EFFECT OF DIALECTICAL BEHAVIOR THERAPY

Effect of Dialectical Behavior Therapy 1 Running Head: EFFECT OF DIALECTICAL BEHAVIOR THERAPY The Effect of Dialectical Behavior Therapy On the Self-harming and Suicidal Behaviors Associated With Borderline Personality Disorder Rita E. Rohde Adler Graduate School

Effect of Dialectical Behavior Therapy 2 Abstract Borderline Personality Disorder (BPD) is a personality disorder that greatly affects both personal and vocational relationships. The behaviors associated with BPD are often wearing on relationships and difficult to treat. Two of the most common problems associated with this disorder are self-harming and suicidal behaviors. This thesis gives a brief description of BPD, the behaviors associated with it and the Adlerian View of the behaviors of the BPD person. The common treatment approaches will be described as well as what research has found regarding the efficacy of Dialectical Behavior Therapy (DBT) on the self-harming and suicidal behaviors. The limitations of those studies and implications for further research in this area will also be addressed.

Effect of Dialectical Behavior Therapy 3 The Effect of Dialectical Behavior Therapy On the Self-harming and Suicidal Behaviors Associated With Borderline Personality Disorder Introduction Borderline Personality Disorder (BPD) is a serious mental illness characterized by unstable moods, interpersonal relationships, unstable self-image, and self-harming and suicidal behaviors (Sarason & Sarason, 1999). There are three main problems in people with BPD, including disturbances in identity, as well as affective and impulse disturbances. It is estimated that BPD is diagnosed in approximately 2% of the general population, 10% in clients treated on an outpatient basis, and 20% of the inpatient psychiatric establishments (American Psychiatric Association [DSM-IV-TR], 2000). Three Main Problems in People With BPD Identity disturbance. People with BPD often feel an inner emptiness or have feelings of non-existence and an intolerance of being alone. They often rely on external sources for selfdefinition (Sarason & Sarason, 1999). Such a dependency on external structure to define who they are and the impending changes in relationships or circumstances, whether real or imagined, often manifests in an intense fear of abandonment (DSM-IV-TR, 2000). This fear of abandonment often produces intense clinging and dependency behaviors from those with BPD. They are uncertain about their own self-image and depend on the approval from others to define themselves. The disturbances in their identity, self-image, gender identity, values, loyalties, and goals are often marked by sudden shifts in relationships, friends, interests, opinions, and vocational

Effect of Dialectical Behavior Therapy 4 aspirations (DSM-IV-TR, 2000). These individuals change roles suddenly when they feel a lack of meaningful relationship with a nurturing and supportive person. Affective disturbance. The instability in moods, which is usually expressed in intense and inappropriate anger, often results in unstable interpersonal relationships. People with BPD get angry when the other person in the relationship sets limits, boundaries, or tries to end the relationship (Sarason & Sarason, 1999). They may idolize someone at the first or second meeting and become intimate early in relationships. This lack of boundaries and self-definition often results in people with BPD feeling as if the other person is not there enough for them and thus they often devalue the strengths and personal significance of others (Sarason & Sarason, 1999). Impulse disturbance. The lack of self-identity and the intense emotional responses to circumstances and others often result in impulsive, often self-harming and suicidal behaviors in the people with BPD (Sarason & Sarason, 1999). The intense emotional response people with BPD feel leads them to express themselves through self-harming behaviors (SHB) such as wrist slashing, body banging, burning, puncturing their skin, and excessive hair removal (Sarason & Sarason, 1999). Disturbances in identity, affect, and impulses become a problem for those diagnosed with BPD because the behaviors often times interfere with daily life. The behaviors may prove to be detrimental to vocational aspirations because of their difficulty in inhibiting behaviors and/or responses when they perceive a situation as stressful (Bateman & Fonagy, 2004). The good or bad, black and white thinking of those with BPD skews the perception of relationships that are formed, whether at work or in their personal life. Due to this misconception of relationships, problems can arise amongst co-workers and friends because people with BPD often cross the personal boundaries of others. The often faulty and unrealistic expectations they have of the

Effect of Dialectical Behavior Therapy 5 other person in the relationship exacerbates these relationship problems. People with BPD may develop self-harming and suicidal behavior problems because of the aforementioned problems and disturbances. These self-harming and suicidal behaviors disrupt and have damaging impact on their personal lives with respect to relationships with family, friends, and co-workers. The self-harming and suicidal behaviors associated with BPD can be extreme in nature, difficult to treat, and costly, due to frequent hospitalizations. All the behaviors associated with BPD contribute to the self-harming and suicidal behaviors. Therefore, this paper mentions many of these behaviors. However, the focus will be on the self-harming and suicidal behaviors and the efficacy of Dialectical Behavior Therapy (DBT) in the reduction of the behaviors, which contribute to the self-harming and suicidal behaviors. Borderline Personality Disorder Personal relationships for those with BPD are very unstable due to their self-perception and the perception they have of others. This instability begins in early adulthood and is pervasive throughout many different aspects of their lives. People diagnosed with BPD tend to interpret situations and/or relationships through a lens of perceived abandonment. Their intense fear of abandonment that brings on feelings of fear and rejection has a negative impact on their personal relationships. Those diagnosed with BPD interpret relationships and circumstances in their lives through the beliefs they hold about themselves. They tend to view everything as good or bad, right or wrong, and that the outcomes of their relationships and/or circumstances are based on themselves being either good or bad. The behaviors mentioned earlier allow people with BPD to avoid the pain of perceived abandonment by others. In many cases however, the behaviors that were originally intended to

