Dialectical behavioural therapy (DBT) is a cognitive behavioural treatment of borderline personality disorders. Diagnostically there is sometimes an overlap between patients diagnosed as suffering from a multi-impulsive disorder, known in the Diagnostic and Statistical Manual of Mental Disorders III (American Psychiatric Association, 1987) as ‘borderline personality disorder’, and those diagnosed as suffering from an eating disorder.
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Lorraine Parker, RMN, is a nurse specialist at Leicestershire and Rutland Healthcare NHS Trust
In the eating disorders unit at Leicestershire and Rutland Healthcare NHS Trust, we have found that some of our patients have a diagnosis incorporating personality disorder and so we have attempted to apply DBT. It is essentially a skill-based therapy, offering patients practical coping techniques.
A proportion of this patient group can present with multiple difficulties. These arise from the maladaptive coping mechanisms that they have developed. Life can become an emotional struggle, an ‘all or nothing’ way of coping, as this woman’s description illustrates (Fairburn, 1995): ‘My eating problem has taken over my whole life. My friendships have been upset by my violent swings in mood. I never talk to my parents since they have never understood what I am going through, yet we are so close. I have so little self-confidence. I get terribly depressed and anxious. I can’t face people.
‘My life revolves around my eating. I can no longer concentrate on my work, which has suffered as a result. I no longer enjoy sharing meals with family or friends. I have lost all self-confidence and self-respect. I don’t like myself any more.’
The emotional state of such patients can be highly volatile. Episodes of anxiety can trigger irritability, which can then result in outbursts of anger. This can be directed at others but more often it is directed inwards, in the form of self-injury.
There are similarities between the symptoms of patients with a diagnosis that incorporates personality disorder and patients with a diagnosis of bulimia nervosa. According to Cooper (1993) the binges almost always occur in secret. An appearance of ‘normal’ eating is often maintained in front of others. However, the emotions experienced after a binge can be complicated: an immediate sense of relief at having given up the struggle not to eat, which is soon replaced by feelings of shame, guilt and disgust. In most cases depression follows a binge.
Patients often describe a sense of hopelessness together with extreme distortion of body image. Feelings of anger and frustration can intensify to the extent where patients resort to the misuse of laxatives as a form of self-punishment. Self-destructive behaviour can be more drastic after a binge and can include cutting. This can result in minor skin wounds, but in some cases is much more serious.
Patients have explained the need to cut themselves in a number of ways. For many it is a violent expression of anger and a direct form of self-punishment. But it is also used to release tension, either as the urge to binge builds up or following a binge.
Introducing the DBT programme
Like most services, we had patients with eating disorders for whom psychodynamic psychotherapy, interpersonal psychotherapy and cognitive therapy did not have a significant effect.
We believed DBT could offer a solution to the problems of this group. So in September 1997, six members of the team began a 10-day course in DBT. It was divided into two parts, each consisting of five days of theory and practice. The training took nine months to complete.
Between study days, the team had to complete certain tasks to consolidate the theory. The required tasks were to prepare a case presentation, describe our intended programme format and identify problem areas in implementing a DBT programme. There were also individual assignments and a DBT open exam.
We discovered the best way to complete the required tasks was to form what is known in DBT as the ‘consultation team’, which includes all those who will be working within the DBT framework.
Initially, we established parts of the DBT programme as a training exercise for the team. This occurred with the permission of an already established patient group of people diagnosed with anorexia in a day programme.
Although the DBT programme was not intended for use with this patient group, we wanted to discover the effects of its skills training techniques on issues with which this group struggled.
When the team was confident with the programme’s framework and some of its techniques, we established a full DBT programme for outpatients. The criteria for inclusion within the framework were that all patients would already be in our service and would have a diagnosis of an eating disorder and presenting symptoms that would fit a diagnosis of borderline personality disorder (APA, 1987).
