An Overview of Dialectical Behaviour Therapy in the Treatment of
Borderline Personality Disorder
by Barry Kiehn and Michaela Swales ©
Patients showing the features of Borderline
Personality Disorder as defined in DSM-IV are notoriously difficult
to treat (Linehan 1993a). They are difficult to keep in therapy,
frequently fail to respond to our therapeutic efforts and make
considerable demands on the emotional resources of the therapist,
particular when suicidal and parasuicidal behaviours are prominent.
Dialectical Behaviour Therapy is an innovative
method of treatment that has been developed specifically to treat this
difficult group of patients in a way which is optimistic and which
preserves the morale of the therapist.
The technique has been devised by Marsha Linehan
at the University of Washington in Seattle and its effectiveness has
been demonstrated in a controlled study, the results of which will be
summarised later in this paper.
BORDERLINE PERSONALITY DISORDER
Dialectical Behaviour Therapy is based on a
bio-social theory of borderline personality disorder. Linehan hypothesises
that the disorder is a consequence of an emotionally vulnerable
individual growing up within a particular set of environmental
circumstances which she refers to as the 'Invalidating Environment'.
An 'emotionally vulnerable' person in this
sense is someone whose autonomic nervous system reacts excessively to
relatively low levels of stress and takes longer than normal to
return to baseline once the stress is removed. It is proposed that
this is the consequence of a biological diathesis.
The term 'Invalidating Environment' refers
essentially to a situation in which the personal experiences and
responses of the growing child are disqualified or "invalidated"
by the significant others in her life. The child's personal
communications are not accepted as an accurate indication of her
true feelings and it is implied that, if they were accurate,
then such feelings would not be a valid response to circumstances.
Furthermore, an Invalidating Environment
is characterised by a tendency to place a high value on self-control
and self-reliance. Possible difficulties in these areas are not
acknowledged and it is implied that problem solving should be easy
given proper motivation. Any failure on the part of the child to perform
to the expected standard is therefore ascribed to lack of motivation
or some other negative characteristic of her character. (The feminine
pronoun will be used throughout this paper when referring to the patient
since the majority of BPD patients are female and Linehan's work has
focused on this subgroup).
Linehan suggests that an emotionally vulnerable
child can be expected to experience particular problems in such an
environment. She will neither have the opportunity accurately to
label and understand her feelings nor will she learn to trust her
own responses to events. Neither is she helped to cope with situations
that she may find difficult or stressful, since such problems are not
acknowledged. It may be expected then that she will look to other people
for indications of how she should be feeling and to solve her problems
for her.
However, it is in the nature of such an
environment that the demands that she is allowed to make on others
will tend to be severely restricted. The child's behaviour may
then oscillate between opposite poles of emotional inhibition
in an attempt to gain acceptance and extreme displays of emotion in
order to have her feelings acknowledged. Erratic response to this
pattern of behaviour by those in the environment may then create a
situation of intermittent reinforcement resulting in the behaviour
pattern becoming persistent.
Linehan suggests that a particular consequence
of this state of affairs will be a failure to understand and control
emotions; a failure to learn the skills required for 'emotion modulation'.
Given the emotional vulnerability of these individuals this is postulated
to result in a state of 'emotional dysregulation' which combines in a
transactional manner with the Invalidating Environment to produce the
typical symptoms of Borderline Personality Disorder.
Patients with BPD frequently describe a history
of childhood sexual abuse and this is regarded within the model as
representing a particularly extreme form of invalidation.
Linehan emphasises that this theory is not
yet supported by empirical evidence but the value of the technique
does not depend on the theory being correct since the clinical
effectiveness of DBT does have empirical support.
PATIENTS' CHARACTERISTICS
Linehan groups the features of BPD in a
particular way, describing the patients as showing dysregulation in
the sphere of emotions, relationships, behaviour, cognition and the
sense of self. She suggests that, as a consequence of the situation that
has been described, they show six typical patterns of behaviour, the
term 'behaviour' referring to emotional, cognitive and autonomic
activity as well as external behaviour in the narrow sense.
Firstly, they show evidence of 'emotional
vulnerability' as already described. They are aware of their difficulty
coping with stress and may blame others for having unrealistic
expectations and making unreasonable demands.
