Borderline Personality Disorder (BPD) is a severe mental health condition imposing adverse outcomes both for patients and their families. Health care specialists and researchers have dedicated much time and effort to finding an effective treatment for this disorder. So far, dialectal behavior therapy (DBT) has been reported to have the most positive effect on BPD individuals’ behaviors. The present paper is aimed at researching BPD, DBT, core predictors of therapy dropout, and BPD patients’ carers’ experiences.
Borderline Personality Disorder
BPD is one of the severest mental disorders characterized by unstable emotional behavior. The American Psychiatric Association (APA, 2013), defines BPD as a “pervasive pattern of instability” of self-image, interpersonal relationships, and affects (p. 663). The onset of BPD occurs in early adulthood, and the condition can be manifested in different contexts, including delirious attempts to avoid imagined or real abandonment, intense and unstable interpersonal relationships, identity disturbances, self-damaging impulsivity, recurrent suicidal behavior, marked mood reactivity leading to affective instability, constant feeling of emptiness, intense anger manifestation, and “stress-related paranoid ideation” (APA, 2013, p. 663). BPD affects from 0.5% to 5.9% of people (Farrés et al., 2018). The disease is commonly associated with considerable economic costs, both direct and indirect.
Research indicates high comorbidity rates between BPD and other mental conditions. Navarro-Haro et al. (2018) report comorbidity between BPD and anorexia nervosa, binge eating disorder, and bulimia nervosa. Both independently and in a combination with other mental disorders, BPD is associated with a high risk of suicide attempts (Linehan et al., Navarro-Haro et al., 2018; 2015; Stratton et al., 2020). There is no significant difference in the prevalence of BPD in males and females (Probst et al., 2019). Apart from eating disorders, BPD is commonly associated with comorbid substance abuse, physical and mental disability, and mood and anxiety disorders. The core symptom of BPD is emotion dysregulation, other signs being instability in interpersonal connections, self-image, and impulse control (Probst et al., 2019). Emotion dysregulation in BPD is composed of increased and labile negative affect, emotion sensitivity, regulation strategies deficit, and maladaptive strategies surplus. Emotion dysregulation is also characterized by difficulties in understanding, awareness, and emotion acceptance, as well as by difficulties in one’s ability to manage impulsive behaviors (Probst et al., 2019). Emotion regulation deficits are linked not only to BPD but also to depression, somatoform disorders, and anxiety.
Findings of neuroimaging studies show that BPD is associated with dysfunctions in prefrontal, corticostriatal, and limbic pathways. Furthermore, impulsive behavior in BPD patients is connected with decreased serotonin neurotransmission in the mentioned structures (Probst et al., 2019). Results of research that involved functional magnetic resonance imaging indicate the emotion dysregulation in BPD individuals is caused by hyperreactivity in the amygdala (Probst et al., 2019). BPD emotional regulation has also been associated with other physiological parameters.
BPD is characterized not only by interpersonal difficulties but also by prevalent cognitive, behavioral, and affective problems. Morton et al. (2012) single out the following aspects of BPD manifestation in patients:
- difficult feelings (fluctuating negative emotions and intense negative feelings);
- problematic behavior patterns (potentially self-damaging behavioral impulses, angry fits of temper, deliberate self-harm, hectic efforts to escape abandonment);
- intense and unstable personal connections and confusions in the sense of self (dissociation, unstable self-image, the feeling of emptiness, transient symptoms of psychosis).
The understanding of approaches to BPD treatment has evolved considerably over the past few decades. Whereas earlier, BPD was considered as an “untreatable condition,” it is now treated with a variety of evidence-based psychotherapeutic approaches (Choi-Kain et al., 2017). Among the most effective ones, scholars single out DBT, systems training for emotional predictability and problem solving (STEPPS), mentalization-based treatment (MBT), transference-focused psychotherapy (TFP), and schemafocused therapy (SFT) (Choi-Kain et al., 2017; Morton et al., 2012). DBT is currently considered as the most effective approach to BPD treatment.
