Dialectical Behavior Therapy Is Not Always The Most Effective Treatment For Borderline Personality Disorder

In the psychiatric community, borderline personality disorder (BPD) and dialectical behavior therapy (DBT) tend to be spoken in the same breath. Diagnosed with BPD? Then you need to enter DBT treatment. I was one of those individuals for whom DBT was the first-line treatment when I was diagnosed with BPD in 1990, following my second suicide attempt.

According to the National Education Alliance for Borderline Personality Disorder (NEABPD), “BPD can be defined as a serious mental illness that centers on the inability to manage emotions effectively. The disorder occurs in the context of relationships: sometimes all relationships are affected, sometimes only one.”

The NEABDP states that “BPD usually begins during adolescence or early adulthood.” However, three decades ago, I was not diagnosed until I was twenty-nine years old.

At the time I was diagnosed, Marsha Linehan, Ph.D., a psychologist from The University of Washington had developed a new treatment designed to treat patients who had high rates of suicide attempts. The innovative treatment, known as dialectical behavior therapy or DBT contained elements of Zen and consisted of four modules: Mindfulness, Interpersonal Effectiveness, Emotion Regulation and Distress Tolerance. The definitive manual, “Cognitive-Behavioral Treatment of Borderline Personality Disorder,” was published in 1993.

I was fortunate in that I received my diagnosis prior to the onset of managed care and the era of insurance companies’ tendency to dictate treatment. Following a brief acute inpatient stay in New York City, I was transferred to a psychiatric hospital in a northern suburb of Manhattan. The hospital had a long-term unit dedicated to treating individuals diagnosed with BPD, specializing in DBT.

Even with the intense stigma attached to BPD in the 1990s, the staff on the long-term unit had chosen to work with us, from the psychiatrists to the nurses to the social workers. The eighteen patients (all women) on the unit formed a cohesive community. It was the first time in my life I felt safe and where I didn’t feel I was a freak for having attempted to kill myself or having scars all over my body from cutting myself with razor blades. No one recoiled at the sight of me. I felt accepted for who I was.

On the unit, immersion in DBT was total. We attended several skills groups a day. We had individual coaching sessions, plus individual therapy sessions. We filled out diary cards every evening as homework. We were informally coached to use our skills by the staff throughout the day whenever we were experiencing a difficult time. I was able to stay on the unit for ten months (until my insurance balked at paying for additional time) and I cycled through the four modules several times. Out in the community, I was still miles away from being a functioning member of society.

I still practice and use some of the skills today, over thirty years later. Each time I practice a skill, I learn a different way of applying it to my life. Although building mastery is one of the emotion regulation skills, mastery of the DBT skills themselves is an ongoing process and a lifelong ambition to which to aspire.

There are multiple studies touting the efficacy of DBT. One study completed in 2006 stated, “our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.”

A second study completed in 2010, found “DBT produced non-significant reductions in DSH (deliberate self-harm) and hospitalization when compared to the TAU+WL (treatment as usual plus waiting list) control, due in part to the lower than expected rates of hospitalization in the control condition.”

DBT is based on the here-and-now, teaching adaptive coping skills to replace the ones that are self-destructive, such as self-harm, engaging in reckless behaviors (such as driving at high speeds) and others (i.e., promiscuity, gambling, etc.)

Researcher Dr. Mary Zanarini conducted a 10-year longitudinal study on BPD inpatients. She found that the 10-year course of BPD was characterized by high rates of remission, low rates of relapse, and severe and persistent impairment in social functioning.

Additionally, the 10-year outcome of patients with BPD in the CLPS (Collaborative Longitudinal Personality Disorders Study) demonstrated a distinctive, clinically useful, and diagnostically validating course characterized by remissions more enduring and by functional impairment more severe than many other major psychiatric disorders. The article stated future BPD therapies need to address functional impairment, i.e., to incorporate social learning and rehabilitation strategies.

Given this data from the longitudinal study, what enabled me, in 2021 to have been working full-time as a psychiatric social worker for almost twenty years? (I took a break from 2006 through 2008 due to a severe depressive episode.) I never married or had children, but my only brother is my best friend and biggest cheerleader. He asked me to walk him down the aisle at his wedding in 2018.

I have strong relationships with friends from different areas of my life, such as writing, entrepreneurship, friends I’ve stayed in touch with from various jobs I’ve had and random friends from random times in my life. I’ve also remained close to extended family, primarily cousins scattered across the world.

In 2005, I began a different type of evidence-based treatment for BPD called transference-focused psychotherapy or TFP. TFP is a psychodynamic treatment developed by Dr. Otto Kernberg. TFP “helps clients to establish an increased affect regulation achieved through the growing ability of the client to psychologically reflect and integrate thoughts, emotions and behavior and to establish positive relationships with others” (Kernberg, 2016). These relationships include not only romantic partners but parents (alive or deceased), siblings, friends, co-workers, supervisors, etc.