On the other hand they have internalised the
characteristics of the Invalidating Environment and tend to show
'self-invalidation'. They invalidate their own responses and have
unrealistic goals and expectations, feeling ashamed and angry with
themselves when they experience difficulty or fail to achieve their
goals.
These two features constitute the first pair
of so-called 'dialectical dilemmas', the patient's position tending
to swing between the opposing poles since each extreme is experienced
as being distressing.
Next, they tend to experience frequent
traumatic environmental events, in part related to their own
dysfunctional lifestyle and exacerbated by their extreme emotional
reactions with delayed return to baseline. This results in what
Linehan refers to as a pattern of 'unrelenting crisis', one crisis
following another before the previous one has been resolved. On the
other hand, because of their difficulties with emotion modulation,
they are unable to face, and therefore tend to inhibit, negative
affect and particularly feelings associated with loss or grief.
This 'inhibited grieving'and the 'unrelenting crisis' constitute
the second 'dialectical dilemma'.
The opposite poles of the final dilemma are
referred to as 'active passivity' and 'apparent competence'. Patients
with BPD are active in finding other people who will solve their
problems for them but are passive in relation to solving their own
problems. On the other hand, they have learned to give the impression
of being competent in response to the Invalidating Environment. In
some situations they may indeed be competent but their skills do
not generalise across different situations and are dependent
on the mood state of the moment. This extreme mood dependency is
seen as being a typical feature of patients with BPD.
A pattern of self-mutilation tends to develop
as a means of coping with the intense and painful feelings experienced
by these patients and suicide attempts may be seen as an expression
of the fact that life is at times simply does not seem worth
living. These behaviours in particular tend to result in frequent
episodes of admission to psychiatric hospitals. Dialectical Behaviour
Therapy, which will now be described, focuses specifically on this
pattern of problem behaviours and in particular, the parasuicidal
behaviour. DIALECTICAL BEHAVIOUR THERAPY The term 'dialectical' is
derived from classical philosophy. It refers to a form of argument
in which an assertion is first made about a particular issue
(the 'thesis'), the opposing position is then formulated (the
'antithesis' ) and finally a 'synthesis' is sought between the
two extremes, embodying the valuable features of each position
and resolving any contradictions between the two. This
synthesis then acts as the thesis for the next cycle.
In this way truth is seen as a process which
develops over time in transactions between people. From this
perspective there can be no statement representing absolute truth.
Truth is approached as the middle way between extremes. The dialectical
approach to understanding and treatment of human problems is therefore
non-dogmatic, open and has a systemic and transactional orientation.
The dialectical viewpoint underlies the entire structure of therapy,
the key dialectic being 'acceptance' on the one hand and 'change' on the
other. Thus DBT includes specific techniques of acceptance and validation
designed to counter the self-invalidation of the patient. These are
balanced by techniques of problem solving to help her learn more adaptive
ways of dealing with her difficulties and acquire the skills to do so.
Dialectical strategies underlie all aspects of treatment to counter
the extreme and rigid thinking encountered in these patients. The dialectical
world view is apparent in the three pairs of 'dialectical dilemmas' already
described, in the goals of therapy and in the attitudes and communication
styles of the therapist which are to be described. The therapy is behavioural
in that, without ignoring the past, it focuses on present behaviour
and the current factors which are controlling that behaviour. THERAPIST
CHARACTERISTICS IN DBT The success of treatment is dependant on the quality
of the relationship between the patient and therapist. The emphasis is on
this being a real human relationship in which both members matter and in
which the needs of both have to be considered. Linehan is particularly alert
to the risks of burnout to therapists treating these patients and therapist
support and consultation is an integral and essential part of the treatment.
In DBT support is not regarded as an optional extra. The basic idea is
that the therapist gives DBT to the patient and receives DBT from his
or her colleagues. The approach is a team approach. The therapist is
asked to accept a number of working assumptions about the
patient that will establish the required attitude for therapy:
1. The patient wants to change and, in spite of appearances, is trying
her best at any particular time.