Dialectical Behavior Therapy for BPD Treatment
Out of a variety of approaches employed to alleviate BPD symptoms, DBT has earned the most attention and approval of researchers and practitioners alike. DBT is acknowledged to be the “best established psychosocial treatment for BPD” (Winter et al., 2016, p. 52). The central element of DBT is the acquisition of emotion regulation by patients (Probst et al., 2019). With the help of DBT, specialists can explain and modify the main problems of BPD as a consequence of the collaboration between people with elevated emotional sensitivity and such individuals or environments that cannot understand these vulnerabilities or respond to them promptly (Choi-Kain et al., 2017). DBT suggests that patients with BPD can learn to manage their interactions and sensitivities more effectively through acquiring mindfulness-enhancing skills since the latter can teach BPD-diagnosed individuals to tolerate stressful situations, regulate emotions, and manage connections. DBT is arranged for teams of mental health care providers and is considered among the most “time intensive modalities” for clinicians and patients (Choi-Kain et al., 2017, p. 23). The principal mechanism of change involved in DBT is the generalization and acquisition of skills with the aim of making them more mindful and emotionally regulated.
Commonly, DBT consists of four intervention modes: individual psychotherapy, group therapy, consultation team meetings, and phone calls (Soler et al., 2012). The greatest emphasis in DBT is made on training individuals on emotion regulation skills and behavioral capabilities (Winter et al., 2016). The skills trained at group therapy sessions consist of four modules: emotion regulation, interpersonal effectiveness, mindfulness, and distress tolerance (Soler et al., 2012). Distress tolerance skills and mindfulness skills are reported to be the most typically practiced ones among BPD patients. That is why mindfulness is the first skill to be trained in group therapy during DBT. Researchers single out three qualities pertaining to practicing mindfulness: (a) noticing, observing, and increasing awareness, (b) noting, labeling, and describing, (c) participating (Linehan, as cited in Soler et al., 2012, p. 151). There are also three supplementary features associated with practicing mindfulness: (a) allowance and acceptance with no judgment, (b) concentration on the present moment, (c) effectiveness. The preeminent aim of mindfulness is to promote patients’ consciousness of their attention and to increase integrity between their rational and emotional thinking processes.
The BPD model that influences DBT suggests the following:
- BPD is a condition involving emotion dysregulation emerging from crucial deficiencies in emotion-regulation, interpersonal, and distress-tolerance skills;
- individuals’ adaptive behavioral skills are frequently interfered with or constrained by maladaptive behavior;
- maladaptive behaviors (suicidal or other impulsive behaviors) are intensified in the process of reinforcement (Neacsiu et al., 2010).
Hence, DBT concentrates on teaching patients to form new behavioral skills and promoting the process of substituting maladaptive behaviors with skillful ones. There is evidence of DBT’s effectiveness in reducing emotional problems and suicidal inclinations of BPD individuals (Neacsiu et al., 2010). DBT treatment is reported to have a positive impact on a variety of behavioral outcomes and indicators, such as anger, depression, and emotional distress.
DBT is viewed as a low-cost and efficient therapeutic approach for BPD treatment. According to research, patient dropout rates are lower with this type of therapy compared to other approaches (Farrés et al., 2018). DBT concentrates on promoting the motivation for change, advancing appropriate behavior, promoting the transfer of newly acquired skills to daily life, and supporting mental health specialists’ skills (Kliem et al., 2010). Still, the greatest priority in DBT is the reduction of suicidal and self-harmful behaviors.
Over recent years, researchers have investigated a variety of DBT adaptations with the aim of singling out the most economical and effective one. Farrés et al. (2018) and Linehan et al. (2015) have compared DBT group skills training with other types of DBT (case management and individual therapy plus activities group). Scholars have found that DBT alone is rather effective and can bring positive results, such as decreased rates of suicidal behaviors and improved anger management. Taking into consideration the diversity of scholarly investigations on DBT, it is viable to consider this therapeutic approach as the most effective in fighting BPD.