Components of the programme
There are six components to our programme. We gave four of them a high priority: the consultation group; individual therapy; telephone contact, and the skills group. Together they provide staff and patients with a cohesive framework.
The consultation group allowed for a focused approach to the DBT model and space to discuss progress and problem areas. It also allowed space for ‘cheerleading’ team members who were stretched.
The skills group appeared to consolidate individual sessions, with more emphasis on education, feedback and problem-solving. The telephone contact helped patients at times of crisis and enabled identification of positive coping mechanisms between individual sessions and the skills group.
With most personality disordered patients, a closer, warmer therapeutic relationship is necessary than is maintained in the case of an acute disorder such as anxiety or depression. It is known that difficulties in the therapeutic relationship can lead to resistance, non-compliance, lack of compliance, or negative transference. Most practitioners find that some instinctive patient resistance is usual in therapeutic encounters.
The view of self, and the view of others, can be extreme and highly exaggerated in people with eating disorders and borderline personality disorders. This exaggerated view may then become manifest in a number of ways.
Shelton and Levy (1981),Wachtel (1982) and Ellis (1985), wrote that the most common themes in the lack of the therapeutic collaboration involved distrust of the therapist, personal shame, grievances against others or fear of rejection.
Linehan (1993) highlighted a number of other factors which may contribute to therapeutic non-compliance. These include: the patient lacking the ability to be collaborative; the therapist lacking the necessary skills to develop a therapeutic working relationship with this type of patient; environmental factors that may prevent, change or reinforce dysfunctional behaviours, and the patient’s fears regarding changing and the ‘new self’. Knowledge of such factors provided the team with insights into therapeutic difficulties which arose with our patient group.
The skills training programme
This consists of four modules: ‘core mindfulness’; ‘interpersonal effectiveness’; ‘emotion regulation’, and ‘distress tolerance skills’. The aim is to teach individuals to manage dysfunctional behaviours and maintain relationships, even though their emotions and responses appear totally deregulated.
The skills training programme was at times difficult to teach - patients felt ‘invalidated’ and ‘patronised’ by some of the terminology. In addition, they believed that they already ‘knew’ what was happening to them both emotionally and psychologically: what they wanted to know was how to let others know what was happening.
The advantage of the skills training component of DBT is that the patient is taught the function of their emotions and then, in turn, becomes a tutor to others.
Linehan (1993) states that integrating behaviours to produce a skilful response is important. Very often an individual has the component behaviours of a skill but cannot put them together coherently when necessary. In the terminology of DBT, ‘almost any desired behaviour can be thought of as a skill’. The central aim of the programme is to replace ineffective, maladaptive, or non-skilled behaviour with skilful responses.
All seven patients on the programme completed the year. The most significant outcome was the effectiveness of the model.
The programme was not without its problems, but we discovered that DBT gave us strategies to help resolve them, such as recommitment into treatment and chain analysis.
This enabled the therapy to address behaviours the patients had agreed they wanted to refrain from but would resort to during periods of intense crisis. It also permitted understanding of the patients’ choice not to use skills that would enable them to feel ‘validated’ rather than ‘invalidated’.
One of the many things that staff learnt was that the model lent itself to expansion. It enabled us to create our own module specifically for eating disorders.
The team gained a better understanding of this patient group and their presenting symptoms. In addition,we acquired a greater ability to work with these patients, rather than on them.
We believe there is a place within health services for a DBT programme. The unacceptable alternative is to continue passing these patients around the system, which could be viewed in DBT style as reinforcing or adding to the ‘invalidating’ environment.
Garner, D.M., Garfinkel, P.E. (1985)Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York: The Guildford Press.
Kagan, J., Haveman, E. (1976)Psychology - An Introduction. New York: Harcourt, Brace, Jovanovich.
Kernberg, O.F. (1984)Severe Personality Disorders - Psychotherapeutic Strategies. New Haven and London: Yale University Press.
Pervin, L.A. (1993)Personality, Theory and Research. New York: The Guildford Press.