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Feasibility of Using Video to Teach a Dialectical Behavior Therapy Skill to Clients With Borderline Personality Disorder
Available online at www.sciencedirect.com
Cognitive and Behavioral Practice 16 (2009) 214–222 www.elsevier.com/locate/cabp
Feasibility of Using Video to Teach a Dialectical Behavior Therapy Skill to Clients With Borderline Personality Disorder Jennifer Waltz, University of Montana Linda A. Dimeff, Behavioral Tech Research, Inc., Seattle Kelly Koerner, Private Practice, Seattle Marsha M. Linehan, University of Washington Laura Taylor, Village Family Psychiatry, Richmond Christopher Miller, Department of Veteran Affairs Puget Sound Health Care System, Seattle This study tested the feasibility of using a psychoeducational video recording to teach a behavioral skill from the Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b) skills training program to individuals meeting criteria for borderline personality disorder. A video presenting a DBT emotion-regulation skill was developed and the extent to which viewers learned the skill material was evaluated via a randomized controlled trial (RCT), utilizing a within-subjects design. Thirty individuals meeting DSM-IV criteria for borderline personality disorder participated. Participants were recruited from mental health treatment settings and were naïve to DBT. Viewing the video was associated with significant increases in knowledge of the skill, relative to viewing a control video, and with increases in participants' expectations of positive outcomes for skill use. In addition, participants rated the video as relevant and helpful. A remarkably high number (80 %) utilized the skill taught subsequent to viewing the video when assigned to do so, and overall reported significant decreases in negative affect after using the skill. Video appears to be feasible as a medium for teaching DBT skills material under controlled conditions; future research is needed to examine the effectiveness of video in more naturalistic settings.
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personality disorder (BPD) is a longstanding and often debilitating disorder characterized by intense, labile emotions, impulsivity, serious relationship difficulties, and lack of sense of self (American Psychiatric Association [APA], 1994). Clients who meet criteria for BPD often present with an intense degree of suffering, suicidality, and complex set of diagnoses. They are at significant risk for suicide, with rates of completed suicide found to be 5% to 10% (Frances, Fyer & Clarkin, 1986; Linehan, Rizvi, Welch & Page, 2000). Recent, large-scale epidemiological research has found the prevalence rate of BPD to be quite high, 5.9% in the general population (Grant et al., 2008). Individuals meeting criteria for BPD are also heavily represented in mental health treatment settings (Zanarini, Frankenburg, Hennen, & Silk, 2004). Meeting criteria for BPD is associated with poor treatment outcomes for individuals receiving therapy for Axis I disorders, such as major depression (Markowitz et al., 2007, Phillips & Nierenberg, 1994) and others. ORDERLINE
1077-7229/08/214–222$1.00/0 © 2009 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b) was developed to address the challenges presented by this population by providing a cognitivebehavioral, multimodal, team-based treatment that is both deeply compassionate and solidly change-focused. Seven randomized controlled trials (RCTs), carried out across four different research groups, have found support for its efficacy in the treatment of BPD (see Lynch, Trost, Salsman, & Linehan, 2007, for review). Support for the development of comprehensive DBT programs is therefore a priority. A central assumption in DBT is that clients meeting criteria for BPD have significant skills deficits that contribute to their emotional and behavioral dysregulation. Thus, a primary component of DBT is behavioral skills training, designed to increase clients' capabilities in the areas of emotion regulation, distress tolerance, interpersonal effectiveness and mindfulness (Linehan, 1993b). DBT skills are primarily taught in a group skills training class that includes didactic instruction, homework assignments, and homework review. The incorporation of the skills into clients' behavioral repertoires is viewed as a primary mechanism of change in DBT, and thus is understood to be crucial to the success of the treatment.
Using Video to Teach DBT Skills From a DBT perspective, the process of learning new behavioral skills includes the components of: (a) skill acquisition, (b) skill strengthening, and (c) skill generalization (Linehan, 1993b). Skill acquisition, the focus of the current work, involves the client learning the important concepts that inform the skill, when the skill is likely to be useful, and specifically how to do the skill. Skill acquisition is facilitated in DBT skills training primarily by didactic instruction, as well as written material and modeling. Skill acquisition is understood to be a crucial first step toward clients incorporating new skills into their behavioral repertoires. A number of barriers can interfere with clients successfully grasping skills material. These barriers include missing group sessions, or being inattentive, distractible, or dissociating during group. Group members are sometimes overwhelmed by painful emotions and/or preoccupied by life difficulties, making it hard for them to concentrate. The skills training material is intellectually challenging for some clients; multiple repetitions of the concepts may be needed before thorough understanding of their nuances and how to fully apply them is achieved. If effective, video provides a flexible, transportable, and convenient way for skills information to be presented that may address some of the challenges faced by DBT programs. Video recordings, computer-based interventions, and other self-administered therapy adjuncts have been used successfully to treat agoraphobia (Ghosh & Marks, 1987), panic disorder (Gould & Clum, 1995; Parry & Killick, 1998), and bingeeating disorder (Peterson et al., 1998). The purpose of this research was to test the feasibility of using video to teach a DBT skill. We were interested in establishing whether an instructional video medium could successfully be used to increase knowledge of a DBT skill in individuals meeting criteria for BPD. Given that, to our knowledge, no available empirical data speak to this issue, the study was designed to maximize internal validity. As a first step in examining feasibility, we sought to determine whether increases in skill knowledge would be found under controlled conditions, in a sample naïve to the skills material. We used an iterative process of development involving feedback from DBT experts and target end-users to create a 26-minute video recording of DBT treatment developer Marsha M. Linehan teaching the DBT skill of “opposite action” (Linehan, 1993b). This skill is from the emotionregulation module, and focuses on reducing painful emotions that one wishes to change. It was selected because of its centrality to the goal of increasing emotionregulation capabilities, a top priority in DBT. It was also chosen for its relative uniqueness to DBT, and because it could be taught independently of other DBT skills in a circumscribed manner.
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The video's efficacy was tested using a controlled, within-subjects design with participants who met criteria for BPD (n = 30). Outcome variables included: skills knowledge, outcome expectancies for using the skill, interest in and satisfaction with the video, and skill use in everyday life. Participants were assigned the homework of utilizing the skill in the week following viewing the video, and follow-up assessments of skill use and the extent to which the emotion changed pre- to post-skill-use were done. We also examined the relationship between educational, cognitive and emotional factors, and skills knowledge gains, to explore whether these factors predict degree of skills acquisition. Years of education, verbal IQ estimate, memory, attention, depression, and level of distress at the time of skill training were tested as possible predictors.