2. Her behaviour pattern is understandable given her background and
present circumstances. Her life may currently not be worth living
(however, the therapist will never agree that suicide is the
appropriate solution but always stays on the side of life. The solution
is rather to try and make life more worth living).
3. In spite of this she needs to try harder if things are ever to
improve. She may not be entirely to blame for the way things are
but it is her personal responsibility to make them different.
4. Patients can not fail in DBT. If things are not improving it is
the treatment that is failing. In particular the therapist must
avoid at all times viewing the patient, or talking about her,
in pejorative terms since such an attitude will be antagonistic
to successful therapeutic intervention and likely to feed into
the problems that have led to the development of BPD in the first
place. Linehan has a particular dislike for the word "manipulative"
as commonly applied to these patients. She points out that this
implies that they are skilled at managing other people when
it is precisely the opposite that is true. Also the fact that
the therapist may feel manipulated does not necessarily imply
that this was the intention of the patient. It is more probable
that the patient did not have the skills to deal with the situation
more effectively. The therapist relates to the patient in two
dialectically opposed styles. The primary style of relationship
and communication is referred to as 'reciprocal communication',
a style involving responsiveness, warmth and genuineness on
the part of the therapist. Appropriate self-disclosure is
encouraged but always with the interests of the patient in mind.
The alternative style is referred to as 'irreverent communication'.
This is a more confrontational and challenging style aimed at bringing
the patient up with a jolt in order to deal with situations where
therapy seems to be stuck or moving in an unhelpful direction. It
will be observed that these two communication styles form the opposite
ends of another dialectic and should be used in a balanced way as
therapy proceeds. The therapist should try to interact with the patient
in a way that is:
1. accepting of the patient as she is but which encourages change.
2. centred and firm yet flexible when the circumstances require it.
3. nurturing but benevolently demanding. The dialectical approach
is here again apparent. There is a clear and open emphasis on the limits
of behaviour acceptable to the therapist and these are dealt with in a
very direct way. The therapist should be clear about his or her personal
limits in relations to a particular patient and should as far as possible
make these clear to her from the start.
It is openly acknowledged that an unconditional relationship between
therapist and patient is not humanly possible and it is always possible
for the patient to cause the therapist to reject her if she tries hard
enough. It is in the patient's interests therefore to learn to treat her
therapist in a way that encourages the therapist to want to continue
helping her.
It is not in her interests to burn him or her out. This issue is
confronted directly and openly in therapy. The therapist helps therapy
to survive by consistently bringing it to the patient's attention when
limits have been overstepped and then teaching her the skills to deal
with the situation more effectively and acceptably. It is made quite
clear that the issue is immediately concerned with the legitimate needs
of the therapist and only indirectly with the needs of the patient who
clearly stands to lose if she manages to burn out the therapist. The
therapist is asked to adopt a non-defensive posture towards the patient,
to accept that therapists are fallible and that mistakes will at times
inevitably be made. Perfect therapy is simply not possible. It needs
to be accepted as a working hypothesis that (to use Linehan's words)
"all therapists are jerks". PATIENTS' AND THERAPISTS'
AGREEMENTS This form of therapy must be entirely voluntary and depends
for its success on having the co-operation of the patient. From the
start, therefore, attention is given to orienting the patient to
the nature of DBT and obtaining a commitment to undertake the work.
A variety of specific strategies are described in the Linehan's
book (Linehan 1993a) to facilitate this process. Before a patient
will be taken on for DBT she will be required to give a number
of undertakings:
1. To work in therapy for a specified period of time (Linehan
initially contracts for one year). and, within reason, to attend
all scheduled therapy sessions.
2. If suicidal or parasuicidal behaviours are present, she
must agree to work on reducing these.
3. To work on any behaviours that interfere with the course of
therapy ('therapy interfering behaviours').
4. To attend skills training.
The strength of these agreements may be
variable and a "take what you can get approach" is
advocated. Nevertheless a definite commitment at some
level is required since reminding the patient about her
commitment and re-establishing such commitment throughout the
course of therapy are important strategies in DBT.
