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The case described by Rizvi and Salters-Pedneault provides an excellent example of the successful application of clinical science in the treatment of a client with multiple severe and chronic problems. I will highlight key DBT implementation issues throughout the case, but also will address systemic issues for both the client and for therapists employing rigorous clinical science in their use of dialectical behavior therapy (DBT).
Although DBT was developed specifically to treat multi-problem people with severe emotion dysregulation (about which BPD is a kind of prototype), the structure of research funding in the United States has effectively limited clinical trials to one year or less (cf. Kliem, Kröger, & Kosfelder, 2010). In contrast, funding structures in other countries often do not have these arbitrary time limitations (but generally do not have as much overall funding, either), so the few studies with patients with BPD that have evaluated more than one year of treatment have been done in Europe (e.g., Bateman & Fonagy, 2009; Giesen-Bloo, van Dyck, Spinhoven, et al., 2006). But, in the case of Melissa, treatment continued (appropriately and successfully) for about four years. Thus, necessarily, the clinicians involved had to adjust the treatment substantially. In this case, these adjustments included changing therapists and managing a rather extreme set of difficulties not specifically included in any randomized clinical trials of DBT.
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