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The Outcomes for Dialectical Behaviour Therapy, Research Paper Example

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Research Paper

Introduction

Borderline personality disorder (BPD) is a disorder of the personality and emotions that can be quite debilitating to those who are afflicted by it, as well as challenging to treat. BPD patients experience a great deal of instability in their emotional and thought lives, and this spills over to their identity, their relationships, and their behaviour more generally (Chapman and Gratz 2007 pp. 15-16). They frequently have strong fears of abandonment, a poor sense of self, and struggles with depression, anger, and other negative emotional symptoms. Treating BPD has often entailed some use of pharmacotherapy, but psychotherapy is widely recognized as not only efficacious but necessary as well.

Two of the major therapies in use are cognitive behavioural therapy (CBT) and dialectical behaviour therapy (DBT), both of which aim to help patients address their behaviours by understanding them in context, analyzing them, and learning to overcome them by distancing themselves and, in effect, stepping outside of the behaviours. The key difference is that DBT draws upon Zen Buddhist influences as well, and promotes an emphasis on the dialectic. Analyzing the efficacy of these two therapies is therefore of considerable interest for clinical practice.

Accordingly, the following research strategies were used: first, an online search of Google Books for texts concerning BPD, CBT, and DBT. The key emphasis here was on obtaining helpful information from the field about the disorder and these two treatment strategies, and how they are related. Secondly, the database EBSCOHost was searched, using a variety of keywords pertaining to BPD, CBT, and DBT, and articles were selected based on dealing with BPD and, in general, at least one of the two strategies.

Borderline Personality Disorder: History, Features, Aetiology

The historical roots of the borderline personality disorder diagnosis lie with the view, prevalent as far back as the nineteenth century, that psychiatric disorders could be typified according to two major categories: neurosis and psychosis (Chapman and Gratz 2007 p. 15). Then as now, neurosis was used to designate patients with a grasp of reality, but who had such emotional issues as depression and anxiety disorders (p. 15). Psychosis, on the other hand, described patients with an inadequate grasp on reality, including presenting symptoms such as hallucinations; schizophrenia and other disorders afflicted these patients (p. 15).

There were patients, however, who presented symptoms that were somewhat intermediate: on the one hand, they were too troubled to placed with neurotics; on the other hand, they were not quite as poorly off as those afflicted with psychosis (Chapman and Gratz 2007 pp. 15-16). The term borderline was coined to describe the condition of these patients, whose presenting symptoms included a tremendous amount of instability “in their emotions, their thinking, their relationships, their identity, and their behaviour” (p. 16). A key milestone in the origins of the diagnosis was the work of Adolph Stern, who in 1938 identified the disorder (Gunderson and Links 2008 p. 1). In the 1950s and 1960s, scholars such as Knight and Kernberg advanced the borderline diagnosis, helping to differentiate it from other disorders. In particular, Kernberg (1967) identified borderline personality organization in terms of “failed or weak identity formation, primitive defences (namely, splitting and projective identification), and reality testing that transiently lapsed under stress” (p. 3). Since the 1960s, the diagnosis underwent significant shifts, from a personality organization to a syndrome, and then to a disorder (p. 5). From the 1970s on, the diagnosis became much more widespread and well-recognised (p. 6).

Today, borderline personality disorder is recognized by a number of well-defined features. Fundamentally, it is an emotional disorder: as Chapman and Gratz (2007) explained, “People with BPD are unstable in their emotions, their thinking, their relationships, their identity, and their behaviour” (p. 16). According to the International Classification of Diseases (ICD) (2010), the overarching disorder is emotionally unstable personality disorder, characterized by impulsivity, a lack of consideration for the consequences of one’s actions, and unpredictable and capricious moods (F60.3). BPD patients tend to quarrelsome and high-conflict personalities, tendencies which tend to be magnified when their designs are thwarted (F60.3). There are two main types: “the impulsive type, characterized predominantly by emotional instability and lack of impulse control,” on the one hand, and “the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts” (F60.3).