Effect of Dialectical Behavior Therapy 6 draw the attention of others, are most often the very reasons people with BPD experience relational problems. Their impulsivity and suspiciousness make it difficult to form relationships. When in relationships, they become very dependent and want the relationships to be exclusive but deny it when confronted. This denial often takes the form of intense anger due to their fear of abandonment, and in turn often repels others. Those with BPD have difficulty connecting with others due to their emotional instability and the sudden shifts in anxiety and depression (Sarason & Sarason, 1999). In their frantic effort to avoid abandonment, they may use complaining about physical symptoms and making or carrying out self-destructive threats as manipulative behaviors (Sarason & Sarason, 1999). They may binge drink or abuse other drugs in an effort to relieve their emotional pain, and to get attention from significant others. Under the influence of drugs and alcohol they may become promiscuous in their effort to connect with another person. These impulsive and SHBs often lead to even more instability in their personal and vocational lives. The instability in relationships may lead to employment problems and disjunctive relationships within their family. Those in relationship with people who have BPD often get burned out from the intense emotional upheaval, the black and white thinking, and continuous dependencies of those with BPD. Those with BPD usually lead a turbulent life, as do those who live with or around them. Diagnostic Criteria of Borderline Personality Disorder The diagnosis of BPD requires meeting five or more criteria according to the DSM-IV- TR, which is as follows: 1. Desperate efforts to avoid abandonment, whether real or imagined, which relate to their black and white thinking about themselves being good or bad.

Effect of Dialectical Behavior Therapy 7 2. A pattern of relationships with sudden shifts in perceptions of others, poor boundaries, and having a high expectation of others to always be there. 3. Unstable self-image resulting in rapid and dramatic changes in vocation, friends, values, and sexual identity; may be supportive at times, however, change suddenly to being needy and demanding of others. 4. Impulsivity in self-harming, self-mutilating behaviors and/or gestures. 5. Suicidal behaviors and/or attempts after felt rejection, abandonment, and/or expectations placed on them by self or others. 6. Experience instability of affect due to their rapidly shifting mood; intense feelings of anger, fear, and despair. These highs and lows are in reaction to personal stressors. 7. Chronic feelings of emptiness. 8. Inappropriate expression of intense feelings, and/or emotions. 9. Short-lived periods of depersonalization or dissociative symptoms. Of course, it is important to rule out other disorders, and to address co-occurring disorders. Causes of Borderline Personality Disorder The causes of BPD have not been identified, however, many of the people diagnosed with BPD are women, and a significant number of those diagnosed have been the victim of childhood sexual abuse (Hampton, 1997). According to Shearin & Linehan (1994) the biological reasons for BPD may be due to problems with the emotion regulation centers in the brain. This may be due to genetics, problems with fetal development, and/or trauma in early childhood. The environmental-social factors may include growing up in and/or living in an environment that was

Effect of Dialectical Behavior Therapy 8 mostly invalidating, where the person s feelings, emotions, thoughts, and actions were wrong or didn t matter. The biological and environmental factors interacting may reinforce one another throughout the life of those who may be later diagnosed with BPD. An Adlerian View of the Behaviors Associated with Borderline Personality Adlerians view behavior as being socially embedded and goal orientated (Carlson, 2006). Along with the view of behaviors, Adlerians believe a person s mental health is measured according to the three life tasks which are, love-intimacy, friendship, and work. The behaviors of the people with BPD affect their ability to achieve stability in those life tasks. As previously discussed the three main problems are the identity, affect, and impulse disturbances of those with BPD. These disturbances influence how they achieve their goals in the three life tasks. People with BPD lack courage in the face of the life tasks and become overwhelmed by their inability to meet those tasks. This lack of courage brings them to a point of using destructive, self-harming, and suicidal behaviors. Thus they live on the useless side of life (Beames, 1992). Manipulative behaviors, self-destructive threats, binge drinking, and the use of other drugs allow them to achieve their goals in the life tasks. Those goals are unconsciously created to distance themselves in relationships, whether personal or vocational. Their self-created fictional goal may be the result of the inferiority complex created by their feelings of never measuring up to what life demands, thus contributing to their feelings of inferiority (Beames, 1992). The behaviors exhibited by people with BPD create conflict within the three life tasks. These conflicts create the appearance of movement, yet in reality, they are at a standstill on the useful side of life (Beames, 1992). To make progress in the areas of life tasks, they need to be