The therapist agrees to make every reasonable
effort to help the patient and to treat her with respect, as
well as to keep to the usual expectations of reliability and
professional ethics. The therapist does not however give any
undertaking to stop the patient from harming herself. On the
contrary, it should be make quite clear that the therapist is
simply not able to prevent her from doing so. The therapist will
try rather to help her find ways of making her life more worth
living. DBT is offered as a life-enhancement treatment and not
as a suicide prevention treatment, although it is hoped
that it may indeed achieve the latter.
MODES OF TREATMENT
There are four primary modes of treatment
in DBT :
- Individual therapy
- Group skills training
- Telephone contact
- Therapist consultation
Whilst keeping within the overall model,
group therapy and other modes of treatment may be added at
the discretion of the therapist, providing the targets
for that mode are clear and prioritised.
The individual therapist is the primary
therapist. The main work of therapy is carried out in the
INDIVIDUAL THERAPY sessions. The structure of individual
therapy and some of the strategies used will be described
shortly. The characteristics of the therapeutic alliance have
already been described.
Between sessions the patient should be
offered TELEPHONE CONTACT with the therapist, including out of
hours telephone contact. This tends to be an aspect of DBT
balked at by many prospective therapists. However, each
therapist has the right to set clear limits on such contact
and the purpose of telephone contact is also quite clearly
defined.
In particular, telephone contact is not
for the purpose of psychotherapy. Rather it is to give the
patient help and support in applying the skills that she is
learning to her real life situation between sessions and to
help her find ways of avoiding self-injury. Calls are also
accepted for the purpose of relationship repair where the
patient feels that she has damaged her relationship with
her therapist and wants to put this right before the next
session. Calls after the patient has injured herself are not
acceptable and, after ensuring her immediate safety, no
further calls are allowed for the next twenty four hours.
This is to avoid reinforcing self-injury.
SKILLS TRAINING is usually carried out
in a group context, ideally by someone other that the
individual therapist. In the skills training groups patients
are taught skills considered relevant to the particular
problems experienced by people with borderline personality
disorder. There are four modules focusing in turn on four
groups of skills:
- Core mindfulness skills.
- Interpersonal effectiveness skills.
- Emotion modulation skills.
- Distress tolerance skills.
The 'core mindfulness skills' are
derived from certain techniques of Buddhist meditation,
although they are essentially psychological techniques and no
religious allegiance is involved in their application.
Essentially they are techniques to enable one to become more
clearly aware of the contents of experience and to develop the
ability to stay with that experience in the present moment.
The 'interpersonal effectiveness skills'
which are taught focus on effective ways of achieving one's
objectives with other people: to ask for what one wants effectively,
to say no and have it taken seriously, to maintain relationships
and to maintain self-esteem in interactions with other people.
'Emotion modulation skills' are ways of
changing distressing emotional states and 'distress tolerance skills'
include techniques for putting up with these emotional states if
they can not be changed for the time being.
The skills are too many and varied to be
described here in detail. They are fully described in a teaching
format in the DBT skills training manual (Linehan,
1993b).
The therapists receive DBT from each other
at the regular THERAPIST CONSULTATION GROUPS and, as already
mentioned, this is regarded as an essential aspect of therapy.
The members of the group are required to keep each other in the
DBT mode and (among other things) are required to give a formal
undertaking to remain dialectical in their interaction with each
other, to avoid any pejorative descriptions of patient or therapist
behaviour, to respect therapists' individual limits and generally
are expected to treat each other at least as well as they treat
their patients. Part of the session may be used for ongoing
training purposes.
STAGES OF THERAPY AND TREATMENT TARGETS
Patients with BPD present multiple problems
and this can pose problems for the therapist in deciding what
to focus on and when. This problem is directly addressed in DBT.
The course of therapy over time is organised into a number of stages and
structured in terms of hierarchies of targets at each stage.
The PRE-TREATMENT STAGE focuses on assessment,
commitment and orientation to therapy.
STAGE 1 focuses on suicidal behaviours,
therapy interfering behaviours and behaviours that interfere with
the quality of life, together with developing the necessary skills
to resolve these problems.
STAGE 2 deals with post-traumatic stress
related problems (PTSD)
STAGE 3 focuses on self-esteem and individual treatment goals.
