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Effectiveness of Dialectical Behavior Therapy – Part One

The effectiveness of Dialectical Behavior Therapy (DBT) for Borderline Personality Disorder has been assessed in two major trials. The first trial, performed by Marsha Linehan in 1991, compared the effectiveness of Dialectical Behavior Therapy relative to treatment as usual (TAU). The second trial examined the effectiveness of DBT skills training when added to standard community psychotherapy.

In the first randomized controlled trial, there were three main goals:

The first goal was to reduce the frequency of parasuicidal behaviors. This is clearly of importance, not only because of the distressing nature of the behavior, but also because of the increased risk of completed suicide in this group. 1

The second goal was to reduce the behaviors that interfere with the progress of therapy – called “therapy interfering behaviors” – as the attrition rate from therapy in women with Borderline Personality Disorder who had a history of parasuicidal behaviors is high.

The third goal of Dialectical Behavior Therapy was to reduce behaviors that interfere with the patient’s quality of life. In this study, this last goal was interpreted more specifically as a reduction in in-patient psychiatric days, which is hypothesized as interfering with the patient's quality of life.

Participants in the study all met the Diagnostic and Statistical Manual for Mental Disorders (DSM-IIIR) criteria for Borderline Personality Disorder, and were matched for age, number of lifetime parasuicidal episodes, number of lifetime admissions to hospital, and anticipated poor or good prognosis.

There were 22 patients in each group. The experimental group received standard Dialectical Behavior Therapy as outlined above. The experience of the patients in the treatment as usual (TAU) group was variable – some received regular individual psychotherapy, and others dropped out of individual therapy while continuing to have access to in-patient and out-patient services. All of the participants were assessed on the number of parasuicidal episodes and a range of measures of mood on the questionnaires.

Patients were blindly assessed at pre-treatment, and at four, eight, and twelve months, and followed up at six and twelve months post-treatment. Measures of treatment compliance and other treatment delivered (i.e., in-patient psychiatric days) were also taken. At pre-treatment, there were no significant differences on any of the measures between the control and experimental groups, including demographic criteria.

With regard to the first goal of the trial (e.g., the reduction of suicidal behavior) during the year of treatment, the patients in the control group engaged in more parasuicidal acts than did the Dialectical Behavior Therapy patients at all time periods. The medical risk for parasuicidal acts, however, was higher in the control group than in the DBT group.

Patients in the DBT group were more likely to start and to remain in therapy than those in the control group. The one year attrition rate in the DBT group was 16.7% compared to 50% for those in the control group.

With regard to the third goal of the trial study, patients in the control group had significantly more in-patient psychiatric days per person than did those receiving Dialectical Behavior Therapy; 38.6 days per year, as opposed to 8.46 days per year for the DBT group.

These results were considered as indicating the superiority of Dialectical Behavior Therapy over treatment as usual (TAU); however, one major criticism of the trial is that the patchy and variable therapeutic experience of the control group can be considered to favor Dialectical Behavior Therapy. This criticism may be challenged, though, since one of the treatment goals of DBT is to keep the patient in therapy, and it does seem to have succeeded in doing that.

It is interesting to note that, although the Dialectical Behavior Therapy patients showed significant gains across the three areas of interest (number of parasuicides, treatment compliance and in-patient days), there were no between-group differences on any of the measures of mood and suicidal ideation on the questionnaires.

1. Stone, M.H. (1987) The course of borderline personality disorder. In Tasman, A., Hales, R.E. & Frances, A.J. (eds) American Psychiatric Press Review of Psychiatry. Washington DC; American Psychiatric Press inc. 8, 103-122.

About the Author

David Oliver is the founder of BorderlineCentral.com a one stop source of information on how to cope and deal with borderline personality disorder.

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