 2: Objective: Following early life stress (ELS), individuals have been shown to develop maladaptive coping strategies including externalising behaviours such as aggression that persist across the life span. Yet, little is known about the possible underlying mechanisms for this association. This study explored these relationships using neuroimaging methods and clinical data from a 30-year longitudinal dataset investigating adults with ELS and cross-sectional controls without ELS. Methods: Forty-one participants (Mage = 25.66 years, SD = 2.96) participated in the study: 15 participants with ELS, and 26 controls. Participants completed the Amygdala Reactivity Paradigm while a functional magnetic resonance imaging (fMRI) scan was recorded to probe amygdala reactivity and behavioural responses to emotionally salient stimuli. Blood-oxygen-level-dependent signals from bilateral amygdala and relevant subfields were analysed and correlated with clinical measures of coping in adulthood, and aggressive/hostile behaviour across the lifespan. Results: Although fMRI data showed no significant between-group differences on contrasts of interest, key differences were noted on trials of neutral faces. Compared to controls, individuals with ELS demonstrated significantly faster reaction time on all trials with greatest difference for neutral faces, and significantly less accuracy on trials with negative faces and shapes, but not neutral faces. Higher amygdala reactivity to neutral faces was significantly positively correlated with emotion-oriented methods of coping in adulthood, and aggressive and hostile behaviours during mid-adolescence and adulthood but not childhood or late-adolescence.

Trauma-sensitive yoga (TSY) is an adjunctive trauma treatment paradigm that modifies a studio-style yoga class to make it more accessible for individuals who have experienced trauma. A core outcome of TSY practice is greater connection to one’s physical body and ability to read one’s own physical signals. Since individuals with chronic trauma often engage in body-based avoidant behaviors, such as self-harm, substance abuse, or dissociation, they may benefit from a treatment that promotes embodiment, such as TSY. Dialectical Behavior Therapy (DBT) is a therapy often used with individuals who have emotional reactivity resulting from trauma. However, DBT focuses on internal and cognitive processes that are different from those employed in yoga, suggesting these two treatments work via different mechanisms. A program was developed for individuals with Borderline Personality Disorder which formally integrates Trauma Center TSY, a protocolized yoga treatment for trauma, with DBT, so that clients can learn a wider array of skills to target trauma reactions. The integration of TSY and DBT modalities are likely to complement and enhance one another’s effectiveness in treating chronically traumatized individuals through increased embodiment.

While research demonstrates that opposite action (OA) impacts emotion (Rizvi & Linehan, 2005), we lack an understanding of the mechanisms by which it produces opposite emotions. The current study dismantled emotion regulation skill components by comparing tasks with different combinations of cognitive, emotive and behavioral components. I predicted that the OA condition would be the most effective in altering negative emotion. University students (n = 194) completed a sadness induction and were randomly assigned to either a (1) control, (2) low arousal positive imagery (3) high arousal positive imagery, or (4) OA plus high arousal positive imagery condition. The control condition experienced the smallest changes in emotion in the predicted directions across most emotion outcomes, followed by the low arousal positive imagery condition and last, the OA and high arousal positive imagery conditions, which did not tend to differ from each other. Using opposite emotion (valence and arousal) was effective in changing sadness; however, the behavioral component did not change emotion above and beyond the cognitive and emotive components tested. Study conditions were not different in the time they spent persisting on a distressing task. The behavioral component of OA might not be important for emotion change; however, it seems likely that self-reported levels of discomfort and vividness in mental imagery experienced by the OA condition hindered the effectiveness of the behavioral component. This finding could shed light on the importance of building therapeutic rapport to increase comfortability engaging in OA prior to introducing it in psychotherapy.

Mindfulness trainings, which tend to include daily home meditation practice, have been found to improve in- and pre-service teachers well-being, but findings indicate that participants struggle to complete the recommended home meditation practice. A mindfulness training based on Dialectical Behavior Therapy (DBT) skills may be a more feasible training format for teachers because the home practice is informal and easily integrated into daily life. DBT skills are also discrete and easy-to-understand and directly relate to the intrapersonal and interpersonal challenges teachers face. Although DBT skills-based trainings have been used with non-clinical populations, to date no study has been identified exploring the use of DBT skills training with teachers generally or pre-service teachers specifically. This dissertation reports the findings of a study of a DBT skills-based training with pre-service teachers to improve their mindfulness and well-being. This study spanned 81 days and used a multiple-baseline single-case experimental design with longitudinal daily diary data from 11 participants. Qualitative homework data, facilitator reflections, and post-training interviews with four participants provided supplementary qualitative data. Quantitative findings indicate that the DBT skills training resulted in higher levels of mindfulness and positive affect the evening after participants attended trainings and continued elevated positive affect the following evening. The study did not find phase effects of training. Qualitative evidence shows that participants used DBT skills in a variety of personal and professional settings to address negative emotions or deal with difficult situations. According to interviews and homework data, the skills presented were easy to understand and apply. The discussion includes limitations of the study and implications for future research.

