Borderline Personality Disorder and Dialectical Behaviour Therapy: Expectations and Experiences of Mental Health Staff

Dr V R Badrakalimuthu, Dr A Wills

 

Background

Gunderson (2001) described Dialectical Behaviour Therapy (DBT) as, ‘since 1987, the single most remarkable entry in the therapeutic strategies for Borderline Personality Disorder (BPD). BPD, a heterogeneous condition with significant differences in individual symptom patterns, has a 10% mortality rate due to suicide. No wonder that mental health staff describe individuals diagnosed with BPD as the most challenging and difficult patients encountered in their practice (Rossen & Bland, 2005).

We survey the experiences and expectations of mental health staff with patients having a diagnosis of BPD and, their perspective on treatments with particular reference to DBT.

Method

250 mental health trained workers across the Hampshire Partnership NHS Trust were randomly selected from a regularly updated register maintained by the Clinical Governance and Audit Team based in Southampton. A postal questionnaire was sent to this sample with a request to return the completed questionnaire in six weeks. The questionnaire (Appendix 1) had the following divisions:

1. Team and role in the Team

2. Involvements with patients diagnosed with BPD

3. Resources available

4. Patient preferences

5. Staff knowledge and opinion on DBT

If the response to the second division was negative, the instruction was to return the questionnaire without answering further questions. The responders were encouraged to add their comments to provide input on pragmatic difficulties and realities in formulating management plan for patients with BPD.

Results

203 staff responded (81.2%). CMHT (50.73%) and In-patient teams (29.55%) were the bulk of responders. Nurses (78.32%) were the single largest professional group. 179 (88.11%) had worked with patients having diagnosis of BPD and proceeded to complete the study.

Table 1: Team

CMHT	In-Patient	CRHT	AOT	Others
103	60	9	3	28

Table 2: Role

CPN	SW/ ASW	Psychologist	Doctor	OT	Others
159	20	3	3	8	10

Resources

131 (73.18%) said that DBT was available in their team and 125 (69.83%) said DBT was the most common psychological therapy considered in formulating a management plan.

Table 3: Psychological Therapy Considered

DBT	CBT	Group Therapy	Counselling	Others
142	39	2	10	10

Patient Preferences

138 (77.09%) had patients treated with DBT. 172 (96.72%) said that their patients were aware of options other than medications. Though 89 (49.72%) said their patients preferred DBT to other psychological therapies, only 81 (45.25 %) said that the patients found DBT useful.

Table 4: Patient preference of therapy

DBT	CBT	Group Therapy	Counselling	No answer	Varies
101	56	7	23	13	3

Staff knowledge and opinion on DBT

Though 109 (60.89%) felt that DBT has the best evidence base, only 75 (41.89%) were confident in talking about DBT with their patients. 49 (27.37%) were less confident and 55 (30.72%) were uncertain. This could be reflection of the observation that only 84 (46.5%) had either attended lectures or trained in DBT. The rest had heard (18.43%), read (8.93%) or discussed (27.37%) about DBT. Though an overwhelming 115 (64.24%) suggested workshops, surprisingly 8 (4.4%) suggested a successful outcome in their practice would improve their understanding of DBT. Evidence based articles (16.20%) and lectures (12.29%) were the other suggestions.

The staff and their belief on client expectations were almost similar with improvement in daily living with coping strategies being the single most expected benefits from DBT.

Table 5: Expected outcome

	Patient	Staff
Improvement of BPD	9	9
Improvement in self harm	11	7
Reduced hospital admissions	9	9
Improve daily living –coping strategies	85	66
Varies	7	0
Combinations	46	85
No answer/ not known	12	3

 

Discussion

To our knowledge, this is the first and largest survey involving mental health staff on their opinions on DBT. Our observation on the popularity and preference for DBT across the Hampshire Partnership NHS Trust is a reflection of Brennerhassett and O’ Raghallaigh (2005) comment in their editorial that Linehan’s most important achievement with this therapy has been to instil a sense of hope in people with BPD and their therapists.  Though 73.18% had suggested that DBT was available in their team, there were also comments that, access to DBT is a postcode lottery with long waiting lists, overstretched services and long waiting lists.  