Method Participant Recruitment Flyers describing the study were distributed by a research assistant to community mental health center therapists at staff meetings and via mail to private practitioners. Therapists and case managers then distributed flyers to their clients. Subjects were also recruited from a university-based research clinic serving clients from the community. The research clinic coordinator provided information about the study to individuals who met criteria for BPD. All potential participants were screened by phone to insure that they were: (a) currently receiving mental health treatment of some kind (e.g., psychotherapy, case management, pharmacotherapy, etc.; to insure that if a participant had any negative reactions to their participation, he/she had a mental health professional to seek assistance from), (b) naïve to DBT (to insure they had not been previously exposed to the video's content); and (c) identifying themselves as having met criteria for BPD or having characteristics of BPD (as required by IRB). If the caller met these criteria and was still interested in the study, he/she was scheduled for a first session. Participants Study participants were 30 individuals meeting DSM-IV (APA, 1994) criteria for BPD based on the Structured Clinical Interview for DSM-IV, II (SCID II; First, Spitzer, Gibbon, & Williams, 1996). They were recruited from the sites described above. The following inclusion/exclusion criteria were utilized: (1) 18 years of age or older, (2) literate, (3) meets BPD criteria, (4) no previous formal DBT treatment, (5) not actively psychotic, (6) estimated verbal IQ of 90 or above (based on AM-NART score; Grober & Sliwinski, 1991), (7) aware of diagnostic status, and (8) currently a client of a mental health treatment provider (numbers 7 and 8 were included to address IRB concerns). Thirty-eight participants were screened. Six
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were disqualified because they did not meet criteria for BPD, one was not literate and one was disqualified because of threatening behavior toward the experimenter. All but one of the participants were female; mean age was 32.5 (SD = 9.1). Approximately three-quarters were unemployed and approximately 90% were making $15,000/year or less. All participants met diagnostic criteria for at least one Axis I diagnosis, as assessed by the SCID I (Spitzer, Williams, Gibbon, & First, 1992), with PTSD (67%) and major depressive disorder (63%) being the most frequent. Other anxiety disorders, eating disorders, and substance use disorders followed in level of frequency. GAF scores averaged 48.5 (SD = 12.3), indicative of “serious symptoms” or “serious impairment in social, occupational or school functioning” (p. 32), according to DSM-IV criteria. In addition, participants averaged 29.4 (SD = 13.5) on the BDI (Beck et al., 1961), falling in the moderate to severe range for depression. The average score on the AM-NART (Grober & Sliwinski, 1991), an estimate of verbal IQ, was 111.7 (SD = 8.0; range = 95–127). Participants' average scores on tests of attention (mean = 9.9, SD = 2.8; range = 6–18 on Digit Span) and memory (mean = 9.7, SD = 3.4; range = 4– 16 on WMS-III Logical Memory, immediate recall; mean = 10.2, SD = 3.4; range = 4–17 on WMS-III Logical Memory, delayed recall) fell in the average range. Design A randomized controlled trial was conducted, utilizing a within-subjects design. All participants viewed the experimental video recording and a control video recording. They were randomly assigned to the order of viewing the videos, with half the sample watching the experimental video recording first, and the other half viewing the control video first. The first participant was randomly assigned to one condition, and all subsequent participants alternated between the two conditions. The experimenters administering the interventions were aware of which video recording the participants were viewing first and which second. Participants were aware that they would be viewing two video recordings, one teaching a behavioral skill to assist in regulating negative emotions and the other on an informational topic. Video Recording Intervention The experimental condition video, Opposite Action: Changing Emotions You Want to Change (Linehan, Waltz, Dimeff, & Koerner, 2000), features DBT treatment developer, Marsha M. Linehan, teaching “opposite action,” a skill from the DBT emotion-regulation module (Linehan, 1993b). (Note that the authors conducting this feasibility study were also developers of the videorecording.) The skill of opposite action involves changing the behavioral-
expressive components of an unwanted emotion by acting in a way that is opposite to or inconsistent with the undesired emotion. Acting opposite to the behavioralexpressive aspects of the emotion includes both overt actions (for example, gently avoiding a person you are angry at or approaching what you are afraid of), as well as postural and facial expressiveness. The idea is not to block expression of an emotion. Instead, it is simply to change the behavioral-expressive component of the emotion, with the specific purpose of reducing the intensity of the emotion. Linehan provides the viewer with a step-by-step, how-to guide for applying opposite action as follows: First, figure out what emotion you are experiencing. Second, determine the emotion's action urge, or what the emotion is compelling you to do (e.g., attacking when angry, withdrawing and becoming inactive when depressed). Third, ask yourself, “Do I really want to reduce this emotion?” There are many situations in which it is not necessarily appropriate to change an emotion (e.g., experiencing grief after the death of a loved one). In addition, there are situations in which an emotion is “justified” and thus should not be changed; for example, if one is feeling fear in the context of actual danger, rather than reducing the emotion by approaching, one will more likely want to get out of the situation. Fourth, figure out the emotion's opposite action. For sadness, the opposite of withdrawing is to get active or do things that generate feelings of competence and self-confidence. Table 1 summarizes these components of the opposite action skill (Waltz, Dimeff, Koerner, & Linehan, 2000). Fifth, do opposite action in a complete, whole-hearted manner. Finally, limitations of the skill are discussed. The video is 26 minutes in length and includes numerous graphics and real-life examples to illustrate and strengthen learning of primary teaching points. The control condition was designed to control for factors of time, attention, and repeated testing. Because this research is at an early stage, only these factors were controlled for. The control condition video recording was selected to be similar in length and production quality to the experimental video, but not on a mental health topic. It was an episode from a PBS series entitled “The Desert Speaks” on the “culinary, medicinal and scientific uses” (Arizona Public Media, n.d., para.1) of pepper plants (Knipe et al., 1999). Measures Participant screening variables and predictors of outcome— psychopathology. 1. Structured Clinical Interview for DSM-IV, I & II (SCID I & II; Spitzer, Williams, Gibbon, & First, 1992; First et al., 1996). The SCID-II, BPD section was used to assess potential participants for inclusion in the study. In addition, the Axis I segments
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Table 1
Opposite Action Behaviors When Emotion is Not Justified and You Want to Change It Emotion
Action Urge
Fear/anxiety
Run/avoid
Anger Sadness
Attack/engage in judgmental thinking Withdraw/become inactive
Shame
Hide
Opposite Action
– Do what you are afraid of – Approach events, places, tasks, people, and activities you are afraid of – Gently avoid – Cultivate empathy and decency – Get active – Do things that make you feel competent and confident – Approach – Repeat the behavior openly and matter-of-factly
Adapted from a brochure accompanying the Opposite Action video recording (Waltz, Dimeff, Koerner & Linehan, 2000).
were administered to characterize the Axis I diagnoses of the sample. 2. Beck Depression Inventory (BDI; Beck et al., 1961). The BDI was used to assess depressive symptoms on a continuous scale, in order to examine potential relationships between depression and skill learning. Participant screening variables and predictors of outcome— cognitive functioning. Three brief, robust neuropsychological measures were administered to assess current cognitive functioning. We used these measures to address our exclusion criteria, to characterize the cognitive functioning of the sample, and to examine relationships between cognitive abilities and degree of information learned from the video recording. Specifically, we examined verbal IQ, attention and memory variables. 1. Nelson Adult Reading Test, American Version (AMNART; Grober & Sliwinski, 1991). The AM-NART is a widely used measure that yields a verbal IQ score that correlates highly with the Wechsler Adult Intelligence Scale–Revised (WAIS-R; Wechsler, 1981) verbal IQ score. Respondents read a list of words presented in written form, and are scored for accuracy of pronunciation. 2. Wechsler Memory Scale III – Logical Memory (WMS-III; Wechsler, 1997). The Logical Memory subscale assesses memory for narrative material. This subscale was chosen because of the relevance of narrative memory to the task of observing a video recording and remembering material encountered. 3. Wechsler Memory Scale III – Digit Span subscale (WMS-III; Wechsler, 1997). The Digit Span subscale was utilized as a measure of attention. Dependent variables. 1. Skill knowledge: Opposite Action Knowledge Questionnaire (Waltz & Dimeff, 1999). This
questionnaire was designed for the study, and incorporated several items from another skills knowledge questionnaire (Foertsch, McKee & Hamel, 1996). The measure consists of 22 multiple choice-type items assessing the most important concepts and steps involved in the opposite action skill. Sixteen questions directly assess knowledge of skill content. Examples include: “The primary thing one must do when doing opposite action for fear is: (a) relax, (b) approach, (c) gently avoid, (d) breathe deeply”; “The first step in managing difficult emotions is: (a) deciding if the emotion is justified or unjustified, (b) identifying what emotion you feel, (c) meditating and being mindful of your behavior, (d) talking to someone else about your mood.” Six questions were framed in a more applied format. For example: “Beth is scared of talking to strangers. She has to go to the bank to withdraw money, but she does not know anyone who works there. Which of the following most clearly shows the action urge associated with fear? (a) Beth avoids going to the bank and asks her sister to withdraw money for her; (b) Beth goes to the bank and starts crying; (c) Beth goes to the bank and withdraws her money; (d) Beth goes to the bank and becomes angry with the teller.” Test-retest reliability of the Opposite Action Knowledge Questionnaire was assessed on a sample of 55 undergraduate, DBT-naïve students who completed the measure twice with a reading delay period in the interim, resulting in a correlation of .89 (p b .001). The measure showed reasonable internal consistency with a Cronbach's alpha of .84 using the current study sample. 2. Outcome expectancies: Based on a comparable outcome expectancies measure (Fromme, Kivlahan, & Marlatt, 1986), a 16-item measure was developed to assess the extent to which participants expected positive outcomes resulting from the
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application of the opposite action skill. The scale used a Likert-type rating (1 = disagree, 2 = slightly disagree, 3 = slightly agree, 4 = agree) and included both positively and negatively keyed items (e.g., “people I care about would find me easier to be around,” “another equally intense negative emotion would just come along instead”). Cronbach's alpha was .81. This measure was administered before and after participants viewed the experimental video recording. 3. Client satisfaction: An 8-item measure was developed to assess participants' levels of overall satisfaction with the video recording, their degree of interest, and the relevance of the material taught. Ratings were made on a 5-point Likert-type scale (e.g., 1 = not helpful/relevant/interesting to 5 = extremely helpful/relevant/interesting). This measure was administered after viewing the Opposite Action video recording. 4. Skill use and effectiveness: Participants were provided a homework sheet that was based on one from Linehan's Skills Training Manual for Borderline Personality Disorder (1993b). The homework sheet asks respondents to report on: (a) which emotion they were experiencing at the time of skill use; (b) the action urge they experienced; (c) what behaviors they engaged in to carry out the skill; and (d) the intensity of the emotion prior to and after utilizing the skill, rated on a scale of 0–100, with 100 being the most intense. A structured telephone interview was used to assess whether participants had practiced the skill and how many times, and was administered approximately 1 week following the experimental session. Interviewers asked participants a series of specific questions that paralleled the prompts on the homework sheet. Participants were also asked to mail in their homework sheets. Procedures Two sessions were conducted in the laboratory, a diagnostic screening assessment and an experimental session. At one site the laboratory was on a university campus, at the other it was in an office building. At the initial assessment session, participants completed the informed consent form, a demographics measure, the SCID I, and the BPD items from the SCID II. All SCID interviews were administered by a master's-level clinician who had been trained to criterion as an assessor in an NIMH-funded RCT. Those who met study criteria were scheduled for the experimental session approximately 1 week following the diagnostic screening. Participants were paid $20 for completion of the diagnostic screening assessment.
