Women with a serious mental disorder called borderline personality disorder who received a specialized form of cognitive behavioral therapy were half as likely to attempt suicide as women who were treated by expert therapists in dealing with difficult patients.

In addition, the women who received the treatment called dialectical behavior therapy also were less likely to go to an emergency room for suicidal behavior or to be hospitalized for psychiatric reasons, said Marsha Linehan, lead author of a new study appearing in today’s issue of the Archives of General Psychiatry. None of the women in the study who attempted suicide were successful during the one-year study and a one-year follow-up.

Women who received the therapy also were significantly less likely to switch therapists or drop out of treatment, said Linehan, a University of Washington psychology professor who directs the UW’s Behavioral Research and Training Clinics. This is the seventh randomized controlled study conducted at the UW and elsewhere to show that dialectical behavior therapy, which balances change and acceptance, is the most effective treatment for borderline personality disorder. The treatment was developed at the University of Washington.

The study is the first in a series to identify specific elements of the treatment that make it so effective in dealing with patients who have borderline personality disorder, which is notoriously difficult to treat. The new research was designed to determine whether treatment was successful because of the skill of therapists or because of the treatment itself.

“The importance of the study is that is shows a very specific treatment, dialectical behavior therapy, was very effective in treating people with borderline personality disorder, and this therapy is uniquely effective in treating suicidal behavior. We cut the number of suicide attempts in half,” said Linehan.
An estimated 5.8 million to 8.7 million Americans, mostly women, suffer from borderline personality disorder. People with the condition have a multiple spectrum of disorders are marked by emotional instability, difficulty in maintaining close relationships, eating disorders, impulsivity, chronic uncertainty about life goals and addictive behaviors such as using drugs and alcohol. They also have a very high suicide rate and a have major impact on the medical system by being among the highest users of emergency and in-patient medical services.

“People with borderline personality disorder have difficulty regulating their emotion and their lives so dialectical behavior therapy is designed to help clients build a life worth living,” said Linehan “Not only do they attach to us, we attach to them.”

The study involved 101 women between the ages of 18 and 45 who met the criteria for borderline personality disorder, including suicidal behavior -  two suicide attempts or self-injuries in the past five years with at least one of them in the previous eight weeks. The women were computer matched and randomly assigned to treatment conditions for one year of treatment plus a year of post-treatment follow-up.

Half the women were assigned to therapists who were trained in dialectical behavior therapy. The others were assigned to one of a group of expert therapists nominated by community mental health leaders, including heads of inpatient psychiatric units and clinical mental health agencies. These community therapists were selected on the basis of their skill in working with difficult patients and used a variety of treatment approaches. However, none were cognitive behavioral therapists.

The women in the dialectical behavior therapy group received weekly individual psychotherapy and weekly group skills training, as well as telephone access to their therapist for a year. The study did not mandate the type of treatment provided by the expert therapists to the other group of women. Instead, the therapists were told to provide the type and amount of therapy they believed was best suited to each patient, with a minimum of one individual session a week for one year. Additional treatment could be prescribed as needed. Women in both groups were tracked every four months for an additional year following treatment to measure the effects of their therapy.

Another major finding of the study is that treatment by expert therapists may be better than treatment that is usually offered to people with borderline personality disorder, according to Linehan.

“These people usually are told that they can’t be treated. But therapy by experts who can deal with suicide and borderline personality problems is a definite second choice after a therapist trained in dialectical behavior therapy,” she said.

The National Institute of Mental Health supported the research. Co-authors of the study are Katherine Comtois, Angela Murray, Milton Brown, Heidi Heard, Kathryn Korslund, Darren Tutek, Sarah Reynolds and Noam Lindenboim of the University of Washington and Robert Gallop of West Chester University in Pennsylvania.

University of Washington