Effect of Dialectical Behavior Therapy 9 aware of their fictional goals. It is in identifying where they are, the efforts they have made to get there, and where it is that they want to go that change can take place and progress can be made. Their behaviors are the product of the problem. The problem is not within them, instead it is between them and what they face and yet avoid solving. The main problem for people with BPD is their lack of relationship skills, emotional dysregulation, and lack of identity. Common Treatment Approaches for BPD The treatment approach for BPD varies depending on the orientation of the therapist. The therapy is based on the three main problems associated with BPD which are identity, affective, and impulse disturbances. Following are common treatment approaches to BPD. Psychoanalytic Therapy Psychoanalysts may use intensive face to-face psychotherapy sessions up to three times per week for years (Sarason & Sarason, 1999). The focus or emphasis of treatment is on the present behavior, rather than the client s past childhood experiences. The therapist works with the client to identify and discuss the client s distortions of reality (Sarason & Sarason, 1999). With the focus on the present behaviors, thoughts, feelings, and desires, the therapist can assist the client to change. Cognitive Therapy Cognitive therapists focus on the limitations of BPD in the following three areas: automatic thoughts, cognitive distortions, and unrealistic underlying assumptions (Sarason & Sarason, 1999). The goal of therapy is to increase the client s skills in reality checking. Identifying automatic thoughts and doing reality-checking enables the client to see and change the unrealistic expectations of them self and others, thus reducing the need for the self-harming

Effect of Dialectical Behavior Therapy 10 and suicidal behaviors that affect the relationships of the people with BPD. Behavior Therapy Behavior therapists teach effective social and coping skills to help manage anxiety (Sarason & Sarason, 1999). The behavior therapist suggests that by using the skills taught the client deals with their affective reactions and thus is able to control their behaviors (Sarason & Sarason, 1999). Biological Therapy Biological orientated clinicians make use of medications as a way to control behaviors, thoughts, and affective reactions. While medication alone does not prove to be effective, a combination of therapy approaches may increase the probability of effectiveness. One example is using the biological approach in combination with psychotherapy. The medication may assist in curbing behaviors, while the client identifies and challenges their cognitive distortions, which results in those behaviors. Dialectical Behavior Therapy Dialectical Behavior Therapy (DBT) is much like the standard cognitive-behavioral therapies (CBT) in that DBT emphasizes the assessment as an ongoing process, collects data on the client s current behaviors, and has treatment goals that are clearly defined. There are four modes of DBT, which consist of individual therapy, group skills training, telephone contact, and therapist consultation (Sperry, 2003). The group skills training consists of four groups of skills: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. A DBT therapist looks at the client s reality from a holistic view. The dialectic aspect of DBT puts the attention on both the immediate and larger contexts of the behavior and their connection to the behavior patterns (Linehan, 1993). Reality is not seen as fixed, but is made up

Effect of Dialectical Behavior Therapy 11 of opposing forces and constantly changing. These processes and/or changes are more important than the content or structure (Linehan, 1993). The focus of DBT therapy is on helping the client be more at ease with change rather than on maintaining a stable and consistent environment (Linehan, 1993). Dialectical thinking is key in DBT and is a matter of finding a middle path to the extreme thinking, emotions, and relationships, which many times result in the SHBs of the people with BPD. Dialectical thinking is flexible, holistic, and asks what is being left out (Spradlin, 2003). This way of thinking assists them to set personal limits, to acknowledge that these limits can be flexible from time to time, and that they can allow others to set their own limits. Compared to other approaches of treatment, DBT has been very effective in treating selfharming and suicidal behaviors (Sperry, 2003). Overview of Dialectical Behavior Therapy Although the behaviors associated with BPD are difficult to treat, DBT, developed by Marsha Linehan, is a promising therapy. It is effective in reducing those behaviors, some of which result in or lead to self-harming and suicidal behaviors. DBT is based on a biosocial theory that has demonstrated its effectiveness in controlled treatment trials (Swenson, Torrey, Koerner, 2002). DBT works under the premise that emotional dysfunction, along with social and environmental factors and their interactions, are the etiology of BPD (Shearin & Linehan, 1994). DBT is a CBT that focuses on the behaviors associated with BPD, mainly suicidal, and other SHBs. An understanding of DBT is advantageous in comparing its efficacy to Treatment as Usual (TAU) within the realm of the empirical studies used for this thesis. Three Stages of DBT Treatment Stage one. The first stage of treatment is to decrease the behaviors that are threatening to

Effect of Dialectical Behavior Therapy 12 the patient. The SHBs associated with BPD include gambling, driving recklessly, cutting, picking, and hitting one s self (DSM-IV-TR, 2000). These behaviors may also include those that interfere with treatment such as absenteeism, being late for appointments, cognitive and emotional problems, as well as other problems that affect the patient s quality of life (Robins & Chapman, 2004). The impulsivity of people diagnosed with BPD lead in many cases, to behaviors such as promiscuity, drug and alcohol abuse, eating disorders, and of utmost concern, suicidal behaviors. These behaviors are executed without the intent to die. However, the volatile perceptions and irregularity of thoughts in people with BPD make the SHBs a challenge for treatment (Brodsky & Stanley, 2002). Stage two. Once the SHBs are controlled, clients enter stage 2 of the treatment. This stage consists of using exposure strategies to get them to experience emotions in an appropriate manner. The use of exposure strategies helps in the healing of past trauma and in reducing therapy interfering behaviors. These behaviors include avoidance of therapeutic goals through being late for or missing appointments, issues with therapeutic boundaries, the premature termination of the therapeutic relationship due to those boundary issues, and/or their black and white thinking. Other therapy interfering behaviors may be the manipulation of the therapy sessions in an effort to avoid the underlying issues of their behaviors, thoughts about themselves that result in those behaviors, and thoughts about the therapeutic relationship. By working through the presenting issues, whether work related or in their personal relationships, people with BPD are exposed to their emotions, thoughts, and perceptions which can be checked out with the therapist during the session time. The therapist then assists the clients in working through those emotions in a healthy manner, by identifying the emotion, the thoughts behind the emotion, and appropriate expressions of that emotion. Stage 2 requires the

