We recommend using dialectical behavior therapy (DBT) to treat Alex. Additionally, we recommend exploring different psychopharmacological options to mitigate some of Alex’s BPD symptoms. In what follows, we describe DBT and then explain why we will be using it with this client. After that, we discuss the possibility of psychopharmacological treatment.
Description of DBT
Marsha Linehan and her colleagues developed DBT to treat a group of “chronically suicidal, self-injurious women” who had BPD symptoms, including impulsivity, mood instability, “problems with a sense of self and with relationships,” and the appearance of being “thought disordered under emotional stress” (Koons, 2008, pp. 109-110). Linehan theorized that emotional dysregulation, or the inability to control one’s emotional responses to different events, caused all of these other problems (Koons, 2008, p. 110).
Koons (2008) writes that DBT rests on three foundations. First, DBT rests on the foundation of behaviorism, as “it seeks to understand how maladaptive behaviors are learned and to replace maladaptive behaviors with new, more skillful behaviors” (p. 112). Second, DBT rests on Zen, as both clients and therapists are encouraged to develop mindfulness skills, that is, the ability to focus one’s full attention on one thing at a time and to observe events in a non-judgmental manner (p. 114). Third, DBT rests on dialectics, as clients learn to replace dichotomous thinking with the view that truth can contain opposing viewpoints and apparent contradictions (p. 115). It can be argued DBT rests on one final foundation, that of the therapist’s “radical acceptance and validation” of the client’s “current capabilities and behavioral functioning” (Dimeff & Linehan, 2001, p. 1). Paris (2010) notes that while “[e]mpathy and validation are essential elements of any therapy,” they are “particularly important for BPD patients, who are sensitive to the slightest hint of invalidation” and “will not listen to anything” a therapist says “unless their feelings are accepted” (p. 58).
Pederson (2015) writes that DBT has five main functions: “motivating clients, teaching skills, generalizing skills to natural environments, motivating and improving the skills of therapists, and structuring the treatment environment” (p. 55). These functions are typically “divided among modes of service delivery, including individual psychotherapy, group skills training, phone consultation, and therapist consultation team” (Dimeff & Linehan, 2001, p. 1). Skills are taught through four main modules: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness (Pederson, 2015, p. 125). The contents of the mindfulness module were briefly described above. The distress tolerance module “outlines healthy coping behaviors” that can help clients survive personal crises (Pederson, 2015, p. 126). The emotion regulation module “emphasizes the importance of self-care to decrease emotional vulnerability” and helps clients to “increase positive emotions and step out of mood-congruent behaviors that maintain negative emotions” (Pederson, 2015, p. 126). The interpersonal effectiveness module “delineates skills to increase self-respect, improve relationships, and practice assertiveness to get wants and needs met” (Pederson, 2015, p. 125).
DBT consists of different phases, each of which the client must complete before moving to the next one (Brodsky & Stanley, 2013, p. 75). In the Pretreatment and Orientation phase, the therapist describes DBT and secures the client’s commitment (Brodsky & Stanley, 2013, p. 75). Stage 1 “targets the reduction of life-threatening behavior” (75). Stage 2 primarily attempts “to increase the capacity of nontraumatic emotional experiencing, and to address” how traumatic events “are interfering with quality of life goals” (Brodsky & Stanley, 2013, p. 76). Stage 3 focuses on “[o]ther quality of life issues, such as self-actualization in social and vocational arenas,” and Stage 4 focuses on “increasing joy and a sense of freedom, and of completeness and connectedness” (Brodsky & Stanley, 2013, p. 76). Treatment duration depends on the client and for some clients can last several years (ABCT fact sheets, n.d.).
Justification for Using DBT
The American Psychiatric Association (2010) states that both psychodynamic therapy and DBT have been shown in randomized controlled trials (RCT) to effectively treat BPD (p. 10), but it notes that there are “relatively few methodologically rigorous efficacy studies” regarding psychodynamic therapy and BPD (p. 47). By contrast, as we will outline below, there are by now almost 30 years of RCTs showing DBT’s effectiveness. Moreover, Paris (2010) makes a strong argument that many psychodynamic therapies fail to effectively treat many BPD patients because such patients “are constantly in the throes of emotion dysregulation” and thus cannot “make use of analytic procedures” (p. 58). Paris (2010) also argues that DBT is preferable because, unlike some psychodynamic therapies, it offers a structured approach, something which most BPD patients need, as they themselves “lead chaotic lives and have a deficient psychic structure” (p. 58). For these reasons, we have decided to use DBT with Alex.
Marsha Lineham and her colleagues conducted the first RCTs on DBT. Linehan, Armstrong, Suarez, Allmon, and Heard (1991) conducted a RCT on 44 women with BPD who had a history of suicide attempts. Half of these women received DBT and the other half received treatment as usual (TAU); 13 of those in the TAU group received individual psychotherapy and 9 did not receive psychotherapy (p. 1061). After one year, the women who received DBT had fewer suicide attempts, fewer days of hospitalization, and a lower treatment dropout rate (p. 1060). Linehan, Tutek, Heard, and Armstrong (1994) conducted an RCT in which 26 women with BPD were assigned to either DBT or TAU, and after one year, the women who received DBT “had significantly better scores on measures of anger, interviewer-rated global social adjustment, and the Global Assessment scale and tended to rate themselves better on overall social adjustment” (p. 1771).
