MARSHA M. LINEHAN, Ph.D. is the originator of Dialectical Behavior Therapy and is a professor in the Department of Psychology at the University of Washington.
NOTE: Writing of this manuscript was partially supported by grants MH34486 and DA08674 from the National Institutes on Mental Health and Drug Abuse, respectively, Bethesda, Maryland.
Borderline personality disorder (BPD) represents a major health problem for the 1990s and beyond. It is a prevalent disorder that is severe, chronic, and persistent. The number of individuals meeting criteria for the disorder is high, approximately 11% of all psychiatric outpatients and 20% of psychiatric inpatients. In addition to being prevalent, follow up studies consistently indicate that the diagnosis of BPD is chronic. Between 57 and 67% continue to meet criteria four to seven years after the first diagnosis and up to 44% continue to meet criteria fifteen years later.
The severity of BPD is perhaps best seen in the high mortality rate of the disorder. Approximately 10% of BPD patients eventually die by suicide. The suicide rate is much higher among the 36 to 65% of BPD individuals who have attempted suicide or otherwise injured themselves intentionally at least once in the past. Looking at suicide rates from the reverse angle, 12 to 33% of all individuals who die by suicide meet criteria for BPD. The emotional costs of BPD are enormous. BPD individuals describe chronic feelings of anger, emptiness, depressions and anxiety. They experience extreme frustration and anger, and occasionally experience brief psychotic episodes. They describe chaotic relationships and "confused identities." Even among those who have not attempted suicide, suicide ideation is common. The quality of life ratings for some of the problems frequently experience by BPD individuals suggest that their quality of life is amongst the lowest.
At present there are very few treatments with proven efficacy in treating BPD individuals. In summarizing the findings of pharmacological treatment studies, Paul Soloff, MD., concludes that pharmacotherapy effects, while clinically significant, are nonetheless modest in magnitude. The empirical evidence supporting psychosocial treatments for BPD is similarly meager. This poses a special problem because even when effective pharmacotherapy is given, the complexity and severity of BPD dictates concurrent psychotherapy. To date cognitive-behavioral therapy (specifically, Dialectical Behavior Therapy or DBT) is the only treatment that has been shown in controlled clinical trials to be effective treating BPD.
Dialectical Behavior Therapy: Foundations
DBT is based on a model suggesting that both the cause and the maintenance of BPD is rooted in biological disorder combined with environmental disorder. The fundamental biological disorder is in the emotion regulation system and may be due to genetics, intrauterine factors before birth, traumatic events in early development that permanently affect the brain, or some combination of these factors. The environmental disorder is any set of circumstances that pervasively punish, traumatize, or neglect this emotional vulnerability specifically, or the individual's emotional self generally, termed the invalidating environment. The model hypothesizes that BPD results from a transaction over time that can follow several different pathways, with the initial degree of disorder more on the biological side in some cases and more on the environmental side in others. The main point is that the final result, BPD, is due to a transaction where both the individual and the environment co-create each other over time with the individual becoming progressively more emotionally unregulated and the environment becoming progressively more invalidating.
Emotional difficulties in BPD individuals consists of two factors, emotional vulnerability plus deficits in skills needed to regulate emotions. The components of emotion vulnerability are sensitivity to emotional stimuli, emotional intensity, and slow return to emotional baseline. "High sensitivity" refers to the tendency to pick up emotional cues, especially negative cues, react quickly, and have a low threshold for emotional reaction. In other words, it does not take much to provoke an emotional reaction. "Emotional intensity" refers to extreme reactions to emotional stimuli, which frequently disrupt cognitive processing and the ability to self soothe. "Slow return to baseline" refers to reactions being long lasting, which in turn leads to narrowing of attention towards mood congruent aspects of the environment, biased memory, and biased interpretations, all of which contribute to maintaining the original mood state and a heightened state of arousal.
