Dialectical behaviour therapy for borderline personality disorder

Adages, Aphorisms, and Proverbs in Psychiatry and Psychotherapy: Tools for Assessment and Treatment

OBJECTIVE

This study aimed to examine how adages, aphorisms, and proverbs arise in psychiatric management and psychotherapy and how they might be used to assist assessment and treatment.

METHODS

A selective narrative literature review was conducted to supplement clinical observations and case vignettes.

RESULTS

Adages appear to act as heuristic cognitive structures that serve as shortcuts for assessing situations, educating, persuading, aiding emotional self-regulation, and influencing courses of action. Some types of psychotherapy-such as dialectical behavior therapy, rational emotive behavior therapy, and acceptance and commitment therapy-and self-help programs such as Alcoholics Anonymous routinely utilize adages. The extent to and contexts in which adages spontaneously arise during general psychiatric and psychotherapeutic interactions have not been systematically studied. Clinicians can ascertain patients' favorite adages and appraise how patients respond to other sayings through exploratory questioning and by evoking responses to stock series of adages. As therapeutic tools, adages may help patients more easily conceptualize clinicians' interpretations and insights and may serve as encouraging affirmations.

CONCLUSIONS

Considering the potential utility of adages as therapeutic cognitive scaffolds, how patients and clinicians spontaneously use adages, how adages are used therapeutically, and the adages most suitable for particular patients in particular circumstances deserve further study. In psychiatric management and psychotherapy, clinicians' sensitivity to timing and patients' circumstances, culture, and receptivity may determine whether introducing a particular aphorism or proverb will have a positive impact or come across as a vapid and potentially harmful platitude.

Mindfulness in psychotherapy: an introduction

‘Mindfulness' has become a popular topic among psychological therapists. This introductory article explains what mindfulness is and how it can be developed, before exploring how it has been incorporated within psychoanalytic and cognitive–behavioural psychotherapies. These reflect general as well as specific presumed therapeutic actions. At present, variations in the way mindfulness is understood, taught and applied mean that it is too early to fully assess its potential. They demonstrate how the use of attention and awareness in therapy cuts across traditional divisions and where mindfulness in therapy is most in need of further investigation.

Principles of managing patients with personality disorder

The management of individuals with personality disorder is one of the most challenging and sometimes controversial areas of psychiatry. This paper describes the principles involved in identifying the clinical problems and formulating a management plan for patients with personality disorder in everyday clinical practice. It demonstrates that the principles of assessing and managing personality disorders and the clinical skills required are no different from those of treating any other chronic mental disorder.

Dangerous severe personality disorder

The Draft Mental Health Bill was published in June 2002 and was widely criticised. There were particular concerns regarding the possible detention of those with personality disorders solely for the protection of the general public. Subsequently the Draft Bill was omitted from the Queen's speech in November 2002. The Department of Health has stated that it intends to push for the Bill's inclusion in the next Parliamentary year. This review attempts to summarise the present situation so as to inform the debate. It considers the relationship between personality disorder and risk, with examination of treatment models and the existing and proposed mental health legislation.

Self and identity in women with symptoms of borderline personality: A qualitative study

Identity disturbance has been suggested to be a core feature of borderline personality disorder (BPD). However, there is little known about the identity of individuals with symptoms of BPD from the participant's perspective. This study availed of in-depth lightly structured life story interviews with five female participants. Thematic analysis was utilized to derive three themes of identity: connection, distance between us, and hurt and healing. Results provided support for multiple and flexible conceptualizations of identity in comparison to the idea of a unitary self/identity. Results also suggested that participants were able to establish differing connections to others ranging from disconnection to intimacy and care. Participants reported that their identities were impacted upon by historical and current family/relationship dysfunction, but life stories also illustrated the positive impact of healing relationship experiences. Findings provide support for psychological theories that consider a multiple and relational self/identity and the empowerment of healthy aspects of the self in BPD recovery. Studies that assess the association between insight and change may further our knowledge into this complex population.

Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder

Borderline personality disorder (BPD) is a complex disorder that is difficult to treat. However, dialectical behaviour therapy (DBT), developed by Dr. Marsha Linehan in the early 1990s, has emerged as a promising treatment option for those diagnosed with BPD. DBT is a multi-pronged treatment approach delivered normally in outpatient settings over 12 months and requires highly skilled and trained therapists. Many trials have provided evidence to support the use of DBT in the treatment of BPD. However, outcome measures vary and are mostly limited to measurable behavioural outcomes such as incidences of deliberate self-harm or suicidal thoughts. Two recent Cochrane reviews conclude that DBT does benefit those with BPD, but more robust evidence is needed. DBT training for health care professionals also has the potential to shift health care professionals' attitudes from one of therapeutic pessimism to one of optimism.

A Service Evaluation of a 1-Year Dialectical Behaviour Therapy Programme for Women with Borderline Personality Disorder in a Low Secure Unit

Background: Previous studies about the effectiveness of Dialectical Behaviour Therapy for the treatment of Borderline Personality Disorder have had promising results. However, no previous studies have examined its effectiveness when delivered in low secure inpatient services for women. Aims: To evaluate clinical outcomes during and after a 1-year period of admission within a low secure unit for women offering a Dialectical Behaviour Therapy programme. Method: A naturalistic, within subjects study of clinical data collected as part of routine practice was conducted. Participants were18 consecutively admitted women who met the diagnostic criteria for Borderline Personality Disorder and had completed at least 1 year of treatment. Measures covered: risk behaviours; self-reported symptoms of Borderline Personality Disorder, and current mood and symptom experience; staff reports of clinical problems, needs and social functioning. Scores were compared between admission and at 6 months and 1 year. Results: There was a statistically significant improvement on all 13 measures over the year's treatment. Most improvement was demonstrated between admission and 6 months. Conclusions: Engagement in1-year's treatment was associated with significant reduction in risk behaviours and both staff-rated and self-rated outcome measures. Some significant questions remain about which elements of the programme are most effective but the results are encouraging.