Effect of Dialectical Behavior Therapy 13 client to have adequate control over the SHBs so as not to repeat their old patterns of behavior when emotions come up (Brodsky & Stanley, 2002). Stage three. It is in this stage that the clients apply learned strategies to their social and vocational functioning. This stage includes addressing other interpersonal concerns and difficulties as well. The goals for stage three are to experience ordinary levels of happiness and unhappiness, and an improvement in relationships and self-esteem. Functions of DBT There are 4 functions of the DBT treatment. The first function is assisting clients to learn and apply new skills in order to reduce the behaviors. Tackling any obstacles that interfere with treatment, learning to generalize the skills and knowledge they gained to their daily life, and motivating the therapist who works with BPD clients through continuing supervision and education accomplish this reduction in behaviors. Four Skills Taught in DBT The 4 skills taught in DBT are mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness (Robins & Chapman, 2004). DBT s core is based on acceptance and change. This is expressed by validating the clients while assisting with and teaching problemsolving skills that help them move toward healing. It is in using these skills that people with BPD can reach their goals of therapy. Within the following four skills, a subset of skills will be briefly described. Mindfulness. The goal of this skill is to bring clients to a place of being awake for, participating in, and inhabiting their life (Spradlin, 2003). The focus of mindfulness in the life of people with BPD is to become more attentive to and aware of the emotions they experience in daily life. The premise is to look at the attention and inattention that clients give to emotions

Effect of Dialectical Behavior Therapy 14 (Spradlin, 2003). Being mindful is about letting go of the preconceived notions about self, others, and circumstances that often cause problems in the client s life. Marsha Linehan (1993) says there are two skills of mindfulness, the what and how skills. The what skills include teaching the clients to observe their environment and notice their thoughts, feelings, emotions, and to experience them without a reaction. In noticing these things, it is important that they do not try to change them immediately, but become familiar with them. It is essential for them to notice the flow of their thoughts, emotions, and feelings, while continuing to allow them to come and go. Another what skill is helping the clients describe or put words to their experience and to acknowledge the thoughts, emotions, physical reactions, etc., that are a part of their experience. It is necessary for them to stay descriptive, and to keep it simple (Spradlin, 2003). Most people with BPD have come from a background where it was not safe to express their thoughts, feelings, emotions, and physical sensations. Therefore, it is imperative they become aware of them within their current environment. Participating is the last sub skill within mindfulness. This is when clients practice the skills mentioned previously, and in doing so, become more involved in their present life. It is through staying in the moment that this ability to participate begins. It is taking each moment and being present to it by not allowing thoughts, feeling, actions, and emotions of the past interfere with the present. The other sub skill within mindfulness that Linehan (1993) points out involves the how skills. These how skills consist of ways to practice mindfulness, including being nonjudgmental, one-mindedness, and practicing effectiveness. The first how skill is for clients to learn to be non-judgmental. It is important to see the

Effect of Dialectical Behavior Therapy 15 facts and not rely on preconceived notions of what should be, could be, or must happen. It is necessary for clients to accept the emotions they feel without judging whether they are right or wrong. Of equal importance is the ability to be separate from them and just notice them, while looking at what is harmful and helpful without judgment. It is important for clients to be able to accept the emotion, thoughts, or actions and then to let them go in order to come back fully into the present moment. The next how skill is to be one-minded which means to do only one thing at a time. The client needs to be fully present in the moment, let go of distractions and go back to what is happening in the present. The important thing is for them to give all their attention to one thing at a time. The last skill in practicing mindfulness is to look at the effectiveness of the other skills, look at what works for them, and do those things. It is important that clients avoid being caught up in their own misconceptions of right versus wrong, fair versus unfair, and to play by the rules of each situation or circumstance (Linehan, 1993). Distress tolerance. Distress tolerance skills are learned and used by people with BPD to bear their painful experiences in a skillful manner, rather than using impulsive behaviors to cope with their pain. Distress tolerance includes two categories, which are crisis survival skills and acceptance skills (Spradlin, 2003). The crisis survival skills assist people in getting through the pain of a crisis with concrete and tangible activities. The activities help in distracting attention from situations that cannot be changed for the better within that moment (Spradlin, 2003). These may include activities that promote physical or mental exercise, developing connections with other people, using the opposite emotion technique, and doing soothing activities.

