A Promising Treatment for Borderline
Personality Disorder
Dialectical Behavior Therapy, often referred to as DBT, is an empirically
researched psychotherapeutic treatment developed by Dr. Marsha Linehan,
Professor of Psychology, University of Washington, for patients struggling
with chronic suicidality, intentional self-harm and borderline personality
disorder (BPD). This therapy, employing cognitive and behavioral principles,
is rapidly becoming a standard for treating borderline patients in both this
country and abroad. DBT consists of two primary components involving
individual psychotherapy once a week and a weekly skills training group.
Additionally, patients are offered telephone consultations with their
individual therapist as needed.
Biosocial theory. DBT is based on a biosocial theory of
personality functioning in which BPD is seen as a biological disorder of
emotional regulation. The disorder is characterized by heightened sensitivity
to emotion, increased emotional in-tensity and a slow return to emotional
baseline. Characteristic behaviors and emotional experiences associated with
BPD theoretically result from the expression of this biological dysfunction in
a social environment experienced as invalidating by the borderline patient.
Although there are many examples of invalidating environments, all share
three characteristics: (1) individual behaviors and communications are
rejected as invalid; (2) emotional displays and painful behaviors are met with
punishment that is erratically administered and intermittently reinforcing;
(3) the environment oversimplifies the ease with which problems may be solved
and needs met. Most of us have encountered such environments at some point in
our lives and we commonly deal with them by changing our behavior to meet
expectations, or by changing the environment so that it is no longer
invalidating, or, ultimately, by simply leaving the environment. The dilemma
for the borderline patient occurs when the individual is unable to meet
expectations, cannot change the environment or cannot leave, thus experiencing
what has been called a "double bind."
Treatment. The primary dialectic that defines the core
treatment strategies in DBT is the tension between acceptance of the patient
and the expectation that the patient needs to change. Acceptance strategies,
drawn from Zen practice, involve emotional, behavioral and cognitive
validation as well as teaching the patient personal strategies for validation.
One example of a validation strategy would be recognizing how self-mutilation
can be adaptive (i.e., useful for regulating emotion).
The antithesis of acceptance is the expectation of change. This expectation
is embodied in behavioral therapy with its emphasis on problem solving,
rationality, logic and gaining knowledge by testing hypotheses. Strategies for
promoting change include problem solving, contingency procedures, skills
training, exposure and cognitive modification.
An example of a problem-solving procedure is the use of a "chain
analysis" to diminish cutting (self mutilation) behaviors. A chain
analysis reviews the environmental and personal antecedents and consequences
of the cutting behavior in mi-nute detail. An important goal of this procedure
is to identify points during the chain of events when the borderline patient
has an opportunity to do something different. This sets the stage for the
patient to avoid the problematic behavior in the future.
DBT is organized along a fourfold hierarchy. The first priorities are
suicidal or parasuicidal behaviors and ideation. The second priorities are
behaviors that interfere with therapy. Third is behavior that interferes with
quality of life. The fourth priority of DBT addresses skills deficits commonly
found in individuals with BPD.
The goals of skills training are to change behavioral, emotional and
thinking patterns that cause personal misery and in-terpersonal distress.
Specific goals include reducing dysregulation while increasing adaptive (i.e.,
more regulated) behaviors. Patients are taught to attend to the moment without
judgment or impulsivity, a quality Dr. Linehan describes as "core
mindfulness." Newly learned skills enable patients to improve emotional,
cognitive and interpersonal functioning.
Empirical results. DBT was compared to treatment as usual
(TAU), typically consisting of psychopharmacological treatment and
intermittent supportive psychotherapy. In a landmark study, Linehan and
colleagues found the following:
1. Compared with TAU, subjects assigned to DBT had
significantly fewer and less severe parasuicidal behaviors during the
treatment year. These results were obtained even though DBT was no better than
TAU at improving self-reports of hopelessness, suicide ideation or reasons for
living.
2. DBT was dramatically more
effective than TAU in limiting treatment drop out, the most serious behavior
interfering with therapy. At the end of one year, only 16.4 percent of DBT
patients had left treatment. In contrast, approximately 50 percent of TAU
patients had dropped out.
3. Subjects assigned to DBT had
a tendency to enter psychiatric inpatient units less often and had fewer
inpatient psychiatric days. Those in DBT had an average of 8.46 inpatient
days over the year compared with 38.86 inpatient days for subjects receiving
TAU. This finding suggests that DBT is cost effective.
4. DBT subjects rated themselves
as more successful at changing their emotions and improving general emotional
control. They also had significantly lower scores on self-reported measures of
anger and anxious
rumination.
In a subsequent study, the standard DBT (DBT
individual therapy and the DBT
skills group) was compared to a once weekly individual psychodynamic therapy
and the DBT skills group. This study showed that the DBT skills group lost its
effectiveness when combined with individual psychodynamic therapy. This study
also supported the practice of providing telephone consultations to patients
between sessions when needed. To explain this point, Linehan likens life to a
basketball game—having a therapist unavailable between sessions would be
like a coach being unavailable during the game.
DBT is usually considered a one-year treatment. In this time, the therapy
targets behaviors involving life and death, behaviors that impede therapy and
activities that affect quality of life. Concurrently, the patient learns
techniques taught in the skills group. This one-year treatment has been
empirically validated and designated as Stage I by Dr. Linehan; she has
developed sequels to this treatment that are currently being evaluated. Stage
II, which is begun only after the patient has acquired the basic skills of
Stage I, is based on the rationale that patients must be able to cope with the
consequences of trauma and focuses on reducing posttraumatic stress. Stage III
emphasizes increasing self-respect, reducing self-hatred and achieving
individual goals and interpersonal connections.
Additional Reading:
Linehan, Marsha M. (1993). Cognitive-Behavioral Treatment of Borderline
Personality Disorder. New York: Guilford Press.
Linehan, Marsha M. (1993). Skills Training Manual for Treating Borderline
Personality Disorder. New York: Guilford Press.
Linehan, M., Asuicidal borderline patients. Archives of General Psychiatry
(1991). 48: 1060-1064.
Shearin, Edward N. and Linehan, Marsha M. Dialectical behavioral therapy
for borderline personality disorder: theoretical and empirical foundations.
Acta Psychiatrica Scandinavica (1994). 89 (suppl. 379): 61-68.
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This article was contributed by Elizabeth T. Murphy, PhD, and John
Gunderson, MD. Dr. Murphy conducts outpatient DBT individual therapy and
skills groups with patients at McLean Hospital. Dr. Gunderson is director of
McLean’s Ambulatory Personality Disorder Service and Psychosocial Research
Program, and is Professor of Psychiatry at Harvard Medical School.
