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Clinical Practice in Mental Health 

A personality disorder is a pattern which is of the inner experience of a person where and the patient's behaviour diverge away from the individual's expectations. The altered patterns are consistent and fixed with situations and conditions which ultimately lead to impairment or high amount of distress. A borderline personality disorder is a very severe disorder which is associated with the patient's mental status and is marked by changes in behaviour, their functioning, their self-image and their moods. Patient's experiences result in unstable relationships and actions which are impulsive. People suffering from this disorder will also have to go through intense episodes of depression, anxiety and anger which could last for hours or even up to many days. Prevalence of this disorder in people is about 1.4% (National Institute of Mental Health, National Institute of Health (2020).

Over the last few years, various strategies and techniques are developed to help patients with a borderline personality disorder. One of the therapies is dialectical behaviour therapy. This theory is a behavioural-cognitive treatment which was initially designed to cure the patients who are suffering from the borderline disorder. The word dialectical here means a philosophy which defines the nature of reality. In this therapy, it is very significant that balance is maintained between change and acceptance by the patient. The strategies of this theory consist of interventions which are change-oriented like cognitive restructuring and management of consistency. It also focuses on the fact that accepting reality by the patient is necessary and he/she should change the behaviour which is needed to be changed. Dialectical behaviour therapy sees suicide as a consequence of emotional suffering which is unbearable. So for that, strategies are implemented in this to regulate the emotions effectively. People who are emotionally dysfunctional are encouraged to alter or change the problematic behaviour by various techniques (Prada, Perroud, Rüfenacht & Nicastro, 2018). Therefore, it can be said that dialectical behaviour therapy could help people who are diagnosed with a borderline personality disorder so that they reduce their self-harming behaviour. We can also combine this therapy with other techniques so that it could further improve the patient’s experiences.

The study which was conducted by Lars and his fellow associate includes 1-year follow-up for observing post-treatment results in teenagers who have a tendency to self-harm themselves. Their study has divided these adolescents into two groups. One group received the dialectal behaviour therapy for 19 weeks and the other was given enhanced usual care in a clinic which is for adolescent psychiatry. Assessments about various factors were done during 19 weeks period of treatment and 1 year of follow up after that. The factors that were looked at were self-harm, depression, borderline symptoms, suicidal ideation, hopelessness and overall functioning. A total number of participants was 75. Hospitalization frequencies, visits to the emergency department and other settings which are related to mental health were also recorded in the follow-up time period. It was found that after 52 weeks of keeping track post-treatment, the group who received dialectal behaviour therapy has reduced the number of times tried to self-harm themselves. Whereas, other factors such as borderline symptoms and depression and so on were not changed. The therapy was not effective for borderline symptoms. On the other hand, enhanced usual care also promoted a reduction in self-harm and also other factors such and borderline personality disorder symptoms, depression, hopelessness and so on. Therefore, the researchers concluded that dialectal behaviour therapy was more helpful in treating self-harm related problem in adolescents as compared to enhanced usual care. The evidence which is presented here is good for reducing self-harm with the help of dialectal behaviour therapy in the patients suffering from a borderline personality disorder but it is not helpful in controlling the borderline symptoms which is a very big disadvantage of dialectal behaviour therapy. Therefore, this research proves that dialectal behaviour therapy is not that much credible in treating borderline symptoms but only self-harm problem in individuals (Mehlum et al., 2016).

The study done by Linehan and her other fellow researchers evaluated the significance of components of skill training of dialectical behaviour theory by comparing it with skill training in addition to case management, dialectical behaviour theory individual therapy in addition to activities group and general dialectical behaviour theory which only consist of individual therapy and skills training. They performed a randomized trial which involves 1 year of providing treatment and 1 year of doing follow-ups. There were 99 women chosen for the study who have been diagnosed with borderline personality and have tried to commit suicides at least two times in their lives or have tried to self harm themselves in the previous years or have attempted suicide only eight weeks prior to screening or have attempted to do suicide in the last year. The researchers undertook a random method to assign the subjects to each and every condition. Treatment was given for 4 long years in a clinic or sometimes in a community setting which is used by case managers or therapists. Results were estimated in every quarter. They have hypothesized that standard dialectical behaviour theory will outstand other techniques. Therefore, the study of multiple dialectical behaviour theory interventions which were performed with the help of trained therapist outlined that general dialectical behaviour theory which involves skills training and individual therapy is more effective than other dialectical behaviour theory which has either skills training or individual therapy. This intervention could reduce suicide rates among women. Hence, the evidence that is presented here is good and the strength of this study is that it has taken a large number of participants who have a borderline personality disorder and have tried to commit suicide or self-harm in the past. The other strength is that it has compared the dialectical behaviour theory with two other interventions and therefore stated that general dialectical behaviour theory is more effective as it uses both individual therapy and skills training. Therefore, the study is credible in proofing that dialectical behaviour theory can reduce the rate of self-harm in the clients who are diagnosed with borderline personality disorder (Linehan et al., 2015).

