DBT for BPD: how can benefits be maintained long-term?

Before we try to understand the experiences and benefits of people receiving Dialectical Behaviour Therapy (DBT), let’s briefly introduce the principles of this psychotherapy. DBT is an approach to helping people who have difficulties regulating their emotions and behaviour. It consists of a skills group and individual sessions, access to between-session coaching by telephone or email, and consultation team meetings for the individual therapists and group leaders to problem-solve, maintain motivation, prevent burnout, and ensure adherence to the DBT model (Sayrs and Linehan, 2019).

The skills that are usually addressed are: interpersonal skills, emotion regulation skills, the ability to tolerate distress, mindfulness, and the skill of ‘walking the middle path’ (i.e. thinking with more balance and nuance, rather than in extreme ways). DBT has come more popular since the mid-1990s following successful research trials demonstrating its effectiveness (Chapman, 2006).

In the past few years, DBT has a growing body of evidence on its efficacy and cost-effectiveness for people who have received a diagnosis of ‘Borderline Personality Disorder’ (BPD) (Linehan et al., 2006; Verheul et al., 2018). Consequently, it is supported and recommended by NICE guidelines as a first-line evidence-based treatment for ‘BPD’. Research shows that compared to other psychological treatments (i.e. ‘treatment as usual’) DBT has helped to reduce incidents of self-harming behaviours and subsequent hospital admissions (Linehan et al., 2006).

This background information on DBT helps us identify some of the benefits. It seems to work for some people with a diagnosis of BPD, but for how long are the therapeutic effects present after the end of treatment?

Gillespie and colleagues (2022) identified that, although quantitative research designs highlight promising findings, in-depth qualitative data from individuals with a diagnosis of BPD who have completed a DBT intervention are not well captured or represented in the literature. Further exploration of the therapeutic processes (i.e. learning and implementing new skills, becoming responsible and accountable to change, and forming a therapeutic alliance) and mechanisms of change (i.e. therapeutic relationship, engagement, self-efficacy) are necessary to understand the impact of DBT in the longer-term. Thus, the authors of this study asked a series of questions applicable to people who had reportedly benefitted from the intervention, including:

DBT outcomes in participants’ lives, coping and approach to problems at a long-term follow-up;
DBT-related processes that had an effect in participants’ lives at long-term follow-up and;
Potential benefits of DBT at two or more years post-treatment.

Dialectical Behaviour Therapy (DBT) appears to be effective for individuals diagnosed with borderline personality disorder, yet it is unknown for how long.

Methods

The authors conducted their study within a region in the Republic of Ireland. DBT is offered in community settings and people can be referred to a DBT team (currently four teams/sites within this region). The recruitment took place across the four teams, and all participants received a 12-month DBT programme (Linehan, 1993), aside from one participant who received 6-months. As stated in the paper, the programme included ‘individual therapy sessions, group skills training, phone coaching and consultation team meetings for DBT therapists.’

All participants had a few things in common: they had completed the DBT programme and reported benefits during the intervention; they were service users and engaged with adult community mental health services in the region; they had received a diagnosis of BPD; and they were going through severe emotional dysregulation. The study only included people who were at two years post-treatment at the time of recruitment, as they were interested in exploring long-term outcomes. People who were currently receiving the DBT programme, reported no benefits of the programme, completed the programme in less than two years prior to recruitment, engaged with drugs or alcohol at the time of the interview, or were extremely emotionally dysregulated or experienced dissociation or psychotic symptoms at the time of the interview were excluded.

Semi-structured interviews were conducted via telephone or online platforms due to the pandemic. All qualitative data were transcribed and analysed following the approach suggested by Braun & Clarke (2006).

Results

A total of 12 individuals participated in the study, with the majority being female, married or in a relationship, and on medication.

Three main themes were identified:

DBT is life-changing, but not a magic wand: a foundation to build from

Participants felt that DBT was a life-changing therapeutic experience, but not the end of their therapeutic journey.
The DBT programme offered a solid ground to develop further skills after its completion. For example, some participants continued engaging with DBT and received ‘booster sessions’, while others engaged with a different therapeutic modality (i.e. schema therapy).
Participants wished to have the opportunity for a brief refresher course, or a long-term check-in with the participants to get a sense how they are feeling post-treatment.

Responding versus reacting to problems

The DBT programme gave participants a sense of control in their lives; they were empowered to manage difficult situations, setbacks (e.g. a physical health problem) and the emotional dysregulation.
Participants described that they used the skills acquired in the programme to self-soothe, pause, take a step back, and then respond to the situation compared to acting impulsively. As a result, a few participants reported noticing a reduction in hospitalisation.
Lastly, participants felt able to apply the skills automatically in their day-to-day lives to effectively cope with problems.