The DSM-IV-TR gives nine criteria for the borderline diagnosis; any individual who displays five of the nine is considered borderline (Kreger 2008 p. 25). These nine criteria are: first, “strong reactions to fear of abandonment, whether real or imagined”; second, “a history of troubled relationships with extremes in behaviour and attitude”; third, “poor sense of self”; fourth, “impulsive and self-destructive behaviour by at least two means”; fifth, “repeated suicidal tendencies”; sixth, “intense and frequent moodiness and irritability”; seventh, “an ongoing feeling of emptiness”; eighth, “intense and uncontrollable anger”, and ninth, “persistent feelings of detachment” (p. 25). Sansone and Sansone (2011) note that there are quite significant gender differences with BPD: common features of BPD in males include volatile, explosive temperaments and tendencies for novelty seeking that are greater compared with female BPD patients (p. 16). Men with the disorder are also more likely to be comorbid for antisocial personality disorder, and for substance abuse (p. 16). Female BPD patients, on the other hand, are more likely to evince problems pertaining to “eating, mood, anxiety, and posttraumatic stress disorders” (p. 16).

The aetiology of BPD is complex, and appears to be a mixture of biological and psychological, including sociocultural, factors (Krawitz and Jackson 2008 p. 31). On the biological side, BPD patients appear to have differences in brain functioning, especially a “’sluggish serotonin system’” (p. 32). This feature has been statistically linked to mood disorders, to depression, and to “irritability, anger, and impulsivity” (p. 32). BPD patients are statistically more likely to have lower volumes of the amygdala and the hippocampus (p. 32). However, what is not known is causation: specifically, whether these differences represent predispositions to the disorder, or if they are instead a response to it, or even a mixture of the two (p. 32).

In any event, it is clear that there are psychological factors that contribute to the disorder as well: in particular, traumatic experiences during childhood have been linked to the disorder (Krawitz and Jackson 2008 p. 33). Sexual abuse is a major risk factor for the condition: 70% of people with BPD are survivors of sexual abuse, though that still leaves 30% who are not (p. 33). However, most survivors of sexual abuse do not develop the disorder, so the association, while real, is clearly not absolute (p. 33). Moreover, physical abuse, neglect, and emotional deprivation are other risk factors for developing BPD (p. 33).

Cognitive and Dialectical Behavioural Therapies

Cognitive Behavioural Therapy (CBT) was first developed by Aaron Beck (1967), who argued that the tendencies of BPD patients for negative thinking, both about the world and about themselves, were the central problem: if BPD patients could be retrained to reject such thinking, they would be able to overcome their tendencies towards low mood and depression (Mondimore and Kelly 2011 pp. 161-162). Beck believed that these tendencies came about due to patients’ negative early experiences with the world, which taught them the habit of thinking poorly about themselves (pp. 161-162). What was needed, Beck believed, was to break the habit. And to do that, he broke with conventional psychotherapeutic practice: instead of focusing on the past in order to help the patient ascertain how the pattern was established in the first place, Beck believed in focusing on the present (p. 162). For Beck, the how was not terribly important: what mattered instead was the what, and that meant helping the patient recognize the pattern and change it in the present (p. 162).

In fact, this model took some time to be fully recognized as a compelling approach for personality disorders: early on, it was seen as more of an approach for short-term problems, due to its focus on the present (Rafaeli 2009 p. 290). However, Beck’s emphasis on schemas lent CBT to the task of addressing such deep-seated personality disorders as BPD, particularly with the recognition that those schemas characteristic of disorders like BPD emerge “from the interaction of children’s temperament with their formative environment” (p. 291). With this compelling model, CBT has been used not only to help BPD patients, but also to help those suffering from other mental illnesses, notably PTSD (Zayfert et al. 2005 pp. 637-638).

Beck argued that BPD patients are subject to a great deal of cognitive distortion, including tendencies to catastrophize and polarize (Mondimore and Kelly 2011 p. 162). The purpose of CBT is to help the patient understand how their assumptions and interpretations drive them to emotional states and behaviours that are distressing, dysfunctional, and counter-productive (Fusco and Apsche 2005 p. 76). These negative and maladaptive patterns of thinking and behaviour, called schema, essentially function as psychological scripts that drive the condition (p. 76). CBT focuses on how the individual cognitively interprets experiences that they find to be upsetting, the idea being that if the individual can understand how they consistently distort their experiences in ways that contribute to such negative behaviour, they will be able to make better interpretations that will help them to engage in better behaviours (p. 76).