Upon their arrival for the experimental session, participants completed the BDI and a brief semistructured interview to assess for proximal factors that may affect their cognitive performance (e.g., recent use of illicit drugs, etc.), and the three neuropsychological measures to assess current cognitive functioning. Next, participants completed the pretest skills knowledge test (Time 1). They then watched the first video recording they were assigned, completed the first posttest of the knowledge measure (Time 2), watched the other video recording and completed a final posttest knowledge measure (Time 3). Participants completed the measure of outcome expectancy before and after viewing the experimental video recording, and the consumer satisfaction measure following viewing the experimental video. Participants were paid $50 for the experimental session. Following completion of the experimental session, participants were assigned the homework of practicing the DBT skill of opposite action during the following week. Homework was assigned via video recording instruction to insure consistency. Participants were provided with the homework sheet to record their practice, and a self-addressed, stamped envelope to return it in. A follow-up phone call was scheduled for approximately 1 week following the experimental session to assess skill use and effectiveness. Participants were informed that they would be paid $5 for participating in the follow-up phone call, regardless of whether they had practiced the skill, and $5 for returning their homework sheet, even if they returned it blank. No significant adverse events or reactions were observed during the course of the study.
Results Skill Knowledge Table 2 shows the means and standard deviations for each condition and time-point. Each condition's percentage correct on the Opposite Action Knowledge Questionnaire is represented in Figure 1. Analyses included a repeated measures ANOVA using time (Time 1, Time 2, Time 3) and treatment condition (experimental video first, control video first) with the data meeting underlying assumptions (e.g., homogeneity of variance, sphericity). There was a significant effect for time (F = 74.51, p b .001), which was modified by a Condition × Time interaction (F = 18.744, p b .001), with an effect size, calculated using Cohen's f2 (1988), of .40, which would be considered a medium effect. Follow-up t-tests (two-tailed) were conducted and results supported the hypotheses. That is, from Time 1 to Time 2 no change was seen for the group that viewed the control video first, t(14) = -1.92, p = .08, but a significant change was observed for the group that viewed the experimental video first, t(14) = -6.72, p b 001. Additionally, from Time 2 to Time 3 a significant change was observed for the group that viewed the experimental
Using Video to Teach DBT Skills Table 2
Means and Standard Deviations on Opposite Action Knowledge Measure at Pre-test and Post Viewing of Control and Experimental Video Recordings Condition
Control video first Experimental video first Cohen's d ⁎
Time 1
Time 2
Time 3
Mean
SD
Mean
SD
Mean
SD
.48 .46
.14 .14
.51 .72
.15 .19
.78 .73
.17 .21
.14
1.24
.26
⁎ Interpretation of Cohen's d(1988): small = .20; medium = .50; large = .80.
video second, t(14) = -7.57, p b .001, but not for the group that viewed the control video second, t(14) = -.36, p = .73. Concordant with these findings, the conditions differed in terms of mean scores at Time 2, t(28) = 3.31, p b .01, but not in terms of mean scores at Time 3, t(28) = -.79, p = 43. Outcome Expectancies Results from a paired-samples t-test showed a significant increase in outcome expectancy ratings, t(26) = -5.36, p b .001, from Time 1 (M = 2.63, SD = .44) to post-experimental video (M = 2.93, SD = .36). The effect size, calculated using Cohen's d (1988), was .83, which is considered a large effect. Participant Satisfaction Participant satisfaction with the Opposite Action video recording was high. Table 3 summarizes satisfaction data. Ratings were made using a 5-point scale (1 = not at all; 5 = extremely). The average level of overall satisfaction with the video corresponded to a rating approximately halfway between “helpful” and “very helpful.” Ninety-seven percent of the sample indicated
they would watch the Opposite Action video and others like it were they to be available at their mental health clinic. Skill Practice Participants were assigned a homework practice to apply the skill of opposite action during the week following the experimental session. From the original 30 participants, we were able to obtain follow-up phone call data from 24 (80%). The remaining 6 participants could not be reached. All of the people who participated in the phone follow-up reported that they had practiced the skill of opposite action at least once since viewing the video recording. This represents 80% of the overall sample. Eighteen participants (75% of those participating in follow-up phone calls) reported having used the opposite action skill more than once. Fifteen participants (62.5%) reported having used the opposite action skill in the context of experiencing anger, 5 (20.8%) in the context of fear/anxiety, 3 (12.5%) when sad, and 1 when experiencing shame/embarrassment. Note that the video recording provides the most detail on changing anger and fear. Participants rated the intensity of their painful emotion before and after using the skill on a 100-point scale (100 being the most intense). Results are presented in Table 4. Emotion intensity decreased from an average of approximately 76 to an average of 38. This decrease was statistically significant, t(22) = 6.83, p b .001. Similar results were found for ratings made by participants on returned homework sheets. Nineteen participants returned a total of 33 homework sheets (9 participants returned more than one). Emotion intensity ratings decreased from an average of 74 (scale of 0–100) to an average of 33 following skill use, t(17) = 9.4, p b .001.
Figure 1. Percent Correct on the Opposite Action Knowledge Measure at Pre-test and Post Viewing of Control and Experimental Video Recordings.