Dialectical behavior therapy (DBT) is the treatment of choice for borderline personality disorder (BPD), which is the most commonly treated personality disorder in community mental health settings. While DBT has been studied extensively using traditional research methods, there is a dearth of literature on DBT or BPD that was conducted using less traditional, qualitative methods from any field of study. BPD is also associated with a highly negative stigma among mental health practitioners, often resulting in lower quality care. This combination of sterile treatment of BPD and DBT as research topics and stigma among mental health practitioners results in the silencing of the voices of those DBT is intended to treat.The purpose of this study was to discover how clients’ experiences in DBT skills group contribute to their attainment of a more complex sense of self. This study examined the process by which individuals exhibiting symptoms of BPD began to integrate previously dissociated parts of the psyche, progressing toward a more integrated sense of self. This study focused on how this occurred in the context of the dialectical behavior therapy (DBT) skills group in which these individuals participated as part of their treatment. By using qualitative and practitioner action research methods, this study highlighted clients’ subjective experiences with the sense of self and the recovery facilitated by the relational aspects of DBT skills group. Participants in DBT skills training groups began to trust their own interpretations of events and developed a capacity for relationships that are mutually empathic and mutually empowering. By presenting evidence of DBT skills group’s function as a context for growth-fostering relationships, the multifaceted results of this dissertation highlighted clients’ exploration of the complex notion of the sense of self and the recovery of lost aspects of themselves. The data presented in this study demonstrate the impact of the relational context of DBT skills training group on participants’ ability to authentically integrate aspects of their internal experiences as well as building relational competencies necessary to sustaining healthy, fulfilling relationships with others. The implications of this work underscore the need for a more complex and compassionate conceptualization of BPD among mental health practitioners, as well as the necessity of DBT practitioners’ ongoing research and reflection on their own practice.

Heavy drinking puts college students at risk for academic failure, alcohol use disorders, and even death. Although several interventions have proven moderately successful, overall rates of collegiate heavy drinking and consequences have significantly increased since 1998, as interventions may not adequately address underlying reasons for drinking. Research has consistently shown that college students who drink primarily to regulate emotions (i.e., internal drinking motives) are heavier drinkers, experience more consequences, and are likely to continue drinking heavily after college. Further, internal drinking motives are indicative of emotion dysregulation and associated personality traits. Dialectical Behavior Therapy (DBT) is empirically supported and includes a group-based component designed to teach concrete behavioral emotion regulation, mindfulness, and distress tolerance skills. DBT skills training alone has been shown to reduce substance abuse and binge eating and is a promising, but untested, strategy for reducing collegiate alcohol abuse. The aims of the current study were threefold: (a) examine the efficacy of a DBT-based emotion regulation skills training (ERST) as an intervention for college student drinking, (b) examine theoretically-informed mechanisms of change (i.e., changes in mindfulness, emotion regulation, and distress tolerance), and (c) examine intervention moderators (i.e., gender, readiness to change, and internal drinking motives). After completing pre-test measures, college students reporting two or more heavy drinking episodes during the past month were randomly assigned to an ERST or assessment-only control (AO) condition. ERST participants completed a single 3-hour group session of ERST within 7 days of completing pre-intervention measures and all participants completed two additional assessments. The current study found that ERST participants showed significantly greater reductions in heavy drinking and alcohol-related consequences relative to AO control participants. Contrary to hypotheses, intervention participation did not increase hypothesized mechanisms of change (i.e., mindfulness, emotion regulation, or distress tolerance) although emotion regulation and distress tolerance moderated intervention efficacy. Finally, ERST participation appeared to serve as a protective factor against heavy drinking and consequences for internally motivated drinkers. Overall findings provide preliminary support for the feasibility of ERST as a new intervention for reducing problematic drinking by college students and suggest future directions for mechanisms of change and moderation hypotheses.