La regulación emocional: precisiones y avances conceptuales desde la perspectiva conductual

La Regulación emocional (RE) ha sido un concepto que ha cobrado relevancia en los últimos años en diferentes áreas aplicadas de la psicología, debido al papel que parece tener en el funcionamiento de los individuos en los diferentes contextos. En la psicología conductual ha sido abordada principalmente por dos perspectivas terapéuticas: la cognitiva-conductual y el análisis clínico conductual. La primera de ellas atiende a aspectos de tipo mediacional para la explicación y la segunda a conceptos del análisis del comportamiento. Las diferencias en estos dos puntos de vista, para explicar este fenómeno dentro de una aproximación conductual, han derivado en dos problemas principales: (a) no existe una definición unificada de la Regulación emocional y (b) los mecanismos explicativos son inciertos. Se menciona la importancia de revisar el fundamento conceptual de este término y el desarrollo de investigaciones que den cuenta de los procesos que lo explican.

A two-model integrated personality disorder service: two-year follow up of effect upon psychiatric bed use

Purpose

– Following on from an earlier published study, the purpose of this paper is to further clarify with a larger sample and over a longer timescale of two years the effect of a therapeutic-community informed personality disorder service intervention upon psychiatric in-patient bed use. The service integrates two psychoanalytical models; a mentalization-based treatment (MBT) and a service user network (SUN) model.

Design/methodology/approach

– The number of psychiatric bed days used by patients attending each arm of the service model (SUN and MBT) was collated using the electronic patient records system. Bed use in the six-12-18-and 24-month period before each patient started treatment was compared with bed use in the same periods after starting treatment.

Findings

– There appeared no significant increase after intervention in the group of patients using no psychiatric beds prior to intervention. Bed use in the second group (those using beds prior to intervention) appeared significantly reduced by six months and the reduction continued to prove significant at 12 and 18 months post-intervention. In relation to the component arms of the service, a significant reduction in bed use was seen in each of the MBT and SUN interventions at six, 12, 18 and 24 months after commencement. However, due to the small sample sizes, these results lacked sufficient power to afford a meaningful comment upon the effect of component arms.

Research limitations/implications

– Intervention by the TC informed two-model integrated personality disorder service had a statistically significant effect overall on reducing bed use, which was maintained at six and 12 months.

Practical implications

– The paper supports the finding of the authors’ previous study; a therapeutic model of care that significantly reduces psychiatric bed use. That the reduction in psychiatric bed use continues to further appear highly significant at 18 months suggest that our service has an enduring effect upon inpatient psychiatric resources.

Originality/value

– The paper describes a unique model of care currently successfully employed in the therapeutic management of people with personality disorder. The model is replicable and effective and offers some possibilities for the development of therapeutic-community informed practice.

A literature review exploring the efficacy of case formulations in clinical practice. What are the themes and pertinent issues?

There is a paucity of research exploring the validity, reliability and impact on clinical outcome of Cognitive Behavioural Psychotherapy (CBP) case formulations. This review considers a variety of literature that relates to formulations and their use, it also draws on other types of psychotherapy where there appears to be a more established and robust research base. The literature review explores the research that has taken place within CBP and considers the themes that emerge from this research. Several themes were identified and these relate to decision-making and experience, specific guidelines to aid quality of formulations and a significant lack of understanding of clients' views on the formulation process and its outcome. It is unclear whether formulations do influence the successfulness of therapy. Recommendations are made as to what further research is needed and the form this should take.

Buddhist psychology, psychotherapy and the brain: a critical introduction

Buddhist psychology is increasingly informing psychotherapeutic practice in the western world. This article: (a) provides a general background to Buddhist tradition; (b) outlines the central tenets of Buddhist psychology, with particular emphasis on the practice of meditation; (c) provides an overview of research into the effects of Buddhist practice on the brain; (d) outlines the relationships between Buddhist psychology and existing forms of psychotherapy; (e) provides an overview of Buddhist approaches to specific psychiatric disorders and the psychological aspects of physical disorders; and (f) discusses the emergence of Buddhist psychotherapy in western societies and explores likely future developments. There is a need for further research into the neuroscientific correlates of Buddhist concepts of mind and the evidence-base for the use of specific techniques (e.g., meditation) in psychotherapeutic practice.

Lessons from an Australian community dialectical behaviour therapy programme for borderline personality disorder

In 2003, the National Institute for Mental Health in England (NIMHE) published guidelines for the development of services for people with personality disorders (NIMHE, 2003), prompting community mental health teams (CMHTs) to reassess their service provision for this patient group. The guidelines did not recommend any particular treatment approach, but CMHTs were encouraged to develop specialist programmes. For many CMHTs the focus has been on borderline personality disorder, as it is one of the most prevalent personality disorders seen in adult mental health services and has high costs for both the patient and the service (Moran, 2002). The evidence base for which treatment may be most effective within the community remains small, however, and this has left many CMHTs unclear regarding a suitable programme. Here I will outline a CMHT-based dialectical behaviour therapy (DBT) programme operating in Western Australia and reflect on why I feel it is an option that CMHTs in the UK looking to develop their service should consider.