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Borderline personality disorder (BPD) is a severe and chronic mental health illness, which can be described as the inability to regulate emotions and control impulses (). Individuals may also have poor interpersonal skills, self image, a high level of disturbed cognitions and suicidality. The disorder which causes severe psychosocial impairment affects 1-2% of the general population, with 60- 70% of individuals with BPD will attempt suicide and 80% will intentionally self harm. BPD patients therefore require a high interaction with mental health services, with 10% of psychiatric inpatients and 20% of outpatient suffering from BPD. The disorder has also been shown to have a high frequently of co-morbidity, which can lead to poorer outcome in treatment in mental health services.
With BPD being a difficult disorder to treat with a high level of contact with mental health services has Dialectical Behaviour Therapy (DBT) become a “cult” for clinicians, with the ideology of the treatment model surpassing the effects on symtomatology and the empirical evidence? Should the model of treatment be held to a higher standard than other therapies specifically designed for BPD such as mentalization psychotherapy, transerference focused psychotherapy, schema-focused psychotherapy, CAT general psychiatric management and systems training for emotional predictability and problem solving (Wieniberg, Ronninstam, Goldbatt, Schechter and Maltsberger, 2010)? To address these questions the model’s application to the disorder and the empirical research which underpins its gold standard appearance needs to be observed.
DBT was initially formulated as a treatment for emotionally dysregulated and impulsive disorders such as BPD and for patients who had para-suicidal tendencies (). The DBT model comprises of an amalgamation of bio-social theory of BPD and diathesis therapy. The approach to therapy consists of persuasive dialogue and relationships to effect change in individuals with BPD and it observes the immediate and larger context of behaviour displayed by the individual (). The ideology of the therapy is to focus the individual attention to deal with the multiple co-existing tensions that must be dealt with treating the multi-disordered patients, whilst also dealing with the individual’s behavioural styles and responses to therapy. Diathesis allows for a greater insight into the relationship which is created between the client and the therapist; which is an important aspect to the effectiveness of treatment when dealing with BPD and suicidality. The main aim of the intervention is to create a life worth living for individuals with BPD (Linehan, 1993).
Bio-social theory suggests that BPD symtomatology (specifically the inability to regulate emotions and behaviour) may be caused by an invalidating rearing environment and a biological emotionally vulnerability (). Longitudinal studies have consolidated this theory with research showing that genetics can cause a predisposition to emotional vulnerability and in conjunction with early childhood experiences can predict BPD symtomoatology developing further. Genetics and adverse childhood experiences might cause emotional deregulation and impulsivity leading to dysfunctional behaviours and psychological conflicts and deficits. Linehan () suggested that BPD that may be consequence of an emotionally vulnerable individual growing up with a particular set of environmental circumstances which she refers to as the invalidating environment. Several studies have suggested that early abuse and neglect can be a predictive factor for the development of adult BPD due to disruptive attachment and associated self-other representations.() Linehan incorporated these ideologies into the framework of the treatment and interaction importance of the therapist and client.
These philosophies and theories encapsulating BPD give the foundation to the DBT model and allow for the implementation of the structure and format of the extensive treatment model. The treatment utilises a combination of CBT enhanced techniques, mindfulness and an acceptance based focus to help shape and re-enforce adaptive behaviours and responses to emotions and situations whilst creating a validating therapeutic environment().
DBT is one of the only psychosocial interventions for individuals with BPD to utilise an adaptation of mindfulness mediation. The tool is utilised to help individuals improve their ability to attention to and control(). Linehan (2001) researched formal mindfulness meditation (e.g. sitting meditation) as an adjunct to treatment as usual tool for individuals suffering from high levels of suicidality. She found however that the activity was shown to be unsuccessful as it cased caused high levels of distress or behaviour dyscontrol. Research has shown that extensive formal mediation can be contraindicated for BPD individuals, it allows for thought and distorted cognitions to be left active and unsuppressed in the mind casing of negative affect intensity and reactivity in BPD symtomatology. (Rosenthal, Cheavens, Lejnez & Lynch ) Linehan (1993) created a more accessible and less problematic form of mindfulness for BPD individuals (Linehan, 1993a) creating a set of thought skills independent of the formal mindfulness meditation form of practice.