Dialectical behavioural therapy (DBT) was developed by Marsha Linehan as an offshoot of CBT (Bloomgarden 2005 p. 49). DBT is largely patterned after CBT, but with one essential difference: DBT incorporates a number of additional ideas and practices from Zen Buddhism, used by monks (p. 49). The essence of DBT is dialectics, which in this context might best be summarized as “’embracing of opposites’” (p. 49). The idea here is that this is a difficult but needful skill for patients with BPD to master if they are to overcome their disorder: given that they tend to view the entire world in a very black and white fashion, BPD patients find it difficult to reconcile thinking or feeling two different and completely opposite things at the same time (p. 50).

A good example is feelings of anger and love: for BPD patients, feeling both of these towards the same person at the same time is extremely difficult (Bloomgarden 2005 p. 50). And yet, the ability to feel both at the same time is an important capacity to have for a healthy emotional life. Teaching patients to embrace this duality, this seeming contradiction, is an important aspect of DBT (p. 50). An especially important application of this view is with regards to behaviours, including and especially self-destructive ones: DBT holds that when viewed in proper context, any behaviour can be shown to make sense, even in the present (p. 50). This is in contrast to the behavioural view which would propose that non-useful behaviours are retained, even when they are no longer being enforced (p. 50).

DBT has three pillars, the first of which is problem solving: this entails the skill of being able to analyze a problem, evaluate it, and explore different solutions, all essential skills for BPD patients to master (Wheelis 2010 p. 329). The second is validation: the therapist must validate what the patient is thinking and feeling (p. 329). Finally, the third is dialectics, which does two things in DBT: one, provide a philosophy on the very nature of reality itself, and two, provide a way for therapist to relate to patient (p. 329). As Linehan (1993) herself explains, DBT’s seminal characteristic “is an emphasis on ‘dialectics’—that is, the reconciliation of opposites in a continual process of synthesis” (p. 19). The first and most foundational of these dialectics is the idea that patients must be accepted as they are, even while the therapist is attempting to encourage them to change (p. 19). This concept is itself founded on a sort of dialectic between Zen Buddhist practice and Western psychological practice (p. 19).

And it is DBT’s style that most sets it apart from CBT and from other therapies with similar features: DBT requires the therapist to adopt irreverent and even outrageous attitudes about patients’ self-harming and other dysfunctional behaviours, and to alternate this with “therapist warmth, flexibility, responsiveness to the patient, and strategic self-disclosure” (Linehan 1993 p. 19). This is all part of DBT’s view of diagnosis: DBT’s perspective is behavioural, meaning that all diagnoses summarize patterns of behaviour (Swales et al. 2000 p. 9). When the behaviours in question are no longer evident, the diagnosis ceases to obtain, as far as DBT is concerned (p. 9). Therefore, what is needed is for therapist and patient to arrive at that point, essentially breaking down the behaviour through embracing of opposites (p. 9).

As Paris (2008) explains, Linehan’s thesis is that emotional dysregulation (ED), or affective instability, is the central aspect of BPD (p. 140). This drives DBT’s key emphasis, which targets emotional dysregulation in order to improve patients’ abilities to regulate the intensity and stability of their moods (p. 140). DBT promotes empathy from therapist to client, since it is essential for the therapist to validate their patients’ experiences (p. 140). Patients are also taught to identify stressors that they encounter in their day-to-day lives, and to recognize and dissociate themselves from emotional states, so that they will not be overcome by them (p. 140).