Basically in TFP, the relationship that develops between the therapist and the client holds up a mirror to all the other relationships in the client’s life and the enduring patterns of interaction. Through gaining awareness in therapy into the patterns that cause dysfunction, the client can apply that insight to the other relationships in her life.

I worked with Dr. Lev for eleven years. She was a psychiatrist who was specially trained in TFP. For the first eighteen months I was in the midst of a severe depressive episode and was psychiatrically hospitalized six times, receiving a course of electro-convulsive therapy.

My work with Dr. Lev allowed me to resolve my relationship with my mother, who passed away in 2002 from pancreatic cancer. My mother and I had an enmeshed relationship, in which the sicker I was, the more attention I received from her. In our relationship, I had an incentive to stay ill. After her death, at one point, I was acting out my desire to be cared for by manifesting somatic symptoms and excessively going to the emergency room.

As painful as it was, with therapy, I came to realize that my relationship with my mother had been holding me back. After she passed away, I thrived and acknowledged as much as I loved and missed her, if she was still alive, I wouldn’t have been able to make the progress I was able to professionally and personally. My frequent visits to the emergency room decreased and eventually ceased.

Resolving my relationship with my father proved more complicated and treacherous. My relationship with him had been conflicted since childhood, as he was an alcoholic and verbally as well as emotionally abusive. Several of the therapists with whom I worked concurred he suffered from an undiagnosed schizoid personality disorder, characterized by a “pattern of indifference to social relationships, with a limited range of emotional expression and experienceSchizoid personality disorder manifests itself by early adulthood through social and emotional detachments that prevent people from having close relationships.”

I chased his approval throughout my entire life, well into adulthood, until he passed away from sepsis in 2013 at the age of eighty-one. I was fifty-two. I thought I’d feel peace and a sense of relief since my brother and I had shared caretaking duties for the last few years of his life as he declined physically and cognitively. Instead, bottled up rage and resentment imploded and I plummeted into a deep depression and eventually attempted suicide eleven months after his death.

Anger was not an emotion allowed in our household while I was growing up and I went through life terrified of confrontation of any sort. I was furious with my father as he was supposed to be the first role model in my life, setting the stage for all future relationships with men and he failed. I remained a virgin until my early fifties, experimented with BDSM and finally came to the conclusion I’m asexual. I don’t know whether my sexual preferences would have been different if my early childhood experience had varied from the reality it was. I use the DBT skill of radical acceptance to come to terms with the fact this is something I will never know.

After I returned to TFP therapy with Dr. Lev following the suicide attempt, I allowed myself to express years of pent-up anger — not just at my father — but at Dr. Lev and at other people in my life as well. I’d always feared abandonment and rejection if I dared to communicate my fury. When I told Dr. Lev outright I hated her, she stuck with me. She proved I didn’t need to be afraid of her abandoning me. I was ultimately able to transfer this revelation to the other relationships in my life.

I came to realize with help of forgotten memories from my brother that my father was a deeply flawed human being who did the best he did with what he had. I acknowledged he did love my brother and me in his own way. However, I still cannot forgive him for the chaos he caused in my life in terms of my ability to be in an emotionally healthy and physically intimate relationship with a man.

There are studies as to the efficacy of TFP in treating BPD. In 2007, an outpatient study compared outcomes in the primary domains of suicidality, aggression, and impulsivity, and secondary domains of anxiety, depression, and social adjustment. Transference-focused psychotherapy was associated with change in multiple constructs across six domains; dialectical behavior therapy and supportive treatment were associated with fewer changes.

A study was published in 2018, comparing TFP vs. treatment by community psychotherapists for BPD. The study compared 3 groups of patients with BPD treated with TFP, DBT and psychodynamic supportive therapy. TFP and DBT were associated with a significant improvement in suicidality. TFP and supportive therapy improved facets of impulsivity and only the former yielded a significant improvement in anger, irritability and verbal and direct assaultMoreover, only those individuals in the TFP group improved significantly in their reflective function and their attachment style.

In 2016, Dr. Otto Kernberg published “New developments in transference focused psychotherapy.” In the paper, Dr. Kernberg summarized the recent clinical developments in the treatment of borderline patients. These clinical developments further serve to highlight major differences between TFP and DBT.

·Assessment of four major areas of present functioning in the initial diagnostic evaluation (1. studies, work or profession; 2. love and sexuality; 3. family and social life; and 4. personal creativity). Dr. Kernberg states “the evaluation of these areas during the initial diagnostic interview not only contributes significantly to diagnostic precision in the assessment of the personality but pinpoints where the patient stands in terms of his overall present functioning, what the gap is between where the patient is now and where he might be ideally, if he did not suffer from his personality disorder.

