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Dialectical Behavior
Therapy (DBT) for
Borderline Personality Disorder
By Marsha Linehan,
Ph.D.
From The Journal, March 1, 1997, Vol. 8/Iss. 1
MARSHA
M. LINEHAN, Ph.D. is the originator of Dialectical Behavior Therapy
and is a professor in the Department of Psychology at the University
of Washington.
NOTE: Writing of
this manuscript was partially supported by grants MH34486 and
DA08674 from the National Institutes on Mental Health and Drug
Abuse, respectively, Bethesda, Maryland.
Borderline personality disorder
(BPD) represents a major health problem for the 1990s and beyond. It
is a prevalent disorder that is severe, chronic, and persistent. The
number of individuals meeting criteria for the disorder is high,
approximately 11% of all psychiatric outpatients and 20% of
psychiatric inpatients. In addition to being prevalent, follow up
studies consistently indicate that the diagnosis of BPD is chronic.
Between 57 and 67% continue to meet criteria four to seven years
after the first diagnosis and up to 44% continue to meet criteria
fifteen years later.
The severity of BPD is perhaps best
seen in the high mortality rate of the disorder. Approximately 10%
of BPD patients eventually die by suicide. The suicide rate is much
higher among the 36 to 65% of BPD individuals who have attempted
suicide or otherwise injured themselves intentionally at least once
in the past. Looking at suicide rates from the reverse angle, 12 to
33% of all individuals who die by suicide meet criteria for BPD. The
emotional costs of BPD are enormous. BPD individuals describe
chronic feelings of anger, emptiness, depressions and anxiety. They
experience extreme frustration and anger, and occasionally
experience brief psychotic episodes. They describe chaotic
relationships and "confused identities." Even among those who have
not attempted suicide, suicide ideation is common. The quality of
life ratings for some of the problems frequently experience by BPD
individuals suggest that their quality of life is amongst the
lowest.
At present there are very few
treatments with proven efficacy in treating BPD individuals. In
summarizing the findings of pharmacological treatment studies, Paul
Soloff, M.D., concludes that pharmacotherapy effects, while
clinically significant, are nonetheless modest in magnitude. The
empirical evidence supporting psychosocial treatments for BPD is
similarly meager. This poses a special problem because even when
effective pharmacotherapy is given, the complexity and severity of
BPD dictates concurrent psychotherapy. To date cognitive-behavioral
therapy (specifically, Dialectical Behavior Therapy or DBT) is the
only treatment that has been shown in controlled clinical trials to
be effective treating BPD.
Dialectical Behavior Therapy:
Foundations
DBT is based on a model suggesting
that both the cause and the maintenance of BPD is rooted in
biological disorder combined with environmental disorder. The
fundamental biological disorder is in the emotion regulation system
and may be due to genetics, intrauterine factors before birth,
traumatic events in early development that permanently affect the
brain, or some combination of these factors. The environmental
disorder is any set of circumstances that pervasively punish,
traumatize, or neglect this emotional vulnerability specifically, or
the individual's emotional self generally, termed the invalidating
environment. The model hypothesizes that BPD results from a
transaction over time that can follow several different pathways,
with the initial degree of disorder more on the biological side in
some cases and more on the environmental side in others. The main
point is that the final result, BPD, is due to a transaction where
both the individual and the environment co-create each other over
time with the individual becoming progressively more emotionally
unregulated and the environment becoming progressively more
invalidating.
Emotional difficulties in BPD
individuals consists of two factors, emotional vulnerability plus
deficits in skills needed to regulate emotions. The components of
emotion vulnerability are sensitivity to emotional stimuli,
emotional intensity, and slow return to emotional baseline. "High
sensitivity" refers to the tendency to pick up emotional cues,
especially negative cues, react quickly, and have a low threshold
for emotional reaction. In other words, it does not take much to
provoke an emotional reaction. "Emotional intensity" refers to
extreme reactions to emotional stimuli, which frequently disrupt
cognitive processing and the ability to self soothe. "Slow return to
baseline" refers to reactions being long lasting, which in turn
leads to narrowing of attention towards mood congruent aspects of
the environment, biased memory, and biased interpretations, all of
which contribute to maintaining the original mood state and a
heightened state of arousal.