Synthesis

  • CBT: A foundational question in evaluating the efficacy of any therapy is its cost-effectiveness. Palmer et al. (2006) evaluated the cost-effectiveness of CBT, measured in terms of a comparison between CBT and a standard treatment or treatment as usual (TAU), or the standard treatment (TAU) alone (p. 468). Their results did not vindicate CBT: patients in the group that received CBT and the standard treatment exhibited slightly but consistently lower measures of quality of life than those from the group that only received the standard treatment (p. 472). This pattern was observed from the baseline on, through all follow-up points, and although the differences were slight and not statistically significant, the fact that CBT did not deliver a measurable and decisive benefit was very telling (pp. 472, 477-478).

However, other findings from the same trials, the Borderline Personality Disorder Study of Cognitive Therapy (BOSCOT) told a very different story: as Davidson et al. (2006) found, CBT in conjunction with TAU did in fact reduce some very important metrics of BPD dysfunction (pp. 450-451, 458). Specifically, CBT reduced suicidal acts, as well as accident and emergency room contact (p. 458). These significant reductions over the course of two years suggest that CBT does work where it counts the most for BPD patients (p. 458). CBT was also vindicated vis-a-vis TAU in a study on patients with PTSD, a substantial minority of whom also had BPD (Mueser et al. 2008 pp. 260-264). After treatment, and at the three- and six-month follow-ups, the patients who had received CBT were doing significantly better than those who had received TAU (pp. 264-265).

Integrative complexity has been suggested as one of the major metrics of the efficacy of talking therapies for BPD patients (Davidson et al. 2007 pp. 513-514). Integrative complexity consists of two key abilities: first, the ability to recognize “more than one perspective on a problem or situation”, known as differentiation, and second, “the recognition of relations among differentiated components or perspectives”, known as integration (p. 514). Clearly these are important skills for BPD patients to develop if they are to overcome their disorder. In fact, though, what these authors found was that changes in integrative complexity were not associated with beneficial or negative outcomes in treatment, with one key exception: patients’ social functioning improved in association with increased integrative complexity (pp. 513, 518-520).

Since depression is such a common feature of BPD, the literature has explored a number of treatment interventions designed to target this important and very damaging feature of BPD within the therapeutic context. Mindfulness-Based Cognitive Therapy (MBCT) is a particularly promising therapy, one that has been used to help patients with other depressive disorders (Sachse et al. 2011 p. 184). Sachse et al. evaluated the use of this intervention with BPD patients, in order to ascertain whether or not the emphasis on mindfulness and cognitive skills would lead to efficacious treatment outcomes (p. 187). They found that in fact, the intervention successfully improved many patients’ mindfulness abilities, though it did not significantly improve the clinical variables associated with BPD (p. 195). The key finding here is that the intervention does appear to be promising, though it will obviously need some tinkering to improve its efficacy (pp. 196-197).

Of course, a key question in treatment is whether or not pharmacotherapy should be used in conjunction with psychotherapy. Ascertaining the respective effects of the two therapies is of considerable interest for nursing practice in order to optimize outcomes. Bellino et al. (2007) evaluated the efficacy of fluoxetine, which is a selective serotonin reuptake inhibitor (SSRI), in conjunction with two different therapies: cognitive therapy (CT) and interpersonal therapy (IPT) (p. 718). All patients had borderline personality disorder and major depression, thus the ostensible need for the combined program of intervention. What Bellino et al. found was that in fact, both treatments are efficacious in conjunction with fluoxetine, but they are not efficacious in identical ways (pp. 718, 720-721). The combined treatment of fluoxetine plus CT was more efficacious in remedying patients’ anxiety and overall perceptions of their psychological functions, while the combination of IPT and fluoxetine was better at addressing patients’ “perception of social functioning and on interpersonal problems” (pp. 718, 720-721). Overall, the two forms of combined therapy were equally effective in helping patients to overcome their depression (p. 721). However, an important point made by Dopheide (2006) is the lack of adequate assessment of the effects of CBT versus antidepressants for depressed children and adolescents (p. 236). That said, the literature does seem to support a combination CBT and fluoxetine treatment for adolescents (pp. 236-237).