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Table 3
Means and Standard Deviations for Participants' Ratings of Their Satisfaction With the Experimental Video Recording Item rated
Mean
SD
Enjoyed the video Overall rating of video's helpfulness Held interest Relevance to you in your ordinary life Helpful in generating new ways to deal with emotions Likeliness of using what was learned Would you watch this video if available at your clinic/therapist office? Yes = 96.7%
3.17 3.67 3.90 4.20 3.80 3.93
.95 .96 .99 .71 .96 .96
Discussion
Predictors of Skill Knowledge at Posttest Using hierarchical multiple regression, pretest skills knowledge scores were found to be a significant predictor of posttest skills knowledge scores (R2 = .41, Standardized Beta = .64, p b .01). Following this, measures of verbal IQ (AM-NART), attention (Digit Span), memory (WMS-III Logical Memory immediate and delayed recall), years of education, depression (BDI) and distress at the time of the session (SUDS ratings) were entered into separate regression equations to evaluate the extent to which they might predict posttest skills knowledge scores. These regressions also included pretest knowledge scores; hence, a significant effect for the cognitive and mood predictors indicated that they were associated with postviewing knowledge scores after controlling for pretest knowledge scores. Results are shown in Table 5. Due to the small sample size and relatively low statistical power (power of .80 to at best detect a large effect, f2 = .36), we chose to perform separate multiple regression equations for each of the potential predictor variables. Results revealed that only Logical Memory immediate recall scores significantly predicted posttest skills knowledge scores. Because this study represents the first attempt in the literature that we are aware of to assess for cognitive factors that may serve as predictor variables for DBT skills acquisition, Table 5 notes predictors with statistical trends (p b .10), which included years of education and verbal IQ estimate (AM-NART). Table 4
Mean Pre and Post-Skill Use Ratings of Subjective Units of Distress (SUDS) on a 1-100 Scale for Data Collected Via Follow-up Phone Calls and Homework Sheets Returned by Mail. Source of data
Phone call Homework sheets
SUDS rating immediately prior to skill use
SUDS rating immediately following skill use
Mean
SD
Mean
SD
76.3 74.3
17.0 19.0
38.1 32.7
27.4 22.2
The psychoeducational video developed for this study appeared to be an effective means of teaching a DBT skill, supporting the feasibility of video as a means of facilitating DBT skills acquistion. Results showed an increase in skills knowledge in this sample of participants meeting BPD criteria who were naïve to DBT skills. Skill acquisition is a crucial first step in the behavioral change process in DBT; the client must fully understand and process the skill information in order to successfully incorporate the skill into his or her behavioral repertoire. In addition to learning content, participants reported an increase in their confidence that using the skill would be helpful. The majority of participants reported liking the video and rated the content as helpful and relevant to their problems. The majority of the participants also applied what they learned when given a homework assignment to do so. Eighty percent of the participants reported using the skill on at least one occasion between viewing the video and a Table 5
Summary of Standard Multiple Regression Analysis Controlling for Pre-test Scores for Variables Predicting Post-test Skills Knowledge for Opposite Action (N = 30) Variable
Years of education Verbal IQ estimate Digit span Logical memory immediate Logical memory delayed BDI Baseline SUDS
Unstandardized Standardized B
β
ΔR2
.03 .01 .01 .02
.29 + .27 + .18 .33 ⁎
.08 + .07 + .03 .11 ⁎
.01
.24
.06
.00 .02
.01 .16
.00 .02
Note: separate regression analyses controlling for pre-test scores were conducted for each predictor variable, thus ΔR2 represents the amount of variance accounted for by the independent variable above and behind the variance accounted for by pre-test scores. ⁎ p b .05. + trend toward significance, where .05 b p b .10.
Using Video to Teach DBT Skills follow-up assessment approximately 1 week later. Use of the skill appears to have worked as intended. Those participants who said they used the skill reported reductions in the intensity of their painful emotion after applying the skill, compared to preskill level. In other words, they were generally successful in their attempts to change a painful emotion they wished to change. The study offers some preliminary insight into cognitive and emotional variables that may affect skills acquisition in a didactic skills training situation. Poorer immediate recall memory predicted less knowledge gain after watching the video, with years of education and verbal IQ estimate showing trends toward similar outcomes. These findings suggest that DBT skills trainers and therapists should be aware of any potential memory difficulties clients might be experiencing, and expect that clients with poorer memories may not retain as much from a first didactic exposure to a skill. Further research is needed to clarify how cognitive and affective variables affect skills acquisition. This study had several limitations that are important to consider. Two issues regarding the generalizability of the findings are of note. First, the average estimated VIQ for participants in the study was 111, suggesting that this sample generally had above-average verbal skills. The extent to which viewers with lower verbal abilities can learn and benefit from the video is unknown. Given that clients with poorer cognitive functioning may need repeated exposure to skills materials, and thus may be candidates for a videotape intervention, determining whether the video is useful for that population will be important to assess. Second, we do not know from this study the extent to which participants practiced the skill because they were being paid and knew our research team was planning to inquire about their application of the skill. Rates of skill practice in a more naturalistic context could be lower than reported by participants in this study. Because we utilized a within-subjects design to address issues of statistical power, all participants had seen the experimental video by posttest, and thus there was no comparison group for the component of the study that examined skill homework practice. In addition, evaluation of participants' capacity to apply the behavioral skill of opposite action and benefit from its application were based on self-report, which could be affected by demand characteristics. Future studies could address this limitation by incorporating more objective, performance-based measures of skill application. Finally, the outcome measure we developed to assess skill knowledge appears to have included items that could be answered correctly without direct exposure to skill information. Participants averaged 50% correct at pretest, as opposed to the 25% correct we would expect by chance. It is also possible that
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participants were exposed to some type of skill information informally, having all received mental health services. An important focus for future research will be exploring how video can effectively be employed to promote skills acquisition in naturalistic settings. It will be particularly important to examine whether use of video adds to skill knowledge gains within the context of comprehensive DBT programs, with clients already undergoing skills training. In addition, exploring how video can most usefully be employed within DBT programs is also of interest. For example, skills trainers might assign video to be viewed between skills training sessions by all group members; alternatively, they might use video in a more flexible manner, assigning it when someone misses a session or appears to need additional exposure to the material. Another interesting area for examination is how videobased DBT skills training might be employed in innovative ways, outside the context of traditional, comprehensive DBT programs. Central questions here are, to what extent could video be used as a relatively independent skills training intervention, and how much additional therapist or skills trainer intervention is needed to achieve behavior change? Future work could usefully explore the parameters of when, how, and for whom exposure to videobased DBT skills training is useful.
References Arizona Public Media, (n.d.) The Desert Speaks series episode index (episode 901) and program descriptions. Retrieved April 15, 2008, from http://thedesertspeaks.org/episode.cfm?showID=901. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, (4th ed.). Washington, DC: American Psychiatric Association. Beck, A., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Erlbaum. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). User's guide for the structured clinical interview for personality disorders (SCIDII). Washington, DC: American Psychiatric Press. Foertsch, C. E., McKee, M. B., & Hamel, A. (1996). DBT Skills Acquisition Test. Unpublished measure. Frances, A., Fyer, M., & Clarkin, J. (1986). Personality and suicide. Annals of the New York Academy of Sciences, 487, 281–293. Fromme, K., Kivlahan, D. R., & Marlatt, G. A. (1986). Alcohol expectancies, risk identification, and secondary prevention with problem drinkers. Advances in Behaviour Research & Therapy, 8, 237–251. Ghosh, A., & Marks, I. M. (1987). Self-treatment of agoraphobia by exposure. Behavior Therapy, 18, 3–16. Gould, R. A., & Clum, G. A. (1995). Self-help plus minimal therapist contact in the treatment of panic disorder: A replication and extension. Behavior Therapy, 26, 533–546. Grant, B. F., Chou, P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., et al. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on alcohol and related conditions. Journal of Clinical Psychiatry, 69, 533–545.
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Waltz et al. Grober, E., & Sliwinski, M. (1991). Development and validation of a model for estimating premorbid verbal intelligence in the elderly. Journal of Clinical and Experimental Neuropsychology, 13, 933–949. Knipe, F. O. (Writer), & Duncan, D., & Kleespie, T. (Directors). (1999). Chiles [Television series episode]. In F. Sherlock (Producer) The desert speaks. Tucson: Arizona Public Media. Linehan, M. M. (1993a). Cogntive-behavioral treatment of borderline personality disorder. New York: The Guilford Press. Linehan, M. M. (1993b). Dialectical Behavior Therapy skills training manual. New York: The Guilford Press. Linehan, M. M., Rizvi, S. L., Welch, S. S., & Page, B. (2000). Psychiatric aspects of suicidal behaviour: Personality disorders. In K. Hawton (Ed.), International handbook of suicide and attempted suicide Sussex, England: John Wiley & Sons. Linehan, M. M., Waltz, J., Dimeff, L., & Koerner, K. (2000). DBT skills training video: Opposite Action. Seattle: The Behavioral Technology Transfer Group. Lynch, T. R., Trost, W. T., Salsman, N., & Linehan, M. M. (2007). Dialectical Behavior Therapy for borderline personality disorder. Annual Review of Clinical Psychology, 3, 181–205. Markowitz, J. C., Skodol, A. E., Petkova, E., Cheng, J., Sanislow, C. A., Grilo, C. M., et al. (2007). Longitudinal effects of personality disorders on psychosocial functioning of patients with major depressive disorder. Journal of Clinical Psychiatry, 68, 186–193. Parry, R., & Killick, S. (1998). An evaluation of the impact of an individually administered videotape for people with panic disorder. Behavioural and Cognitive Psychotherapy, 26, 153–161. Peterson, C. B., Mitchell, J. E., Engbloom, S., Nugent, S., Mussell, M. P., Crow, S. J., et al. (1998). Binge eating disorder with and without a history of purging symptoms. International Journal of Eating Disorders, 24, 251–257.