Predictors of Dropout from DBT
While DBT is viewed as the most effective treatment approach to utilize for BPD patients, there are risks of individuals’ early dropout from the programs. Dropout is associated with low cost-efficiency of treatment, but this is not the most considerable negative outcome. The severest result of patients’ decision to quit participating in DBT is manifested through adverse psychosocial effects (Stratton et al., 2020). Thus, scholars pay attention to the identification of factors predicting dropout from DBT in order to enhance treatment retention.
Early withdrawal from psychiatric therapy is both quite common and rather problematic. Among the most typical results of early dropout, scholars single out poor treatment outcomes, unfavorable psychiatric health outcomes, poor delivery of treatment services, increased waitlist time, and decreased access for individuals who are in need of treatment (Stratton et al., 2020). As Farrés et al. (2018) note, dropout from DBT poses threats not only to patients but also to mental health providers. Frequent cases of therapy termination disable practitioners to collect sufficient data that could be employed to other patients’ advantage. Furthermore, it is much more difficult to convince BPD individuals to start treatment if they know that too many patients have quit it (Farrés et al., 2018). Finally, there is a considerable limitation for researchers who cannot gain sufficient reliability and validity of studies.
In previous decades, researchers found that people diagnosed with BPD have the highest rate of treatment dropout among patients with personality and psychological disorders. However, more recent studies have indicated equal dropout rates between BPD and non-BPD patients (Stratton et al., 2020). Presumably, such an alteration is connected with the enhancements in BPD treatment approaches’ development, including DBT. Therefore, scholars consider it crucial to single out the predictors of dropout since their identification is likely to help develop targeted interventions and enhance the retention of treatment.
In an endeavor to identify the causes of early dropout among BPD individuals, scholars have analyzed demographic variables, mental health status, and therapeutic process variables. Other factors considered in this respect include clinical and socio-demographic factors, as well as axis I disorders, such as cocaine use disorder and eating disorder (Farrés et al., 2018). Scholars have found that demographic variables do not serve as considerable predictors of early DBT dropout (Farrés et al., 2018; Stratton et al., 2020). Such factors as age and gender, childhood trauma history, marital and employment status, and living alone have not proved to influence the decision of an individual to leave the treatment program.
Meanwhile, patients’ level of education is reported to have some impact on dropout. Still, these findings are inconsistent and require further investigation since some scholars have found that a low education level can serve as a dropout predictor, whereas others have not reported any connection between the level of education and DBT program dropout (Stratton et al., 2020). A probable reason for the link between these factors is that individuals with low education may experience a lack of understanding of their mental health problems, as well as the insufficient comprehension of the need to complete the treatment program.
Whereas demographic variables have not proved to have a considerable impact on dropout rates, a significant effect of BPD’s comorbidity with axis I disorders has been proved. According to Farrés et al. (2018), patients with cocaine use disorder and/or eating disorder should be given specific attention when referred to DBT. Such factors as anger, impulsivity, low compromise with treatment, poor motivation to change, experiential avoidance, and low therapeutic alliance are highly associated with dropout (Farrés et al., 2018). Since patients with both BPD and axis I disorders manifest these indicators, it is crucial for specialists to take these factors into consideration when planning treatment procedures. The more a mental health provider knows about comorbid factors likely to affect dropout, the more likely he or she is to prevent the patient’s premature withdrawal from treatment. As a result, it will be possible to gain maximal effectiveness for patients, practitioners, and researchers alike.
Experiences of BPD Patients’ Carers
When analyzing the effectiveness of DBT with BPD patients, it is necessary to take into consideration the feedback of family and friends who take care of such individuals. Research indicates that BPD patient carers face a variety of challenges in their daily lives due to the complicated condition of their loved ones’ psychiatric health. Unpaid assistance to BPD individuals is manifested through emotional support or daily care. Friends and family members of BPD individuals not only have to deal with their loved ones’ mental health issues but also frequently require additional support themselves.