Cognitive analytic therapy (CAT) is a particularly promising offshoot of CBT, essentially the result of cross-fertilization between CBT and psychodynamic therapy (Daly et al. 2010 p. 274). Daly et al. evaluated the potential of a seven-step CAT model to overcome ruptures in the so-called ‘therapeutic alliance’, ruptures being defined in terms of emotional disconnects between the therapist and the patient (pp. 273-274). What they found was that it largely depended on the quality of the session: while in ‘good’ sessions it was typical enough for two-thirds of ruptures to be resolved, that figure fell to one-third in poor sessions (p. 279). The key difference had to do with whether or not the therapist was willing to undertake a process of “acknowledgment, exploration, linking and explanation, negotiation, consensus, understanding and assimilating warded off feelings, further explanation, change to patterns/aims, and closure” (p. 274). This again attests to the great need of BPD patients to explore and analyze their feelings, in order to be able to deconstruct their harmful patterns of thinking, feeling, and acting (pp. 274-275).

  • DBT: Turning now to DBT, just as it was important to study the efficacy of CBT versus treatment as usual (TAU), the same applies for DBT. Carter et al. (2010) studied the effects of DBT versus TAU and being placed on a DBT waiting list (WL) in terms of reductions in patients’ willingness to engage in direct self-harm (DSH) (pp. 162-164). There were no statistically significant differences for the principal outcomes, though DBT performed slightly better (p. 166). However, DBT did produce quite significant gains in the secondary outcomes concerning patients’ quality of life and disability, indicating that it is of value (p. 166).

DBT has been well-supported in the literature, consistently reducing deleterious outcomes in BPD patients (Harley et al. 2007 p. 362). Harley et al. wanted to examine whether the skills training approach of DBT might be modified in order to improve patient outcomes in situations wherein the traditional, full DBT package might be impractical. What they found was that a modified program, incorporating both DBT skills and an alternative therapy was very successful in improving patient outcomes: the program helped the patients to reduce BPD symptomatology (pp. 364-367).

This is in keeping with findings that mindfulness can help to enhance DBT, and thus, patient outcomes: because BPD patients frequently become depressed, which often endangers their program of treatment by sapping the motivation and willpower to do DBT, the incorporation of a treatment such as mindfulness-based cognitive therapy (MBCT) can lead to an increase in beneficial outcomes (Huss and Baer 2007, Clarkin et al. 2004). Indeed, there is some evidence that DBT works precisely because of the skills that it teaches patients, thereby enabling them to compensate for, and then overcome, the challenges of BPD (Clarkin et al. 2004, Lindenboim et al. 2007). In fact, Neacsiu et al. (2010) found attestation for this ‘skills deficit’ model: their findings indicated that DBT works by helping patients to develop new skills.

However, there is evidence that because it relies on emotional learning, a key challenge for DBT in the therapeutic alliance is patient dissociation: “disintegration of perception, consciousness, identity, and memory” (Kleindienst et al. 2011 p. 433). Kleindienst et al. evaluated this question, and found that in fact, dissociation is a significant factor in reducing efficacious outcomes of DBT (pp. 438-439). However, no specific aspect of dissociation was found to be more important than any other. The findings are clear: while DBT can help patients regulate emotion, dissociation from emotion remains a key challenge (pp. 438-440).

 In order to ascertain the effectiveness of DBT in teaching patients to regulate their emotions, Axelrod et al. (2011) studied the outcomes of borderline patients with patterns of substance abuse, and who were often comorbid with other Axis I disorders (pp. 37-38). The program was DBT, with a mixture of individual, one-on-one therapy sessions and group skill-building sessions (p. 38). The results indicated that indeed, participants greatly improved, with regards to both substance use and the regulation of their emotions (pp. 39-40). In fact, improved regulation of the emotions was found to be significantly tied to reduced substance use (p. 40).

Given that DBT can help borderline patients with substance problems, the question of its efficacy in cases with comorbid eating disorders becomes relevant. Ben-Porath et al. (2009) evaluated outcomes for eating disordered (ED) patients versus ED, comorbid for BPD, noting that the latter group was much less capable of regulating affect, thus compounding the challenges of treatment (p. 226). What Ben-Porath et al. found was that DBT was equally effective with eating disordered (ED) patients who were comorbid for BPD (ED-BPD) as it was with the patients who had ED alone (pp. 235-236). This establishes that DBT is effective in helping patients learn to regulate affect (p. 237).

