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In the previous post, the question came up of whether DBT works. I have not undergone this therapy, so I invite responses from anyone who has.
In the meantime, here is a bit of unexpected skepticism towards DBT from an article in a British journal on psychiatric treatment:
Dialectical behaviour therapy (DBT; Linehan, 1993) is based on the principle that BPD is essentially the result of deficits in interpersonal and self-regulatory skills and that these skills can be taught in therapy. Defective affect regulation is seen as particularly important. Treatment consists of weekly individual and group therapy sessions based on a skills-training model, together with out-of-hours telephone contact with the therapist.
Dialectical behaviour therapy has been shown, in a single study, to be superior to 'treatment as usual' in reducing self-harm and time spent in hospital, but not subjective experiences such as depression and hopelessness (Linehan et al, 1991). There were also significant improvements in social and global functioning and anger (Linehan et al, 1994). However by one year after the end of treatment, rates of self-harm were no different in the DBT group and treatment-as-usual groups, although both had improved (Linehan et al, 1993).
Despite this essentially negative finding, DBT has attracted considerable interest; however, Linehan's study is open to a number of methodological criticisms. Only 39 patients were studied, all of them female, and of these only 20 were fully assessed. The level of self-harm required for entry into the study (two episodes in the last five years and one in the last eight weeks) may have led to the inclusion of patients who were less severely disturbed than those commonly seen in clinical practice. Furthermore, DBT involves a high level of input from professionals and it is not yet clear whether it is the skills training itself or simply the high level of support which leads to the reduction in self-harm.
-Anthony P. Winston, "Recent Developments in Borderline Personality Disorder" (2000)
This assessment of DBT surprised me. I had never heard negative remarks about this therapeutic approach before. Reading Linehan's dense tome on CBT for borderlines helped me a lot in reconfiguring my attitudes. The idea of radical acceptance was at first a big frustrating puzzle to me - another opaque window - but gradually it settled inside me as something useful that I can draw on, especially regarding family relationships.
Anybody else have thoughts on DBT, CBT, Linehan, or this methodological critique from Winston?
I am not against DBT--I would refer the right patients to it all the time. But the DBT community is very tight and doesn't much like a closer examination of some of the shortcomings of the program, or some reasons why they have more success.
ReplyDeleteThis is what I wrote in my book The Essential Family Guide to Borderline Personality Disorder (EFG):
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LIMITATIONS OF DBT
DBT offers great hope and a way to counter the oft-¬repeated (and demonstrably false) maxim that there is no treatment for BPD. Many patients say DBT has improved their lives tremendously. However, DBT is not a miracle cure. As you evaluate treatment alternatives, keep these limitations in mind:
• DBT has been shown to lessen suicidal thoughts and reduce instances of self-¬harm. Studies have not shown that it relieves depression or makes clients happier (although many individuals say it does).
• DBT is appropriate only for patients who acknowledge their illness, want to learn about it, and will work hard in therapy. Higher-¬functioning invisible BPs do not meet this criteria.
• DBT is demanding. Each day, patients fill out diary forms, and most patients spend many hours each week in therapeutic activities. To benefit from the therapy, patients must be highly motivated.
• DBT is not available in all locations. Also, it can be costly (we’ll take a closer look at insurance in the next chapter).
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Now, add to that the difference between DBT and "treatment as usual" the following facts:
* It's been proven again and again that the expectations of the teacher influence the outcome of the teaching. For example, grade school teachers who think they are teaching "gifted" students--even though they are average--expect more and their students excel. Not only are DBT therapists much better trained, but they expect more from clients.
* Treatment as usual takes place once a week. DBT programs require participation two times a week plus homework--again for the HIGHLY MOTIVATED PATIENT.
* In group skills training, patients get emotional group support (although that's not the purpose). Support groups provide validation and show patients that they are not their disorder. I know how much my online groups help family members; this is an important fact we should not overlook.
In sum, while we know DBT is effective in some respects, I don't think we really know WHY.