The targeted behaviours of each stage are
brought under control before moving on to the next phase. In particular
post-traumatic stress related problems such as those related to
childhood sexual abuse are not dealt with directly until stage 1
has been successfully completed. To do so would risk an increase
in serious self injury. Problems of this type (flashbacks for
instance) emerging whilst the patient is still in stages 1 or 2
are dealt with using 'distress tolerance' techniques. The treatment
of PTSD in stage 2 involves exposure to memories of the past trauma.
Therapy at each stage is focused on the
specific targets for that stage which are arranged in a definite
hierarchy of relative importance. The hierarchy of targets varies
between the different modes of therapy but it is essential for
therapists working in each mode to be clear what the targets are.
An overall goal in every mode of therapy is to increase dialectical thinking.
The hierarchy of targets in individual therapy for
example is as follows:
- Decreasing suicidal behaviours.
- Decreasing therapy interfering behaviours.
- Decreasing behaviours that interfere with the quality of life.
- Increasing behavioural skills.
- Decreasing behaviours related to post-traumatic stress.
- Improving self esteem.
- Individual targets negotiated with the patient.
In any individual session these targets
must be dealt with in that order. In particular, any incident
of self harm that may have occurred since the last session
must be dealt with first and the therapist must not allow
him or herself to be distracted from this goal.
The importance given to 'therapy
interfering behaviours' is a particular characteristic of
DBT and reflects the difficulty of working with these patients.
It is second only to suicidal behaviours in importance. These
are any behaviours by the patient or therapist that interfere
in any way with the proper conduct of therapy and risk preventing
the patient from getting the help she needs. They include, for
example, failure to attend sessions reliably, failure to keep
to contracted agreements, or behaviours that overstep therapist
limits.
Behaviours that interfere with the quality
of life are such things as drug or alcohol abuse, sexual
promiscuity, high risk behaviour and the like. What is or
is not a quality of life interfering behaviour may be a matter
for negotiation between patient and therapist.
The patient is required to record
instances of targeted behaviours on the weekly diary cards.
Failure to do so is regarded as therapy interfering behaviour.
TREATMENT STRATEGIES
Within this framework of stages, target
hierarchies and modes of therapy a wide variety of therapeutic
strategies and specific techniques is applied.
The core strategies in DBT are 'validation'
and 'problem solving'. Attempts to facilitate change are surrounded
by interventions that validate the patient's behaviour and responses
as understandable in relation to her current life situation, and
that show an understanding of her difficulties and suffering.
Problem solving focuses on the establishment
of necessary skills. If the patient is not dealing with her
problems effectively then it is to be anticipated either that
she does not have the necessary skills to do so, or does have
the skills but is prevented from using them. If she does not
have the skills then she will need to learn them. This is the
purpose of the skills training.
Having the skills, she may be prevented
from using them in particular situations either because of
environmental factors or because of emotional or cognitive
problems getting in the way. To deal with these difficulties
the following techniques may be applied in the course of therapy:
- Contingency management
- Cognitive therapy
- Exposure based therapies
- Pharmacotherapy
The principles of using these techniques
are precisely those applying to their use in other contexts
and will not be described in any detail. In DBT however they
are used in a relatively informal way and interwoven into
therapy. Linehan recommends that medication be prescribed by
someone other than the primary therapist although this may
not be practical.
Particular note should be made of the
pervading application of contingency management throughout
therapy, using the relationship with the therapist as
the main reinforcer. In the session by session course of
therapy care is taken to systematically reinforce targeted
adaptive behaviours and to avoid reinforcing targeted
maladaptive behaviours. This process is made quite overt
to the patient, explaining that behaviour which reinforced
can be expected to increase.
A clear distinction is made between
the observed effect of reinforcement and the motivation of
the behaviour, pointing out that such a relationship between
cause and effect does not imply that the behaviour is being
carried out deliberately in order to obtain the reinforcement.
Didactic teaching and insight strategies may also be used
to help the patient achieve an understanding of the
factors that may be controlling her behaviour.
The same contingency management approach
is taken in dealing with behaviours that overstep the therapist's
personal limits in which case they are referred
to as 'observing limits procedures'.