Linehan et al. (20006) conducted an RCT with over 100 women with BPD, all of whom had at least two attempted suicides or self-injuries in the last five years and at least one in the last eight weeks. Half of the group received DBT and the other half received community treatment by experts (CTBE), which consisted of treatment by therapists who had been nominated by “community mental health leaders” and were paid the same rate as the DBT therapists. After two years (one year of treatment, one year of “posttreatment follow-up”), it was determined that DBT was more effective at preventing suicide attempts, as well as reducing visits to the emergency room and inpatient psychiatric care; moreover, DBT patients had lower dropout rates.
Independent researchers have also begun to conduct their own RCTs on DBT’s effectiveness at treating BPD. Turner (2000) conducted an RCT in which 24 BPD patients received either DBT or client-centered therapy (CCT), the latter of which emphasized “empathic understanding of the patient’s sense of aloneness” and provided “a supportive atmosphere for individuation” (p. 416). After one year of treatment, the DBT group “showed greater improvement than patients receiving CCT on measures of suicide and self-harm behavior, suicidal ideation, depression, impulsiveness, anger, global psychological functioning, and a reduction in days spent in psychiatric hospitals” (p. 418).
Koons et al. (2001) conducted an RCT involving 20 female veterans diagnosed with BPD. All patients received treatment from the Durham VA Medical Center; some received DBT and some received TAU; of the TAU clinicians, “four described themselves as cognitive-behavioral in their primary orientation, two as psychodynamic, and two as eclectic” (p. 378). After six months of treatment, DBT patients “reported significantly greater decreases in suicidal ideation, hopelessness, depression, and anger expression” (p. 372). Moreover, only DBT patients had “significant decreases in number of parasuicidal acts, anger experienced but not expressed, and dissociation,” and both groups reported a decrease in depression (p. 372).
Verheul et al. (2003) conducted an RCT with 63 women diagnosed with BPD. Approximately half of these women received DBT, while the other half received TAU, which “consisted of clinical management from the original source” (addiction treatment centers for 11 participants and “psychiatric services” for 20 participants) (p. 136). After one year of treatment, the DBT group had significantly lower dropout rates (37 percent compared to 77 percent), and they had “greater reductions in self-mutilating behaviours and self-damaging impulsive acts” (p. 138). Van den Bosch et al. (2005) studies this same group six months after their treatment had ended and found that the DBT group had not relapsed “to the former levels of problem behavior” (p. 1238). Van den Bosch et al. (2005) also found that the DBT group showed “significantly larger reductions in alcohol use than the TAU group, both at 52 and 78 weeks” (p. 1238).
Kliem, Kröger, and Kosfelder (2010) found in their meta-analysis “a moderate effect size for DBT in the treatment of BPD patients.” These authors noted that this effect size “holds true when we compare DBT with TAU, comprehensive validation plus 12-step therapy and community therapy by experts” but that other “borderline-specific treatments might be just as efficacious, including schema-focused therapy, transference-focused therapy, psychoanalytic therapy, and general psychiatric management.” They concluded that studies comparing DBT to these latter therapies should be performed. DBT is included in the National Registry of Evidence-based Programs and Practices produced by the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA (n.d.) states that DBT has no know “adverse effects, concerns, or unintended consequences.”
A Word about Psychopharmacological Treatments
Feurino and Silk (2011) concluded in their literature review that although no medication exists which successfully treats BPD, some mood stabilizers and antipsychotics have been found to treat certain symptoms of BPD, including mood swings, anxiety, and stress-induced cognitive distortions (p. 69). These authors caution that these medications do not work effectively in all patients, and given this and given that BPD patients “may be more sensitive to the side effects of [such] medications,” clinicians should perform a cost-benefit analysis on the effects of medication on each individual patient (p. 73).
References
ABCT fact sheets: Dialectical behavior therapy. (n.d.). Retrieved from http://www.abct.org/Information/?m=mInformation&fa=fs_DIALECTICAL
American Psychiatric Association. (2010). Practice guideline for the treatment of patients with borderline personality disorder. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf
Brodsky, B. S., & Stanley, B. (2013). The dialectical behavior therapy primer: How DBT can inform clinical practice. West Sussex, UK: John Wiley & Sons.
Dimeff, L., & Linehan, M. M. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34(3), 10-13.
Feurino III, L., & Silk, K. R. (2011). State of the art in the pharmacologic treatment of borderline personality disorder. Current Psychiatry Reports, 13(1), 69-75.
Kliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: a meta-analysis using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78(6), 936.
Koons, C. (2008). Dialectical behavior therapy. Social Work in Mental Health, 6(1), 109-132.
Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., ... & Bastian, L. A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371-390.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12), 1060-1064.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., ... & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of general psychiatry, 63(7), 757-766.
Linehan, M. M., Tutek, D. A., Heard, H. L., & Armstrong, H. E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151(12), 1771-1775.
Paris, J. (2010). Effectiveness of different psychotherapy approaches in the treatment of borderline personality disorder. Current Psychiatry Reports, 12(1), 56-60.
Pederson, L. D. (2015). Dialectical behavior therapy: A contemporary guide for practitioners. West Sussex, UK: John Wiley & Sons.
Substance Abuse and Mental Health Services Administration. (n.d.). Dialectical Behavior Therapy. Retreived from http://legacy.nreppadmin.net/ViewIntervention.aspx?id=36
Turner, R. M. (2000). Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder. Cognitive and Behavioral Practice, 7(4), 413-419.
van den Bosch, L. M., Koeter, M. W., Stijnen, T., Verheul, R., & van den Brink, W. (2005). Sustained efficacy of dialectical behaviour therapy for borderline personality disorder. Behaviour Research and Therapy, 43(9), 1231-1241.
Verheul, R., van den Bosch, L. M., Koeter, M. W., De Ridder, M. A., Stijnen, T., & Van Den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder. The British Journal of Psychiatry, 182(2), 135-140.
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