Running head: FINAL PROJECT 1

Final Project: Research and Evaluation

Lisa E. Schallhorn

Walden University

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Final Project

Borderline Personality Disorder (BPD) is a serious

psychiatric disorder which affects between 2.0% and 5.9% of the

general population (Meany-Tavares and Hasking, 2013). BPD is

characterized as a chronic and long-term disorder which is

difficult to treat. Individuals who have been diagnosed with BPD

may have difficulties with identity problems, emotional

instability, lack impulse control, have difficulties managing

relationships, experience anxiety and/or depression, have

substance abuse issues, experience suicidal ideation and

attempts, and may have self-injurious behavior (Perseius,

Jehagen, Ekdahl, Asberg, and Samuelsson, 2003). Dialectical

Behavior Therapy (DBT) has been shown to be effective in treating

the symptoms of BPD and consists of four modules – Mindfulness,

Interpersonal Effectiveness, Distress Tolerance, and Emotional

Regulation (Meany-Tavares and Hasking, 2013). This paper will

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review current research in exploration of the question, what is

the efficacy of Dialectical Behavior Therapy on the treatment of

Borderline Personality Disorder in women? This paper will include

an analysis of the effectiveness of DBT for BPD compared to other

treatment therapies; will explain how DBT lowers suicidal

ideation and attempts, assists clients with emotion regulation

and substance abuse, will address reasons for high drop-out rates

of clients in DBT programs, skill training methods and overall

success of DBT programs, how DBT helps mothers with BPD, an

analysis of a program evaluation, and will explore the cultural

considerations regarding DBT programs for individuals who have

been diagnosed with BPD.

Comparison to Other Therapies

One theme which emerged from the research was how DBT is

more effective in treating BPD than most other types of

therapies. Neacsiu, Rizvi, and Linhan, (2010); Linehan, Comtois,

Murray, Brown, Gallop, Heard, Korslund, Tutek, Reynolds, and

Lindenboim (2006) compared DBT with controlled treatments -

treatment- as-usual (TAU). Compared to TAU, DBT clients were

significantly less likely to attempt suicide or participate in

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self-injurious behaviors. The individuals who participated in DBT

also had lower treatment drop outs and spent less time in

psychiatric units than those who participated in TAU.

Participants who received DBT also experienced significant

reductions in the use of psychotropic medications, depression,

and anger. The authors were careful to control the following

variables: availability of treatment, assistance with getting to

the first appointment with a counselor, hours of individual

sessions offered, therapist training and clinical experience, and

compliance to treatment approaches (Neacsiu, Rizvi, and Linhan,

2010; Linehan, Comtois, Murray, Brown, Gallop, Heard, Korslund,

Tutek, Reynolds, and Lindenboim (2006).

Suicidal Ideation and Self-Injury

A second theme that emerged in the research was the

significantly positive effects regarding suicidal ideation with

women who were diagnosed with BPD and participated in DBT. Bosch,

Koeter, Stijnen, Verheul, and Brink, (2005); Lindenboim, Comtois,

and Linehan, (2007); Linehan, Comtois, Murray, Brown, Gallop,

Heard, Korslund, Tutek, Reynolds, and Lindenboim, (2006); Harned,

Tkachuck, and Youngberg (2013); and Swales, Taylor, and Hibbs

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(2012) all found there was a reduction in life-threatening

behaviors and suicidal ideation when the clients were receiving

DBT. DBT addresses the following areas which contribute to the

reduction of suicidal ideation: increasing behavioral

capabilities, improving motivation for healthy behavior (which

includes management of emotions and cognitions), assuring that

the clients work towards normal functioning in the natural

environment, and the enhancement of the counselor’s ability to

motivate and treat clients in effective ways (Linehan, Comtois,

Murray, Brown, Gallop, Heard, Korslund, Tutek, Reynolds, and

Lindenboim, 2006). The Harned, Tkachuck, and Youngberg (2013)

study informs readers of the value of DBT for individuals

diagnosed with BPD and Post Traumatic Stress Disorder (PTSD).

The participants of this study found the greatest relief from

distress, particularly PTSD and trauma-related distress, when

utilizing skills learned in DBT. These participants demonstrated

the ability to tolerate short-term distress when processing

trauma memories in order to achieve long-term reduction in PTSD.