The research conducted by Fassibinder and her colleagues focused on comparing two significant techniques which are dialectical behaviour theory and Schema therapy for the treatment of people who are suffering from a borderline personality disorder. The people who experience borderline personality disorder usually try to self-harm or try to commit suicide. These both techniques are used to help these patients. Hence, for the research purpose, the researcher's tries to find out which one of them is more effective in treating patients. For performing the studies they have taken two groups of people are they have provided each group with either dialectical behaviour theory or Schema therapy. There were in total of 160 patients. The patients were given a single group and single individual therapy session for every week for about 18 months. Both the programs applied for treatment have similar kind of frameworks which proves that there is equipoise. Data were collected before the starting of the sessions and then after every six months till the therapy was going on. Follow up in addition to this was performed after six months and also after 1 and 2 years. Finally, the data was analyzed to understand the patient experience. In the results, it was found out that dialectical behaviour theory reduces the rates of suicides and behaviour which is self-harming among patients suffering from a borderline personality disorder. It is much faster and effective then Schema therapy. It teaches individuals to accept their emotions and the skills to regulate them. Thus, the study stated that the dialectical behaviour theory would result in improvements in problems and difficulties in the regulation of emotions by patients. Whereas, Schema therapy is an approach which is more general that could only increase the overall quality of life or psychiatric comorbidity. The evidence presented in this study is sufficient to prove the result as the number of participants was appropriate and the time is taken to complete the experiment and for follow up was also enough. The methods utilized were also correct and this study could also be used to say that dialectical behaviour theory helps people to reduce the self-harming tendencies who have a borderline personality disorder (Fassbinder et al., 2018).

The research conducted by Reyes-Ortega used a strategy to improve intervention in borderline personality disorder patients. The patients of this disease have unstable control over impulse, have disturbed interpersonal relationships and they perform repeated self-injuries and have suicidal tendencies. Acceptance and commitment therapy targets cognitive fusion and experimental avoidance to support flexible functional behaviour and produce patterns for consistent action with personal values. Whereas, functional analytical psychotherapy is an intervention which is completely based on relationships which are interpersonal that have been tested for treatment of patients suffering from a borderline personality disorder. The researchers have mixed all the therapeutic elements of dialectical behaviour theory, acceptance and commitment therapy and functional analytical psychotherapy to enhance the improvement of the interventions for borderline personality disorder suffering people and have estimated to compare the results with only acceptance and commitment therapy and dialectical behaviour theory groups. The method utilized by them has 65 patients where 22 patients were assigned for acceptance and commitment therapy and 20 people are designated for dialectical behaviour theory whereas 23 people participated in the combined intervention. All the patients were assessed for various factors and it was found out that there was no difference in all treatment modalities. This shows that dialectical behaviour theory does not have major advantages over other the other two therapies. This study concluded that dialectical behaviour theory alone is not that much significant in treating the patients suffering from a borderline personality disorder (Reyes‐Ortega et al., 2020).

The review conducted by Choi-Kain has taken various techniques and therapies into consideration to treat borderline personality disorder. The first therapy that was taken was the dialectical behaviour theory. This theory states that an individual will become better in managing their interaction and sensitivities with others by the use of skills acquisition that will promote and enhance mindfulness and will make them able to tolerate distress and regulate emotions in a better way. There is a need for therapy sessions every week along with a training session. The other therapy was mentalization-based treatment. Mentalization means complicated capacities which humans develop to imagine feelings and thoughts in his own and in other people minds to understand interactions which are interpersonal. This theory helps when patients have lost touch with reality and are in desperate requirement of proof fro feelings via actions. This theory stabilizes the troubles which a borderline patient feels by supporting and strengthening the capacity of the patient to mentalize within the stress of attachment initialization. The third theory that was chosen was transference focused psychotherapy. It focuses on interpersonal relationships which are problematic in the life of the patient and which increase their emotional stress on them. The last one was schema-focused therapy which lay focus on generating changes to the personality of the patient. They have concluded that dialectical behaviour theory as suggested by other researches also could offer more help in treating patients with a borderline personality disorder if it is paired with skill training and management of cases. Then, it will become a more tentative resource to treat patients (Choi-Kain et al., 2017). Therefore, it can be said that the dialectical behaviour theory can be even more useful if other strategies are used with it.

