Predictors of Improvement in an Open Trial Multi-Site Evaluation of Emotion Regulation Group Therapy

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Emotion Regulation Group Therapy (ERGT; Gratz & Gunderson, 2006; Gratz & Tull, 2011; Gratz, Tull, & Levy, 2014b) is a brief, behavioural group treatment aimed at reducing deliberate non-suicidal self-harm (DSH) in individuals with borderline personality disorder (BPD). ERGT was designed as an adjunctive (i.e., add-on) treatment to augment the treatments provided in routine clinical care, to specifically target DSH through its proposed underlying mechanism – an emotion regulation skills deficit (Gratz, Bardeen, Levy, Dixon-Gordon, & Tull, 2015). Difficulties in emotion regulation, or emotion dysregulation, is characterized by emotional sensitivity, heightened and complex negative affect, a lack of appropriate regulation strategies, and a surplus of maladaptive regulation strategies (Carpenter & Trull, 2013). DSH seems to be particularly prevalent among individuals prone to emotion dysregulation, and research suggests that DSH fills an emotion regulating function, for instance, lower negative affect has consistently been reported to follow after engaging in DSH (Andover & Morris, 2014; Bresin, 2014; Chapman, Gratz, & Brown, 2006; Klonsky, 2007).

ERGT teaches self-harming and emotionally dysregulated individuals emotion regulation skills to reduce emotion dysregulation in general and emotional avoidance in particular. The treatment is founded on an acceptance-based conceptual definition of emotion regulation proposed by Gratz and Roemer (2004) which emphasizes the functionality of emotions (Gratz & Roemer, 2004). Therefore, the focus in ERGT is to expand the patient’s behavioural repertoire towards greater awareness and acceptance of emotions, and to increase the ability to engage in goal-directed behaviours and inhibit impulsive behaviours when experiencing negative emotions. Thus, patients are taught a broad set of strategies to modulate the intensity or duration of their emotional responses, rather than to avoid them entirely (for a more extensive account of the treatment, see Gratz & Gunderson, 2006).

ERGT has been evaluated in three studies in the US (Gratz & Gunderson, 2006; Gratz & Tull, 2011; Gratz, Tull, & Levy, 2014b) and was recently evaluated in a large Swedish multi-centre open trial (Sahlin et al., 2017), with all studies showing the same pattern of results; significant improvements on both DSH and emotion regulation with moderate to strong effect sizes at 6-month follow-up (Cohen’s d ranging between 0.64-0.99 for DSH, and 0.55-1.03 for emotion dysregulation; (Gratz, Tull, & Levy, 2014b; Sahlin et al., 2017)
However, not all patients respond to the treatment, and those who did not may have benefitted from a longer or more intensive treatment than ERGT, such as dialectical behaviour therapy or mentalization based therapy (Bateman & Fonagy, 1999; Linehan, 1993). Identifying patients who are less likely to respond positively to ERGT could aid clinicians in selecting the best treatment for their patients. Indeed, the growing number of psychological treatments available for different disorders and maladaptive behaviours has led to a demand for researchers to identify not only if a particular treatment is efficacious, but also for whom and under what conditions the treatment works (Kraemer, Wilson, Fairburn, & Agras, 2002).

Unfortunately, the literature on predictors of outcome in treatments for BPD and related pathology has produced mixed and contradictory findings, probably due to the wide variability in outcomes and predictors studied, the small sample sizes and the heterogeneity of treatments for BPD. Regarding ERGT, only one prediction analysis has been conducted thus far (Gratz, Dixon-Gordon, & Tull, 2014a). The study found ERGT to be effective for participants across all demographic predictors and that greater clinical severity (i.e., higher baseline emotion dysregulation, greater BPD symptomatology and more frequent lifetime and recent DSH), as predictors of improvement (Gratz, Dixon-Gordon, & Tull, 2014a). However, when implementing a treatment in a novel setting, such as in the Sahlin et al. (2017) study, differences in patient characteristics and therapist expertise and training could influence both the utility of this treatment as well as the patient characteristics that influence treatment response. Therefore, we aimed to replicate previously identified predictors of treatment response to ERGT by investigating many of the same demographic, clinical, and diagnostic predictors in women with BPD or subclinical BPD who had participated in the Swedish open trial evaluation of ERGT described above (Sahlin et al., 2017). Outcomes evaluated were frequency of DSH and difficulties in emotion regulation.

