RESEARCH ON DIALECTICAL BEHAVIOR THERAPY FOR PATIENTS WITH BORDERLINE PERSONALITY DISORDER

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Dialectical behavior therapy (DBT),29, 30 is a cognitive–behavioral treatment approach originally developed to treat chronically suicidal individuals. DBT has subsequently evolved into treatment for suicidal individuals who meet criteria for borderline personality disorder (BPD) and has been adapted for the treatment of patients with BPD with presenting problems other than suicidal behaviors (e.g., substance abuse). DBT combines basic behavioral procedures of skills training; exposure-based procedures; cognitive modification; contingency management; and problem solving with validation, mindfulness practices, reciprocity, and a focus on the patient–therapist relationship.

DBT is designed to be a comprehensive therapy for BPD patients at all levels of severity and complexity of disorder and is conceptualized as occurring in stages based on severity and complexity of disorder. As a comprehensive treatment, DBT serves five functions: (1) it enhances patient capabilities, (2) it improves patient motivation to change, (3) it ensures that new capabilities generalize to the natural environment, (4) it structures the environment in the ways essential to support patients' and therapists' capabilities, and (5) it enhances therapists' capabilities and motivation to treat patients effectively. In standard DBT, these functions are divided among modes of service delivery (e.g., psychoeducational skills training, individual psychotherapy).

As a treatment conducted according to stage of disorder, the primary focus is on stabilizing patients and achieving behavioral control. In stage 1, DBT addresses specific treatment targets in a hierarchical order of importance: (1) decreasing life-threatening and suicidal behaviors including parasuicide episodes; (2) decreasing behaviors that interfere with treatment, particularly noncompliance and premature dropout; (3) decreasing patterns that have a severe effect on quality of life, including Axis I problems and those that necessitate inpatient psychiatric care; and (4) increasing behavioral skills. Parasuicide is any acute, intentional, self-injurious behavior, with or without intent to die.25 Subsequent to achieving behavioral control, it becomes possible to work on other important goals, including (5) increasing emotional experiencing and resolving posttraumatic stress responses (stage 2); (6) enhancing self-respect and (7) resolving problems in living (stage 3); and (8) enhancing the capacity for joy (stage 4). Treatment manuals and all research to date focus on severely multidisordered patients who enter treatment at stage 1.

As a manualized treatment, DBT has been rapidly adopted in community mental health settings. Public mental health outpatient services often focus on the needs of schizophrenic and bipolar patients,43, 44 so DBT has been perceived as a way to improve services by specifically addressing treatment needs of patients diagnosed with BPD. Adequately addressing these needs poses several challenges. BPD is associated with worse outcomes across several Axis I diagnoses,4, 5, 24, 43 indicating that standard treatments may be less effective with this patient group. Characteristics of suicidal BPD patients (e.g., suicide attempts, threats of suicide attempts, and anger) are among the factors reported by psychotherapists as extreme stressors.20 In particular, legal and ethical concerns about patient suicide make it difficult to limit hospital use by patients with BPD who are suicidal and self-injurious,44, 14 contributing to “revolving door” use of involuntary inpatient facilities, which may result in inadvertent iatrogenic effects. The outpatient treatment option of DBT has been discussed as an ethical alternative to involuntary commitment for chronically suicidal patients.10 Consequently, because of the need of patients and mental health professionals to address these issues, dissemination of DBT proceeded quickly after initial data were published in 1991.

Implementation of DBT in community mental health settings has been described in several articles. For example, the American Psychiatric Association awarded the Community Mental Health Center of Greater Manchester in New Hampshire the 1998 Gold Achievement Award for the excellence of their small, community-based DBT program.3 Articles have also described adaptations to partial hospital programs48 and psychiatric inpatient units.6, 47 Despite the multifaceted combination of treatment strategies in DBT, evidence shows that mental health professionals outside of academic research centers can learn DBT effectively.19

Particularly because DBT has been widely adopted as the treatment of choice for chronically suicidal patients with BPD, a critical review of the available evidence for the treatment approach is warranted. This article first reviews the research to date on DBT compared with treatment as usual (TAU) and compared with more rigorous control conditions and turns to the latest findings on DBT applied in new settings and adapted for new treatment populations.

Section snippets

DIALECTICAL BEHAVIOR THERAPY COMPARED WITH TREATMENT AS USUAL

Despite its public health significance, little research is available on the psychosocial treatment of suicidal behavior, and less is available on the treatment of suicidal behavior and other severe dysfunctional behavior among patients meeting criteria for BPD.36 Therefore, the first criteria of evaluating DBT is to determine the feasibility of the treatment to work for the intended problems compared with TAU. But because by definition a naturalistic TAU control group requires investigators to

RANDOMIZED CLINICAL TRIALS OF DIALECTICAL BEHAVIOR THERAPY VERSUS MORE RIGOROUS CONTROL CONDITIONS

Preliminary findings from two additional randomized clinical trials underway at the University of Washington have been reported.32, 33 In these studies, Linehan et al32, 33 evaluated the efficacy of DBT by comparing it with more rigorous control conditions developed specifically to maximize internal validity and to control for effects on clinical outcomes by factors not controlled for in previous DBT studies.

In a replication study32 treating individuals with BPD and parasuicidal behavior, DBT

RESULTS FROM EFFECTIVENESS STUDIES: QUASIEXPERIMENTAL DESIGNS AND NONSTANDARD DIALECTICAL BEHAVIOR THERAPY

Several quasiexperimental studies from program evaluations, pilot studies, and preliminary work as part of randomized clinical trials have been presented, expanding the research base on the efficacy of DBT in other settings compared with different controls or extended to different treatment populations. Often, these studies do not investigate comprehensive standard DBT but rather investigate a component of the comprehensive package or a modification of standard components. Consequently, the

DATA ON MECHANISMS OF CHANGE IN DIALECTICAL BEHAVIOR THERAPY

A few studies provide data regarding mechanisms of change in DBT. Conducted simultaneously with the first randomized clinical trial, Linehan et al29 investigated the effectiveness of a DBT skills-training group (GST) alone (i.e., without individual psychotherapy, skills coaching, or a therapist consultation team). Suicidal women with BPD (n = 19) were referred by their current and continuing non-DBT individual counselors or psychotherapists for DBT skills training and were randomly assigned to

SUMMARY

Research evidence to date indicates that, although DBT was developed for the treatment of patients with suicidal behavior, it can be adapted to treat BPD patients with comorbid substance-abuse disorder and be extended to other patient populations and the treatment of other disorders. Across studies, DBT seems to reduce severe dysfunctional behaviors that are targeted for intervention (e.g., parasuicide, substance abuse, and binge eating), enhance treatment retention, and reduce psychiatric

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