Randomized Trial of Dual-Focused Vs. Single-Focuse

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Abstract: We conducted a randomized comparison of dual-focus schema
therapy with individual drug counseling as enhancements to the residential
treatment of105 substance-dependent patients with specific personality dis-
orders versus those without. Both therapies were manual-guided and delivered
for 6 months by experienced psychotherapists intensively trained and super-
vised with independentfidelity assessment. Using the Cox proportional hazards
model, we found no psychotherapy differences in retention (days in treatment).
Hierarchicallinear modeling indicated that participants with personality dis-
orders started with higher psychiatric,interpersonal, and dysphoria symptoms
and that both therapies reduced symptoms in 6 months. Contrary to predic-
tions,individual drug counseling resulted in more sustained reductions than
did dual-focus schema therapy in several symptoms for several personality
disorders. Ourfindings raised important questions aboutthe added value of
integrative or dual-focus therapies for co-occurring personality disorders and
substance dependence relative to empirically supported therapies focused more
specifically on addiction symptoms.
Key Words: Personality disorder, substance dependence, psychotherapy,
schema tlierapy, drug counseling.
(J Nerv Ment Dis 2011;199: 319-328)

The co-occurrence of axis I and II disorders is very common and
associated with severe psychosocialimpairment(Crouse et al.,
2007; Mertens et al., 2003; Oldham et al., 2009). Although most
clinicians and experts believe thatthese complex patients with axis I
and II disorders need intensive orintegrative treatments,there is very
little research that supports the efficacy ofintegrative or dual-focus
models in comparison with treatments that primarily target one ofthe
disorders (Conrod and Stewart, 2005; Kienast and Foerster, 2008).
There is substantial evidence that psychotherapy and intensive psy-
chosocialtreatments are effective for personality disorders (PDs), and
many patients in more than 100 axis IItreatment outcome studies had
co-occurring axis 1 disorders (Leichsenring and Leibing, 2003; Perry
et al.,1999; Sanislow and McGlashan,1998; Verheui and Herbrink,
2007).In addition, outcomes have been evaluated for subgroups of
axis II patients in the treatment of an axis I diagnosis such as mood
(Diguer et al.,1993; Hardy et al.,1995; Shea et al.,1990), eating
(Fahy et al.,1993; Johnson et al.,1990), anxiety (Brown et al.,1995;
Stravynski et al.,1982), and substance use (Cacciola et al.,1996;
Messina et al., 2003; Woody et al.,1985) disorders. Furthermore,
many treatment outcome studies specifically targeting borderline PD

have included patients with axis I diagnoses, most commonly mood
disorders (Bateman and Fonagy,1999. 2008; Blum et al., 2008;
Clarkin et al., 2007; Davidson et al., 2006; Giesen-Bloo et al., 2006;
Hoglend,1993; Linehan et al.,1991. 2006; Ryle and Golynkina,
2000). However, very few randomized trials have been conducted on
psychotherapy models that provide an integrative or dualfocus in
managing and ameliorating the symptoms of both axis I and II dis-
orders orthatinclude a broaderrange ofPDs.
Dialectical behaviortherapy (DBT; Linehan,1993)for border-
line PD and schema therapy (Young,1994)for a broaderrange ofPDs
have both been adapted and evaluated for substance-dependent
patients in smallrandomized trials and have shown promising results
(Ball et al., 2005; Ball, 2007; Linehan et al.,1999,2002).In addition,
Gregory et al.(2008. 2010) have developed and tested an integrative
psychodynamic modelfor co-occurring borderline PD and alcohol
use disorders that has shown a promising acute treatment and follow-
up (Gregory et al., 2010) symptom improvement. An important
question is whetherthe increased time, cost, and complexity of
training, supervision, and delivery ofintegrative models for dual
disorders is justified based on their superior outcome compared with
existing evidence-based therapies focused mostly on the symptoms of
one ofthe disorders. To date,there is limited supportforthe use of
DBT in substance-dependent patients with borderline PD compared
with an addiction-focused comparison therapy (Linehan et al., 2002;
van den Bosch et al., 2002). A very small clinicaltrial suggested that
DBT may be betterforthis population than would be an uncontrolled
therapy-as-usual,for which limited symptom change seemed best
explained by poorretention and utilization (Linehan et al.,1999).
Similar concerns aboutthe small sample size and the differentialin-
tensity of an uncontrolled treatment-as-usual can be raised aboutthe
promising dynamic deconstructive psychotherapy model by Gregory
et al.(2008. 2010). The current study compared the efficacy of
the dual-focus schema tlierapy (DFST; Ball,1998. 2004; Ball and
Young, 2000), which treats a broaderrange ofPDs and substance de-
pendence, versus individual drug counseling (IDC; Mercer and Woody,
1999), which specifically targets addiction symptoms. Both DFST and
IDC were manual-guided weekly individualtherapies delivered during
the first 6 months in a residentialtherapeutic community.
We have focused on PDs and substance dependence because
these are the most common forms of co-occurring psychiatric dis-
orders and are especially prevalent(70% to 90%)in inpatient or
residential programs (Verheui et al.,1998a). Numerous studies have
found that PDs are associated with worse substance-related outcomes
when provided with routine or standard addiction treatment(Verheui
et al., 2005) butthatthe poor prognosis of antisocial and borderline
PD may be mitigated by adding psychotherapeutic (Cacciola et al.,
1996; Woody et al.,1985), psychiatric (Nace and Davis,1993),
contingency management(Messina et al., 2003), ortherapeutic
community interventions (McKendrick et al., 2007; Ravndal et al.,
2005). Forthis reason, we developed and tested DFST as the first
integrative cognitive behavioraltherapy forthe fullrange of PDs
found in substance-dependent patients (Ball,1998; 2004). DFST
showed promise in two smallrandomized trials when tested against
an individual12-step facilitation therapy in methadone-maintained
patients (Ball, 2007) and against group drug counseling with home-
less substance-abusing clients (Ball et al, 2005) However, both