Introduction to Dialectical Behavioural Therapy Powerpoint

Report
A Brief Introduction to Dialectical
Behaviour Therapy
Dr. Nathalie Lovasz, C.Psych (Supervised Practice)
Head of Adult DBT Program – The Mindfulness Clinic
Dr. Andrew Spice, C.Psych (Supervised Practice)
Head of Adolescent DBT Program – The Mindfulness Clinic
Agenda
Overview of DBT
– Definition, development, research, adaptations
Section 1: Assessment and Case Conceptualization
• Areas of Dysregulation: Signs that DBT may be helpful
• Theoretical model
• Stages of treatment; organizing treatment targets hierarchically
Section 2: Treatment
• Core treatment strategies: Validation and chain analysis
• DBT Skills
– Distress Tolerance
– Emotion Regulation
– Interpersonal Effectiveness
– Mindfulness
Section 3: Additional Issues in DBT
– DBT and Other Professionals
– Recommended Readings
– Further Training
What is DBT?
• Comprehensive cognitive-behavioural
treatment
– Developed by Dr. Marsha Linehan at University of
Washington
– Originally developed to treat chronically suicidal
clients diagnosed with Borderline Personality
Disorder
– Found to be effective for suicidal clients with
multiple other co-occurring behavioural problems
Development of DBT
• CBT did not work for clients with chronic
suicidality and BPD
– Change focus was invalidating
– Clients unintentionally reinforced therapists for
behaviours that were not helpful and
punished/extinguished helpful behaviours
– Unrelenting crisis interfered with treatment/skills
acquisition
• Solutions: Validation, Dialectics, Treatment
Hierarchy, Multi-modal treatment
Research Findings
• DBT has been found to reduce
– Suicidality
– Parasuicidal behavior
– Treatment drop-out
– Hospitalizations
– Substance Use
– Depression, Hopelessness, Anger
(Linehan et al., 1991;1999; Koons et al., 2001, Verheul et al., 2003)
Adaptations of DBT
•
•
•
•
•
•
Substance Use
Adolescents/Children
Binge Eating
Bipolar Disorder
Couples
Inpatient
Components of a DBT Program
1.
2.
3.
4.
Individual (DBT) Therapy
Weekly Skills Training Group
Phone Coaching
Therapist Consultation Team
DBT-informed Therapy:
- Any treatment that does not include ALL FOUR of the above
components
-
E.g. CBT therapy that incorporates some DBT skills
Group only Skills Training
Skills Group + Individual Therapy without Phone Coaching
Skills Group, Individual Therapy, Phone Coaching but no consultation
team
Assessment and Case
Conceptualization
Symptoms of Borderline
Personality Disorder
• Emotion Dysregulation
– Unstable Emotions/Mood
– Intense Anger/Difficulty
Controlling Anger
• Interpersonal Dysregulation
– Unstable/Intense
Relationships
– Frantic Efforts to Avoid
Abandonment
• Behavioural Dysregulation
– Impulsive/Self-Damaging
Behaviours
– Suicide/Self-harm
• Identity/Self Dysregulation
– Unstable Sense of
Self/Identity
– Feelings of Emptiness
• Cognitive Dysregulation
– Stress Related Paranoid
Thoughts
– Dissociation
Practice 1
Identify Areas of Dysregulation in a Practice
Case
Choose one of the two case vignettes provided. Identify as many
areas of dysregulation as possible in the case vignette:
• Emotion
• Interpersonal
• Cognitive
• Behavioural
• Identity/Self
Biosocial Model of BPD
EMOTIONAL VULNERABILITY
• Emotional Sensitivity: More easily triggered emotions
– Responding with intense emotions to things that may
not cause any emotion for someone else
– “Thinner emotional skin”
• Emotional Reactivity: More intense emotions
– Higher emotional baseline
• Slow Return to Baseline: Emotions that stick around
longer
Biosocial Model of BPD
•
•
•
•
INVALIDATION
Emotional Fit: It can be difficult for people with less
intense emotions to understand or teach those with
more intense emotions how to manage their emotions
Denial/Suppression of Emotions: With more intense
emotions, people either doubt and ignore their emotions