Dialectical Behavior Therapy (DBT) is an empirically supported treatment for Borderline Personality Disorder (BPD). Despite its established efficacy in clinical trials, additional “real world” applied research is needed. The present study evaluated the treatment effectiveness of an outpatient DBT program for clients diagnosed with BPD at a New Hampshire community mental health center (NHCMC). A quasi-experimental, single group time-series design was used to assess the effectiveness of services for clients diagnosed with BPD who participated in the DBT program at NHCMC. Records of adults who received outpatient DBT treatment for a minimum of one year were assessed for a change from pre-test to follow-up on the following target outcomes: (a) number of suicide attempts, (b) incidents of self-injurious behavior, (c) substance abuse, (d) psychiatric admissions and length of stay, (e) other hospital admissions and length of stay, and (f) emergency services contacts, including emergency room visits. Participants were also assessed for a change from pre-test to follow-up on indicators of quality of life and overall level of functioning. Using a time-series method, data from individual records were gathered for each client at the following time points: (a) one year, six months, and three months prior to beginning standard DBT, (b) early treatment (start of treatment), (c) six months after the start of treatment, (d) termination from treatment (at least one year), (e) three months and six months to one year following termination. An analysis of the results revealed statistically significant decreases in life-threatening behavior. Several other trends toward client improvement were also identified.

This study examines the relationship between several variables and dropout in an outpatient Dialectical Behavior Therapy (DBT) psycho-educational skills group in a community mental health setting. Treatment completion was defined as completing all of the DBT skills training modules twice. Variables examined included Demographic Variables, Feelings of Empowerment, Quality of Life, Symptom Distress, First Assigned Module, Percent of First Module Completed, Total Percent of Sessions Attended, and Completion of all Modules Once. Cramer’s V and Pearson r correlations were analyzed, and found that all clients who attended 50% or less of their first module did not successfully complete treatment. None of the other independent variables were significantly related to DBT treatment completion. Optimism, Percent of First Module completed, Empowerment, and Self-esteem/Self-efficacy are all significantly correlated with Completion of all Modules Once. Clients who did not complete at least 64% of their first module did not complete all modules once. Percent First Module and Optimism were correlated with Percent of Total Sessions attended. Self-Esteem/Self-Efficacy was significantly positively correlated with Percent of First Module Completed. A multiple regression prediction equation was constructed with Quality of Life as the dependent variable, and found that Race, living situation, and optimism accounted for 29% of the variability in Quality of Life. Limitations of the study and implications for clinicians are discussed, as well as suggestions for future research.

This dissertation examines the effectiveness of a partial skills group component of Dialectical Behavior Therapy (DBT) in female prison inmates. DBT is an evidence-based comprehensive treatment which addresses emotional reactivity, impulsivity and distress tolerance. The psychology staff at the Kentucky Correctional Institution for Women (KCIW) had noted that many of the behaviors leading to disruptive and dangerous situations within their female inmate population are related to inmates reacting to extreme emotionality. In response KCIW staff had implemented DBT on a limited basis. Although the treatment was in place, its effectiveness in promoting safety and security at KCIW had yet to be evaluated. This study used a non-randomized pre-test, post-test control group design to evaluate the effectiveness of this psychoeducational group therapy treatment as offered to volunteering female inmates at KCIW. The evaluation was implemented in order to determine whether the participants developed the adaptive coping skills purported to be taught by the treatment, evidenced a decrease in pathological symptomology, and a decrease in problematic behavior. Data were gathered through inmate self reports and record reviews of disciplinary infractions. A MANCOVA showed a significant overall effect for the treatment. Post hoc analysis showed a significant increase in the level of mindfulness and decrease in anger expression, a measure of distress tolerance, for the treatment participants but not the controls. Analysis of clinically significant change showed that 42% of participants showed significant improvement on the measure of mindfulness, 26% showed significant improvement on the measure of anger expression, and 17% showed significant improvement on the measure of borderline symptomology. There was also a significant increase in the frequency of reported adaptive skills usage between weeks one and two of the treatment. Lastly, there was a decrease in institutional infractions from the month prior to treatment to the month following treatment for the treatment participants, but not the controls. This study shows that delivery of a partial component of DBT may be a useful alternative for correctional institutions for females when the resource-intensive comprehensive DBT program is not feasible.