Ninety-five women (mean age 25.1, SD = 7.0, range 18-49) were recruited and assessed by community-based health care professionals at 14 psychiatric outpatient clinics across Sweden. All met at least three diagnostic criteria for BPD according to the DSM-IV (American Psychiatric Association, 2000), and had engaged in at least three episodes of DSH in the past six months. Mixed effects multilevel modelling was used to identify variables that influenced improvement between pre-treatment and post-treatment, and post-treatment and 6-month follow-up.

We found lower age, greater BPD symptom severity and 6-month pre-treatment DSH frequency, as well as past 3-month suicidal behaviour, to be associated with greater improvements in DSH at post-treatment. Past (pre-treatment) 6-month DSH frequency was also associated with greater continued improvements in DSH during follow-up. Likewise, being on psychotropic medication and having a CBT therapist as treatment as usual was associated with greater reductions in DSH during follow-up. In contrast, greater emotion dysregulation at pre-treatment was associated with an increase in DSH from post-treatment to follow-up, but predicted greater improvements in emotion dysregulation during treatment. Greater BPD symptom severity also predicted greater improvements in emotion dysregulation during follow-up. Regarding co-occurring diagnoses, however, we found depression, post-traumatic stress disorder and social anxiety disorder to be associated with a strong reduction in DSH during treatment, but a significant return of DSH during the 6- month follow-up period. We also found a worsening in emotion dysregulation between post-treatment and follow-up, in individuals with co-occurring social anxiety disorder, compared to those without. Our results suggest that when having a co-occurring diagnosis, booster sessions may be of particular relevance in maintaining the progress obtained.

In summary, this study adds to the growing literature on predictors of outcome in treatments for BPD, with an emphasis on two highly relevant targets for this population: DSH and emotion dysregulation. Our results replicated some of the findings of the previous ERGT prediction study (Gratz, Dixon-Gordon, & Tull, 2014a), particularly regarding baseline levels of DSH and emotion dysregulation. Although these findings simply may have reflected the greater magnitude of change possible when scores were elevated at baseline, the fact that this replicates previous findings clearly suggest that patients with high levels of both DSH and BPD can benefit from treatments for BPD and related pathology.

In particular, and consistent with the premise that research on predictors of treatment response may guide clinical decision making, our results suggest that ERGT is a useful treatment even for individuals with more frequent DSH and more severe BPD pathology.

Text: Hanna Sahlin
Photo: Per Carlbring

Read the full paper (open access):
Hanna Sahlin, Johan Bjureberg, Kim L. Gratz, Matthew T. Tull, Erik Hedman-Lagerlöf, Jonas Bjärehed, Jussi Jokinen, Lars-Gunnar Lundh, Clara Hellner & Brjánn Ljótsson (2018) Predictors of improvement in an open-trial multisite evaluation of emotion regulation group therapy, Cognitive Behaviour Therapy, DOI: 10.1080/16506073.2018.1509119

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Related Articles

• Sahlin, H., Bjureberg, J., Gratz, KL., Tull, MT., Hedman, E., Bjärehed, J., Lundh, L-G., Jokinen, J., Ljótsson, B. & Hellner, C. Emotion Regulation Group Therapy for Deliberate Self-Harm: A Multi-Site Evaluation in Routine Care using an Uncontrolled Open Trial Design. BMJ Open 2017;7: e016220. doi: 10.1136/bmjopen-2017-016220
• Gratz, KL., Dixon-Gordon, KL. & Tull, MT. Predictors of treatment response to an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Personality Disorders 2014;5: 97-107. doi: 10.1037/per0000062