BPD patients’ carers face many complications due to their close ones’ mental health problems. According to Pearce et al. (2017), the distress and psychological symptoms of BPD individuals’ carers are much greater than those of the general population. In fact, the psychological burden among family members is higher than that related to other serious mental diseases. The problems include increased subjective and objective burden, difficulty communicating with mental health services, grief, and such severe mental health issues as anxiety and depression (Pearce et al., 2017). BPD individuals’ caregivers experience marital life difficulties, emotional health problems, and even physical health complications. Other complications include elevated feelings of guilt and grief, low social support, hopelessness, burden, and distress (Pearce et al., 2017). Researchers also note that a higher level of knowledge about the BPD individuals’ mental health problems poses a more considerable negative effect on their family members.
Apart from psychological difficulties, family carers of BPD patients also experience discrimination and exclusion. These are manifested through the inability to contact mental health services and/or communicate with their representatives at a sufficient level (Lawn & McMahon, 2015). According to researchers, the needs of family carers of individuals diagnosed with BPD are frequently underestimated and not understood. The problem of being excluded and discriminated is realized by such caregivers better than by others since they can see this issue both on the part of their BPD-diagnosed family members and on their own part (Lawn & McMahon, 2015). Therefore, additional education is viewed as a crucial prerequisite of successful collaboration between family carers and mental health providers. Healthcare professionals should improve their skills not only in working with BPD-diagnosed persons but also with their caregivers. Friends and family members of BPD individuals have special needs in terms of information access, support, and education that must be met appropriately instead of being underestimated.
Research findings indicate that the majority of family carers are not satisfied with their involvement in discharge planning. Dunne and Rogers (2013) note that since BPD is characterized by increased interpersonal communication difficulties, those related to such patients receive a “very difficult and emotionally draining role” (p. 643). As well as Lawn and McMahon (2015) and Pearce et al. (2017), Dunne and Rogers (2013) emphasize the neglect of unpaid carers’ needs by mental health practitioners and services. Meanwhile, the burden experienced by such caregivers is rather high, including social, physical, emotional, and financial aspects (Dunne & Rogers, 2013). As a result, family carers’ mental health becomes threatened and requires additional consideration.
Scholars report that family carers of BPD persons experience the same or even higher burden. According to Grenyer et al. (2019), such caregivers frequently experience objective burden (household or leisure disruption), as well as subjective one (embarrassment and worry). Furthermore, family members’ additional protection and support of their BPD-diagnosed close people can have a profoundly negative effect on these caregivers. Grenyer et al. (2019) remark that anxious concern and overprotection of BPD-diagnosed individuals are useful for them but, at the same time, have a destructive impact on the carers’ mental health and well-being. To avoid such adverse outcomes for caregivers, scholars suggest psychoeducational group interventions for family and friends.
Psychoeducation interventions for friends and family members of BPD-diagnosed individuals are likely to promote the mental health of both of these population groups. Since DBT is considered as the most effective therapeutic approach for BPD, psychological education of family members might be based on instructing carers on it. Another kind of intervention might be the Making Sense of BPD educational session (Pearce et al., 2017). Whatever approach is selected, family caregivers should be supported in their complicated task of looking after individuals with BPD. Instead of leaving them alone with their close ones’ and their own mental issues, practitioners and psychiatric health services should help them to come up with the most viable coping mechanisms and gain the most effective results of treatment together.
BPD is a serious mental health issue that requires much consideration from mental health facilities and researchers. Not only individuals diagnosed with BPD suffer from their condition, but also their caregivers do. So far, DBT has proved to be the most effective treatment for BPD. Although dropout rates among BPD patients are still high, research indicates that those engaged in DBT are more likely to complete treatment and modify their behaviors. Special attention should be given to family carers since their needs and apprehensions are frequently underestimated by mental health providers.
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