Abstract
The aim was to investigate patients and therapists perception of receiving and giving dialectical behavioral therapy (DBT). Ten deliberate self-harm patients with borderline personality disorder and four DBT-therapists were interviewed. The interviews were analyzed with qualitative content analysis. The patients unanimously regard the DBT-therapy as life saving and something that has given them a bearable life situation. The patients and the therapists are concordant on the effective components of the therapy: The understanding, respect, and confirmation in combination with the cognitive and behavioral skills. The experienced effectiveness of DBT is contrasted by the patient’s pronouncedly negative experiences from psychiatric care before entering DBT.
BORDERLINE PERSONALITY disorder (BPD) is a psychiatric health problem with a reputation of being difficult to deal with and to treat. Patients suffering from BPD are characterized by identity problems and unstable relations, lacking impulse control, emotional instability, and feelings of emptiness often in combination with anxiety, depression, and substance abuse (APA, 1994). To a very great extent it is younger women who are suffering from the disorder (Widiger and Weissman, 1991). Repeated, suicide attempts (intentional, acute, self-injurious behavior with suicidal intent), and acts of deliberate self-harm (intentional, acute, self-injurious behavior without suicidal intent) is very common among these patients. Long-term follow-up studies suggest that 3% to 13% die from suicide McGlashan 1986, Paris 2002 and Stone 1993, and a Swedish study found BPD diagnoses behind 19 (33%) of 58 suicides, committed by adolescents and young adults (Runeson and Beskow, 1991). The literature on the epidemiology of BPD is scarce, but an American review suggests a prevalence between 0.2% and 1.8% in the general population and 15% among psychiatric outpatients (Widiger and Weissman, 1991). A Swedish study found a nearly 30% prevalence of BPD among psychiatric outpatients (Bodlund, Ekselius, Lindström, 1993).
BPD patients often evoke uneasiness and attitudes of being troublesome and manipulative among the staff involved in the treatment (Linehan, 1993). The treatment dropout rates are prominent, and figures as high as 40% to 50% within 6 weeks has been reported (Kelly et al., 1992). There is no specific pharmacological treatment for the disorder. Instead the medication is symptom-oriented with a great variation from patient to patient. Research focusing on medication is not extensive and the scientific quality often weak (Brinkley, 1993).
In 1991, Linehan et al (1991) published the results from a randomized controlled trial of a psychosocial intervention for BPD. The intervention in focus was a form of cognitive-behavioral therapy, called dialectical behavioral therapy (DBT). The therapy especially targets the pattern of suicide attempts and deliberate self-harm in BPD patients. The study showed that DBT resulted in significantly fewer suicide attempts and acts of deliberate self-harm, lower treatment drop out rate and fewer inpatient days compared to the control group (Linehan et al., 1991).
DBT combines intervention strategies from behavioral, cognitive, and supportive psychotherapies, and includes weekly individual and group therapy. The therapy applies a mixture of supportive techniques and directive, problem-oriented techniques (behavior skills training, exposure, contingency management, and cognitive modification). The therapy targets three phases of general treatment goals organized in the following hierarchy: (1) “Stability and security,” aiming towards decreased suicidal behavior and acts of deliberate self-harm, decreased therapy-interfering behaviors and decreased quality-of-life interfering behaviors. (2) Reduction of posttraumatic stress by focusing on traumatic life events. (3) Increased self-respect and achievement of individual life goals. Both during and between sessions the therapist actively teaches and reinforces adaptive behaviors. Therapists, between sessions, have a 24-hour readiness to intervene in their patients’ self-harming behavior by telephone. The treatment sessions are videotaped. The videotapes are used as a basis for supervision sessions (Linehan, 1993). Over the years DBT has made its way into practice in psychiatric health care services in several countries, the region of Lund in southern Sweden being one example. In view of positive treatment outcomes reported, i.e., decreased rates of suicide attempts, episodes of deliberate self-harm and psychiatric inpatient days (Linehan, 1991), DBT seems to be a promising outpatient treatment for self-harming BPD patients. Decreased treatment dropout rates also suggest DBT to be well accepted by the patients. However, DBT as seen from the patients’ and therapists’ perspective has, to our knowledge, not been investigated. The purpose of this study was to describe patients’ and therapists’ perception of receiving and giving DBT treatment.
Conclusion
DBT, seen from the patients’ and therapists’ perspective, to our knowledge, has not been investigated with a qualitative method before. A number of studies have found that DBT seems to work Hawton et al 1999, Koerner and Linehan 2000 and Linehan et al 1991. Besides that, our findings point towards central components that include: the systemized understanding, respect and confirmation in combination with the “toolbox” of techniques and constructive skills the patients are provided and trained to use. A challenge for further qualitative DBT research would be to understand in more detail why and what components that work, so that they can be used more widely in psychiatric services.
