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The Efficacy of a Dialectical Behavior Therapy-Based Journal THE EFFICACY OF A DIALECTICAL BEHAVIOR THERAPY-BASED JOURNAL- WRITING GROUP WITH INPATIENT ADOLESCENT FEMALES: IMPROVING EMOTION REGULATION, DEPRESSIVE SYMPTOMS AND SUICIDAL IDEATION A dissertation presented by Pamela A. Wineman, M.A. To The Department of Counseling and Applied Educational Psychology In partial fulfillment of the requirements for the degree of Doctor of Philosophy in the field of Counseling Psychology Northeastern University Boston, Massachusetts June 29, 2009 Journal Writing 2 THE EFFICACY OF A DIALECTICAL BEHAVIOR THERAPY -BASED JOURNAL- WRITING GROUP WITH INPATIENT ADOLESCENT FEMALES: IMPROVING EMOTION REGULATION, DEPRESSIVE SYMPTOMS AND SUICIDAL IDEATION by Pamela A. Wineman, M.A. Dissertation Committee: Debra L. Franko, Ph.D., Chair Deborah Greenwald, Ph.D. Ralph Buonopane, Ph.D. ABSTRACT OF DISSERTATION Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Counseling Psychology in the Bouvé College of Health Sciences Graduate School of Northeastern University, June 2009 Journal Writing 3 ABSTRACT PURPOSE: To determine whether a dialectical behavior therapy (DBT)-based journal- writing group is effective at increasing the emotion regulation abilities and decreasing depression and suicidal ideation in a sample of inpatient adolescent females. METHOD: Forty inpatient adolescent females completed surveys of emotion regulation, depression, and suicidal ideation (Toronto Alexithymia Scale (TAS-20), Difficulties in Emotion Regulation Scale (DERS), Beck Depression Inventory (BDI), & Suicide Probability Scale (SPS)) at pre- and post-intervention. Twenty-one adolescent females participated in the DBT-based journal-writing experimental group and nineteen adolescent females participated in the Treatment as usual control group. RESULTS: Participants in the experimental group reported significant decreases in suicidal ideation and depressive symptoms and significant increases in emotion regulation abilities (BDI: t = 4.3, p = .000, DERS: t = 2.9, p = .009, TAS-20: t = 2.0, p = .058, SPS: z = -1.9, p = .053), whereas participants in the control group did not report significant change (BDI: t = 1.3, p = .198, TAS-20: t = 0.5, p = .649, DERS: t = 1.4, p = .187, SPS: z = -.1, p = .887). When changes in pre- to post-test scores were compared between the control group and the experimental group, significant results were found only for the BDI (t = -2.5, p = .019). CONCLUSION: A DBT-based journal-writing group is an effective way to decrease depressive symptoms and suicidal ideation and increase emotion regulation abilities in inpatient adolescent females and can be used in the future as a means to maximize treatment gains for adolescents on inpatient units. Journal Writing 4 ACKNOWLEDGEMENTS I would like to thank and acknowledge the following people: • To Dr. Franko, who has been a patient and knowledgeable chairperson and who has taught me what it really takes to be a clinical researcher. I greatly appreciate your guidance and support through this learning process! I can see how much your feedback and input has helped to transform this initial, rough idea into a succinct and comprehensive document. • To Dr. Greenwald, who has been a supporter both clinically and through the dissertation process since the start of the program. Your feedback in courses has helped me grow as a clinician and realize my own strengths and potential. I am now more confident as a practitioner, in large part due to your guidance. • To Dr. Buonopane and Unit 1, to whom without which, none of this would have been possible! Your willingness and accessibility during a long data-collection process made this as stress-free an experience as I could have hoped for. I thank you for all the resources and your expertise with this difficult population. Your dedication to the patients and the program is inspiring and your belief in this project helped me persevere even when complications and frustration set in. • To Andrew, who has lived with all of the behind-the-scenes frustrations and “tantrums” and never stopped encouraging me to push on. Your love and support is unconditional and endless and I cannot express just how appreciative and lucky I know I am to have you in my life. Journal Writing 5 • To my family, Mom, Dad, and Eric, I am so thankful for the continued support and love even when I decided to keep extending my educational and professional journey. You never questioned my plan or my goals and provided endless encouragement along the way. Mom, your own educational journey provided me with the inspiration to press on and understanding that it would be difficult, but I would get there. Dad, your dedication and proof that you can achieve your dreams provided me with a model example to