Psycho-education in a group setting is also an important aspect of DBT. Individual’s are educated in four areas which are mindfulness mediation, emotion regulation, distress tolerance and interpersonal effectiveness. Emotion regulation is designed to assist the individual to “understand the role of emotion in life, identity and label emotions accurately, reduce vulnerability and suffering associated with negative emotions and tolerate and / or change negative emotions” (Linehan). Distress tolerance is an important area for individuals with BPD as it educates on interrupting crises (which also happens in individual sessions during chain analysis), counter balancing impulsiveness and helps aid discovery of individuals ability to tolerate intense emotions and situations. The module helps to facilitate the learning of tools which will assist individuals to not engage in dysfunctional behaviours that exacerbate the situation or negative emotions” (Linehan, 1993). Interpersonal effectiveness is used to help the individual achieve interpersonal objectives without damaging the relationship or the persons self respect (Lienhan,). The functions of skills taught in DBT are designed to help individuals understand, obtain and advance specific behavioural and emotional responses and patterns experienced in everyday life.
Important aspects of DBT as a treatment model for BPD are attention affect, on treatment and the importance that is placed on the therapeutic relationships. Attention affect is an important aspect due to the high levels of emotional pain felt by borderline individuals (Sanislow, Grilo, Morey, et al, 2002) and emotional dysregulation (Zanarini, Frankenburg, DeLuca et al, 2002). DBT is one of the only intervention for borderline that offers formal exposure to different emotions. The important focus on treatment relationship is consistent with attachment insecurities of BPP patients and difficulty developing and sustaining treatment alliance in treatment for BPD (Sanislow, Grilo, Morey et al, 2002). This relationship between the therapist and the individual with BPD is an extremely important aspect of DBT and can also be see in some other therapies such as MBT, both individuals play an active role in the treatment progress. The clear treatment framework makes an intervention work and an active therapist can contain emotional storms, set limits on maladaptive behaviour or image in real relationships. A clear treatment plan is a large aspect of DBT which is incorporated into the highly boundaryed approach with patients.
The combination of a highly structured manual, a highly guided content, and an indepth understanding of BPD creates the foundation for an intrigel treatment model. DBT is considered the recommended treatment by the APA 2001 and the UK department of health (NIMH, 2003). It is also the most empirically established treatment for BPD. The model is also endorsed by the Irish expert group on mental health “Vision of Change” (6006) and more recently by the NHS national institute for health and clinical excellence (NICE) 2009 as being part of a comprehensive treatment programme for persona with BPD and co-morbidity presentations.
DBT is noted to be an intervention with growing of research base that demonstrates its effectiveness in treating BPD individuals (Brassington & Krawitz, 2006, p313. To date a number of RCT trials of DBT have be completed (E.g Bohus et al., 2004; Koones et al., 2001; Soler et al., 2009; Verheul at al., ), these trails have found a reduction in suicidal behaviours, intentional self injury, depression, hopelessness, anger, eating disorders, substance abuse and impulse reactivity. Furthermore they have found an increase in adjustment (general and social), and in positive self-esteem (Linehan, 2010).
A number of these RCT have compared DBT to treatment as usual (TAU) (Linehan et al, 1991,1993,1994; Koons et al, 2001) for individuals with BPD and suicidal tendencies. These studies have shown clinical significant advantages to utilising DBT over treatment as usual for BPD. The research studies showed a reduction in self injury rate and associated medical risk, total psychiatric inpatients hospital days, treatment drop out and anger. However a large majority of the studies could not be generalised as the population consisted of BPD inpatients but showed high efficiency.
Turner (2006) performed an RCT observing DBT and client centred therapy (CCT), this is a psychodynamic treatment. Both interventions showed improvement however the results strongly favoured DBT over CCT. Significant results were found between group in relation to suicidality, affective dysregulation, global mental health functioning, anger, depression and impulsiveness. Other research has shown that DBT can still have high affectivity when dealing with BPD and the high levels of co-morbidity for example Verheul et al (2003) that DBT was as effective with or without the presentation of substance abuse. Previously high level of co-morbity has been shown to have a poor effect on positive effect on symtpomaltoy.
A large amount of previous research observing the effectiveness of DBT consisted of inpatient with BPD, therefore Linehan et al (2006) decided to observe the effectiveness of DBT compared to community treatment by psychotherapy experts in suicide and BPD. Both conditions showed substantial improvement, the DBT group generally exhibited better treatment responses, particularly on outcome related to behaviour specifically targeted by treatment. Subjects assigned to DBT intervention were half as likely to attempt suicide then those assigned to CTBE.