Problem solving and change strategies
are again balanced dialectically by the use of validation
strategies. It is important at every stage to convey to the
patient that her behaviour, including thoughts feelings and
actions are understandable, even though they may be maladaptive
or unhelpful.
Significant instances of targeted maladaptive
behaviour occurring since the last session (which should have
been recorded on the diary card) are initially dealt with by
carrying out a detailed 'behavioural analysis'. In particular
every single instance of suicidal or parasuicidal behaviour is
dealt with in this way. Such behavioural analysis is an important
aspect of DBT and may take up a large proportion of therapy time.
In the course of a typical behavioural
analysis a particular instance of behaviour is first clearly
defined in specific terms and then a 'chain analysis' is conducted,
looking in detail at the sequence of events and attempting to link
these events one to another. In the course of this process
hypotheses are generated about the factors that may be controlling
the behaviour. This is followed by, or interwoven with, a 'solution
analysis' in which alternative ways of dealing with the situation at
each stage are considered and evaluated. Finally one solution should
be chosen for future implementation. Difficulties that may be
experienced in carrying out this solution are considered and
strategies of dealing with these can be worked out.
It is frequently the case that patients
will attempt to avoid this behavioural analysis since they may
experience the process of looking in such detail at their behaviour
as aversive. However it is essential that the therapist should
not be side tracked until the process is completed. In addition
to achieving an understanding of the factors controlling behaviour,
behavioural analysis can be seen as part of contingency management
strategy, applying a somewhat aversive consequence to an episode
of targeted maladaptive behaviour. The process can also be
seen as an exposure technique helping to desensitise the patient
to painful feelings and behaviours. Having completed the
behavioural analysis the patient can then be rewarded with a
'heart to heart' conversation about the things she likes to discuss.
Behavioural analysis can be seen as a way
of responding to maladaptive behaviour, and in particular to parasuicide,
in a way that shows interest and concern but which avoids
reinforcing the behaviour.
In DBT a particular approach is taken in dealing
with the network of people with whom the patient is involved personally
and professionally. These are referred to as 'case management strategies'.
The basic idea is that the patient should be encouraged, with appropriate
help and support, to deal with her own problems in the environment in
which they occur. Therefore, as far as possible, the therapist does
not do things for the patient but encourages the patient to do things
for herself. This includes dealing with other professionals who may be
involved with the patient. The therapist does not try to tell these
other professionals how to deal with the patient but helps the patient
learn how to deal with the other professionals. Inconsistencies between
professionals are seen as inevitable and not necessarily something to
be avoided. Such inconsistencies are rather seen as opportunities for
the patient to practice her interpersonal effectiveness skills.
If she grumbles about the help she is receiving
from another professional she is helped to sort this out herself
with the person involved. This is referred to as the
'consultation-to-the-patient strategy' which, among other things,
serves to minimise the so-called "staff splitting"
which tends to occur between professionals dealing with these patients.
Environmental intervention is acceptable but
only in very specific situations where a particular outcome seems
essential and the patient does not have the power or capability to
produce this outcome. Such intervention should be the exception
rather than the rule.
EMPIRICAL EVIDENCE
The effectiveness of DBT has been assessed
in two major trials. The first (Linehan et al, 1991) compared
the effectiveness of DBT relative to treatment as usual (TAU).
The second (Linehan et al, in press) examined the effectiveness
of DBT skills training when added to standard community psychotherapy.
In the first randomised controlled trial,
there were three main goals:
Firstly, to reduce the frequency of
parasuicidal behaviours. This is clearly of importance because of
the distressing nature of the behaviour but also because of the
increased risk of completed suicide in this group (Stone, 1987).
Secondly, to reduce behaviours that interfere
with the progress of therapy ('therapy interfering behaviours'), as
the attrition rate from therapy in borderline women with a history
of parasuicidal behaviours is high.
Finally, to reduce behaviours that interfere
with the patients' quality of life. In this study this latter goal
was interpreted more specifically as a reduction in in-patient
psychiatric days, which is hypothesised to interfere with the
patient's quality of life.
Participants all met DSM-IIIR criteria for
BPD, and were matched for number of lifetime parasuicide episodes,
number of lifetime admissions to hospital, age and anticipated
good or poor prognosis.