until they explode or become more intense in emotional
expressions
Reciprocal Effects: Emotions that are more intense than
average are more likely to be dismissed by others
Absence/Abuse/Neglect: These can also teach people to
ignore, doubt, or push away emotions
Biosocial Model of BPD
EMOTIONAL VULNERABILITY
+
INVALIDATION
=
BORDERLINE PERSONALITY DISORDER
Practice 2
Apply the Biosocial Model to a Practice Case
Choose one of the vignettes provided. Identify any information
you have that applies to the Biosocial Model:
•Emotional Vulnerability
•Experiences of Invalidation
Stages of Treatment
• Stage I: Stabilization
– Focus:
• Treatment Hierarchy:
–
–
–
–
Reduce Life-Threatening Behaviours
Reduce Therapy-Interfering Behaviours
Reduce Quality-of-Life-Interfering Behaviours
Increase Skills that Replace Ineffective Coping
– Goal:
• Move from behavioural dyscontrol to control to achieve
a normal life expectancy
Target Hierarchy in Stage I
1. Life-Threatening Behaviours
– Suicide
– NSSI
2. Therapy-Interfering Behaviours
– E.g. Missing sessions, not completing homework,
behaviours that interfere with therapist’s motivation to
treat client
3. Quality-of-Life-Interfering Behaviours
– E.g. Substance use, eating disordered behaviours, inability
to keep employment, educational Issues
4. Skills Acquisition
– To replace dysfunctional behaviours
Stages of Treatment
• Stage II: Suffering in Silence
– Focus:
– Address inhibited emotional experiencing
– Reduce PTSD symptoms
– Goal:
• Move from quiet desperation to full emotional
experiencing
Stages of Treatment
• Stage III: Build a Life Worth Living
– Focus:
• Problems in Living
– Goal:
• Life of ordinary Happiness and Unhappiness
• Stage IV: Address Issues of Meaning (Optional)
– Focus:
• Spiritual Fulfilment
• Connectedness to Greater Whole
– Goal:
• Move from incompleteness to ongoing capacity for
Experiences of Joy and Freedom
Practice 3
Identify stages of treatment and applicability of
the treatment hierarchy to a practice case
1. Choose one of the provided case vignettes. List any therapy
goals you and the client might choose to work on
2. Identify at what stage of treatment you would work on each
of these goals
3. For Stage I Goals, create a treatment hierarchy:
• Life-Threatening Behaviours
• Therapy-Interfering Behaviours
• Quality-of-Life Interfering Behaviours
• Skills Acquisition
Treatment
Core DBT Strategies
• Validation and problem-solving form the core
of DBT
– All other strategies built around them
• Problem-solving strategies are change-based
– Analyzing behaviour, committing to change, taking
steps to change
• Validation strategies are acceptance-based
– Engaging client in understanding actions,
emotions, and thoughts
Core DBT Strategies: Validation
• VALIDATION MEANS:
– Communicating to the client that their
responses make sense and are
understandable within current life context
– Finding the kernel of truth in the client’s
perspective or situation
– Acknowledging causes of emotions,
thoughts, and behaviours
Core DBT Strategies: Validation
• IMPORTANT THINGS TO VALIDATE:
–
–
–
–
Emotions: Feelings, wanting, suffering, difficulties
Thoughts: Beliefs, opinions, or thoughts
Actions
Abilities
• REMEMBER:
–
–
–
–
Every invalid response makes sense in some way
Validation is not necessarily agreeing
Validation doesn’t mean you like it
Only validate the valid
A “How To” Guide to Validation
• PAY ATTENTION: Listen actively with body and
mind.
• REFLECT BACK: Say back what you heard
descriptively and non-judgmentally.
• READ MINDS: Be sensitive to what is not being
said by the client. Be open to correction.
• UNDERSTAND: Look for how the client’s
emotions, thoughts, and actions make sense
given their history, state of mind, or current
situation, even if you don’t approve of the
behaviour, emotion, or action itself.