Effect of Dialectical Behavior Therapy 16 The acceptance skills are a key part of distress tolerance. When the clients accept what is happening around them and keep in mind they do not have to like it, they are then able to be intentional about their reactions or responses. It is beneficial for the clients to keep in mind that acceptance does not mean approval. When things cannot be changed, these acceptance skills help them to tolerate what is happening around them and inside them (Spradlin, 2003). It is through acceptance that clients grow, change, and learn from their pain. Emotion regulation. Emotions in people with BPD can be intense and labile. Due to the difficulties they have identifying and regulating emotions, behaviors that can be harming and suicidal often result. Linehan (1993) stresses the following emotion regulation skills within the DBT treatment: identifying and labeling emotions, identifying obstacles to change, reducing vulnerability to the Emotional Mind, increasing positive emotional events, increasing mindfulness of current emotions, opposite action, and using the distress tolerance skills. Identifying and labeling emotions is possible when clients are able to observe and describe many factors involved in their emotions. Some of these include what happened that brought on the emotion, their interpretation of the event which resulted in that emotion, and what is happening in their body in response to that emotion. It is of utmost importance they identify the behaviors they use to express that emotion, and look at how those behaviors affect their functioning in relationships (Linehan, 1993). The obstacles to change can be identified when people with BPD see how they benefit from the emotion. They may use their emotions and/or behaviors to control others or to corroborate their perception and interpretation of the event or relationship that prompted the emotion. It is through them identifying the benefits of the emotion that they can find healthier ways to meet their needs.

Effect of Dialectical Behavior Therapy 17 The importance of reducing vulnerability to the emotional mind is often times difficult for both the clients and therapists. This difficulty is because medication seems to be of little help in controlling the behaviors of people with BPD (Linehan, 1993). To reduce clients vulnerabilities, the therapist works with them to reduce their stressors. These stressors can include a lack of proper nutrition, exercise, medical care, and a lack of being a part of activities. All of these promote a greater self-esteem, self-efficacy, and a reduction in their vulnerabilities. Increasing pleasurable events is a way for people with BPD to control emotions. It is through an increase of these pleasurable events that they are able to be more mindful of their emotions and increase their ability to identify other emotions when they occur. Increasing mindfulness to current emotions allows them to feel those emotions without judging them and without bringing in a secondary emotion, which generates the negative behaviors. They are able to feel their emotions without negative consequences, thus reinforcing that feeling painful emotions is not bad (Linehan, 1993). Opposite action is when clients act the opposite of what they are feeling. This acting is done both behaviorally and through facial expressions. This opposite action assists them in controlling their behaviors through regulating the emotion. Although the emotion is not blocked, it is diminished to a point of tolerance and not the client s sole focus. Distress tolerance techniques assist clients in practicing acceptance and using the crisis survival skills. Crisis survival skills include activities, such as, but not limited to self-soothing activities, focusing on someone or something else to take their mind off themselves, breathing techniques, and making a list of pros and cons. Through practicing acceptance, they become aware of reality and the things they cannot change. It is through acceptance they find that although things may be painful, pain can be a motivation to change. If pain is not acknowledged,

Effect of Dialectical Behavior Therapy 18 things that cause the pain cannot be changed. Emotion regulation requires the use of mindfulness skills (Linehan, 1993). When taking a non-judgmental stance and having an explanation of their current emotions, the clients can regulate and change those emotions. By the client being exposed to and being able to identify the primary and secondary emotions, emotional distress that generally spurs behaviors is reduced. Interpersonal effectiveness. Interpersonal effectiveness is taught in these three segments: basic interpersonal skills, identifying what it is that contributes to interpersonal effectiveness, and looking at things to consider before asking someone for something or verbalizing their opinion on matters. The main goal of this area of skills is for the client to implement assertiveness skills in order to their needs met while maintaining and enhancing their interpersonal relationships. These skills help to increase their ability to be assertive and to obtain the changes they want in their relationships and within their environment. Therapeutic Settings The individual therapist is the primary therapist on the treatment team. The individual therapist will see BPD clients once a week, although during the beginning of therapy and in times of crisis they may have two sessions per week and/or extended time sessions. This is at the discretion of the therapist due to the manipulative behaviors common in people with BPD. If it is not possible to meet more than once a week and/or extend the sessions, phone consultations may be scheduled (Sperry, 2003). Group therapy is a setting that provides the client a place to validate others as well as to receive validation. This setting also allows others to challenge and give support in the growing process. It is through group members holding each other accountable to learn and practice the skills that some of the growth takes place. The client can attend to the skills while in a safe