Phillips, K. A., & Nierenberg, A. A. (1994). The assessment and treatment of refractory depression. Journal of Clinical Psychiatry, 55, 20–26. Spitzer, R. L., Williams, J. B., Gibbon, M. F., & First, M. B. (1992). The Structured Clinical Interview for the DSM-III-R (SCID): I. History, rationale, and description. Archives of General Psychiatry, 49, 624–629. Waltz, J., & Dimeff, L. (1999). Opposite Action Knowledge Questionnaire. Unpublished questionnaire. Waltz, J., Dimeff, L., Koerner, K., & Linehan, M. M. (2000). Opposite Action: Changing emotions you want to change. Seattle: The Behavioral Technology Transfer Group. Wechsler, D. (1981). Wechsler Adult Intelligence Scale Revised. New York: Psychological Corporation. Wechsler, D. (1997). WMS-III: Wechsler Memory Scale, Third Edition. San Antonio: Psychological Corporation. Zanarini, M. C., Frankenburg, F. R., Hennen, J., & Silk, K. R. (2004). Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. Journal of Clinical Psychiatry, 65, 28–36.
This research was supported by grant MH58942-02 from the National Institute on Mental Health, awarded to Jennifer Waltz, Ph.D. Address correspondence to Jennifer Waltz, Ph.D., University of Montana, Department of Psychology, 1555 Mansfield Ave., Missoula, MT 59812; e-mail: [email protected]. Received: April 17 2008 Accepted: August 19 2008
Cognitive and Behavioral Practice 16 (2009) 214–222 www.elsevier.com/locate/cabp
Feasibility of Using Video to Teach a Dialectical Behavior Therapy Skill to Clients With Borderline Personality Disorder Jennifer Waltz, University of Montana Linda A. Dimeff, Behavioral Tech Research, Inc., Seattle Kelly Koerner, Private Practice, Seattle Marsha M. Linehan, University of Washington Laura Taylor, Village Family Psychiatry, Richmond Christopher Miller, Department of Veteran Affairs Puget Sound Health Care System, Seattle This study tested the feasibility of using a psychoeducational video recording to teach a behavioral skill from the Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b) skills training program to individuals meeting criteria for borderline personality disorder. A video presenting a DBT emotion-regulation skill was developed and the extent to which viewers learned the skill material was evaluated via a randomized controlled trial (RCT), utilizing a within-subjects design. Thirty individuals meeting DSM-IV criteria for borderline personality disorder participated. Participants were recruited from mental health treatment settings and were naïve to DBT. Viewing the video was associated with significant increases in knowledge of the skill, relative to viewing a control video, and with increases in participants' expectations of positive outcomes for skill use. In addition, participants rated the video as relevant and helpful. A remarkably high number (80 %) utilized the skill taught subsequent to viewing the video when assigned to do so, and overall reported significant decreases in negative affect after using the skill. Video appears to be feasible as a medium for teaching DBT skills material under controlled conditions; future research is needed to examine the effectiveness of video in more naturalistic settings.
B
personality disorder (BPD) is a longstanding and often debilitating disorder characterized by intense, labile emotions, impulsivity, serious relationship difficulties, and lack of sense of self (American Psychiatric Association [APA], 1994). Clients who meet criteria for BPD often present with an intense degree of suffering, suicidality, and complex set of diagnoses. They are at significant risk for suicide, with rates of completed suicide found to be 5% to 10% (Frances, Fyer & Clarkin, 1986; Linehan, Rizvi, Welch & Page, 2000). Recent, large-scale epidemiological research has found the prevalence rate of BPD to be quite high, 5.9% in the general population (Grant et al., 2008). Individuals meeting criteria for BPD are also heavily represented in mental health treatment settings (Zanarini, Frankenburg, Hennen, & Silk, 2004). Meeting criteria for BPD is associated with poor treatment outcomes for individuals receiving therapy for Axis I disorders, such as major depression (Markowitz et al., 2007, Phillips & Nierenberg, 1994) and others. ORDERLINE
1077-7229/08/214–222$1.00/0 © 2009 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b) was developed to address the challenges presented by this population by providing a cognitivebehavioral, multimodal, team-based treatment that is both deeply compassionate and solidly change-focused. Seven randomized controlled trials (RCTs), carried out across four different research groups, have found support for its efficacy in the treatment of BPD (see Lynch, Trost, Salsman, & Linehan, 2007, for review). Support for the development of comprehensive DBT programs is therefore a priority. A central assumption in DBT is that clients meeting criteria for BPD have significant skills deficits that contribute to their emotional and behavioral dysregulation. Thus, a primary component of DBT is behavioral skills training, designed to increase clients' capabilities in the areas of emotion regulation, distress tolerance, interpersonal effectiveness and mindfulness (Linehan, 1993b). DBT skills are primarily taught in a group skills training class that includes didactic instruction, homework assignments, and homework review. The incorporation of the skills into clients' behavioral repertoires is viewed as a primary mechanism of change in DBT, and thus is understood to be crucial to the success of the treatment.
Using Video to Teach DBT Skills From a DBT perspective, the process of learning new behavioral skills includes the components of: (a) skill acquisition, (b) skill strengthening, and (c) skill generalization (Linehan, 1993b). Skill acquisition, the focus of the current work, involves the client learning the important concepts that inform the skill, when the skill is likely to be useful, and specifically how to do the skill. Skill acquisition is facilitated in DBT skills training primarily by didactic instruction, as well as written material and modeling. Skill acquisition is understood to be a crucial first step toward clients incorporating new skills into their behavioral repertoires. A number of barriers can interfere with clients successfully grasping skills material. These barriers include missing group sessions, or being inattentive, distractible, or dissociating during group. Group members are sometimes overwhelmed by painful emotions and/or preoccupied by life difficulties, making it hard for them to concentrate. The skills training material is intellectually challenging for some clients; multiple repetitions of the concepts may be needed before thorough understanding of their nuances and how to fully apply them is achieved. If effective, video provides a flexible, transportable, and convenient way for skills information to be presented that may address some of the challenges faced by DBT programs. Video recordings, computer-based interventions, and other self-administered therapy adjuncts have been used successfully to treat agoraphobia (Ghosh & Marks, 1987), panic disorder (Gould & Clum, 1995; Parry & Killick, 1998), and bingeeating disorder (Peterson et al., 1998). The purpose of this research was to test the feasibility of using video to teach a DBT skill. We were interested in establishing whether an instructional video medium could successfully be used to increase knowledge of a DBT skill in individuals meeting criteria for BPD. Given that, to our knowledge, no available empirical data speak to this issue, the study was designed to maximize internal validity. As a first step in examining feasibility, we sought to determine whether increases in skill knowledge would be found under controlled conditions, in a sample naïve to the skills material. We used an iterative process of development involving feedback from DBT experts and target end-users to create a 26-minute video recording of DBT treatment developer Marsha M. Linehan teaching the DBT skill of “opposite action” (Linehan, 1993b). This skill is from the emotionregulation module, and focuses on reducing painful emotions that one wishes to change. It was selected because of its centrality to the goal of increasing emotionregulation capabilities, a top priority in DBT. It was also chosen for its relative uniqueness to DBT, and because it could be taught independently of other DBT skills in a circumscribed manner.