There were 22 patients in each group. The
experimental group received standard DBT as outlined above.
The experience of the patients in the treatment as usual group
was variable; some received regular individual psychotherapy,
others dropped out of individual therapy whilst continuing to
have access to in-patient and day-patient services. All
participants were assessed on number of parasuicidal episodes
and a range of questionnaire measures of mood. Patients were
blindly assessed at pre-treatment, 4, 8 and 12 months and
followed up at 6 and 12 months post-treatment.
Measures of treatment compliance and
other treatment delivered (e.g. in patient psychiatric days)
were also taken. At pre-treatment there were no significant
differences on any of the measures between the control and
experimental groups including demographic criteria.
With regard to the first aim of the
trial (i.e. the reduction of suicidal behaviour), during
the year of treatment patients in the control group engaged
in more parasuicidal acts than DBT patients at all time points.
The medical risk for parasuicidal acts was higher in the
control group than in the DBT group.
Patients in the DBT group were more
likely to start therapy and were more likely to remain in
therapy than those in the control group. The one year attrition
rate in the DBT group was 16.7% compared to 50% for those
in the control group who commenced the year with a new
therapist. The DBT patients reported more individual and
group therapy treatment hours per week than the TAU group,
which reflects the intensive nature of DBT treatment. However,
the control patients reported more day treatment hours
per week.
With regard to the third goal of the
trial, patients in the control group had significantly more
inpatient psychiatric days per person than those receiving
DBT (38.6 days per year as compared to 8.46 days per year
for the DBT group).
These results were considered to
indicate the superiority of DBT over treatment as usual.
However, one major criticism of the trial is that the variable
and patchy therapeutic experience of the control group may
be considered to favour DBT. This criticism can be challenged,
however, since one of the treatment aims of DBT is to keep
the patient in therapy. This it seems to have succeeded in
doing.
However, it is still pertinent to
enquire how well DBT would compare to a consistent treatment
alternative. An attempt was made to explore this by
comparing the DBT patients with those in the TAU group
who received regular individual therapy. It was found
that the gains of the patients in the DBT group over the
TAU group remained even using this more rigorous
comparison.
Despite the more intensive nature
of DBT it remained cheaper than TAU, largely because of
the reduction in the number of in-patient and day-treatment
days received by the DBT patients.
It is of interest that, although
the DBT patients showed significant gains across the
three areas of interest (number of parasuicides, treatment
compliance and inpatient days), there were no between-group
differences on any of the questionnaire measures of mood
and suicidal ideation. During the follow-up year, patients
in the DBT group had higher Global Assessment Scores and
a better work performance than the patients in the TAU group.
In the first 6 months, DBT patients
had fewer suicidal acts, lower anger scores and better
self-reported social adjustment than TAU patients. In
the final 6 months, DBT patients had fewer in-patient days
treatment and better interviewer rated social adjustment
than TAU patients.
The second trial had two parts.
Firstly, it compared standard community psychotherapy (SCP)
plus the group skills component of DBT with SCP alone
without added skills training. Secondly, it compared
the SCP group from the first part of the present study
with the experimental group in the previously described
randomised control trial. In this latter comparison,
assignment to conditions was not random. However, all
subjects were screened in the same way, during the same
time frame and were all subject to blind assessment.
The results of the first part of
this study indicated that the addition of DBT skills
training to SCP for this group of parasuicidal borderline
women did not confer any additional therapeutic benefit.
In this part of the study the skills training was truly
ancillary in that there were no meetings between the individual
therapists and the group therapists, nor were any attempts
made to assist the patient to generalise the skills learnt
in the group to her everyday life.
In the second part of the study there
were some pre-treatment differences between the two groups.
The DBT patients were less depressed than the control
group and reported higher levels of unemployment. These
differences were not considered to be particularly important
for three reasons. Firstly, depression was not correlated with
any of the outcome variables. Secondly, although the lower
depression scores favoured the DBT group, the lower unemployment
favoured the SCP group. Finally, the levels of depression did
not differ between the two groups after the pre-treament point.