A “How To” Guide to Validation
• ACKNOWLEDGE THE VALID: Show you are
taking the client seriously by what you say and
do
• SHOW EQUALITY: Be yourself! Treat the client
as an equal, not as fragile or incompetent
Practice 4
Practice validation
1. Get into pairs
2. One person will be the “storyteller,” one person will be the
“validator”
3. The storyteller tells a story of something that recently
happened to them and that elicited some emotion
4. The validator listens and responds only with validation
5. Switch roles
Core DBT Strategies: Chain Analysis
• Core problem-solving strategy
• Purpose: examine events and situational
factors leading up to and following a
problematic response
Steps of a Chain Analysis
1. Choose a specific instance of behavior to
analyze
2. Describe the behavior specifically
– Topography (“What exactly did you do?”; “What
exactly do you mean by that?”)
– Frequency (“How many times did you do that?”)
– Intensity (“How intense was the feeling on a 1-100
scale?”)
Steps of a Chain Analysis
3. Determine antecedents
– Link client’s behavior to environmental events
• Internal and external events
– Ask when the problem began
• “What set that off?”
• “What was going on the moment the problem started?”
– Fill in links in terms of small units of behavior
• Doing, feeling, thinking, imagining
– Once one link is described, determine the next
• “What next?”
• “How did you get from feeling like you wanted to talk to me
to calling me on the phone?”
Steps of a Chain Analysis
4. Determine consequences
– Those influencing problem behaviour by
maintaining, strengthening, or increasing it
– E.g., preferable events, stopping of aversive
events, opportunities to engage in preferable
behaviours
– Assess external and internal events
5. Determine function of the behaviour
Sample Chain Analysis
Behaviour: Overdose (with suicidal intent)
Vulnerability:
Intoxicated
Emotion:
Despair
Event:
Picked up
by EMS
Event:
Fight with
boyfriend
Urge: Take
pills to
forget
Event:
Boyfriend
visits in
hospital
Thought:
“He will
leave
me”
Thought:
“Will be
better if
I’m
dead”
Emotion:
Love
and
affection
Emotion:
Panic
Action:
Walk to
bathroom
and get
pills
Thought:
“I can’t
live
without
him”
Action:
Take pills
DBT Behavioral Chain Analysis Worksheet
Name: _______________ Date: ______ Target Behavior: _________________________
Types of Links:
A
Actions B Body Sensations
Chain Analysis:
C
Cognitions
E Events
F
Solution Analysis:
Things in myself and my environment that made me
vulnerable:
Vulnerability
Factors


Feelings
Ways to reduce vulnerability in the future:
Prompting Event:
Ways to prevent prompting event in future:
Actual Behaviors and Events:
Skillful alternative behaviors:
E
Problem
Behavior
Consequences
and Harm
(Immediate and
delayed)
Consequences in the environment?
Plans to repair, correct, and over-correct harm:
Consequences in myself?
Adapted from Marsha Linehan’s Chain Analysis Worksheet by Seth Axelrod, PhD 2/13/04
Practice 5
Practice chain analysis using a practice case
1. Get into pairs
2. Choose one of the two vignettes provided
3. One person will role play the client, one person will role play
the counsellor
4. Choose a specific behaviour from the case vignette to chain
analyze e.g., cutting, waiting for faculty member in the
parking lot
5. Role play a chain analysis of this behaviour. The counsellor
will have to ask as many questions as needed to “fill in the
links of the chain”
DBT Skills
•
•
•
•
Distress Tolerance
Emotion Regulation
Interpersonal Effectiveness
Mindfulness
Distress Tolerance
“How to get through a crisis without
making things worse”
Distress Tolerance: Crisis Survival
Skills
• CRISIS SURVIVAL SKILLS are needed:
– When client is in a situation that is
• Highly stressful
• Short-term
• Creating intense pressure to resolve the crisis now
– AND
• Acting on emotions and urges will make things worse
• Client cannot make things better right away
• Client must temporarily tolerate painful events and emotions
• CRISIS SURVIVAL SKILLS are not for:
– Everyday use
– Solving all of life’s problems
– Making life worth living
STOP Skills
Stop
Do not just react. Stop! Freeze! Do not move a muscle! Your emotions may try to
make you act without thinking. Stay in control!