Effect of Dialectical Behavior Therapy 19 environment and with a group who understands their struggles. Efficacy of DBT on the Self-Harming Behaviors Associated with BPD Reduction of Self-Harming Behaviors It is a consistent finding throughout the studies included in this thesis that DBT is effective in reducing suicidal, parasuicidal, and other SHBs (Blennerhassett & Wilson O Raghallaigh, 2005; Leichsenring & Leibing 2003; Verheul, Van Den Bosch, Koeter, Maarten, De Ridder, Stijnen, & Van Den Brink, 2003). Low, Jones, & Duggan (2001) performed a 1-year pilot study comparing DBT treatment to TAU. The DBT consisted of one skills training session and one individual session per week for each of the participants in the DBT group. The participants were females in a high security hospital setting, all of whom were diagnosed with BPD. The results of this pilot study primarily showed that SHB decreased in 10 of the participants. Shearin & Linehan (1992) had gotten similar results in their previous study on the influence of the patient-therapist relationship and its perceived importance by the patient. They also found there was a decrease in the suicidal tendencies of the patients when the therapist was perceived as more friendly and understanding. DBT, along with the change and acceptance techniques, was found to be more effective in decreasing the behaviors associated with BPD than the TAU group. Verheul et al., (2003) reported similar findings in the reduction of SHBs. Reduction in Hospitalization Linehan, Armstrong, Suarez, Allmon & Heard (1991) did a comparison study on the efficacy of DBT as compared to TAU and found that DBT decreased hospitalizations and improved the treatment completion rates which can be attributed to a decrease in SHB. Verheul

Effect of Dialectical Behavior Therapy 20 et al., (2003) found that although SHBs were reduced, there was no significant difference between the groups. Rathus & Miller (2002) reported that 13% of the TAU group was admitted for hospitalization during treatment, while 0% of the DBT group was hospitalized. There were no differences in suicide attempts among the treatment groups (n=8 from each group). Hospitalization stays for BPD patients generally tend to be high. However, Linehan, Heard, & Armstrong (1993) saw a decrease in the psychiatric in-patient days among the DBT group as compared to the TAU. This was a common trend among the studies within this review (Rathus & Miller, 2002; Linehan et al., 1991; McQuillan, Nicastro, Guenot, Girard, Lissner, Ferrero, 2005; and Verheul et al., 2003). This trend of decreasing SHBs may be related to what Linehan et al., (1993) found in their study. This study showed an increase in the Global Assessment Scale (GAS) for the DBT group and a decrease in the anger feelings of the participants, as reported through self-report measures. These findings were within the first 6 months of treatment. Bohus, Haaf, Stiglmayr, Pohl, Bohme & Linehan (2000) also found a decrease in the dissociative symptoms, depressive symptoms and anxiety, along with a reduced hospitalization among the BPD population. Effectiveness of DBT on Those With Severe and Less Severe BPD The DBT treatment was effective for the patients on the severe end of the BPD spectrum. However, research has not found it to be as effective for those less severe BPD patients (Linehan, Tutek, Heard & Armstrong, 1994). These results were most likely due to the changes in the patients tendencies to dissociate and the increase in their survival and coping skills (Low, Jones & Duggan, 2001; Linehan et al., 1994; Shearin & Linehan, 1992). McQuillan et al., (2005) saw an improvement in the scores of the participants on the Beck s Depression Inventory (BDI)

Effect of Dialectical Behavior Therapy 21 and the Beck s Hopelessness Scale (BHS). Therapist Training Increases Effectiveness Clarkin et al., (2004) like other studies, examined the efficacy of DBT on BPD. In addition to this, they examined personality and neurocognitive variables, as well as the patients mechanisms of change throughout treatment. The results showed a decrease in the symptomatology of BPD. Clarkin et al., (2004) was one of the few studies that pointed out that the training of the therapist administering the DBT affects the outcome for the patient. Trained clinicians increased the efficacy of the DBT treatment (Clarkin et al., (2004). Long-Term Efficacy of DBT In looking at the long-term efficacy of DBT on the reduction of BPD symptoms, the following results were found: Low et al., (2001) reported no significant difference between the 3 months preceding treatment and the first quarter of treatment. However, the results for the 2 nd, 3 rd and 4 th quarter showed a significant reduction in SHBs. In all, Low et al., (2001) saw a rebound effect at the first follow-up, which then reduced by the second follow-up at the second half of the 6-month period. Bohus et al., (2000) found DBT treatment to result in a significant reduction of parasuicidal behaviors. Within the first four weeks they were reduced by 88%, of which 66% of these behaviors were reduced to zero. Linehan et al., (1993) found DBT s efficacy and increase in GAS scores to be maintained throughout the follow-up year. Most studies found that TAU treatment deteriorated over time while DBT s retention and completion rate for one year was higher (Rathus & Miller, 2002; Verheul et al., 2003; McQuillan et al., 2005).

Effect of Dialectical Behavior Therapy 22 Methodology of Research Methodology is important when comparing various studies for the efficacy of a treatment. This thesis examines 11 empirical studies that focused on the efficacy of DBT on the SHBs associated with BPD. The diagnostic criteria, participants, design, assessment tools, as well as the other procedures involved, will be discussed in determining the efficacy of DBT on reducing the SHBs associated with BPD. Diagnostic Criteria The diagnosis of BPD was required of the participants for the empirical studies included in this thesis. According to the DSM-IV-TR it is necessary to meet at least five of the criteria for a diagnosis of BPD. Linehan et al., (1993) required that the participants in the study meet at least four of the criteria for BPD, as does Linehan et al., (1991). However, Linehan et al., (1991) also used the Diagnostic Interview for BPD, requiring the participants to meet seven out of the 10 criteria, along with the DSM-IV s diagnostic requirements. Participants in the randomized clinical trial in the Netherlands (Verheul et al., 2003), along with the study involving adolescents (Rathus & Miller, 2002), utilized the Structured Clinical Interview (SCI) for DSM-IV Axis II personality disorders. Also included was the Personality Diagnostic Questionnaire (PDQ) that also had to be positive for BPD to be included in this study. Most of the studies used the DSM- IV diagnostic criteria for BPD in conjunction with other assessments in determining the severity of the BPD diagnoses. The diagnosis of BPD was important in determining participation in all of the studies. Assessments In a pilot study (Low et al., 2001) which took place in a high security hospital, the participants were required to complete the BDI, Reasons for Living Inventory (RFL), Irritability,