An important feature of DBT is the
assumption that it is the emotional regulation system itself that is
disordered, not only specific emotions of fear, anger, or shame.
Thus, BPD individuals may also experience intense and unregulated
positive emotions such as love and interest. All problematic
behaviors of BPD individuals are seen as related to re-regulating
out of control emotions or as natural outcomes of unregulated
emotions.
Dialectical Behavior Therapy: The
Treatment Model
DBT assumes the problems of BPD
individuals are twofold.
First, they do not have many very
important capabilities, including sufficient interpersonal skills,
emotional and self regulation capacities (including the ability to
self regulate biological systems) and the ability to tolerate
distress.
Second, personal and environmental
factors block coping skills and interfere with self regulation
abilities the individual does have, often reinforce maladaptive
behavioral patterns, and punish improved adaptive behaviors.
Helping the BPD individual make
therapeutic changes is extraordinarily difficult, however, for at
least two reasons. First, focusing on patient change, either of
motivation or by teaching new behavioral skills, is often
experienced as invalidating by traumatized individuals and can
precipitate withdrawal, non-compliance, and early drop out from
treatment, on the one hand, or anger, aggression, and attack, on the
other. Second, ignoring the need for the patient to change (and
thereby, not promoting needed change) is also experienced as
invalidating. Such a stance does not take the very real problems and
negative consequences of patient behavior seriously and can, in
turn, precipitate panic, hopelessness and suicidality.
It was the tension and ultimate
resolution of this essential conflict between acceptance of the
patient as he or she is in the moment versus demanding that the
patient change this very moment that led to the use of dialectics in
the title of the treatment. In DBT, treatment requires
confrontation, commitment and patient responsibility, on the one
hand, and on the other, focuses considerable therapeutic energy on
accepting and validating the patient's current condition while
simultaneously teaching a broad range of behavioral skills.
Confrontation is balanced by support. The therapeutic task, over
time, is to balance this focus on acceptance with a corresponding
focus on change. As a world view, furthermore, dialectics anchors
the treatment within other perspectives that emphasize:
the holistic, systemic and
inter-related nature of human functioning and reality as a whole
(asking always "what is being left out of our understanding here?");
searching for synthesis and balance, (to replace the rigid, often
extreme, and dichotomous responses characteristic of severely
dysfunctional individuals);
enhancing comfort with ambiguity and change which are viewed as
inevitable aspects of life.
DBT is designed to address the
following five functions of successful treatments:
-
capability enhancement,
-
motivational enhancement,
-
enhancement of generalizations
of gains,
-
enhancement of capabilities and
motivation of therapists,
-
structuring of the environment
to support clinical progress.
Capability Enhancement
focuses on increasing behavioral and self regulation. All patients
in DBT receive psycho-educational skills training in five areas:
mindfulness (to improve control of attention and the mind),
interpersonal skills and conflict management, emotional regulation,
distress tolerance, and self management. Medications are also used
here for enhancing the individual's ability to self regulate
biological systems.
Motivational Enhancement
focuses on making sure that
clinical progress is reinforced (rather than punished), that
maladaptive behavior is not reinforced, and on reducing other
factors (such as emotions or beliefs) that inhibit or interfere with
clinical progress. Generally, this requires intensive (at least
weekly sessions of one to one and a half hours) individual therapy.
The full range of effective cognitive and behavioral therapies are
integrated into the treatment targeting in order of importance:
reducing suicidal and other life threatening behaviors; reducing
therapy-interfering behaviors (including non-compliance and dropping
out of treatment); reducing sever quality of life interfering
behaviors (including Axis I disorders, such as depression and eating
or / and substance abuse disorders); increasing skillful coping
behaviors, including distress tolerance emotion regulation,
interpersonal effectiveness, and mindfulness; reducing traumatic
emotional experiencing, including post-traumatic stress responses
(for example, continuing reactions to childhood trauma); enhancing
self-respect and mastery and reducing problems in lying; and
resolving a sense of incompleteness.
Enhancing Generalization.