Take a step back
Take a step back from the situation. Get unstuck from what is going on. Let go.
Take a deep breath. Do not let your feelings put you over the edge and make you
act impulsively.
Observe
Take notice of what is going on inside and outside of yourself. What is the
situation? What are your thoughts and feelings? What are others saying or doing?
Proceed mindfully
Act with awareness. In deciding what to do, consider your thoughts and feelings, the
situation, and the thoughts and feelings of other people. Think about your goals. What do
you want to get from this situation? Which actions will make it better or worse?
TIPP Skills
• TIP YOUR TEMPERATURE
• INTENSELY EXERCISE
• PACE YOUR BREATHING
• PROGRESSIVELY RELAX YOUR MUSCLES
TIPP Skills
• Tip the TEMPERATURE of your face: use ice water to calm
yourself down fast by changing the response of your
autonomic nervous system
– Put your face in a bowl of ICE WATER (30 seconds)
– OR splash ICE WATER on your face,
– OR hold a gel ICE pack (or zip-lock ICE WATER) on your
face.
• INTENSELY EXERCISE to calm down a body revved up by
emotion
– Engage in intense exercise, if only for a short while.
– Expend your body’s stored up physical energy by: Running,
Walking , Fast Jumping, Playing Basketball, Weight Lifting,
etc.
TIPP Skills
• PACE YOUR BREATHING BY SLOWING IT DOWN
– Slow your pace of inhaling and exhaling way down (on
average 5 to 7 breath cycles per minute).
– Breathe deeply from the abdomen.
– Breathe more slowly out than when breathing in (for
example, 4 seconds in and 8 seconds out).
• PROGRESSIVELY RELAX YOUR MUSCLES
– Starting with your hands, moving to your forearms, upper
arms, shoulders, neck, forehead, eyes, cheeks & lips,
tongue & jaw, chest, upper back, stomach, buttocks,
thighs, calves, ankles, feet.
– TENSE (5 seconds), then let go and RELAX each muscle (all
the way).
– NOTICE the tension. NOTICE the difference when relaxed.
Pros and Cons
• Use PROS and CONS anytime you have to decide between two
courses of action.
Pros
Acting on Crisis
Urges
Resisting Crisis
Urges
Cons
Distraction
A way to remember these skills is the acronym “ACCEPTS”
Activities:
– Refocus your attention on the task you have to get done
– TV, events, exercise, internet, sports, hobbies
Contributing:
– Volunteering, help a friend, encourage someone
Comparisons:
– Compare how you are feeling now to a time when you felt different
Different Emotions:
– Books, stories, movies, music
Pushing Away:
– Leave the situation; block thoughts from your mind
Other Thoughts:
– Counting; puzzles
Other Sensations:
– Squeeze a rubber ball; hold ice; go out in the rain
Self-Soothing
A way to remember these skills is to think of soothing each of your
FIVE SENSES:
Vision:
• Stars at night; pictures in a book, nature, candles
Hearing:
• Soothing music; invigorating music; sounds of nature; sounds
of the city
Smell:
• Soap, incense, coffee, essential oils, boil cinnamon
Taste:
• Favourite foods; soothing drinks; chew gum
Touch:
• Hot baths; pet your dog or cat; creamy lotion; comfortable
clothing
Group Discussion 1
Discuss how Distress Tolerance skills may be
helpful to our practice cases
At your table, choose one case vignette.
1. How could these distress tolerance skills help the client in the
vignettes accomplish their treatment goals?