Emotion Regulation

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Individuals who have been diagnosed with BPD have problems

with emotion regulation, distress tolerance and interpersonal

skills. Lindenboim, Comtois, and Linehan, (2007); Roepke,

Schroder-Abe, Schutz, Jacob, Dams, Vater, Ruter, Merkl, Heuser,

and Lammers (2010); Ben-Porath, Peterson, and Smee (2004), and

Neacsiu, Rizvi, and Linehan (2009) suggest DBT increases

behavioral skills to reduce the levels of emotional distress such

as anger, impulsiveness and self-loathing. DBT also has been

proven to reduce behaviors which interfere with quality of life

such as somatization, hostility, anxiety, depression, paranoid

ideation, and psychoticism (Ben-Porath, Peterson, and Smee,

2004). Ben-Porath, Peterson, and Smee, (2004) used diary cards

which monitored the clients “system-interfering behaviors”. One

behavior addressed in their DBT program was the excessive use of

psychiatric emergency services. Clients were encouraged to remain

in their own environment during stressful times in order to help

them develop coping skills. Another area addressed using the

diary cards was complaints lodged against mental health

professionals. Excessive complaining about therapists was

considered a form of “system-interfering behavior”. It is common

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for clients with BPD to be unable to control their anger;

therefore, clients were taught how to use interpersonal skills to

regulate their negative emotions. When clients are able to manage

their emotions, their quality of life improves and their

relationships with others improve.

Individuals with BPD often experience serious levels of

depression and the way DBT helps clients with depression is to

help them change their ways of thinking, as well as their

behaviors. Neacsiu, Rizvi, and Linehan (2010) explain if clients

are able to increase their level of emotional processing, the

levels of depression decrease. One of the skills used in DBT is

reframing attitudes and events from negative to positive.

Substance Abuse

Substance abuse is often a problem with individuals

diagnosed with BPD. Alcohol and/or drugs are often used to cope

with the symptoms of BPD. Linehan, Schmidt, Dimeff, Craft,

Kanter, and Comtois (1999) and Bosch, Koeter, Stijnen, Verheul,

and Brink (2005) report 57% to 67% of individuals diagnosed with

BPD are also diagnosed with a substance abuse disorder – either

abuse or dependency. The authors’ studies show that among

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individuals seeking Methadone treatments for opiate addiction,

from 5/2% to 32% have been diagnosed with BPD. Studies show

individuals who are struggling with substance abuse, and also

have a personality disorder, have more serious psychiatric

problems than those without a personality disorder. These

individuals have more life problems such as legal problems; they

are more susceptive to Hepatitis C, HIV, and sexually transmitted

diseases. The authors’ studies demonstrated a significant

reduction in substance use using DBT compared to individuals

assigned to treatment-as-usual (TAU). Also, a significant percent

of individuals who participated in DBT stayed in treatment

programs compared to TAU. Substance abuse is dangerous and risky

for individuals diagnosed with BPD and one of the reasons is they

often are prescribed many different types of medications to

control the symptoms of BPD and combining them with substances is

dangerous and can be deadly (Bosch, Koeter, Stijnen, Verheul, and

Brink, 2005).

Reasons for High Dropout Rates

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Rusch, Schiel, Corrigan, Leihener, Jacob, Olscheweski, Lieb,

and Bohus (2007); Perseius, Jehagen, Ekdahs, Asberg, and

Samuelsson (2003); and McFetridge and Coakes (2010); all

researched the dropout rates of clients in DBT compared to other

types of therapy. All of the authors agreed the dropout rate is

related to higher psychopathology of individuals diagnosed with

BPD. Rusch et al., (2007) identified high experiential avoidance

as the most prominent factor of high dropout rates, whereas,

Perseius et al., (2003) concluded that high anger and impulsivity

was the main contributor to high dropout rates. McFetridge and

Coakes (2010) report uncontrolled anxiety related to the

participants unstable living environment is the main factor

regarding the dropout rate of clients participating in DBT

programs. In addition, Rusch et al., (2007) discovered additional

variables for high dropout rates which include fear of stigma,

perceived discrimination, and being labeled as “mentally ill”.

Skill Training and Overall Success

Cunningham, Wolbert, and Lillie (2004); Lindenboim, Comtois,

and Linehan (2007); Neacsiu, Rizvi, and Linehan (2010); and Ben-

Porath, Peterson, and Smee (2004) all agreed that group and

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individual sessions are key components to skill training and

success in DBT. Ben-Porath et al., (2004) concluded the use of

diary cards are one of the most valuable methods of skill

training. The diary cards require clients to consider the

following areas on a daily basis: suicidal ideation, self-harm

(urges and actions), compliance with psychotropic medications,

substance use, misery-level, admissions into psychiatric

facilities or hospital emergency rooms, and being admitted into

crisis stabilization units and a daily record of skills used.

