Time-limited treatment of hospitalized borderline patients: considerations

The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units

Inpatient treatment of individuals with borderline personality disorder (BPD) is typically fraught with difficulty and failure. Patients and staff often become entangled in intense negative therapeutic spirals that obliterate the potential for focused, realistic, and effective treatment interventions. We describe an inpatient treatment approach to BPD patients which is an application of Dialectical Behavior Therapy (DBT), a cognitive-behavioral therapy for patients with BPD which has been shown to be effective in reducing suicidal behavior, hospitalization, and treatment dropout and improving interpersonal functioning and anger management. The inpatient DBT staff creates a validating treatment milieu and focuses on orienting and educating new patients and identifying and prioritizing their treatment targets. Inpatient DBT treatment techniques include contingency management procedures, skills training and coaching, behavioral analysis, structured response protocols to suicidal and egregious behaviors on the unit, and consultation team meetings for DBT staff.

Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder--a prospective study

Dialectical-Behavioral Therapy for Borderline Personality Disorder (DBT) developed by M. Linehan is specifically designed for the outpatient treatment of chronically suicidal patients with borderline personality disorder. Research on DBT therapy, its course and its results has focused to date on treatments in an outpatient setting. Hypothesizing that the course of therapy could be accelerated and improved by an inpatient setting at the beginning of outpatient DBT, we developed a treatment program of inpatient therapy for this patient group according to the guidelines of DBT. It consists of a three-month inpatient treatment prior to long-term outpatient therapy. In this pilot study 24 female patients were compared at admission to the hospital, and at one month after discharge with respect to psychopathology and frequency of self-injuries. Significant improvements in ratings of depression, dissociation, anxiety and global stress were found. A highly significant decrease in the number of parasuicidal acts was also reported. Analysis of the average effect sizes shows a strong effect which prompts the development of a randomized controlled design.

The use of contracts in the inpatient treatment of the borderline personality disorder

This paper reviews and describes the clinical, administrative, and psychodynamic aspects of the use of contracts. The particular focus is on how the characteristic difficulties which borderline personality disorder patients encounter on inpatient services are helped by contracting. The use of contracts facilitates the therapeutic alliance, and aids in the avoidance of excessive regression and acting out. The improved stabilization of the patient permits a more constructive use of transference and countertransference, and facilitates a clearer examination of Axis I diagnosis and the use of medication. The contracting process can be a useful addition to the inpatient treatment of borderline personality disorder patients.