aspire to. Eric, your sense of humor and way of letting me know that “everything will work out in the end,” helped ease my stress and ground me when I was feeling overwhelmed! • To all my friends, family, and colleagues, for checking in and being curious about my project. You always knew what to say or how to help, especially those (Evie!) who had been through it before. • To Alison, Saleha, Wesleigh, and Na-Yeun, your help with the data collection was invaluable and I never would have finished on time had it not been for your support. I hope you learned about research through your participation in this study and I am confident you will all make wonderful practitioners and/or researchers, whichever you decide. • To Cielo, your help with the data analysis was instrumental in furthering my understanding of statistics. Thank you for your patience and flexibility! • Finally, to all the participants in this study, if not for you, this project would have not been possible. You are all amazingly strong and inspiring young women and your efforts will help to inform treatment for girls struggling with similar challenges in the future. Journal Writing 6 TABLE OF CONTENTS ABSTRACT……………………………………………………………………………. 3 ACKNOWLEDGEMENTS……………………………………………………………. 4 TABLE OF CONTENTS………………………………………………………………. 6 CHAPTER ONE: INTRODUCTION………………………………………………….. 8 Background of the Problem……………….…………………………………… 8 Normal Adolescent Development…. ………………………………........ 8 Existing Treatment on Adolescent Inpatient Units ................................. 9 Emotion Regulation…………………………… ………………………...... 12 Journal Writing………… ……………………………………….............. 14 Theoretical Orientation: Narrative Psychology… ……………………...15 Statement of the Problem………………………………………………………. 16 Purpose of Proposed Study…………………………………………………….. 17 Significance & Potential Benefits……………………………………………… 18 Research Questions & Hypotheses…………………………………………...... 18 CHAPTER TWO: LITERATURE REVIEW………………….……………………..... 20 Adolescents & Mental Health………………………………………………….. 20 Adolescent Development ….…..………………………………………... 20 Adolescent Inpatient Units ……………………………………………... 25 Treatment on Inpatient Units …………………….…………………….. 31 Emotion & Affect……...….…………………………………………………… 44 Emotion Regulation………………………………………………………… ... 44 Emotion Regulation on Inpatient Units……………… ………………...... 51 Measuring Emotion Regulation, Depression, & Suicidal Ideation ……. 57 Treating Emotion Dysregulation: Dialectical Behavior Therapy .............60 Journal Writing ……………………. ………………………………....................... 72 Journal Writing with Different Populations……………………………….. 72 Journal Writing & Emotion Regulation ….…………. ………………................... 82 Theoretical Orientation………………………….……………………………... 83 Present Study…………………………………………………………………... 88 CHAPTER THREE: METHODOLOGY…………………………………………........ 90 Participants…………………………………………………………................... 90 Setting………………………………………………………………………….. 91 Materials……………………………………………………………………….. 92 Measures……………………………………………………………………….. 93 Demographic Information ……………………………………………... 93 Dependent Variables …………………………………………………… 93 Independent Variable…. ………………………………………………..103 Procedures……………………………………………………………………… 103 Journal Writing 7 Study Design….……………………………………………………………....... 106 Data Analysis………………………………………………………………....... 107 CHAPTER FOUR: RESULTS……………………………………………………….... 109 Results….………………………………………………………………………. 109 Comparison of Pre- to Post-Test Data …………………….........……... 111 Hypotheses……………………… ……………………...................…….... 113 CHAPTER 5: DISCUSSION…………………………………………………………... 115 Summary……………………………………………………………………...... 115 Previous Research……………………………………………………………… 116 Clinical Implications…………………………………………………………… 122 Study Limitations & Future Directions…………………………………………124 REFERENCES………………………………………………………………………… 129 Table 1……………………………………………………………………………........ 146 Table 2……………………………………………………………………………........ 147 Table 3……………………………………………………………………………........ 148 Table 4……………………………………………………………………………........ 149 Table 5……………………………………………………………………………........ 150 Appendix 1……………………………………………………………………………... 151 Appendix 2……………………………………………………………………………... 153 Appendix 3…………………………………………………………………………….. 155 Appendix 4…………………………………………………………………………….. 157 Appendix 5…………………………………………………………………………….. 158 Appendix 6…………………………………………………………………………….. 162 Appendix 7…………………………………………………………………………….. 166 Appendix 8…………………………………………………………………………….. 177 Journal Writing 8 CHAPTER ONE: INTRODUCTION This chapter explores the background and statement of the problem, the purpose and significance of the study, the theoretical perspective, and the research questions and corresponding hypotheses. Background of Research Problem This project developed out of the need for more empirical research on adolescent inpatient psychiatric units.
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