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ms such as negative thinking patterns in BPD patients. Moreover, in Verheul, et al. (2003)’s study, patients in the DBT group received 12-months of therapy, according to the DBT manual, by trained psychologists while TAU consisted of two clinical management sessions a month from the patients’ referral source (e.g. addiction treatment centres or psychiatric services). They found that DBT group generated a greater reduction in self-damaging impulsive acts compared to TAU. In fact, their results indicated that TAU patients’ progress deteriorated over time, suggesting that non-specialised treatment could prove detrimental rather than beneficial. Verheul and colleagues (2003) also examined if the efficacy of DBT would be modified by the baseline severity of parasuicidal acts, and found that DBT had a more profound impact on reducing the frequency of self-mutilating behaviours in participants with a higher baseline but showed similar improvements as TAU on patients in the low-severity group. This suggests that DBT should – consistent with its original aims (Linehan, 1991) – be the intervention of choice for only chronically parasuicidal BPD patients. Overall, both Koons, et al. (2001) and Verheul, et al. (2003) showed that DBT is an efficacious treatment for high-risk behaviours and can be conducted with fairly good adherence by a group of therapists at a location independent of the treatment developer. Hence, these studies lend support to the accumulating evidence that mental health professionals outside academic research centres can effectively learn and conduct DBT. Another key follow-up study was carried out to determine whether the success of DBT was attributed to treatment factors that were common to most psychotherapies conducted by experts instead of the unique DBT treatment itself. Linehan’s, et al. (2006) RCT replicated the original study (Linehan, et al.,1991) but introduced a rigorous control condition known as community treatments by experts (CTBE) that was designed to maximise internal validity and control for factors previously uncontrolled for in TAU conditions. CTBE is distinct from TAU conditions whereby the characteristics of CTBE therapists are controlled for the study via selection of therapists and supervisory arrangements. CTBE therapists were experts in treating high-risk clients and were categorised into six groups based on treatments they would usually provide BPD patients (the groups ranged from “behavioural therapist” to “very non-behaviroural”). Linehan’s, et al. (2006) study revealed that DBT surpassed the efficacy of CTBE in preventing suicide attempts by reducing it by half compared with the latter. Additionally, DBT was more effective in reducing inpatient psychiatric hospitalisation and had a significantly greater treatment retention. These results suggest that DBT may be uniquely effective in treating suicidal BPD individuals and its success is not solely due to the general features linked to receiving expert psychotherapy care. Impulsivity seems to be a key traits of BPD that triggers parasuicidal acts; hence, perhaps the efficacy of DBT is attributed to the control of these impulsive tendencies. Impulsive self-harm behaviours act as coping mechanisms for BPD individuals to manage invalidating environments and deal with life sufferings, by lessening the emotional pain, and may additionally help communicate emotional pain to others and elicit help (Ivanoff, et al., 2001). In DBT, mindfulness skill training may be the most salient component as it specifically teaches adaptive emotion regulation skills, that consequently reduces impulsivity. Mindfulness module was designed to balance emotions with reasoning, and teach patients to possess emotional clarity and awareness, instead of acting on impulses and emotion-driven behaviours when distressed (Soler, et al., 2012). Jamilian and colleagues (2014) examined DBT’s success in emotion regulation by specifically evaluating the effectiveness of DBT in reducing impulsivity. They enlisted the valid Baratt Impulsive Scale to measure different types of impulsive behaviours pre- and post-treatment and the results clearly indicated reduction in impulsive behaviour points after participants underwent DBT. The study showed the success of DBT in attenuating impulsivity and may reflect the effectiveness of this ther
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