McLean Hospital Psychiatric Update
A practical resource for the busy clinician
Volume 1, Issue 3

A Promising Treatment for Borderline Personality Disorder

Dialectical Behavior Therapy, often referred to as DBT, is an empirically researched psychotherapeutic treatment developed by Dr. Marsha Linehan, Professor of Psychology, University of Washington, for patients struggling with chronic suicidality, intentional self-harm and borderline personality disorder (BPD). This therapy, employing cognitive and behavioral principles, is rapidly becoming a standard for treating borderline patients in both this country and abroad. DBT consists of two primary components involving individual psychotherapy once a week and a weekly skills training group. Additionally, patients are offered telephone consultations with their individual therapist as needed.

Biosocial theory. DBT is based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation. The disorder is characterized by heightened sensitivity to emotion, increased emotional in-tensity and a slow return to emotional baseline. Characteristic behaviors and emotional experiences associated with BPD theoretically result from the expression of this biological dysfunction in a social environment experienced as invalidating by the borderline patient. 

Although there are many examples of invalidating environments, all share three characteristics: (1) individual behaviors and communications are rejected as invalid; (2) emotional displays and painful behaviors are met with punishment that is erratically administered and intermittently reinforcing; (3) the environment oversimplifies the ease with which problems may be solved and needs met. Most of us have encountered such environments at some point in our lives and we commonly deal with them by changing our behavior to meet expectations, or by changing the environment so that it is no longer invalidating, or, ultimately, by simply leaving the environment. The dilemma for the borderline patient occurs when the individual is unable to meet expectations, cannot change the environment or cannot leave, thus experiencing what has been called a "double bind."

Treatment. The primary dialectic that defines the core treatment strategies in DBT is the tension between acceptance of the patient and the expectation that the patient needs to change. Acceptance strategies, drawn from Zen practice, involve emotional, behavioral and cognitive validation as well as teaching the patient personal strategies for validation. One example of a validation strategy would be recognizing how self-mutilation can be adaptive (i.e., useful for regulating emotion). 

The antithesis of acceptance is the expectation of change. This expectation is embodied in behavioral therapy with its emphasis on problem solving, rationality, logic and gaining knowledge by testing hypotheses. Strategies for promoting change include problem solving, contingency procedures, skills training, exposure and cognitive modification. 

An example of a problem-solving procedure is the use of a "chain analysis" to diminish cutting (self mutilation) behaviors. A chain analysis reviews the environmental and personal antecedents and consequences of the cutting behavior in mi-nute detail. An important goal of this procedure is to identify points during the chain of events when the borderline patient has an opportunity to do something different. This sets the stage for the patient to avoid the problematic behavior in the future.

DBT is organized along a fourfold hierarchy. The first priorities are suicidal or parasuicidal behaviors and ideation. The second priorities are behaviors that interfere with therapy. Third is behavior that interferes with quality of life. The fourth priority of DBT addresses skills deficits commonly found in individuals with BPD. 

The goals of skills training are to change behavioral, emotional and thinking patterns that cause personal misery and in-terpersonal distress. Specific goals include reducing dysregulation while increasing adaptive (i.e., more regulated) behaviors. Patients are taught to attend to the moment without judgment or impulsivity, a quality Dr. Linehan describes as "core mindfulness." Newly learned skills enable patients to improve emotional, cognitive and interpersonal functioning.

Empirical results. DBT was compared to treatment as usual (TAU), typically consisting of psychopharmacological treatment and intermittent supportive psychotherapy. In a landmark study, Linehan and colleagues found the following:

1. Compared with TAU, subjects assigned to DBT had significantly fewer and less severe parasuicidal behaviors during the treatment year. These results were obtained even though DBT was no better than TAU at improving self-reports of hopelessness, suicide ideation or reasons for living.

2. DBT was dramatically more effective than TAU in limiting treatment drop out, the most serious behavior interfering with therapy. At the end of one year, only 16.4 percent of DBT patients had left treatment. In contrast, approximately 50 percent of TAU patients had dropped out.

3. Subjects assigned to DBT had a tendency to enter psychiatric inpatient units less often and had fewer inpatient psychiatric days. Those in DBT had an average of 8.46 inpatient days over the year compared with 38.86 inpatient days for subjects receiving TAU. This finding suggests that DBT is cost effective.

4. DBT subjects rated themselves as more successful at changing their emotions and improving general emotional control. They also had significantly lower scores on self-reported measures of anger and anxious rumination.

In a subsequent study, the standard DBT (DBT individual therapy and the DBT skills group) was compared to a once weekly individual psychodynamic therapy and the DBT skills group. This study showed that the DBT skills group lost its effectiveness when combined with individual psychodynamic therapy. This study also supported the practice of providing telephone consultations to patients between sessions when needed. To explain this point, Linehan likens life to a basketball game � having a therapist unavailable between sessions would be like a coach being unavailable during the game.

DBT is usually considered a one-year treatment. In this time, the therapy targets behaviors involving life and death, behaviors that impede therapy and activities that affect quality of life. Concurrently, the patient learns techniques taught in the skills group. This one-year treatment has been empirically validated and designated as Stage I by Dr. Linehan; she has developed sequels to this treatment that are currently being evaluated. Stage II, which is begun only after the patient has acquired the basic skills of Stage I, is based on the rationale that patients must be able to cope with the consequences of trauma and focuses on reducing posttraumatic stress. Stage III emphasizes increasing self-respect, reducing self-hatred and achieving individual goals and interpersonal connections.

Additional Reading:

Linehan, Marsha M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York:
Guilford Press.

Linehan, Marsha M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York:
Guilford Press.

Linehan, M., Asuicidal borderline patients. Archives of General Psychiatry (1991). 48: 1060-1064.

Shearin, Edward N. and Linehan, Marsha M. Dialectical behavioral therapy for borderline personality disorder:
theoretical and empirical foundations. Acta Psychiatrica Scandinavica (1994). 89 (suppl. 379): 61-68.

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This article was contributed by Elizabeth T. Murphy, PhD, and John Gunderson, MD. Dr. Murphy conducts outpatient DBT individual therapy and skills groups with patients at McLean Hospital. Dr. Gunderson is director of McLean�s Ambulatory Personality Disorder Service and Psychosocial Research Program, and is Professor of Psychiatry at Harvard Medical School.

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