Learning to be effective in a therapist's office or an inpatient or
residential setting is useless if the new behaviors do not
generalize to the patient's everyday life settings. The third task
of therapy, therefore, is to ensure generalization of new behaviors
to the natural environment. In DBT this is generally done by phone
consultations between patient and individual therapist. In
inpatient, residential, and day treatment settings this might be
done by on site consultants with "office hours" for skills
consultation.
Enhancing Therapist's Capability
and Motivation. An effective
treatment is useless if the therapist is unable or unmotivated to
apply the treatment when it is required. Enhancing the therapist's
capabilities and motivation to treat effectively is an unrecognized
but essential part of any treatment program. In DBT, this function
of treatment is met by weekly team consultation meetings of all DBT
therapists. The goal of these meetings is to provide consultation
and support for therapists in their attempts to apply DBT.
Treatment strategies are divided
into four main groups as follows. Dialectical strategies consist of
balancing acceptance and change in all interactions, always
searching for a synthesis and looking to shift the frame of problems
that resist solution. DBT core strategies require the balancing of
validation with problem solving. Validation consists of a set of
strategies emphasizing acceptance and validation of the patient by
listening empathetically, reflecting accurately, articulating that
which is experienced but not necessarily said, clarifying those
disordered behaviors that are due to disordered biology or past
learning history, and highlighting those behaviors that are valid
because they fit current facts or are effective for the patient's
long term goals. The essence of validation is seeing and responding
to the patient as a person of equal status and value. Problem
solving strategies are designed to assess the specific problems of
the individual, figure out what factors are controlling or
maintaining the problem behaviors, and then systematically applying
behavior therapy interventions.
Structuring the Environment.
If the environment continues to reinforce problematic and borderline
behaviors and punishes clinical progress, then it is useless to
expect that treatment gains will be maintained once treatment is
ended. Thus, if treatment is to end, the therapy must assist the
patient in developing an environment that is maximally supportive of
clinical gains. It is equally important that the therapist focus on
providing a treatment atmosphere that encourages progress and does
not encourage relapse. Family sessions and case consultation
meetings with other therapists (always with the patient present)
serve this function in DBT.
Dialectical Behavior Therapy:
Effectiveness
DBT has demonstrated effectiveness
in two controlled randomized clinical trials. In the first study
conducted by myself and my colleagues at the University of
Washington, 47 chronically suicidal BPD patients were randomly
assigned for a year either to DBT or to referral to treatment as
usual in the community. During the year, DBT patients were less
likely to attempt suicide or drop out (84% remained in treatment).
They spent much less time in psychiatric hospitals, had greater
reductions in use of psychotropic medications, and were better
adjusted at the end of the year. They were also less angry than
patients given standard psychotherapy (although at one year not less
depressed or less likely to think about suicide). Most of these
differences persisted a year after treatment ended.
It could be argued that DBT patients
had a better outcome simply because they received more psychotherapy
than the others. But DBT proved to be more effective even after
researchers corrected for the amount of time spent with
psychotherapists, and even after they excluded patients who received
no individual psychotherapy. We are now conducting a large
randomized clinical trial of DBT with a new group of therapists and
patients. Preliminary results suggest that DBT is effective in this
replication study as well.
In a just completed study here at
the University of Washington, 23 drug abusing BPD women were
assigned to DBT or to referral to treatment as usual in the
community. At the end of the one year treatment, use of illicit
drugs was lower and attendance at treatment was higher in the
patients who got DBT versus those referred to treatment as usual in
the community. In several studies researchers at other institutions
have partially replicated our results. They have found less suicidal
behavior among patients given DBT than among similar patients given
a different treatment. These were not true controlled studies,
however, since the patients were not assigned to treatment condition
(DBT versus non-DBT treatment) at random. Thus, it will be very
important to replicate these studies using more rigorous research
methods.
The intense suffering that
accompanies borderline personality disorder, both for the patient
and for the community surrounding the patient, suggest that a high
priority must be put on both developing new more effective
treatments and on dissemination of those that are currently
available. This is especially true in community mental health where
in some states the lack of improved outcomes with some treatments
have led those controlling reimbursement to refuse to treat or pay
for treatment for BPD patients. Although a case might be made for
some that an ineffective treatment is more harmful than no
treatment, the same cannot be said for treatments that have been
shown to be effective in rigorous clinical trials.
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