Inpatient dialectical behavior therapy (DBT) is an effective treatment for borderline personality disorder (BPD), but often treatment is ended prematurely and predictors of dropout are poorly understood. We, therefore, studied predictors of dropout among 60 women with BPD during inpatient DBT. Non-completers had higher experiential avoidance and trait anxiety at baseline, but fewer life-time suicide attempts than completers. There was a trend for more anger–hostility and perceived stigma among non-completers. Experiential avoidance and anxiety may be associated with dropout in inpatient DBT. Low life-time suicidality and high anger could reflect a subtype at risk for discontinuation of inpatient treatment.
Dialectical behavior therapy (DBT; Linehan, 1993) is an effective treatment for persons with borderline personality disorder (BPD). Originally developed for outpatients with BPD, it was later modified for inpatient settings (Bohus et al., 2000, Bohus et al., 2004 and Swenson et al., 2001). However, dropout rates are high even in specialized inpatient settings. Twenty-two percent of women with BPD prematurely ended inpatient DBT in a setting identical to the study reported here (Bohus et al., 2004).
Predictors of dropout are poorly understood despite the prevalence and obvious clinical relevance of this phenomenon. Skodol, Buckley, and Charles (1983) found that in outpatients with BPD higher psychopathology at baseline was related to early treatment dropout. In a study by Gunderson et al. (1989) dropout from inpatient treatment was associated with less baseline psychopathology, less prior psychiatric treatment and fewer suicidal thoughts. Further, high anger and impulsivity were related to early dropout in BPD (Heinssen & McGlashan, 1988). It should be noted, however, that these studies differed not only in terms of inpatient versus outpatient settings but also comprised heterogeneous psychotherapeutic treatments so that conclusions to inpatient DBT should be drawn with caution. Our study, therefore, aimed to examine predictors of dropout identified in those previous studies and their relevance for inpatient DBT.
In recent psychotherapy research, increasing attention has been paid to the concept of experiential avoidance (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). This phenomenon occurs when a person is unwilling to remain in contact with particular private experiences (bodily sensations, emotions, thoughts, etc.) and takes steps to alter the form or frequency of these experiences or the contexts that occasion them, even when these forms of avoidance cause behavioral harm (Hayes et al., 2004). Avoidance of such private experiences may be a major obstacle for successfully engaging in psychotherapy, and, therefore, high experiential avoidance is likely to be associated with therapy dropout. In BPD, deliberate self-harm, a key symptom of this disorder, may function to avoid unwanted emotional experiences (Chapman, Gratz, & Brown, 2006). This is in line with recent data indicating that acceptance-based interventions are effective in BPD (Gratz & Gunderson, 2006). Further, in women with BPD experiential avoidance is associated with proneness to dysfunctional emotions such as anxiety (Rüsch, Corrigan, Bohus, Jacob, et al., 2007). We, therefore, expected that in addition to experiential avoidance anxiety is related to premature termination of therapy.
Additional variables are likely related to premature termination of treatment in BPD. Fear of stigma, perceived discrimination and labeling as “mentally ill” (Rüsch, Angermeyer, & Corrigan, 2005) can lead to ending treatment prematurely since persons with mental illness often try to avoid the negative labeling resulting from psychiatric or psychotherapeutic treatment (Corrigan & Rüsch, 2002). This has been shown for persons with depression (Sirey et al., 2001), but has not been studied in individuals with BPD so far.
We, therefore, wanted to test the hypothesis that high levels of anxiety, anger–hostility, experiential avoidance and perceived stigma as well as current psychopathology and key variables of the clinical history such as the number of life-time suicide attempts and hospitalizations are related to early discontinuation of inpatient DBT.