Despite epidemic levels of chronic pain among older adults, treatment options are severely lacking. The standard treatments for chronic pain suffer from one or more of three main problems: 1) high cost, 2) low effectiveness, 3) high time commitment. Mindfulness treatments for chronic pain have been established and validated in older adult populations; the current study employed a randomized clinical trial to examine whether a briefer version of mindfulness training could be effective. This investigation evaluates the effectiveness of Dialectical Behavior Therapy (DBT) mindfulness skills training on pain management in a sample of 31 older adults. In contrast to the findings of some previous studies demonstrating decreased pain and increased mindfulness, acceptance of pain, and quality of life, no such effects were found in this study. The present findings were discussed to inform the development and application of mindfulness-based treatments for chronic pain.

In the past decade the push for utilization of evidence-based practice (EBP) in mental health has increased dramatically. Due to managed healthcare, lowered spending on state and federal mental health budgets, and requirements by funding agencies such as Medicaid, it is imperative that mental health clinicians (MHCs) be trained in and utilize EBPs to improve funding and ensure continuity of best practice in clinical interventions with clients. Minimal research exists on MHCs and their knowledge and use of EBPs. The present study examined MHCs' perceptions, knowledge, training, and utilization of EBPs, with a specific focus on Dialectical Behavior Therapy (DBT). To date, it is the most prominent and effective EBP for treating Borderline Personality Disorder (BPD) and associated parasuicidal and suicidal behaviors. Current research supports its effectiveness in treating a myriad of other commonly treated disorders. The exploratory study provides insight into MHCs level of interest in receiving more EBP awareness and DBT training. Results indicate that though clinicians have received training in EBP and DBT, most of that training has been encouraged through career settings. Age of the clinician, years in practice, and type of training background are predictors of level of education, knowledge and training. Results show the majority of clinicians are interested in EBP, aware of the impact EBP can have on treatment effects, and report desire to have more training in EBPs and DBT specifically. These results could provide a necessary bridge between disciplines to allow clinicians, irrespective of training, to provide the most clinically effective treatments to clients.

Dialectical Behavior Therapy (DBT) demonstrates effectiveness in the treatment of individuals diagnosed with Borderline Personality Disorder in an outpatient setting. DBT has also been adapted for inpatient settings and demonstrates effectiveness with this population. To date no published literature examines the effectiveness of the standard outpatient model implemented in an inpatient setting. Furthermore, the literature examining inpatient DBT is done on treatment units where DBT is the sole treatment modality. There is no published literature regarding the use of DBT in conjunction with another treatment program. Therefore, this study examines the effectiveness of the standard outpatient DBT model implemented in conjunction with psychosocial rehabilitation or treatment as usual in a state hospital. This study also examined the effects of neuropsychological functioning and symptomatology on DBT outcome, as all previous research excludes individuals with psychotic disorders, bipolar disorder, and cognitive impairments. Results suggest that the standard outpatient DBT model can benefit individuals in a state hospital, that individuals who receive psychosocial rehabilitation in conjunction with DBT demonstrate more benefit than individuals who receive treatment as usual in conjunction with DBT, that neuropsychological functioning has an impact on DBT outcomes, and that positive symptoms do not impact DBT outcomes. Adviser: William D. Spaulding

Mindfulness is a core component of dialectical behavior therapy (DBT), a widely utilized treatment for borderline personality disorder (BPD); however, the import of mindfulness in treating BPD has yet to be demonstrated, and the relationship of mindfulness to BPD constructs is unclear. The current study utilized structural equation modeling to examine the relations of mindfulness with BPD features and the underlying constructs of interpersonal problem-solving effectiveness, impulsivity, emotion regulation strategies, and neuroticism in 342 young adults. Mindfulness was significantly related to effectiveness in interpersonal problem-solving, impulsivity and passivity in emotion regulation, and borderline features. Furthermore, mindfulness continued to predict borderline features when controlling for interpersonal problem-solving and impulsive/passive emotion-regulation strategies, as well as when controlling for neuroticism. It is concluded that difficulties with mindfulness may represent a core feature of BPD and that improvement in mindfulness may be a key component of treatment efficacy with BPD. It is recommended that the unique contribution of mindfulness be investigated in future treatment-outcome research.