Prevention of personality disorders
Finally, one randomized clinical trial examined an experimental enrichment program for 3- to 5-year-old children designed to help prevent personality disorders in later life.22 The enrichment program included educational, nutritional, and physical exercise components. When measured at age 17, participants in the enrichment program had lower scores for schizotypal personality and antisocial behavior than participants in usual community conditions. This study suggests that early efforts at prevention may help decrease the likelihood of certain personality disorders later in life.
Overall, several psychosocial therapies show promise for the treatment of various personality disorders, and DBT has been proved to be an empirically supported treatment for BPD. Several of the treatments, including DBT and Bateman and Fonagy's partial hospitalization programs,12 are multimodal and structured. These treatments use each modality to target specific aspects of patients' problems. One key aspect of psychosocial treatments may be the comprehensiveness and structure of the treatment.
DBT is a highly structured and comprehensive treatment. Other elements unique to DBT, such as mindfulness, validation, targeting, and dialectics, may contribute to its effectiveness.23 The following section provides an overview of DBT, particularly focusing on how DBT uses its multiple modalities to target problem behaviors often seen in BPD.
Each patient has an individual therapist who is responsible for integrating all modes of DBT, planning treatment, managing all life-threatening behaviors and crises, ensuring progress toward targeted areas, and consulting with the patient on how to interact with other treatment providers in an effective manner. The individual therapist also aims to strike a balance between working to change the patient/s ineffective behavior and validating the patient. Patients typically attend 1 hour of individual therapy per week.
Individual therapists organize session time according to an explicit ranking of behavioral targets. The highest priority target is life-threatening behaviors, including suicide attempts, intentional self-injury, and urges for these behaviors. When these behaviors occur, the therapist and patient conduct a detailed behavioral analysis of the precipitating events and results of these behaviors. The goal of the analysis is to precisely identify moments when the patient can engage in more effective and skillful behavior and to teach patients skills to enable them to behave more effectively when similar situations occur in the future.
The second highest priority in individual therapy is to eliminate therapy interfering behaviors. Therapists focus on eliminating any behaviors that may impede therapy from proceeding, such as failure to attend or to complete homework. The third highest target is quality of- life interfering behaviors, such as criminal behaviors, interpersonal dysfunction, high-risk sexual behavior, or homelessness.
Group skills training
DBT explicitly addresses skill deficits by systematically teaching 4 sets of skills: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness (Table).
The first target in group skills training is to eliminate any group-destroying behaviors; the second is to increase skill acquisition; and the third is to decrease group-interfering behavior. These targets help maximize the chances that group members will learn skills. A typical format for a skills group is to meet for 21.2 hours weekly, with the first half of the meeting focusing on homework review and the second half focusing on teaching new skills.
Skills addressed in dialectical behavior therapy
Individual dialectical behavior therapists use phone consultations with patients outside of therapy sessions. The purpose of the consultation is to briefly intervene to help the patient avoid dysfunctional behavior and, instead, engage in effective behavior. Patients are encouraged to contact their therapist before engaging in self-harm behaviors and therefore do not have to engage in suicidal or self-harm behaviors to gain access to the clinician.
Therapist consultation team
All individual and group therapists participate in a consultation team designed to help therapists acquire, integrate, and generalize effective therapeutic behaviors. One of the main functions of the team is to help therapists avoid burnout when working with patients with BPD. The team helps its members adhere to DBT principles and progress toward competence, plan effective interventions, reduce personal characteristics that interfere with therapy, effectively operate within the mental health network, and provide support to one another.
A variety of psychosocial interventions for personality disorders show promise; DBT for BPD has specifically been proved to be effective. Further randomized controls are necessary, particularly of treatments for personality disorders other than BPD.
Dr Salsman is a research associate in the department of psychology at the University of Washington in Seattle. He works with Marsha Linehan, PhD, researching dialectical behavior therapy and borderline personality disorder. Dr Salsman/s work is supported by grants to Marsha Linehan from the National Institute of Mental Health and the National Institute of Drug Abuse.
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- Turner RM. Naturalistic evaluation of dialectical behavioral therapy-oriented treatment for borderline personality disorder. Cognitive Behav Practice. 2000; 7:413-419.