Q. I am the director of a large community psychiatric rehabilitation center in Mexico, MO. We serve approximately 325 clients with serious and persistent mental illness, some of whom are diagnosed as having BPD. One of the communities we serve has a large state-operated psychiatric hospital that is being converted to a primarily forensic facility. There will only be a few usable beds for non-forensic persons. They have invited us to participate in a training for DBT and are wanting us to use a pure DBT approach. The structure of our system is such that most of our clients do not qualify for out-patient therapy and have not historically improved in our rehab community support approach focused in bachelor level case workers with master level supervisors. While there are none of our supervisor's who don't believe that we could benefit from the approach, they are very hesitant to lock ourselves into a pure DBT approach stating that it is not researched for the specific population that we serve who all have co-occurring axis I diagnoses. The psychologist from the state-operated facility states that DBT is the only non-medication approach that has been documented to have a higher efficacy than other approaches. Our staff have countered that the initial results of the Linehan study have not proven to be long-term. That relapse rates have been high and the initial enthusiasm for this approach may have been overstated. They also stated that early DBT studies were focused on mostly middle-class white women who still had some support systems in place. The population that we are talking about are persons whose behavior has resulted in very long-term state hospitalizations. They are somewhat suspicious of the state's long-term commitment to funding intensive out-patient therapy (they may be dumping to move the risk to someone else, i.e. a community mental health center). My staff want to participate in DBT training (some have already attended one-day trainings) and others have attended Nancy Blum's (University of Iowa) STEPP training and believe a more eclectic approach is a better approach since many of our clients and potential clients have few family or community support systems.

A. You probably know the literature on DBT better than I do. The initial reports with DBT were very exciting and promising, but the initial hope seems to have dissipated when reality is examined. There is little doubt that DBT therapy can be an important component of treating BPD, but it is a component, and at best a marginally proven one.

There is overwhelming controlled data that pharmacological interventions benefit many patients with BPD. Likewise, there is abundant neurochemical data that BPD is accompanied by biological changes in a number of neurotransmitters, hormones, and receptors in the brain. While one may argue over the cause of these anomalies--genetic, social, traumatic, learned, combinations of all of these, etc. -- the bottom-line is we need to treat these folks. To an extent the cause of the BPD becomes a pedantic exercise. When you have a sick patient, it is imperative to relieve their suffering safely, quickly, and appropriately. If therapy with DBT is as effective as initially stated, its use would be growing by leaps and bounds. Its a good form of cognitive therapy, but it is not the brass ring we are all looking for. Likewise, the medications are not either. Both are options which should be made available to all patients. To offer only one, especially when data is unequivocal on the benefits of pharmacotherapy, is malpractice.

I empathize with your situation. The patients you are treating are not middle class housewives from Seattle. They are chronic, lower socioeconomic, treatment refractory, and probably disenfranchised individuals. You need to keep these realities in mind when you are treating as far as goal setting. When I first took a golf lesson a few years back, my pro watched me hit about 30 balls, and said, "If you want to play at about a 12 handicap, we can do that. If you see yourself as a scratch golfer, get another pro." Most honest assessment of my ability to date (14 handicap). Your patients will never be scratch golfers. They have a huge handicap, literally and figuratively, and will be lucky to be mainstreamed. Many will never be able to leave your facility. That is okay though. Most patients usually tell you what they want, and that is what you need to shoot for. It could be getting a GED, getting a college degree, or it may be just being well enough to live in a group home. Make sure its what the patient has aspirations to do. All too often I see therapists acting out their own what is God's vs. Caesar's issues through a patient. Make a realistic assessment of their abilities and help get them there. Know a 40 handicap from a 20 from a 10 and the rare scratch handicap. The forty handicap will never be a 10 if the nervous system will not allow it.

Since BPD is likely a number of different maladies, like diabetes, all lumped together because of similar behaviors, it is foolhardy to think any single approach is the answer. The more options we can provide patients to get well, the better their chances of improving. As strong as my belief in pharmacotherapy, I will not treat patients not engaged in therapy. Just as you need to fix what is physically wrong in diabetics, or broken bones, or heart by-pass patients before doing therapy, you still need the therapy to maximize recovery. What to eat and when in diabetics, muscle strengthening once the cast is off and the broken bones heal, and jogging after the by-pass, are all imperative for full recovery. All are done after you fix the physical malady. If BPD is biological, and the data strongly suggests to the point of near certainty that it is, talking to a physical illness is ridiculous. I have yet to see a Type I diabetic have their sugar levels reduced via talk therapy.

Keep your options open. I would have qualms as to the abilities of any director who hitches his or her star to only one form of treatment. DBT may work, but it sure as heck will not work in everyone. Multiple options, especially those proven, seem to make the most sense.