An important feature of DBT is the assumption that it is the emotional regulation system itself that is disordered, not only specific emotions of fear, anger, or shame. Thus, BPD individuals may also experience intense and unregulated positive emotions such as love and interest. All problematic behaviors of BPD individuals are seen as related to re-regulating out of control emotions or as natural outcomes of unregulated emotions.
Dialectical Behavior Therapy: The Treatment Model
DBT assumes the problems of BPD individuals are twofold.
First, they do not have many very important capabilities, including sufficient interpersonal skills, emotional and self regulation capacities (including the ability to self regulate biological systems) and the ability to tolerate distress.
Second, personal and environmental factors block coping skills and interfere with self regulation abilities the individual does have, often reinforce maladaptive behavioral patterns, and punish improved adaptive behaviors.
Helping the BPD individual make therapeutic changes is extraordinarily difficult, however, for at least two reasons. First, focusing on patient change, either of motivation or by teaching new behavioral skills, is often experienced as invalidating by traumatized individuals and can precipitate withdrawal, noncompliance, and early drop out from treatment, on the one hand, or anger, aggression, and attack, on the other. Second, ignoring the need for the patient to change (and thereby, not promoting needed change) is also experienced as invalidating. Such a stance does not take the very real problems and negative consequences of patient behavior seriously and can, in turn, precipitate panic, hopelessness and suicidality.
It was the tension and ultimate resolution of this essential conflict between acceptance of the patient as he or she is in the moment versus demanding that the patient change this very moment that led to the use of dialectics in the title of the treatment. In DBT, treatment requires confrontation, commitment and patient responsibility, on the one hand, and on the other, focuses considerable therapeutic energy on accepting and validating the patient's current condition while simultaneously teaching a broad range of behavioral skills. Confrontation is balanced by support. The therapeutic task, over time, is to balance this focus on acceptance with a corresponding focus on change. As a world view, furthermore, dialectics anchors the treatment within other perspectives that emphasize:
1. the holistic, systemic and interrelated nature of human functioning and reality as a whole (asking always "what is being left out of our understanding here?");
2. searching for synthesis and balance, (to replace the rigid, often extreme, and dichotomous responses characteristic of severely dysfunctional individuals);
3. enhancing comfort with ambiguity and change which are viewed as inevitable aspects of life.
DBT is designed to address the following five functions of successful treatments:
enhancement of generalizations of gains,
enhancement of capabilities and motivation of therapists,
structuring of the environment to support clinical progress.
Capability Enhancement focuses on increasing behavioral and self regulation. All patients in DBT receive psycho-educational skills training in five areas: mindfulness (to improve control of attention and the mind), interpersonal skills and conflict management, emotional regulation, distress tolerance, and self management. Medications are also used here for enhancing the individual's ability to self regulate biological systems.
Motivational Enhancement focuses on making sure that clinical progress is reinforced (rather than punished), that maladaptive behavior is not reinforced, and on reducing other factors (such as emotions or beliefs) that inhibit or interfere with clinical progress. Generally, this requires intensive (at least weekly sessions of one to one and a half hours) individual therapy. The full range of effective cognitive and behavioral therapies are integrated into the treatment targeting in order of importance: reducing suicidal and other life threatening behaviors; reducing therapy-interfering behaviors (including noncompliance and dropping out of treatment); reducing sever quality of life interfering behaviors (including Axis I disorders, such as depression and eating or / and substance abuse disorders); increasing skillful coping behaviors, including distress tolerance emotion regulation, interpersonal effectiveness, and mindfulness; reducing traumatic emotional experiencing, including post-traumatic stress responses (for example, continuing reactions to childhood trauma); enhancing self-respect and mastery and reducing problems in lying; and resolving a sense of incompleteness.
Enhancing Generalization. Learning to be effective in a therapist's office or an inpatient or residential setting is useless if the new behaviors do not generalize to the patient's everyday life settings. The third task of therapy, therefore, is to ensure generalization of new behaviors to the natural environment. In DBT this is generally done by phone consultations between patient and individual therapist. In inpatient, residential, and day treatment settings this might be done by on site consultants with "office hours" for skills consultation.