During the treatment year there were no
significant differences between the groups with regard to
staying in therapy. There were some slight differences
in the distribution of therapeutic hours, with DBT patients
reporting more group treatment hours than the SCP group. Most
importantly, however, there were no significant relationships
between number of treatment hours and any of the outcome variables.
Over the treatment year, standard DBT patients compared to
SCP patients had fewer parasuicidal episodes, fewer episodes
leading to medical treatment and fewer psychiatric in-patient
days. DBT patients also reported less anger than the SCP patients.
This research then provides some evidence
for the therapeutic efficacy of DBT. This evidence is primarily
derived from one randomised control trial in which DBT was found
to be superior on a number of variables to treatment as usual. Clearly
this finding requires replication. There is also some evidence to
suggest that DBT is superior to other forms of psychotherapy with
this group of patients. However, this result comes from a comparison
made using only a sub-sample of patients in the randomised trial
(Linehan et al, 1991) and from a further comparison between two groups
from different studies (Linehan et al, in press). Consequently,
the effectiveness of DBT compared to other alternative treatments
awaits further exploration. This will remain a challenge, particularly
given the high drop-out rates from treatment of this group of patients.
SUMMARY AND CONCLUSIONS
Dialectical Behaviour Therapy then is a novel
method of therapy specifically designed to meet the needs of
patients with Borderline Personality Disorder and their therapists.
It directly addresses the problem of keeping these patients in
therapy and the difficulty of maintaining therapist motivation
and professional well-being. It is based on a clear and potentially
testable theory of BPD and encourages a positive and validating
attitude to these patients in the light of this theory.
The approach incorporates what is valuable
from other forms of therapy, and is based on a clear acknowledgement
of the value of a strong relationship between therapist and patient.
Therapy is clearly structured in stages and at each stage a clear
hierarchy of targets is defined. The method offers a particularly
helpful approach to the management of parasuicide with a clearly
defined response to such behaviours. The techniques used in DBT
are extensive and varied, addressing essentially every aspect of
therapy and they are underpinned by a dialectical philosophy that
recommends a balanced, flexible and systemic approach to the work
of therapy. Techniques for achieving change are balanced by
techniques of acceptance, problem solving is surrounded by
validation, confrontation is balanced by understanding. The patient
is helped to understand her problem behaviours and then deal
with situations more effectively. She is taught the necessary
skills to enable her to do so and helped to deal with any problems
that she may have in applying them in her natural environment.
Generalisation outside therapy is not assumed
but encouraged directly. Advice and support available between sessions
and the patient is encouraged and helped to take responsibility for
dealing with life's challenges herself. The method is supported by
empirical evidence which suggests that it is successful in reducing
self-injury and time spent in psychiatric in-patient treatment.
REFERENCES
Linehan, M.M. (1993a) Cognitive Behavioural
Treatment of Borderline Personality Disorder. The Guilford Press,
New York and London.
Linehan, M.M. (1993b) Skills Training Manual
for Treating Borderline Personality Disorder. The Guilford Press,
New York and London.
Linehan, M.M., Armstrong, H.E., Suarez, A.,
Allmon, D. & Heard, H.L. (1991) Cognitive-behavioural treatment
of chronically parasuicidal borderline patients. Archives of
General Psychiatry, 48, 1060-1064.
Linehan, M.M., Heard, H.L. & Armstrong,
H.E. (in press) Dialectical behaviour therapy, with and without
behavioural skills training, for chronically parasuicidal borderline
patients.
Stone, M.H. (1987) The course of borderline
personality disorder. In Tasman, A., Hales, R.E. & Frances,
A.J. (eds) American Psychiatric Press Review of Psychiatry.
Washington DC; American Psychiatric Press inc. 8, 103-122.
©Barry Kiehn, Consultant Child and
Adolescent Psychiatrist, Gwynfa Adolescent Service, Pen-y-Bryn
Road, Upper Colwyn Bay, Clwyd, North Wales, LL29 6AL.
e-mail:b.kiehn@bbcnc.org.uk
© Michaela Swales, Chartered Clinical
Psychologist, Gwynfa Adolescent Service and Lecturer in the
Psychology of Adolescence, University College of North Wales,
Bangor, Gwynedd, LL57 2DG. e-mail: pss051@bangor.ac.uk
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