An important aspect of the research was the data that showed the effect that DBT has upon the mental health service. During the year CTBE patients were twice as likely as DBT subjects to visit the emergency room for SI (33.3% CTBE v 15.6 DBT) and they were three times more likely to be admitted for SI (35.6% CTBE v 9.8% DBT) (Linehan et al, 2006b) DBT used significantly fewer crisis services (e.g psychiatiric emergency room visits and inpatient admissions) then CTBE. BPD have been shown to a high level of interaction with mental health services which can cause pessisium and prejudice towards the disorder and burnout of clitions (Swenson, Torrye, Koner, 2002). Therefore DBT is not only helping the individual but the disorder in the relam of the services that the individual come in contact with.
Wienberg, Ronningstam, Goldblatt, Schechter, Maltsberger, 2011 observed the common factors in empirically supported treatments for borderline which are DBT, metallization- based psychotherapy, transference-focused psychotherapy, schema focused psychotherapy, general psychiatric management, systems training for emotional predictability and problem solving. The research observed the treatment in 12 categories, multimodal treatment, clear treatment framework, explicit target behaviour, attention to affect, focus on treatment relationship, active therapist, interpretations, exploratory interventions, supportive interventions, change-orientated interventions, support for therapist and attention to functioning.
The manuals of the interventions were compared and reared using the following rating system, -2 was given score if a intervention contraindicated in a manual, if categories was not in the manual it was given a 0, if the intervention was somewhat or apssongly described it was cored with a 1. If it was distinctly present, it was scored 2. When the intervention was emphasized as important it was given a 3. The study showed that DBT gained a score of 3 of 11 of the categories and received a -2 for interpretations. DBT similar to MBT discourages the use of interpretations for example making unconscious content conscious. Some of the areas that DBt scored higher then other specific borderline treatments were active therapy which is not an aspect of STEPPS and support for therapist which is not aspect of TFP.
DBT, however some researchers have suggested that there is some encouraging and some not so encouraging research results which have been shown (Schell, 2000). These finding maybe due to large limitations in a muber of the DBT studies which have been performed…..
Follow ups – (lenehan et al, 1993) TAU an dDBT- 39 patients were followed up after participating in research – were followed up at 6 and 12 months postreatment for parasuicidal behaviours (allsubjects and inpatient hopsitaliazation and social emotional functiong.
Reluctance of patients to come to follow up interview reduced number
DBT showed significantly fewer parasuicidal episodes and fewer medically treated episodes at six months
At 12 months there was no significant difference, this suggested to be related to small statistical power related to the small sample.
Further analysis controlling for variables may increase validity (Linehan, Heard and Armstrong, 1993)
However large meta analysi have found from published empirical articles..results across studies, with outpatient DBT lesser parasuicidal thendency behaviour, psychiatric hospitilisation, anger and psychotropic medication usage, increased functioning and social adjustment.
Some inpatients published studies have found no significant effect however small numbers and more severly dysfunctional treatment groups despite RCT, in need of more research (Springer & Silk, 1996)
Therapist – supervision and motivation may contribute to outcome (Hoffman, 1993) – however this was counteracted by Lienehan who presented research compaing TAU ad DBT clients did not differ in their ratings of their therapist healfulness, DBT and TAU therapist did not difer in rating of interest or caring however DBT displayed significant better results in improvement of symptomatlogy.
Fewer psychicatic h Ospitilization days then TAU – a valauable outcome however can also be misleading giving the appearance that high functioning clients –
DBT see hosptilation as a therapy interfering behaviour, re-enforcing parasuicial behaviours and support theough individila therapy, chain analysi and 24 hour fone contact with therapist.
Should be interprested not in iolation as an outcome of clients functioning but an indication that programme is being aheard to.
Generalization and relaiability of DBT – small groups a lot use 24 particpants or less even tho low statistical power with small group there is still significant power results consistently shown increasing the roubustness of the intervention.
Repition and larger numbers needed
Participants largely femal with BPD anh high levels of dysfunctional behaviour.
More work need to be doen on less severe patients and out-paitents to increase generaliability
Lenihan has been a large contributer to the research which has been peformed to observe effectivenss this may have lead to inadvertent experiemtn bias
DBT differential effectiveness has not been established, clinmtions must weigh the empirical support and limitations presented for DBT, as well as treatment philosophy and fit questions that go beyond the research base, against their empirical and experimental knowledge o fthe support and limitation of other approaches. The weighting these factors will vary, depending on particular clientel, practice setting and training approach.
DBT is almost clearly a treatment for reducing parasuisicd by women with BPD and without speicifc other comorbid conditions. Utilising DBT with clients who do not fit this clinical picture should be considered experimental. The imprived social-emotional function of DBT subjects does suggest that DBT might be useful with nonparasuicidal BPD clients??….
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