Lindenboim, et al., (2007) also believed in homework assignments

to enhance skills training. Their study demonstrated individuals

who complied with homework assignments reported lower

symptomology and higher success rates. Programs which focused on

the homework aspect in the first half of each weekly session to

reinforce skills training experienced greater success because of

the reinforcement of the skills that are being taught and

learned. Neacsiu et al., (2010) and Cunningham et al., (2004)

both concluded weekly skill training is instrumental regarding

positive behavioral outcomes including suicidal behavior and

emotional distress regulation. Participants in these two studies

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reported the skills which help them control their emotions were

the most useful. These skills include self-soothing, distraction,

and mindfulness. Cunningham et al., (2004) reports some

interesting thoughts revealed by participants in their study. One

participant stated:

“You have got to stay in the moment. If you get really

overrun by fears or the

future you need to say “Am I okay right now?” Instead of

taking on the whole

future and all of my fears and trying to solve them right

now, I take what is

practical and what is in the here and now and what I feel

right now and what I

can do in this moment”

Treatment Needs of Mothers with Borderline Personality Disorder

Zalewski, Stepp, Whalen, and Scott (2015) addressed the

treatment needs of women with BPD who are also mothers. There are

very few studies which have studied mothers who are attempting to

parent with this debilitating mental health disorder. Children

who are exposed to a mother with BPD may experience insecure

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attachment, emotional dysregulation, depression, and substance

abuse. Mothers with BPD report to being more distressed, less

satisfied, and feeling less competent in their parenting roles

(Newman, 2007), as cited by Zalewski, Stepp, Whalen and Scott.

This qualitative study revealed the necessity of mothers

receiving help with learning how to communicate their mental

health disorder. It also addressed the mothers concerns about how

BPD impacts their children. Through the coding of the study, the

following themes emerged regarding participants receiving DBT

skills: commonality with other mothers, relief of fear of

judgment of own parenting, and dealing with the fear of exposing

children to BPD traits. The mothers in this study reported they

benefited by learning new parenting skills, increasing their

confidence as a parent, and being able to communicate their

feelings with other members of their group and with the

counselor. Surprisingly, none of the other research studies

selected addressed the subject of DBT and mothers diagnosed with

BPD.

Program Evaluation

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Swales, Taylor, and Hibbs (2012) conducted a study of 105

different DBT programs in

order to evaluate the effectiveness of DBT for clients diagnosed

with BPD between 1994 and

2007. Out of the 105 programs, 97 of the programs provided

useable data. Out of the 97 programs, 66 (62.8%) were still

actively running and 39 (37.1%) became inactive. The programs

which ended reported the most commons reasons were: lack of

organizational support (68%), high staff turnover (63%), and

insufficient allocated time to deliver the program (56%) (Swales,

Taylor, and Hibbs, 2012). The authors reported the most

vulnerable time for programs using DBT is in the second year,

shortly after the second week of training has been completed. The

staff experiences an absence of clear strategic planning and

implementation. The second most vulnerable time is in year five

which researchers hypothesize is due to staff turnover.

Implementing DBT requires a great deal of training and support

for the facilitators. If this is not provided, studies show a 40-

50% failure rate of DBT programs (Swales, Taylor, and Hibbs,

2012).

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Ben-Porth, Peterson, and Smee, (2004) state the community

mental health setting is a good fit for the implementation of

DBT. There are many borderline clients who must be admitted to

Crisis Stabilization Units (CSU) for a short period of time

because of behaviors that escalate rapidly, which is common with

individuals diagnosed with BPD. These individuals are treated

from one to two days and benefited from learning abbreviated DBT

skills presented by experienced therapists.

Cultural Differences

Hamamura, Heine, and Paulhus (2007) report there are

cultural differences in response styles in a number of studies

regarding DBT and the ways of thinking. This study showed

participants within the East-Asian heritage demonstrate more

ambivalent and moderate responding than North Americans in self-

report items. The East-Asian culture may have a more dialectical

way of thinking about themselves or the ability to tolerate

contradictory beliefs. This study demonstrated the importance of

considering dialectical thinking when interpreting results from

cross-cultural studies. Interestingly, the other research studies

selected did not provide information regarding the cultural

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background of the participants, which could be considered a

limitation of each of the studies.