Meaningful and healthier relationships with others

Participants felt that DBT skills helped them nurture connection and healthy relationships with people in their lives.
They felt that they were able to form and maintain more open and meaningful connections, but also be able to stop engaging with people who had a negative impact in their lives.
Lastly, participants’ self-compassion increased, and the compassion towards others followed. Participants felt they had strong support systems and were able to help people and teach them skills to manage their feelings.

The in-depth exploration of the long-term impact of DBT suggests that it offers a strong foundation and is perceived as only the start of the therapeutic journey.

Conclusions

The authors concluded:

‘Findings indicated that participants continued to report experiencing benefits from DBT a number of years after completing the programme. […] Participants found DBT to be a life changing experience that enabled further self-development in the years following the programme, gave participants a sense of control in their lives and skills to manage difficulties, and contributed to improved relationships and connections with others.’

As stated by the authors, DBT was found to be “a life-changing experience that enabled further self-development, gave a sense of control and skills to manage difficulties.”

Strengths and limitations

The study comes with numerous strengths. The language used by the authors was very sensitive throughout; we felt they appropriately voiced the needs and views of the participants. The qualitative design allowed participants to share their experiences of receiving a year-long DBT programme and the long-term impact in their lives in various contexts (i.e. managing difficulties, healing, maintaining relationships). The research questions addressed the gaps in the current literature and highlighted opportunities for further research. For example, bringing our service’s lens, it would be really helpful to identify differences between subgroups; is the therapeutic impact, learning and application of DBT skills in day-to-day life dependent on the age, generation and cohort beliefs of participants? Additionally, thinking of service evaluation and development, are there ways the findings could be considered by services, and maybe offer online webinars or refresher courses to support people on their journey post-group?

However, the study doesn’t come without its limitations. The delegation of research tasks wasn’t clear. Although the authors followed the Braun and Clark (2006) thematic analysis approach, only one of the researchers familiarised with the data, conducted the initial coding, and completed the data analysis. To eliminate bias, it would have been helpful if more people from the research team were involved in the formation of the themes throughout the 6-stages process, rather than only reviewing the themes. Moreover, the lead author refers to keeping a reflective journal, but they don’t provide any additional information on how this reflective exercise supported their analysis, or informed their thinking and research position.

The qualitative design allowed people to share their lived experiences, but clarity on the use of reflective journal would be helpful in the interpretation of the findings.

The qualitative design allowed people to share their lived experiences, but clarity on the use of a reflective journal would be helpful in the interpretation of the findings.

Implications for practice

The findings provide insights to better understand the mechanisms of DBT. Clinicians may enhance their knowledge on the long-term therapeutic effects and advise on maintenance, i.e. psychoeducation individually or in groups with people who are diagnosed with ‘personality disorders’. However, the research needs to be extended and gather service user’s suggestions on ways to maintain the use of DBT skills in day-to-day lives; for example, could services offer a post-group refresher session to support participants on their therapeutic journeys? What component of DBT is the most effective according to group participants?

Service development is another key area for change. Services can evaluate DBT for certain populations across the lifespan and their cost-effectiveness, such as older adults who experience difficulties regulating their emotions. Does ‘DBT-informed work’ still produce effective outcomes if the comprehensive DBT programme is not offered?

Clinicians may use the findings to offer psychoeducation on the mechanisms and long-term therapeutic effects of DBT, while also advise on maintenance.

Statement of interests

None.

Links

Primary paper

Gillespie, C., Murphy, M., Kells, M., & Flynn, D. (2022). Individuals who report having benefitted from dialectical behaviour therapy (DBT): a qualitative exploration of processes and experiences at long-term follow-up. Borderline Personality Disorder and Emotion Dysregulation, 9(1), 1-14.

Other references

Chapman A. L. (2006). Dialectical behavior therapy: current indications and unique elements. Psychiatry (Edgmont (Pa. : Township)), 3(9), 62–68.

Flynn D, Kells M, Joyce M, Corcoran P, Hurley J, Gillespie C, et al. Multisite implementation and evaluation of 12-month standard dialectical behavior therapy in a public community setting. J Pers Disord. 2020;34(3):377–93. Available from.

Kröger C, Schweiger U, Sipos V, Arnold R, Kahl KG, Schunert T, et al. Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting. Behav Res Ther. 2006;44(8):1211–7. Available from.

Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatr. 2006;63(7):757–66. Available from: .

McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatr. 2012;169(6):650–61. Available from. .

Pasieczny N, Connor J. The effectiveness of dialectical behaviour therapy in routine public mental health settings: an Australian controlled trial. Behav Res Ther. 2011;49(1):4–10. Available from.

Sayrs, J. H., & Linehan, M. M. (2019). DBT teams: Development and practice. Guilford Publications.

Verheul R, Van Den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, Van Den Brink W. Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. Br J Psychiatr. 2003;182(2):135–40. Available from. https://doi.org/10.1192/bjp.182.2.135.