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The video's efficacy was tested using a controlled, within-subjects design with participants who met criteria for BPD (n = 30). Outcome variables included: skills knowledge, outcome expectancies for using the skill, interest in and satisfaction with the video, and skill use in everyday life. Participants were assigned the homework of utilizing the skill in the week following viewing the video, and follow-up assessments of skill use and the extent to which the emotion changed pre- to post-skill-use were done. We also examined the relationship between educational, cognitive and emotional factors, and skills knowledge gains, to explore whether these factors predict degree of skills acquisition. Years of education, verbal IQ estimate, memory, attention, depression, and level of distress at the time of skill training were tested as possible predictors.
Method Participant Recruitment Flyers describing the study were distributed by a research assistant to community mental health center therapists at staff meetings and via mail to private practitioners. Therapists and case managers then distributed flyers to their clients. Subjects were also recruited from a university-based research clinic serving clients from the community. The research clinic coordinator provided information about the study to individuals who met criteria for BPD. All potential participants were screened by phone to insure that they were: (a) currently receiving mental health treatment of some kind (e.g., psychotherapy, case management, pharmacotherapy, etc.; to insure that if a participant had any negative reactions to their participation, he/she had a mental health professional to seek assistance from), (b) naïve to DBT (to insure they had not been previously exposed to the video's content); and (c) identifying themselves as having met criteria for BPD or having characteristics of BPD (as required by IRB). If the caller met these criteria and was still interested in the study, he/she was scheduled for a first session. Participants Study participants were 30 individuals meeting DSM-IV (APA, 1994) criteria for BPD based on the Structured Clinical Interview for DSM-IV, II (SCID II; First, Spitzer, Gibbon, & Williams, 1996). They were recruited from the sites described above. The following inclusion/exclusion criteria were utilized: (1) 18 years of age or older, (2) literate, (3) meets BPD criteria, (4) no previous formal DBT treatment, (5) not actively psychotic, (6) estimated verbal IQ of 90 or above (based on AM-NART score; Grober & Sliwinski, 1991), (7) aware of diagnostic status, and (8) currently a client of a mental health treatment provider (numbers 7 and 8 were included to address IRB concerns). Thirty-eight participants were screened. Six
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were disqualified because they did not meet criteria for BPD, one was not literate and one was disqualified because of threatening behavior toward the experimenter. All but one of the participants were female; mean age was 32.5 (SD = 9.1). Approximately three-quarters were unemployed and approximately 90% were making $15,000/year or less. All participants met diagnostic criteria for at least one Axis I diagnosis, as assessed by the SCID I (Spitzer, Williams, Gibbon, & First, 1992), with PTSD (67%) and major depressive disorder (63%) being the most frequent. Other anxiety disorders, eating disorders, and substance use disorders followed in level of frequency. GAF scores averaged 48.5 (SD = 12.3), indicative of “serious symptoms” or “serious impairment in social, occupational or school functioning” (p. 32), according to DSM-IV criteria. In addition, participants averaged 29.4 (SD = 13.5) on the BDI (Beck et al., 1961), falling in the moderate to severe range for depression. The average score on the AM-NART (Grober & Sliwinski, 1991), an estimate of verbal IQ, was 111.7 (SD = 8.0; range = 95–127). Participants' average scores on tests of attention (mean = 9.9, SD = 2.8; range = 6–18 on Digit Span) and memory (mean = 9.7, SD = 3.4; range = 4– 16 on WMS-III Logical Memory, immediate recall; mean = 10.2, SD = 3.4; range = 4–17 on WMS-III Logical Memory, delayed recall) fell in the average range. Design A randomized controlled trial was conducted, utilizing a within-subjects design. All participants viewed the experimental video recording and a control video recording. They were randomly assigned to the order of viewing the videos, with half the sample watching the experimental video recording first, and the other half viewing the control video first. The first participant was randomly assigned to one condition, and all subsequent participants alternated between the two conditions. The experimenters administering the interventions were aware of which video recording the participants were viewing first and which second. Participants were aware that they would be viewing two video recordings, one teaching a behavioral skill to assist in regulating negative emotions and the other on an informational topic. Video Recording Intervention The experimental condition video, Opposite Action: Changing Emotions You Want to Change (Linehan, Waltz, Dimeff, & Koerner, 2000), features DBT treatment developer, Marsha M. Linehan, teaching “opposite action,” a skill from the DBT emotion-regulation module (Linehan, 1993b). (Note that the authors conducting this feasibility study were also developers of the videorecording.) The skill of opposite action involves changing the behavioral-
expressive components of an unwanted emotion by acting in a way that is opposite to or inconsistent with the undesired emotion. Acting opposite to the behavioralexpressive aspects of the emotion includes both overt actions (for example, gently avoiding a person you are angry at or approaching what you are afraid of), as well as postural and facial expressiveness. The idea is not to block expression of an emotion. Instead, it is simply to change the behavioral-expressive component of the emotion, with the specific purpose of reducing the intensity of the emotion. Linehan provides the viewer with a step-by-step, how-to guide for applying opposite action as follows: First, figure out what emotion you are experiencing. Second, determine the emotion's action urge, or what the emotion is compelling you to do (e.g., attacking when angry, withdrawing and becoming inactive when depressed). Third, ask yourself, “Do I really want to reduce this emotion?” There are many situations in which it is not necessarily appropriate to change an emotion (e.g., experiencing grief after the death of a loved one). In addition, there are situations in which an emotion is “justified” and thus should not be changed; for example, if one is feeling fear in the context of actual danger, rather than reducing the emotion by approaching, one will more likely want to get out of the situation. Fourth, figure out the emotion's opposite action. For sadness, the opposite of withdrawing is to get active or do things that generate feelings of competence and self-confidence. Table 1 summarizes these components of the opposite action skill (Waltz, Dimeff, Koerner, & Linehan, 2000). Fifth, do opposite action in a complete, whole-hearted manner. Finally, limitations of the skill are discussed. The video is 26 minutes in length and includes numerous graphics and real-life examples to illustrate and strengthen learning of primary teaching points. The control condition was designed to control for factors of time, attention, and repeated testing. Because this research is at an early stage, only these factors were controlled for. The control condition video recording was selected to be similar in length and production quality to the experimental video, but not on a mental health topic. It was an episode from a PBS series entitled “The Desert Speaks” on the “culinary, medicinal and scientific uses” (Arizona Public Media, n.d., para.1) of pepper plants (Knipe et al., 1999). Measures Participant screening variables and predictors of outcome— psychopathology. 1. Structured Clinical Interview for DSM-IV, I & II (SCID I & II; Spitzer, Williams, Gibbon, & First, 1992; First et al., 1996). The SCID-II, BPD section was used to assess potential participants for inclusion in the study. In addition, the Axis I segments
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Table 1
Opposite Action Behaviors When Emotion is Not Justified and You Want to Change It Emotion
Action Urge
Fear/anxiety
Run/avoid
Anger Sadness
Attack/engage in judgmental thinking Withdraw/become inactive
Shame
Hide
Opposite Action
– Do what you are afraid of – Approach events, places, tasks, people, and activities you are afraid of – Gently avoid – Cultivate empathy and decency – Get active – Do things that make you feel competent and confident – Approach – Repeat the behavior openly and matter-of-factly
Adapted from a brochure accompanying the Opposite Action video recording (Waltz, Dimeff, Koerner & Linehan, 2000).