2. How would you teach these skills to a client?
Emotion Regulation
“How to understand emotions, change
ineffective emotions, and be less
vulnerable to negative emotions”
Emotion Encyclopedia
Basic Emotion
Related Emotion Words
Anger
Aggravation, agitation, annoyance, bitterness, exasperation, ferocity, frustration, fury
Disgust
Abhorrence, antipathy, aversion, condescension, contempt, dislike, derision, disdain,
distaste, hate,
Envy
Bitterness, covetous, craving, discontented, disgruntled, displeased, dissatisfied, downhearted
Fear
Anxiety, apprehension, dread, edginess, fright, horror, hysteria, jumpiness, nervousness
Happiness
Joy, enjoyment, relief, amusement, enthrallment, hope, satisfaction, bliss, enthusiasm,
jolliness
Jealousy
Cautious, clinging, clutching, defensive, fear of losing someone or something,
mistrustful
Love
Adoration, affection, arousal, attraction, caring, charmed, compassion, desire,
enchantment
Sadness
Despair, grief, misery, agony, disappointment, homesickness, neglect, alienation,
discontentment, pity, anguish, dismay, hurt, rejection, crushed, displeasure, insecurity,
sorrow, defeat
Shame
Contrition, culpability, discomposure, embarrassment, humiliation, mortification, selfconscious, shyness
Guilt
Apologetic, culpability, regret, remorse, sorry
Model of Emotion: Observe and
Describe Emotions
• Prompting Event
– What set off the emotion?
• Emotion
– i.e., anger, fear, joy
• Interpretations
– Thoughts, judgments, beliefs
• Experiencing
– Body changes
• Action Urges
– e.g., withdraw, attack, eat
• Expressing
– Behaviours – what you said or did
• Aftereffects
– Consequences – your state of mind; others’
reactions; reinforcements
Opposite Action
Changing ineffective emotions by ACTING OPPOSITE to the emotion
• Fear
– Urge: Freeze, run, avoid
– Opposite action: Approach
• Anger
– Urge: Attack, hit, yell
– Opposite action: Gently avoid; do something nice
• Sadness
– Urge: Withdraw, cry, isolate
– Opposite action: Get active
• Guilt/Shame
– Urge: Hide/avoid
– Opposite action: Face the music; repair mistakes
Group Discussion 2
Discuss how Emotion Regulation skills may be
helpful to our practice cases
At your table, choose one case vignette.
1. How could these emotion regulation skills
help the client in the vignettes accomplish
their treatment goals?
2. How would you teach these skills to a client?
Interpersonal Effectiveness
“How to get your needs met while
maintaining your relationships and selfrespect”
Identifying Interpersonal Priorities
• Goal Effectiveness
– What do I want from the other person?
• Relationship Effectiveness
– How do I want the other person to feel about me?
• Self-Respect Effectiveness
– How do I want to feel about myself?
Goal Effectiveness – DEAR MAN
Effectively making a request
• What to say: DEAR
– Describe: Describe the situation. Stick to the
facts.
– Express: Express feelings using “I” statements.
– Assert: Ask for what you want.
– Reinforce: Explain positive effects of getting what
you want.
Goal Effectiveness – DEAR MAN
Effectively making a request
• How to say it: MAN
– Mindful: Keep your focus on what you want.
– Appear confident: Make eye contact; confident
tone of voice
– Negotiate: Be willing to give to get. Ask for the
other person’s input.
Practice 6
Practice using DEAR MAN to make a request
1. Get into pairs
2. One person will make a request using DEAR MAN
for something a person might ask of another person
3. Switch roles
Mindfulness
“How to pay attention to the present
moment without judgment, rejection, or
attachment”
Mindfulness
“WHAT” SKILLS
• Observe
• Describe
• Participate
“HOW” SKILLS
• Non-judgmental
• Effective
• One-mindful
Non-judgmental
• Notice, but don’t evaluate as “good” or “bad”
• Acknowledge harmful and helpful, but don’t judge
– E.g., replace “You’re a jerk” with “I feel mad when you do that”
• Catch judgments so that you have more control over
your emotions
• Steps
1. Notice judgments
2. Don’t judge your judgments
3. Replace judgments with descriptions (things you can see,
hear, feel, taste, touch)
Practice 9
Practice non-judgmental
1. Get into pairs
2. Think of a difficult client you have worked with or
choose a client from the case vignettes
3. Describe your client to the other person without
judgment
4. For the listener: pay attention and note any
judgments that occur
5. Switch roles
Additional Issues in DBT
• Interacting with Other Professionals
• Further Training
• Recommended Readings
DBT and Other Professionals
• Ancillary mental health treatments are acceptable in DBT
– However, there can be only one primary individual therapist at