· The primary new development highlighted by Dr. Kernberg “consists in an expansion of the concept of the total transference situation to include exploration in the transference of dissociated and “unaware” expressions of severely self-destructive tendencies in the patient’s external lifeThe slowly accumulating gravity of this acting out may be detected by an on-going, in depth exploration of the patient’s functioning outside the treatment situation.”

The assessment of these factors allow the TFP therapist to gain a greater understanding of the patient in terms of overall functioning and provides a more comprehensive picture for the therapist of the patient’s life outside of sessions. Additionally, this information provides valuable insight into any divide between the patterns with which the patient presents with in real life and what she states are her life goals, i.e. future capabilities and present functioning.

Consideration of these factors also contributes to addressing the deficits found in Dr. Mary’s Zanarini’s 10-year longitudinal study of severe and functional impairment in social learning and rehabilitation by gathering the information regarding these issues for each patient at the start of the TFP treatment and incorporating it throughout.

In the book “A Primer of Transference-Focused Psychotherapy For The Borderline Patient,” the authors state “the most important indicator of readiness for termination is evidence of intrapsychic integration that is sustained over a period of time.” They go on to say that “evidence of this often is seen around separations.” Recall one of the nine criteria of BPD is frantic efforts to avoid real or imagined abandonment, so the ability to tolerate an extended separation without acting out is a marker of significant progress.

Everyone who is diagnosed with BPD presents differently. According to the 2014 study, The Structure of Borderline Personality Disorder Symptoms: A Multi-method, Multi-sample Examination, “the DSM-5 defines BPD in terms of nine symptoms that span affective, interpersonal, and intrapersonal disturbances. A diagnosis requires the presence of any five symptoms, which allows for 256 combinations by which an individual could receive a BPD diagnosis. This variety of potential combinations raises the possibility that there are different dimensions or forms of BPD, which might have different etiologies, follow different paths of change, and respond to different treatments.”

I struggled with anorexia for twenty-five years. However I did not remain in a malnourished state for twenty-five consecutive years. I’d lose a significant amount of weight, be hospitalized on an inpatient eating disorder unit, and discharge as weight restored.

Depending on where I was emotionally and physically, it might be up to a year before I’d relapse — typically I’d be discharged to a partial hospitalization program for additional support — but I’d always relapse eventually. I was inpatient nine times and the prolonged, severe malnutrition, caused irreversible damage to my body. I now live with osteoporosis (having sustained multiple fractures), chronic GI issues due to excessive laxative and enema abuse. Additionally, all my teeth had to be pulled, again due to excessive bone loss.

The anorexia was fueled in part by the illusion that perfectionism existed and was attainable, not just in the pursuit of thinness, but in all aspects of my life, including my work. Validation was seeing my weight rapidly drop on the scale, but I craved the same validation and praise from my supervisors at work. When it wasn’t immediately forthcoming I’d (unconsciously) become rageful and begin to self-destruct. I’d plunge into a depression and would be unable to function at my job. I experienced intractable migraines lasting for three or four days with the same result.

I needed to get my validation elsewhere, ideally from within. The BPD internal experience is typically one of chaos and emptiness. I was calming the chaos with starving and filling the chasm with the compliments I received as I became increasingly skeletal.

I signed up for a memoir class at a local writing center and wrote about what I knew: my experience with mental illness. The first piece I submitted for publication was to an anthology. I wrote about my anorexia, and it was accepted! I experienced a different type of high at seeing my name in print. Though I didn’t realize it at the time, writing, and publishing my work provided a significantly more sustainable high than starving and self-harm.

Allowing myself to internalize the accolades I received regarding my writing eventually translated to other areas of my life, such as my work. I gained confidence in the quality of my own work and my need to seek outside approval gradually decreased.

If that pattern did start to manifest itself, I now had the awareness and insight to recognize the emergence of a self-destructive pattern and halt it.

It’s worth noting the foundation I built with the DBT skills continued to be valuable as I was undergoing TFP. TFP was an intense treatment as I explored painful life experiences. I frequently utilized my DBT skills to help me tolerate the emotions unearthed in the sessions with Dr. Lev without resorting to self-destructive behaviors.

Without transference-focused psychotherapy, I would not have been able to achieve continuing success in my career and with my writing. I now have a blog on the website of Psychology Today which has over 879K hits and I continue to publish essays on the subject of mental health and recovery.

My success in these areas gave me the self-confidence to feel as though I was on equal footing with others and deserve to be among them, such as when I attended a week-long intensive writer’s conference at Sarah Lawrence College or when I felt ready to challenge myself and initiate a job search, leaving a position where I was comfortable but stagnant.

In 2020, I entered the arena of entrepreneurship and launched a mental health advocacy and awareness organization. This venture is a passion of mine and I finally felt ready to be able to manage both my full-time position and this side-hustle. With my drive and motivation, I don’t intend for it to remain a side-hustle for long.


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