were administered to characterize the Axis I diagnoses of the sample. 2. Beck Depression Inventory (BDI; Beck et al., 1961). The BDI was used to assess depressive symptoms on a continuous scale, in order to examine potential relationships between depression and skill learning. Participant screening variables and predictors of outcome— cognitive functioning. Three brief, robust neuropsychological measures were administered to assess current cognitive functioning. We used these measures to address our exclusion criteria, to characterize the cognitive functioning of the sample, and to examine relationships between cognitive abilities and degree of information learned from the video recording. Specifically, we examined verbal IQ, attention and memory variables. 1. Nelson Adult Reading Test, American Version (AMNART; Grober & Sliwinski, 1991). The AM-NART is a widely used measure that yields a verbal IQ score that correlates highly with the Wechsler Adult Intelligence Scale–Revised (WAIS-R; Wechsler, 1981) verbal IQ score. Respondents read a list of words presented in written form, and are scored for accuracy of pronunciation. 2. Wechsler Memory Scale III – Logical Memory (WMS-III; Wechsler, 1997). The Logical Memory subscale assesses memory for narrative material. This subscale was chosen because of the relevance of narrative memory to the task of observing a video recording and remembering material encountered. 3. Wechsler Memory Scale III – Digit Span subscale (WMS-III; Wechsler, 1997). The Digit Span subscale was utilized as a measure of attention. Dependent variables. 1. Skill knowledge: Opposite Action Knowledge Questionnaire (Waltz & Dimeff, 1999). This
questionnaire was designed for the study, and incorporated several items from another skills knowledge questionnaire (Foertsch, McKee & Hamel, 1996). The measure consists of 22 multiple choice-type items assessing the most important concepts and steps involved in the opposite action skill. Sixteen questions directly assess knowledge of skill content. Examples include: “The primary thing one must do when doing opposite action for fear is: (a) relax, (b) approach, (c) gently avoid, (d) breathe deeply”; “The first step in managing difficult emotions is: (a) deciding if the emotion is justified or unjustified, (b) identifying what emotion you feel, (c) meditating and being mindful of your behavior, (d) talking to someone else about your mood.” Six questions were framed in a more applied format. For example: “Beth is scared of talking to strangers. She has to go to the bank to withdraw money, but she does not know anyone who works there. Which of the following most clearly shows the action urge associated with fear? (a) Beth avoids going to the bank and asks her sister to withdraw money for her; (b) Beth goes to the bank and starts crying; (c) Beth goes to the bank and withdraws her money; (d) Beth goes to the bank and becomes angry with the teller.” Test-retest reliability of the Opposite Action Knowledge Questionnaire was assessed on a sample of 55 undergraduate, DBT-naïve students who completed the measure twice with a reading delay period in the interim, resulting in a correlation of .89 (p b .001). The measure showed reasonable internal consistency with a Cronbach's alpha of .84 using the current study sample. 2. Outcome expectancies: Based on a comparable outcome expectancies measure (Fromme, Kivlahan, & Marlatt, 1986), a 16-item measure was developed to assess the extent to which participants expected positive outcomes resulting from the
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application of the opposite action skill. The scale used a Likert-type rating (1 = disagree, 2 = slightly disagree, 3 = slightly agree, 4 = agree) and included both positively and negatively keyed items (e.g., “people I care about would find me easier to be around,” “another equally intense negative emotion would just come along instead”). Cronbach's alpha was .81. This measure was administered before and after participants viewed the experimental video recording. 3. Client satisfaction: An 8-item measure was developed to assess participants' levels of overall satisfaction with the video recording, their degree of interest, and the relevance of the material taught. Ratings were made on a 5-point Likert-type scale (e.g., 1 = not helpful/relevant/interesting to 5 = extremely helpful/relevant/interesting). This measure was administered after viewing the Opposite Action video recording. 4. Skill use and effectiveness: Participants were provided a homework sheet that was based on one from Linehan's Skills Training Manual for Borderline Personality Disorder (1993b). The homework sheet asks respondents to report on: (a) which emotion they were experiencing at the time of skill use; (b) the action urge they experienced; (c) what behaviors they engaged in to carry out the skill; and (d) the intensity of the emotion prior to and after utilizing the skill, rated on a scale of 0–100, with 100 being the most intense. A structured telephone interview was used to assess whether participants had practiced the skill and how many times, and was administered approximately 1 week following the experimental session. Interviewers asked participants a series of specific questions that paralleled the prompts on the homework sheet. Participants were also asked to mail in their homework sheets. Procedures Two sessions were conducted in the laboratory, a diagnostic screening assessment and an experimental session. At one site the laboratory was on a university campus, at the other it was in an office building. At the initial assessment session, participants completed the informed consent form, a demographics measure, the SCID I, and the BPD items from the SCID II. All SCID interviews were administered by a master's-level clinician who had been trained to criterion as an assessor in an NIMH-funded RCT. Those who met study criteria were scheduled for the experimental session approximately 1 week following the diagnostic screening. Participants were paid $20 for completion of the diagnostic screening assessment.
Upon their arrival for the experimental session, participants completed the BDI and a brief semistructured interview to assess for proximal factors that may affect their cognitive performance (e.g., recent use of illicit drugs, etc.), and the three neuropsychological measures to assess current cognitive functioning. Next, participants completed the pretest skills knowledge test (Time 1). They then watched the first video recording they were assigned, completed the first posttest of the knowledge measure (Time 2), watched the other video recording and completed a final posttest knowledge measure (Time 3). Participants completed the measure of outcome expectancy before and after viewing the experimental video recording, and the consumer satisfaction measure following viewing the experimental video. Participants were paid $50 for the experimental session. Following completion of the experimental session, participants were assigned the homework of practicing the DBT skill of opposite action during the following week. Homework was assigned via video recording instruction to insure consistency. Participants were provided with the homework sheet to record their practice, and a self-addressed, stamped envelope to return it in. A follow-up phone call was scheduled for approximately 1 week following the experimental session to assess skill use and effectiveness. Participants were informed that they would be paid $5 for participating in the follow-up phone call, regardless of whether they had practiced the skill, and $5 for returning their homework sheet, even if they returned it blank. No significant adverse events or reactions were observed during the course of the study.
Results Skill Knowledge Table 2 shows the means and standard deviations for each condition and time-point. Each condition's percentage correct on the Opposite Action Knowledge Questionnaire is represented in Figure 1. Analyses included a repeated measures ANOVA using time (Time 1, Time 2, Time 3) and treatment condition (experimental video first, control video first) with the data meeting underlying assumptions (e.g., homogeneity of variance, sphericity). There was a significant effect for time (F = 74.51, p b .001), which was modified by a Condition × Time interaction (F = 18.744, p b .001), with an effect size, calculated using Cohen's f2 (1988), of .40, which would be considered a medium effect. Follow-up t-tests (two-tailed) were conducted and results supported the hypotheses. That is, from Time 1 to Time 2 no change was seen for the group that viewed the control video first, t(14) = -1.92, p = .08, but a significant change was observed for the group that viewed the experimental video first, t(14) = -6.72, p b 001. Additionally, from Time 2 to Time 3 a significant change was observed for the group that viewed the experimental
Using Video to Teach DBT Skills Table 2
Means and Standard Deviations on Opposite Action Knowledge Measure at Pre-test and Post Viewing of Control and Experimental Video Recordings Condition
Control video first Experimental video first Cohen's d ⁎
Time 1
Time 2
Time 3
Mean
SD
Mean
SD
Mean
SD
.48 .46
.14 .14
.51 .72
.15 .19
.78 .73
.17 .21
.14
1.24
.26
⁎ Interpretation of Cohen's d(1988): small = .20; medium = .50; large = .80.
video second, t(14) = -7.57, p b .001, but not for the group that viewed the control video second, t(14) = -.36, p = .73. Concordant with these findings, the conditions differed in terms of mean scores at Time 2, t(28) = 3.31, p b .01, but not in terms of mean scores at Time 3, t(28) = -.79, p = 43. Outcome Expectancies Results from a paired-samples t-test showed a significant increase in outcome expectancy ratings, t(26) = -5.36, p b .001, from Time 1 (M = 2.63, SD = .44) to post-experimental video (M = 2.93, SD = .36). The effect size, calculated using Cohen's d (1988), was .83, which is considered a large effect. Participant Satisfaction Participant satisfaction with the Opposite Action video recording was high. Table 3 summarizes satisfaction data. Ratings were made using a 5-point scale (1 = not at all; 5 = extremely). The average level of overall satisfaction with the video corresponded to a rating approximately halfway between “helpful” and “very helpful.” Ninety-seven percent of the sample indicated
they would watch the Opposite Action video and others like it were they to be available at their mental health clinic. Skill Practice Participants were assigned a homework practice to apply the skill of opposite action during the week following the experimental session. From the original 30 participants, we were able to obtain follow-up phone call data from 24 (80%). The remaining 6 participants could not be reached. All of the people who participated in the phone follow-up reported that they had practiced the skill of opposite action at least once since viewing the video recording. This represents 80% of the overall sample. Eighteen participants (75% of those participating in follow-up phone calls) reported having used the opposite action skill more than once. Fifteen participants (62.5%) reported having used the opposite action skill in the context of experiencing anger, 5 (20.8%) in the context of fear/anxiety, 3 (12.5%) when sad, and 1 when experiencing shame/embarrassment. Note that the video recording provides the most detail on changing anger and fear. Participants rated the intensity of their painful emotion before and after using the skill on a 100-point scale (100 being the most intense). Results are presented in Table 4. Emotion intensity decreased from an average of approximately 76 to an average of 38. This decrease was statistically significant, t(22) = 6.83, p b .001. Similar results were found for ratings made by participants on returned homework sheets. Nineteen participants returned a total of 33 homework sheets (9 participants returned more than one). Emotion intensity ratings decreased from an average of 74 (scale of 0–100) to an average of 33 following skill use, t(17) = 9.4, p b .001.