I think it's a good bet that if I took highly motivated family members, had them see a therapist once a week, and had them attend a support group once a week where they learn skills from EFG they would do very well. No research dollars need be spent.
In fact, I think the family members would be less depressed and better able to cope with just a support meeting once a week where they all go out to dinner or do something fun together.
To end this post, I am NOT anti-DBT. Whatever its merits, it has helped revolutionize the way we see treatment of BPD.
I just think that if we know just what makes the program effective, we can use this in places where DBT does not exist, is not affordable, or the patients are not qualified.
Randi Kreger
www.BPDCentral.com
I have done the first two modules of DBT because unfortunately Australia's Medicare system compensates half for only twelve DBT sessions. BPD is only a very 'new' mental illness in Australia. Anyway, I have to completely agree with Winston's second paragraph. DBT was very helpful for me when I was doing it and for some time afterwards. Four months on and I find myself more and more grappling with my almost insatiable compulsion to self-harm because fading from my mind, which they teach in DBT, are the reasons why I shouldn't do it. I'm not harming anyone else, and it helps me in the short-term so why shouldn't I?
ReplyDeleteMy 'rages' have decreased because now I am more introspective of why I want to lash out. However, I am still as irritable, angry and anxious. I am learning to self-soothe as I know now (after the DBT) that I need to do this, although it is difficult whilst working, studying and self-therapising (not a word but I like it). I need to keep myself as busy as possible though.
DBT has taught me to be more introspective, to look into myself and realise why I do what I do, and in turn this acts as some form of cognitive therapy for me. However, DBT never really did help with the depression or the emptiness I often feel. There were external factors existing in my life at the time which could have impacted on this though. The therapist I adored left just as I started DBT and I was given someone I just couldn't connect with, and who focussed more on my eating disorder than my unhappiness. Apparently we were only allowed to talk about issues embedded in DBT, not my own personal issues. That is something I really didn't like about it.
And one other thing before I finish, I think for the most part, DBT helped because I met others who experienced similar feelings and emotions to myself. I was actually quite depressed at the end when I was not allowed to stay in touch with any of the people I'd met.
Thanks for reading,
Joanna
This comment has been removed by the author.
ReplyDeleteHey Lisa!
ReplyDeleteWhile there may be some detractors, DBT is highly-effective in treating individuals with borderline personality disorder and those with traits of BPD such a self-injury.
DBT has now been around for almost 20 years. Dozens of peer-reviewed studies have consistently revealed that DBT works for a lot of people and over a long period of time. Heck, DBT has now been successfully adapted to treat eating disorders and substance abuse.
Does it mean that it's a perfect therapy? Nope. Does it mean that it's the "best" therapy for everyone with BPD? Not a chance. Does it mean that it's going to always work in helping someone create a "life worth living"? No one is promising that.
But it is really effective and countless lives have been saved because of those sometimes-annoying diary cards.
DBT naysayers are few and far between.
Amanda
I don't have BPD, but just learning about DBT has helped me immensely in dealing with the people in my life who do. Its emphasis on affirmation, self-acceptance, paradox, and humor can be appealing and helpful to everyone. I agree with Ms. Kreger that its best application as treatment is for highly motivated patients.
ReplyDeleteDBT was very successful for myself.I'd give it 10 out of 10.
ReplyDeletedbt and related workbooks as well as videos and other texts have been helpful to me. i still struggle, but also appreciate LMJ's points about alcohol intake control. i do not struggle with self-harm and suicide ideation so i am not sure about dbt in that regard, but the paradoxical concept of radical acceptance is helpful to me as is the notion of opposite action.