Effect of Dialectical Behavior Therapy 23 Depression, and Anxiety Scale (IDAS), BHS, Beck Scale for Suicidal Ideation (BSI), and impulsiveness scale. While other studies included did not require participants to complete many of these self-reported assessments, there were measures taken in other studies that enabled the clinicians to determine the severity of the SHBs. This was also done to compare and contrast the past and present behaviors in defining the diagnoses of the participants. McQuillan et al., (2005) employed the use of the International Personality Disorder Examination Screening Questionnaire (IPDE) as an assessment tool. However, instead of using the normal score of three out of the 10 subscales, they required a score of four to reduce the possibility of false positives within their study. Measures were taken in several of the studies to determine the co-morbidity of other disorders. Participants with cognitive impairments/deficits, developmental disorders, and/or mental retardation were excluded from many of the studies. This was due to the cognitive abilities that are required to understand and incorporate the information and processing that is involved with DBT. Some of the disorders excluded were Schizophrenia, Bi-polar, Chronic Psychotic Disorder, Psychosis, thought disorders, affective, delusional, delirium, and dementia disorders. These exclusions permitted the clinicians to narrow down the causes of the behaviors associated with the diagnosis of BPD in order to measure the effectiveness of DBT on those behaviors. Measured at pre and post treatment were lifetime hospitalizations, previous psychological treatment, and therapeutic failures. McQuillan et al., (2005); Verheul et al., (2003) measured self-mutilating behaviors by the Lifetime Parasuicidal Count (LPC) at base line and the adapted version of the LPC at 22 weeks and 52 weeks after randomization of the participants. Verheul et al., (2003) also assessed the frequency of BPD symptoms for the 3 months before the study,

Effect of Dialectical Behavior Therapy 24 using the applicable sections of the Borderline Personality Disorder Severity Index (BPDSI). This measured the recurrent parasuicidal and self-damaging impulsive behaviors. Many of the studies found it necessary to include only those people with BPD who had recent hospitalizations and/or suicidal behaviors. Linehan et al., (1991) included participants who had at least two attempts of parasuicide within the last 5 years, one of them within the 8 weeks before joining the study. Linehan et al., (1991, 1994) also required the participants to have 10 recent suicidal behaviors. A treatment history and parasuicidal history interview was conducted in some of the studies to determine the time span of these behaviors. The measure to determine the frequency and treatment associated with these behaviors was done by asking the participants (in some studies) questions from the Parasuicide History Interview (PHI) (Linehan et al., 1993). In the study conducted on adolescents (Rathus & Miller, 2002), participants were assessed on their suicide attempts by the clinicians administering the Harkavy-Asnis Suicide Survey (HASS) and the SSI. At least one suicide attempt within the previous 16 weeks was to be verified before allowing participation in the adolescent study (Rathus & Miller, 2002). Participants The participants included in the 11 empirical studies were mostly female and chronically suicidal. This gender bias is a common trend throughout all of the studies included, which may be due to the diagnosis of BPD being prevalent among females. Low s et al., (2001) sample consisted of 10 females, all of whom met the diagnostic criteria for BPD. However, 7 out of the final sample of 10 participants met the criteria for other personality disorders such as paranoid, anti-social, schizotypal, and avoidant. This is unlike other studies included that controlled for co morbid diagnoses of the same type. Low et al., (2001) began their study with 17 females. Of these 4 dropped out within the first 4 months, 1 due to a

Effect of Dialectical Behavior Therapy 25 security issue, 2 due to limited cognitive ability and 1 who was unwilling to participate. Rathus & Miller, (2002) did include males in their study. However, 93% of the participants within the DBT group and 73% of the TAU group were female. The following studies consisted of only females: Linehan et al., (1994), study consisted of 26 females; Linehan et al., (1993) 39 females; Verhuel et al., (2003) 58 females; and Linehan et al., (1991) 44 females. Shearin & Linehan, (1994) conducted a study on how the therapist-patient relationship affected the reduction on BPD symptomatology through the use of DBT therapy. The sample was small, made up of only 4 patient-therapist pairs. Their sample consisted of females 18-45 years old who met the criteria for a diagnosis of BPD according to the DSM-III-R (Shearin & Linehan, 1994). The females in this study had multiple parasuicide behaviors, one of which was within the 8 weeks prior to initiation into the study. Bohus et al., (2000) conducted a prospective study that looked at the efficacy of DBT on BPD behaviors within a hospital setting and for the 3 months following the study. The sample consisted of 24 female patients who had a diagnosis of BPD according to the DIB-R, scoring at least 8 points, and meeting at least five of the criteria for a DSM-IV diagnosis. The participants were to have had parasuicidal acts of which landed them in the hospital for physical injury and/or one suicide attempt within the previous 2 years (Bohus et al., 2000). Clarkin et al., (2004) reported their sample was male and female. However, the numbers for each gender were not given in the article. The sample size was 109 participants, all of whom met the DSM-IV criteria for a diagnosis of BPD and were ruled out for substance abuse, schizophrenia, or a schizophrenic disorder (Clarkin et al., 2004).