In the study presented by Feigenbaum, he explained the dialectical behaviour theory programme which consists of several things such as skills training which focuses on developing new abilities and capabilities. It usually has four modules, they are mindfulness, interpersonal effectiveness, emotional regulation and tolerance of distress. He further explained that in the program there could individual sessions of therapy also which will last for 60-90 minute every week. During this time, the individual and the therapist will talk about the problems so that they can be solved. The other step includes telephonic consultation or consultations meetings. The researcher also mentioned that dialectical behaviour theory happens in five stages. The stages are pre-commitment stage, stage 1, stage 2 and stage 3 and 4. During the pre-commitment stage, the therapist explains the understanding that will be gained from the assessment and that the client or subject should commit to decreasing the behaviour which is self-harming. The client also agrees to work on his interpersonal relationships. The first stage involves focusing on developing new skills that will immediately reduce life-threatening behaviour. Stage two involves the step where an individual's ability is increased to experience a complete range of emotions. Steps are also taken to eliminate the symptoms of the post-traumatic disorder. Stages three and four involve the development of patient’s self-respect. The study also outlines the strategies used in dialectical behaviour theory. They are the strategy to enhance the patient's commitment towards the therapy, strategies for problem solving and strategies for validation. The study concluded that dialectical behaviour theory offers a complete range of abilities and skills to an individual so that he/she can manage and regulate their emotions so that they won’t harm themselves (Janet Feigenbaum et al., 2010). 

In the research conducted by May, Richardi and Barth they have first provided with the introduction of dialectical behaviour theory and how it is effective with patients which have a borderline personality disorder and also some other psychiatric disorder. They stated that there have been various researches for studying the dialectical behaviour theory efficacy by the help of randomized controlled trials. They have also mentioned that compilation shows that dialectical behaviour theory is furthermore effective than treatments which are community-based. Dialectical behaviour theory reduces parasuicidal activities and behaviours and increases adherence to the treatment. This theory also helps in lessening the number of hospitalized cases. Dialectical behaviour theory also reduces substance abuse and disorder associated with binge eating. With that, it also deducts depression in patients. In addition, this theory studies with various other disorders such as bipolar disorder, bulimia nervosa, post-traumatic stress disorder, anorexia, trichotillomania, attention-deficit hyperactive disorder and so on. Therefore, it can be concluded that dialectical behaviour theory can be used to treat patient with borderline personality disorder and various other disorders that are life-threatening to the patients (May, Richardi & Barth, 2016).

In conclusion, it can be said that dialectical behaviour theory can help people who have a mental illness which is a borderline personality disorder. People suffering from this problem have issues with maintaining and creating relationships and also have tendencies to self-harm. They also try to commit suicide many a time. With that, they feel hopeless, lonely and also have to go through intense episodes of emotions like anger and anxiety. Dialectical behaviour theory can help these people as it is the most effective therapy. This was also proved by many studies which are conducted. There are various good pieces of evidence which support these claims as researches have compared this theory with other techniques too and have founded that dialectical behaviour theory is better than the other theories. The strength of this theory is that it takes the patients situations under consideration and help them to change their problematic behaviour by subsequently reducing the immediate risk on the patient’s life. However, some studies mention that combing this therapy with skill training and case management would create a more beneficial effect. So, dialectical behaviour theory should be used for treating borderline personality disorder patient by also combing other strategies which could improve the therapy sessions and reduces the self-harm behaviour of the patient.

References for Dialectal Behaviour Therapy

Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience Reports4(1), 21-30.

Fassbinder, E., Assmann, N., Schaich, A., Heinecke, K., Wagner, T., Sipos, V., ... & Schweiger, U. (2018). PRO* BPD: Effectiveness of outpatient treatment programs for borderline personality disorder: A comparison of Schema therapy and dialectical behavior therapy: Study protocol for a randomized trial. BMC Psychiatry18(1), 341.

Janet Feigenbaum. (2010). Self-harm – The solution not the problem: The Dialectical Behaviour Therapy Model, Psychoanalytic Psychotherapy, 24(2), 115-134. 10.1080/02668731003707873

Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., ... & Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry72(5), 475-482.

May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. Mental Health Clinician6(2), 62-67.

Mehlum, L., Ramberg, M., Tørmoen, A. J., Haga, E., Diep, L. M., Stanley, B. H., ... & Grøholt, B. (2016). Dialectical behavior therapy compared with enhanced usual care for adolescents with repeated suicidal and self-harming behavior: Outcomes over a one-year follow-up. Journal of the American Academy of Child & Adolescent Psychiatry55(4), 295-300.

National Institute of Mental Health, National Institute of Health (2020). Personality disorder. Available at https://www.nimh.nih.gov/health/statistics/personality-disorders.shtml

Prada, P., Perroud, N., Rüfenacht, E., & Nicastro, R. (2018). Strategies to Deal with suicide and non-suicidal self-injury in borderline personality disorder, the case of DBT. Frontiers in Psychology9, 2595. https://doi.org/10.3389/fpsyg.2018.02595

Reyes‐Ortega, M. A., Miranda, E. M., Fresán, A., Vargas, A. N., Barragán, S. C., Robles García, R., & Arango, I. (2020). Clinical efficacy of a combined acceptance and commitment therapy, dialectical behavioural therapy, and functional analytic psychotherapy intervention in patients with borderline personality disorder. Psychology and Psychotherapy: Theory, Research and Practice93(3), 474-489.

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