ReplyDeletei too have found (ok, do not sneer!) some elements of 12-step programs to be helpful esp. after a former professor who is trained as a psychiatrist invited me to an aa meeting. i am trying to be a bit more spiritually inclined even via yoga and/or meditation. lastly, i really like the about.com bpd therapist and she had a post about listening to music to alter your mood. i am a fan of drowning my own sorrows, etc. but also turn to lighter fare--comedy or upbeat music, film, art to help me gain perspective. also, walks with my dogs do wonders! bits and pieces and learning from others helps a great deal. also, not feeling so isolated in my craziness assists in making the madness more (self) manageable.
ps--could you recommend other books you find/found helpful? I like the Linehan workbook as well as a DBT workbook, which is cheaper--Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (McKay et al. 2007). A 1997 book by Santoro entitled: The Angry Heart: Overcoming Borderline and Addictive Disorders : An Interactive Self-Help Guide also received positive reviews by those dealing with living w/ bpd and related traits, etc. Thanks!
ReplyDeleteHave you tried to read the bigger book by LInehan for clinicians? I checked a book out from the library by Bateman and Fonagy: Mentalization-based treatment for bpd. I like this approach but would like an affordable therapist utilizing this technique. They also wrote another book, which I have not read, but this one by Bateman and Fonagy helps me see I have trouble mentalizing. With that being said, the concept of mindfulness that I have learned more about through LInehan and Kiera Van Gelder in relation to bpd AND the concept of mentalization seem fruitful. Mindfulness helps me work towards acceptance, tolerance, and validation of myself and others in terms of emotions whereas mentalization assists me understanding relational aspects of my thoughts, beliefs and actions involving others experiences, my experiences and my experiences of those other people and their experiences. hmmm, now if only that made any sense. hope to read further and thank you for any recs.
pss--i requested that the book, Girl in need of a tourniquet : memoir of a borderline personality, become a part of the NY public library collection and now it is available! Yay. I am so excited bc it makes the book so much more accessible to read in the library or take home for many folks. I purchased my own copy but I am psyched that it is now in the public library. I wish there were books like these (Buddha and the Borderline, Girl in need of a tourniquet) when I was younger and would look through the library and local bookstores. What is extra great imho is that although it may be cataloged in various ways these books are shelved with the other texts on bpd/mental health issues. I love how there is more diversity now and various perspectives represented. I also am happy to see the new book by Valerie Porr, in NYC, who really helped me out a great deal. I found out I am younger than her daughter but she is truly compassionate and knowledgable plus helpful to families and people living with bpd alike.
ReplyDeletei was fortunate to be able to begin the process of dbt...it is working for me but perhaps i am older now and i am tired of the madness.
ReplyDeletei find dbt awesome and from one borderline to another, i highly recommend it.
Let me first say that I love your blog and will read your book too. I've thought about writing and seeing where it takes me.
ReplyDeleteNow for DBT. I have symptoms of BPD, bipolar, ADD, and a diagnosis of temporal lobe epilepsy so life is interesting to say the least.
DBT right now is being somewhat forced on me. I thought my therapist just wanted me to read this book on DBT for bipolar and then discuss it like he said. However, it is clear to me that we are doing more than that.
My session last night was quite invalidating. I told him some difficult things about myself and what I head back was I live in the past and worry about the future and basically everyone has trauma, challenges, problems etc. The indirect message seemed to be suck it up.
I've been with him a long time and he's helped me by the way we have been doing therapy. But, apparently, he doesn't think so.
Now, I'm in hell and am coming apart at the seams. I do not see how this type of therapy helps me especially if it continues to be so invalidating. I get enough of that every day from certain people in my life.
This type of therapy seems to protect therapists from burnout (Marsha's words not mine) so since that is a component, the rest is suspect as far as I'm concerned.
I'm done with it, he will be told this and if that is not acceptable, we're done.
Having said all this I am glad it works for some people and applaud them for their success.
Therapy is an individualized process or it should be.
I have a behaviorist friend with BPD that absolutely swears by DBT. I don't know much about it, but as long as it helps more people than it hurts, it's a good option for people to at least try. I don't believe that any treatment is a "one size fits all" type of deal, so if it fits for the person in need of therapy, then it fits. If not, then don't force it and try something else.
ReplyDelete