Conclusion

There is strong evidence of the effectiveness of DBT for

individuals who have been diagnosed with BPD. The studies

reviewed conclude DBT is more effective than treatments as usual

(TAU) such as psychotherapy and other cognitive behavioral

therapy (CBT) methods. Research pointed to a decrease of suicidal

attempts and ideations and self-injurious behaviors by

individuals participating in DBT. Some studies reported lower

treatment drops outs, which resulted in better emotion regulation

and better control of impulsivity. In addition, some studies

suggest statistically significant decreases in substance abuse,

depression, and anger which contribute to a higher quality of

life. Several of the studies correlate skill-building with the

improvement of symptomology of individuals diagnosed with BPD.

One study addressed issues of mothers with BPD and how DBT helps

mothers to be able to explain their mental illness to their

children and helps them to be better mothers, as they are able to

control their life-altering symptoms of BPD. More research is

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needed on the effectiveness of DBT within different cultural

backgrounds of individuals diagnosed with BPD. All of the studies

included in this paper concluded that DBT is the most effective

type of therapy for individuals with BPD.

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References

Ben-Porath, D.D., Peterson, G.A., & Smee, J. (2004). Treatment of

individuals with borderline

personality disorder using dialectical behavior therapy in a

community mental health

setting: Clinical application and a preliminary

investigation. Cognitive and Behavioral

Practice, 11, 424-434.

Bosch, L.M.C., Koeter, M.W.J., Stijnen, T., Verheul, R., & Brink,

W.V. D. (2005).

Sustained efficacy of dialectical behavior therapy for

borderline personality disorder.

Behavior Research and Therapy, 43, 1231-1241.

Cunningham, K., Wolbert, R., & Lillie, B. (2004). It’s about me

solving my problems: Clients’

Assessments of dialectical behavior therapy. Cognitive and

Behavioral Practice, 11,

248-256.

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Hamamura, T., Heine, S.J., & Paulhus, D.L. (2007). Cultural

differences in response styles: The

role of dialectical thinking. Personality and Individual Differences,

44, 932-942.

Harned, M.S., Tkachuck, M.A., Youngberg, K.A. (2013). Treatment

preference among suicidal

and self-injuring women with borderline personality disorder

and posttraumatic stress

disorder. Journal of Clinical Psychology, 69(7), 749-761.

Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop,

R.J., Heard, H.L.,

Korslund, K.E., Tutek, D.A., Reynolds, S.K., & Lindenboim,

N. (2006). Two-year

randomized controlled trial and follow-up of dialectical

behavior therapy vs therapy

by experts for suicidal behaviors and borderline personality

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Lindenboim, N., Comtois, K.A., & Linehan, M.M. (2007). Skills

practice in dialectical behavior

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therapy for suicidal women meeting criteria for borderline

personality disorder.

Cognitive and Behavioral Practice, 14, 147-156.

Meaney-Tavares, R., & Hasking, P. (2013). Coping and regulating

emotions: A pilot study of a

Modified dialectical behavior therapy group delivered in a

college counseling service.

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McFetridge, M., & Coakes, J. (2010). The longer-term clinical

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Neacsiu, A.D., Rizvi, S.L., & Linehan, M.M. (2010). Dialectical

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Perseius, K.I., Jehagen, A.O., Ekdahl, S., Asberg, M., &

Samuelsson, M. (2003). Treatment of

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suicidal and deliberate self-harming patients with

borderline personality disorder using dialectical behavioral

therapy: The patients’ and the therapists’ perceptions.

Archives of Psychiatric Nursing, 15, 5, 218-227.

Roepke, S., Schroder-Abe, M., Schutz, A., Jacob, G., Dams, A.,

Vater, A., Ruter, A., Merkl, A.,

Heuser, I., & Lammers, C.H. (2011). Dialectic behavioural

therapy has an impact on

self-concept clarity and facets of self-esteem in women with

borderline personality

disorder. Clinical Psychology and Psychotherapy, 18, 148-158.

Rusch, N., Schiel, S., Corrtigan, P.W., Leihener, F., Jacob,

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(2008). Journal of Behavior Therapy and Experimental Psychiatry, 39, 497-

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dialectical behavior therapy:

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Mental Health, 21(6), 548-

555.

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Zalewski, M., & Stepp, S.D., Whalen, D.J., Scott, L.N. (2015). A

qualitative assessment of the

Parenting challenges and treatment needs of mothers with

borderline personality disorder.

Journal of Psychotherapy Integration. Advance online publication.

http://dx.doi.org/10. 1037/a0038877.

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