Dialectical behaviour therapy in the treatment of borderline personality disorder - O'Connell & Dowling (2014) - Article


Introduction

Borderline personality disorder is the most common complex and severely impairing personality disorder (Anon, 2012). It is characterized by experiences of intense and rapid changes in mood and affect, dysfunction of emotion regulation, emotional lability, engagement in destructive and self-harming behaviour, and an extremely poor capacity to engage in effective relationships. Individuals with BPD often experience chronic feelings of emptiness, and they make excessive efforts to avoid abandonment. Individuals with BPD often experience intense emotional pain and distress but in the literature and by health professionals they are often negatively approached and with less empathy than individuals with other disorders.

A variety of psychotherapeutic approaches is used in the management of BPD. DBT has been studied the most and is considered to be the most effective treatment. Although it is an effective therapy, health care professionals still show therapeutic pessimism towards clients with BPD.

What is DBT?

DBT is a complex therapy given for at least one year. The main purpose is to change behaviour and manage emotions and behaviour through a balance of both acceptance and change. It uses principles from CBT but the difference is that less emphasis on cognitive methods is placed. It focuses on the learning and practice of new skills. Mindfulness also plays an important role together with acceptance and dialectics. There are 3 core principles that underline DBT. (1) a holistic philosophy that supports a dialectical philosophy (2) opposites are synthesized in dialectical philosophy, one learns to regulate intense emotions (3) movement of the therapist and client to a central meeting point rather than to opposites, maintained through a balance of acceptance and change. According to the biopsychosocial model proposed by Linehan, BPD is primarily a dysfunctional emotional regulation system. DBT is given in four kinds of interventions: group therapy, individual psychotherapy, phone calls and consultation team meetings. The treatment goals of DBT are to reduce parasuicidal and life-threatening behaviours, to reduce behaviours that interfere with therapy and to reduce behaviours that seriously impair the person’s quality of life.

DBT: early developments

Linehan, who developed DBT after being admitted herself conducted a randomized controlled trial to investigate the effectivity of DBT in chronically suicidal woman diagnosed with BPD. DBT showed to be more effective than treatment as usual (TAU) in reducing parasuicidal behaviour, attendance to therapy, reducing hospital admissions and social adjustment and work performance after 6 and 12 months. Another replication of Linehan et al.’s study compared DBT to community treatment by experts (CTBE). It was found that CBT was more effective than CTBE in preventing suicide attempts and was more effective in reducing visits to the emergency department. Again it is also more effective in maintaining treatment although 25% dropped out compared to 59% in CTBE. Van den Bosch et al.(2005) reported a significant effect on the amount of impulsive and self-mutilating behaviour and alcohol consumption.

Recently, another RCT has been performed and this study failed to replicate some of the earlier find effects. This study did not find reduction in deliberate self-harm or in hospitalisations. This might be due to inaccurate training of the therapists or to the shorter duration of this study. It is also difficult to measure the success or failure of DBT in terms of emotional dysregulation since there is no consensus on what can be seen as normal.

Also the DBT skills training has been studied. In one study DBT skills training was compared to standard group therapy (SGT). This study showed a greater improvement across more psychopathology scales and higher retention rates.

Most studies are focused on measurable behavioural outcomes. Davenport et al. (2010) investigated changes in personality pre- and post-DBT. Their approach was based on the five-factor model of personality traits. The hypothesis that those who had not undergone DBT were under-controlled when compared with post-treatment participants was shown to be correct. The pre-treatment group also had higher scores for neuroticism and lower consciousness and agreeable mean scores compared with the norms. The post-treatment group had higher consciousness and agreeableness scores. However, there was no significant difference between pre-and post-treatment extraversion and neuroticism scores. This lack of change on neuroticism between pre- and post-treatment is in line with Linehan’s biopsychosocial theory.

Cochrane reviews have shown that if the individual with BPD complied to his/her treatment plan, there was a reduction in anxiety, depression, self-harm, hospital admission and use of prescribed medication. However, the studies included were too small and there are too little conducted to provide full confidence in their findings.

Discussion

DBT is the most often chosen treatment at the moment but this is also because most of the research focuses on DBT rather than on other treatments. Other treatments are not necessarily less effective but are less often studied. The studies always investigate women, therefore, it is not generalizable to men. Other therapies could be, among others, manual-assisted cognitive therapy (MACT), cognitive analytic therapy or interpersonal therapy.

At this moment more research is conducted on DBT in individuals with BPD who have also other psychological problems, such as eating disorders or depression. Adapted forms of DBT or parts of it might be effective in treating disorders such as bipolar disorder or dementia.

The training of the therapists is fundamental to the success of the therapy. DBT skill training can also be of advantage for staff who reported personal changes. This training can also improve pessimistic attitudes toward individuals with BPD, which will of course have a positive effect on the client.

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