Similarly, Chen et al. (2008) evaluated DBT for participants who had either binge-eating disorder (BED) or bulimia nervosa (BN) comorbid with BPD, and found substantial improvement across all metrics, including self-harming behaviours, ED behaviours, and other non-ED Axis I symptoms (p. 508). A customized DBT skills training module for patients who are also eating disordered has been convincingly shown to be effective as well (Palmer et al. 2003 p. 284). Notably, this program helped patients to reduce both self-harming behaviours and eating disordered behaviours (p. 284).

The role of DBT in helping patients learn how to regulate affect and personality was investigated by Davenport et al. (2010), who evaluated pre- and post-treatment BPD patients’ personality traits and self-control (p. 61). They found that pre-treatment BPD patients had significantly lower scores in the domains of “Self-Control, Agreeableness and Conscientiousness” compared with post-treatment BPD patients who had had the benefit of DBT (p. 62). What did not differ between the two groups was their scores for “Extraversion, Neuroticism or Openness to Experience” (p. 62).

DBT has been vindicated in a number of different settings. Swenson et al. (2001) reported on its successful application in a hospital inpatient setting, noting the especial challenges of the hospital setting for application of the DBT model (in particular, the power distance between staff and patients) (pp. 310-311). Since BPD patients are often hospitalized for suicide attempts, the cardinal priority of inpatient DBT must be to target the behaviours of the patient that lead them to hospitalization (p. 311). And Hjalmarssson et al. (2008) reported on the success of DBT in an outpatient setting, one in which a number of therapists were learning and adopting DBT for the first time (pp. 21-23). After a year, the therapists reported feeling much more confident about the therapy, and the patients reported positive measures with regards to outcomes of the treatment (pp. 23-24). In particular, parasuicidal measures declined precipitously amongst the outpatients (p. 24).

And in the setting of a prison, DBT has been shown to be effective in treating inmates with BPD (Nee and Farman 2007 pp. 163-167). In particular, DBT skills such as mindfulness have been shown to be efficacious in helping inmates to ascertain the character of their feelings, the stressors that trigger them, and how to manage them (pp. 166-167). Through the application of DBT, even very troubled and violent inmates can become much more manageable and healthy (pp. 163-167).

DBT has also proven exceptionally popular with patients, who typically request it (Hodgetts 2007 p. 174). Patients have reported that they enjoy DBT homework assignments, and appreciated how these assignments helped them to master important skills (p. 174). And as Stepp et al. (2008) explained, this is small wonder: the literature indicates that the very thing that makes DBT so effective is the way that its several treatment strategies, working together in different but complimentary ways, reduce emotional dysregulation (p. 550). In particular, the skills that DBT teaches patients help them to overcome the behavioural patterns of BPD, thus reducing symptomatology of the disorder (p. 550).

Recommendations

Both CBT and DBT show a great deal of promise, but can it be said that one is preferable to other? Although there is some evidence for the efficacy of CBT with regard to treating BPD patients, DBT appears the more successful of the two strategies for treatment. DBT should probably be the treatment strategy of choice, given its flexibility, dynamic power, and popularity with patients. However, mindfulness skills should also be taught with especial emphasis, in order to help patients to regulate affect. Future research should continue to explore how to best teach DBT skills to BPD patients, as well as potential applications to other disorders. DBT should be further explored for use with other disorders, and comparisons should be made between DBT use with other disorders and with BPD in order to ascertain possible strategies for best practices. Dissociation is a particular challenge that will have to continue to be overcome, and certainly warrants further research to investigate new approaches for breakthroughs.

Conclusion: Though a great challenge, BPD is a challenge that can be overcome. CBT and especially DBT offer sound treatment interventions that focus on behaviours and their contexts. DBT in particular is very successful, and should be the preferred method of treatment for clinicians; teaching of mindfulness skills can further enhance DBT.

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