Figure 1. Percent Correct on the Opposite Action Knowledge Measure at Pre-test and Post Viewing of Control and Experimental Video Recordings.
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Table 3
Means and Standard Deviations for Participants' Ratings of Their Satisfaction With the Experimental Video Recording Item rated
Mean
SD
Enjoyed the video Overall rating of video's helpfulness Held interest Relevance to you in your ordinary life Helpful in generating new ways to deal with emotions Likeliness of using what was learned Would you watch this video if available at your clinic/therapist office? Yes = 96.7%
3.17 3.67 3.90 4.20 3.80 3.93
.95 .96 .99 .71 .96 .96
Discussion
Predictors of Skill Knowledge at Posttest Using hierarchical multiple regression, pretest skills knowledge scores were found to be a significant predictor of posttest skills knowledge scores (R2 = .41, Standardized Beta = .64, p b .01). Following this, measures of verbal IQ (AM-NART), attention (Digit Span), memory (WMS-III Logical Memory immediate and delayed recall), years of education, depression (BDI) and distress at the time of the session (SUDS ratings) were entered into separate regression equations to evaluate the extent to which they might predict posttest skills knowledge scores. These regressions also included pretest knowledge scores; hence, a significant effect for the cognitive and mood predictors indicated that they were associated with postviewing knowledge scores after controlling for pretest knowledge scores. Results are shown in Table 5. Due to the small sample size and relatively low statistical power (power of .80 to at best detect a large effect, f2 = .36), we chose to perform separate multiple regression equations for each of the potential predictor variables. Results revealed that only Logical Memory immediate recall scores significantly predicted posttest skills knowledge scores. Because this study represents the first attempt in the literature that we are aware of to assess for cognitive factors that may serve as predictor variables for DBT skills acquisition, Table 5 notes predictors with statistical trends (p b .10), which included years of education and verbal IQ estimate (AM-NART). Table 4
Mean Pre and Post-Skill Use Ratings of Subjective Units of Distress (SUDS) on a 1-100 Scale for Data Collected Via Follow-up Phone Calls and Homework Sheets Returned by Mail. Source of data
Phone call Homework sheets
SUDS rating immediately prior to skill use
SUDS rating immediately following skill use
Mean
SD
Mean
SD
76.3 74.3
17.0 19.0
38.1 32.7
27.4 22.2
The psychoeducational video developed for this study appeared to be an effective means of teaching a DBT skill, supporting the feasibility of video as a means of facilitating DBT skills acquistion. Results showed an increase in skills knowledge in this sample of participants meeting BPD criteria who were naïve to DBT skills. Skill acquisition is a crucial first step in the behavioral change process in DBT; the client must fully understand and process the skill information in order to successfully incorporate the skill into his or her behavioral repertoire. In addition to learning content, participants reported an increase in their confidence that using the skill would be helpful. The majority of participants reported liking the video and rated the content as helpful and relevant to their problems. The majority of the participants also applied what they learned when given a homework assignment to do so. Eighty percent of the participants reported using the skill on at least one occasion between viewing the video and a Table 5
Summary of Standard Multiple Regression Analysis Controlling for Pre-test Scores for Variables Predicting Post-test Skills Knowledge for Opposite Action (N = 30) Variable
Years of education Verbal IQ estimate Digit span Logical memory immediate Logical memory delayed BDI Baseline SUDS
Unstandardized Standardized B
β
ΔR2
.03 .01 .01 .02
.29 + .27 + .18 .33 ⁎
.08 + .07 + .03 .11 ⁎
.01
.24
.06
.00 .02
.01 .16
.00 .02
Note: separate regression analyses controlling for pre-test scores were conducted for each predictor variable, thus ΔR2 represents the amount of variance accounted for by the independent variable above and behind the variance accounted for by pre-test scores. ⁎ p b .05. + trend toward significance, where .05 b p b .10.
Using Video to Teach DBT Skills follow-up assessment approximately 1 week later. Use of the skill appears to have worked as intended. Those participants who said they used the skill reported reductions in the intensity of their painful emotion after applying the skill, compared to preskill level. In other words, they were generally successful in their attempts to change a painful emotion they wished to change. The study offers some preliminary insight into cognitive and emotional variables that may affect skills acquisition in a didactic skills training situation. Poorer immediate recall memory predicted less knowledge gain after watching the video, with years of education and verbal IQ estimate showing trends toward similar outcomes. These findings suggest that DBT skills trainers and therapists should be aware of any potential memory difficulties clients might be experiencing, and expect that clients with poorer memories may not retain as much from a first didactic exposure to a skill. Further research is needed to clarify how cognitive and affective variables affect skills acquisition. This study had several limitations that are important to consider. Two issues regarding the generalizability of the findings are of note. First, the average estimated VIQ for participants in the study was 111, suggesting that this sample generally had above-average verbal skills. The extent to which viewers with lower verbal abilities can learn and benefit from the video is unknown. Given that clients with poorer cognitive functioning may need repeated exposure to skills materials, and thus may be candidates for a videotape intervention, determining whether the video is useful for that population will be important to assess. Second, we do not know from this study the extent to which participants practiced the skill because they were being paid and knew our research team was planning to inquire about their application of the skill. Rates of skill practice in a more naturalistic context could be lower than reported by participants in this study. Because we utilized a within-subjects design to address issues of statistical power, all participants had seen the experimental video by posttest, and thus there was no comparison group for the component of the study that examined skill homework practice. In addition, evaluation of participants' capacity to apply the behavioral skill of opposite action and benefit from its application were based on self-report, which could be affected by demand characteristics. Future studies could address this limitation by incorporating more objective, performance-based measures of skill application. Finally, the outcome measure we developed to assess skill knowledge appears to have included items that could be answered correctly without direct exposure to skill information. Participants averaged 50% correct at pretest, as opposed to the 25% correct we would expect by chance. It is also possible that
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participants were exposed to some type of skill information informally, having all received mental health services. An important focus for future research will be exploring how video can effectively be employed to promote skills acquisition in naturalistic settings. It will be particularly important to examine whether use of video adds to skill knowledge gains within the context of comprehensive DBT programs, with clients already undergoing skills training. In addition, exploring how video can most usefully be employed within DBT programs is also of interest. For example, skills trainers might assign video to be viewed between skills training sessions by all group members; alternatively, they might use video in a more flexible manner, assigning it when someone misses a session or appears to need additional exposure to the material. Another interesting area for examination is how videobased DBT skills training might be employed in innovative ways, outside the context of traditional, comprehensive DBT programs. Central questions here are, to what extent could video be used as a relatively independent skills training intervention, and how much additional therapist or skills trainer intervention is needed to achieve behavior change? Future work could usefully explore the parameters of when, how, and for whom exposure to videobased DBT skills training is useful.
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This research was supported by grant MH58942-02 from the National Institute on Mental Health, awarded to Jennifer Waltz, Ph.D. Address correspondence to Jennifer Waltz, Ph.D., University of Montana, Department of Psychology, 1555 Mansfield Ave., Missoula, MT 59812; e-mail: [email protected]. Received: April 17 2008 Accepted: August 19 2008