Roughly about half of the staff felt that the patients were finding DBT either to be helpful but time consuming, unhelpful or that there was no other choice than DBT. The written comments included that helpful nature can as expected be generalised, experience with DBT was limited in time and that many of the patients found it difficult to cope with the modules in DBT. Since Linehan’s report in 1991, Verheul et al (2003) has replicated the success of DBT, Kroger et al (2006) has demonstrated its efficacy in inpatient setting and Linehan et al (2006) and van den Bosch et al (2005) have demonstrated its sustainability. Some of the staff has remarked that DBT was similar in content to the coping skills, intensive one to one contact and crisis plans with an option of hospital admission made by the treating team. This is reflected in the patient and staff expectation for DBT being improvement of daily living skills with coping strategies. This could be an observation in favour of Bateman and Fonagy’s Partial Hospitalisation Treatment Model (1999).

Roughly two-thirds felt that DBT has the best evidence base for treatment of DBT. In a comprehensive critique on DBT, Blennerhassett and O’Raghallaigh (2005) debate that the studies on DBT are limited by the numbers and lack of evidence for improvement in some of the core features of BPD. They also comment on the shortage of suitably trained staff to deliver the treatment which is also an observation in our study.

We are surprised about the greater importance given for training in DBT than successful outcomes in personal practice. Krawitz (2004) found that optimism, enthusiasm, confidence and willingness to work with people with BPD improved following the workshop. Cleary et al (2002) found that mental health staff are ready to identify resources which would help them in working with patients with BPD. If the staff prefer workshops, then manual based DBT (Evans et al, 1999) could prove to be useful in training the staff and reducing the lack of resources.

Limitations

Though the 81.2% response rate and heterogeneity in the roles of the responders could be limitations, these observations are pragmatic reflections when one considers the geographical and numerical extent of the study population. The focus of the questionnaire on DBT could also have limited the discussion on the other successful treatment forms which are hard and dry.

Conclusion

It is heartening to note that patients and staff are aware and willing to try different modalities of treatment. The workshops for staff would increase the understanding of DBT and would also lead to impetus on evidence based allocation and utilisation of mental health resources.

Declaration of interest

None

References

Bateman,A. & Fonagy,P. (1999) Effectiveness of partial hospitalisation in the treatment of borderline personality disorder: a randomised controlled trial. American Journal of Psychiatry, 156, 1563-1569

Bland,A.R & Rossen, E.K, Clinical supervision of Nurses Working with patients with Borderline Personality Disorder. Issues in Mental Health Nursing, 26, 507-517

Blennerhassett,C.R. & O’Raghallaigh, W.J. (2005) Dialectical behaviour therapy in the treatment of borderline personality disorder. British Journal of Psychiatry, 186, 278-280

Cleary,M., Siegfried,N., Walter,G. (2002) Experience, knowledge and attitudes of mental health staff regarding clients with a borderline personality disorder. International Journal of Mental Health Nursing, 11, 186-191

EvansK., Tyrer,P., Catalan, J., et al (1999) Manual- assisted cognitive behaviour therapy (MACT): a randomised controlled trail of brief intervention with bibiliotherapy in the treatment of recurrent deliberate self harm. Psychological Medicine, 29, 19-25

Gunderson,J.G. (2001) Borderline Personality Disorder: A Clinical Guide. Washington, DC: American Psychiatric Publishing.

Krawitz, R. (2004) Borderline personality disorder: attitudinal change following training. Australian and New Zealand Journal of Psychiatry, 38, 554-559

Kroger,C., Schweiger,U., Sipos,V., etal (2006) Effectiveness of dialectical behaviour therapy for borderline personality disorder in inpatient setting. Behaviour Research and Therapy, 44, 1211-1217

Linehan,M.M,  Armstrong, H.E., Suarez, A., et al (1991) Cognitive –behavioural treatment of chronically parasuicidal borderline patients. Archives of general Psychiatry, 48, 1060-1064

Linehan, M.M, Comotis, K.A, Murray, A.M, et al (2006) Two-year Randomised Controlled Trial and Follow-up of Dialectical Behaviour Therapy vs Therapy by Experts for Suicidal Behaviours and Borderline personality Disorder. Archives of General Psychiatry, 63, 757-766

Van Den Bosch,L.M.C, Koeter, M.W.J, Stijnen,T., et al (2005), Sustained efficacy of dialectical behaviour therapy for borderline personality disorder.  Behaviour Research and Therapy, 43, 1231-1241

Verheul, R., Van den Bosch, L.M.C., Koeter, M.W.J, et al (2003) Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. British Journal of Psychiatry, 182, 135-140

 

Copyright Priory Lodge Education 2007

First Published September 2007

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