Effect of Dialectical Behavior Therapy 26 Limitations of Studies Sample Size Sample size, gender bias, age, severity of the BPD diagnosis, distribution of participants to treatment groups and the cognitive abilities of participants, all play a role in the ability to generalize the findings in the studies included in this review. The sample sizes varied among the studies, ranging from the Low et al., (2001) sample of 10, to Rathus & Miller (2002), whose sample was 111 participants. In the study conducted by Linehan et al., (1993) the sample size of 39 participants would not show differences, like the study of Rathus & Miller (2002) whose study was larger. Gender Bias DBT was developed as a treatment specifically for females diagnosed with BPD (Robins et al., 2004). Keeping this in mind, the gender of the participants in the included studies is mostly female, which makes it difficult to generalize the results to the male population. Linehan, Dimeff, Reynolds, Comtois, Welch, Heagerty & Kivlahan (2002) required the participants to be female, while other studies such as Rathus & Miller (2002) took 111 consecutive outpatient admissions to an adolescent program. Subjects of Linehan s et al., (1991) study were all female, referred by other clinicians. This was also the case in Verheul et al., (2003), which consisted of 58 women referred by clinicians. Age of Participants The age range of participants varied within the included studies. However, in all, the range tended to encapsulate the ages of 18 to 70 years old. The exception would be Rathus & Miller (2002), which designed the study specifically for adolescents. The studies with participants on the high end of the age range may have had an effect on the outcome of the

Effect of Dialectical Behavior Therapy 27 studies. This may be due to the symptoms, behaviors, and the severity of BPD decreasing with age (Hampton, 1997). Severity of Diagnosis The severity of the symptoms among the participants was mostly consistent across the studies. A requirement of the included studies was that participants have a recent hospitalization due to suicidal/parasuicidal behaviors. This makes it difficult to generalize the results to BPD populations of less severity (Linehan et al., 1991; Rathus & Miller, 2002; Low et al., 2001). The participants of the Rathus & Miller (2002) study were adolescents and were not considered as chronic as the adult population with BPD. Linehan et al., (1993) conducted a study that also indicated that generalization of efficacy to the less severe populations was not distinguishable. This was most likely due to the lack of this population with BPD being included in their study. McQuillan s et al., (2005) study was conducted to show the efficacy of DBT on the SHBs associated with BPD as a form of crisis treatment. The methodology McQuillan et al. employed differed from other studies included and therefore, resulted in better outcomes compared to the other studies. Linehan et al., (1994) was another study that included participants with severe symptoms of BPD. The preceding information on the severity of the BPD in participants indicates that non-suicidal patients or those with less severe symptoms who are diagnosed with BPD may not benefit as greatly from DBT. Distribution to Treatment Groups The distribution of participants, the lack of a control group, and unequal comparison groups also contribute to the limitations. In Low et al., (2001), Shearin & Linehan, (1992), Linehan et al., (1991), McQuillan et al., (2005) studies there was no control group. This was due

Effect of Dialectical Behavior Therapy 28 to ethical reasons, in that it is unethical to withhold treatment from people whose behaviors are life threatening. Assignment to groups is determined to be a limitation due to lack of randomization within some studies. Rathus & Miller (2002) assigned their participants to groups according to a triage model, based on the greatest need for treatment. Those participants with more suicide attempts and the greatest number of hospitalizations were assigned to the DBT group (Rathus & Miller, 2002). Linehan et al., (1994); Linehan et al., (1991); and Verhuel et al., (2003), conducted studies in which participants were randomly assigned to either DBT or TAU. Linehan et al., (2002) conducted a study including BPD patients recruited from other mental health clinics, substance abuse clinics, and methadone maintenance clinics. They were then randomly assigned to treatment groups. In other studies however, the setting played a part in assigning participants to groups. Low et al., (2001) had no comparison group, as it took place within a high security hospital with all the participants being detained. Researcher Training Marsha Linehan, the developer of DBT for clients with a diagnosis of BPD, was involved in many of the studies included (Linehan et al., 1993; Linehan et al., 1991; Linehan et al., 1994; Shearin & Linehan, 1992). Her involvement may have had an effect on the outcome of these studies. These participants worked with more effectively trained therapists, whereas the DBT may not have been as effective with less experienced therapists (Linehan et al., 1991). The follow-up study conducted by Linehan et al., (1993) was one of the studies in which individual psychotherapy was not controlled for during the follow-up period. Linehan et al., (1994) conducted their study in the facility where the DBT was developed. This may have given them a more favorable outcome than the other studies that took place outside of such a setting.