Enhancing Therapist's Capability and Motivation. An effective treatment is useless if the therapist is unable or unmotivated to apply the treatment when it is required. Enhancing the therapist's capabilities and motivation to treat effectively is an unrecognized but essential part of any treatment program. In DBT, this function of treatment is met by weekly team consultation meetings of all DBT therapists. The goal of these meetings is to provide consultation and support for therapists in their attempts to apply DBT.
Treatment strategies are divided into four main groups as follows. Dialectical strategies consist of balancing acceptance and change in all interactions, always searching for a synthesis and looking to shift the frame of problems that resist solution. DBT core strategies require the balancing of validation with problem solving. Validation consists of a set of strategies emphasizing acceptance and validation of the patient by listening empathetically, reflecting accurately, articulating that which is experienced but not necessarily said, clarifying those disordered behaviors that are due to disordered biology or past learning history, and highlighting those behaviors that are valid because they fit current facts or are effective for the patient's long term goals. The essence of validation is seeing and responding to the patient as a person of equal status and value. Problem solving strategies are designed to assess the specific problems of the individual, figure out what factors are controlling or maintaining the problem behaviors, and then systematically applying behavior therapy interventions.
Structuring the Environment. If the environment continues to reinforce problematic and borderline behaviors and punishes clinical progress, then it is useless to expect that treatment gains will be maintained once treatment is ended. Thus, if treatment is to end, the therapy must assist the patient in developing an environment that is maximally supportive of clinical gains. It is equally important that the therapist focus on providing a treatment atmosphere that encourages progress and does not encourage relapse. Family sessions and case consultation meetings with other therapists (always with the patient present) serve this function in DBT.
Dialectical Behavior Therapy: Effectiveness
DBT has demonstrated effectiveness in two controlled randomized clinical trials. In the first study conducted by myself and my colleagues at the University of Washington, 47 chronically suicidal BPD patients were randomly assigned for a year either to DBT or to referral to treatment as usual in the community. During the year, DBT patients were less likely to attempt suicide or drop out (84% remained in treatment). They spent much less time in psychiatric hospitals, had greater reductions in use of psychotropic medications, and were better adjusted at the end of the year. They were also less angry than patients given standard psychotherapy (although at one year not less depressed or less likely to think about suicide). Most of these differences persisted a year after treatment ended.
It could be argued that DBT patients had a better outcome simply because they received more psychotherapy than the others. But DBT proved to be more effective even after researchers corrected for the amount of time spent with psychotherapists, and even after they excluded patients who received no individual psychotherapy. We are now conducting a large randomized clinical trial of DBT with a new group of therapists and patients. Preliminary results suggest that DBT is effective in this replication study as well.
In a just completed study here at the University of Washington, 23 drug abusing BPD women were assigned to DBT or to referral to treatment as usual in the community. At the end of the one year treatment, use of illicit drugs was lower and attendance at treatment was higher in the patients who got DBT versus those referred to treatment as usual in the community. In several studies researchers at other institutions have partially replicated our results. They have found less suicidal behavior among patients given DBT than among similar patients given a different treatment. These were not true controlled studies, however, since the patients were not assigned to treatment condition (DBT versus non-DBT treatment) at random. Thus, it will be very important to replicate these studies using more rigorous research methods.
The intense suffering that accompanies borderline personality disorder, both for the patient and for the community surrounding the patient, suggest that a high priority must be put on both developing new more effective treatments and on dissemination of those that are currently available. This is especially true in community mental health where in some states the lack of improved outcomes with some treatments have led those controlling reimbursement to refuse to treat or pay for treatment for BPD patients. Although a case might be made for some that an ineffective treatment is more harmful than no treatment, the same cannot be said for treatments that have been shown to be effective in rigorous clinical trials.