a time
• “Consultation to the patient” approach:
– Teach the client to act as their own agent in obtaining
appropriate care
– Do not intervene, solve problems, or act for the patient with
other professionals
• Rationale:
– Teaching effective self-care
– Decreasing “splitting”
– Promoting respect for the client
When Another Professional Calls:
• Obtain as much information about the
situation as they will give
• Provide caller with necessary information the
client cannot give, and verify information
client has given
• Tell them to follow their normal procedures
• Ask to talk to the client
• Coach client on how to best cope with
situation and interact with the professionals
Further Training and Certification
• Training Opportunities
– Behavioral Tech
• Founded by Marsha Linehan
• Gold Standard for Training
• Online workshops/training, Web Shorts, Multi-day
Workshops, Consultation, Intensive Trainings for Individuals
and Teams
• http://behavioraltech.org/training/
– Oshawa Psychotherapy Training Institute
• Facilitated by Clinicians from CAMH
• Four-part Training – 2 days each, often offered to suit 9-5
work schedules (evening and weekend)
• Parts can be taken individually
• http://www.oshawapsychotherapytraining.com/courses/certi
ficate-programs/dbt-1
Further Training and Certification
• Training Opportunities
– CAMH
• Dialectical Behaviour Therapy Certificate Program
• Four-part training – A-D, 8 evenings each
• http://www.camh.ca/en/education/about/AZCourses
– The Mindfulness Clinic
•
•
•
•
Supervision, Consultation, Individualized Workshops
DBT Training Courses may be offered in the future
Parts can be taken individually
http://www.themindfulnessclinic.ca/therapytraining/dialectical-behaviour-therapy-dbt/
Further Training and Certification
• DBT Certification
– Offered through Linehan Institute
– Requires:
•
•
•
•
•
•
•
•
•
•
Graduate Degree from Accredited Institution
Licensed as independent mental health provider
40-hours of Didactic DBT Training
Completion of Treatment with at Least Three DBT cases using full-mode
DBT
12-months and current participation on DBT consultation team
Read skills manual, complete all homework in skills manual, facilitate
teaching of all skills in manual in individual or group format
Exam
Letter of Recommendation
Work Product Demonstration
Demonstrated Mindfulness Experience
– Other Certification Programs Exist but do not offer the same
standards/credibility
Options for Treatment Referrals in
Ontario
Publically Funded
• Toronto, ON
– Centre for Addiction and Mental Health
– Davenport Perth Neighbourhood Centre – Surfing
Tsunamis Program
• London, ON
– London Health Sciences Centre – Victoria Hospital
• Hamilton, ON
– St. Joseph’s Health Care DBT Program
Options for Treatment Referrals in
Ontario
Private Treatment Options
– The Mindfulness Clinic: Toronto, ON
• Comprehensive Adult and Adolescent DBT Program
– Individual Therapy
– Adult Skills Training Groups
– Adolescent Multi-Family Skills Training Groups
– Phone Coaching
– Weekly Therapist Consultation Team
– More info:
http://www.themindfulnessclinic.ca/therapytraining/dialectical-behaviour-therapy-dbt/
Options for Treatment Referrals in
Ontario
Private Treatment Options
• Broadview Psychology: Toronto, ON
• http://www.broadviewpsychology.com/
• Behavioural Health: Guelph, ON
• Comprehensive DBT Program
• http://www.behaviouralhealth.net
• Dr. Carmen Weiss & Associates: Burlington, ON
• Group and Individual DBT-based Treatment
• http://drcarmenweiss.ca/group-options/dialecticalbehaviour-therapy-dbt-options/
Further Reading
Further Reading
References
Dimeff, L. A., & Koerner, K. (Eds.) (2007). Dialectical Behavior Therapy in clinical practice: Applications across disorders and
settings. New York: Guilford Press.
Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, 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.
Koerner, K. (2011). Doing Dialectical Behavior Therapy: A practical guide. New York: Guilford Press.
Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A.
(2001). Efficacy of Dialectical Behavior Therapy in Women Veterans with Borderline Personality Disorder. Behavior Therapy, 32,
371-390.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior
Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292.
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2006). Dialectical Behavior Therapy with suicidal adolescents. New York: Guilford
Press.
Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , 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.

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