Few thoughts:
- DBT is a valuable therapy but most patients are not at the point where they can engage in this. much work is about getting patients to engage in therapy
- contrary to popular belief DBT is not really a treatment "for" borderline personality disorder. it does not really alter character structure. it was developed to treatment chronically parasuicidal individuals and focuses largely on crisis management. Even Linehan has said it was really the first phase of treatment for these patients so they could engage in more enduring therapeutic work. It is certainly helpful at reducing suicidal and self-injurious behavior and hospitalizations but it doesn't focus on broken character structure
- DBT is not the only therapy for borderline personality disorder -
mentalization-based treatment, transference focused psychotherapy and
schema focused cognitive therapy all have their place
- a motivational interviewing approached focused on rolling with resistance and provided lots of praise and validation is important when working with these patients
- actually the APA's own guidelines "Good Psychiatric Management" recommends using pharmacotherapy to target particular symptom clusters. In fact general psychiatric management has been shown to be just as good as DBT at reducing suicidal behavior, health care utilization, ER visits, and psychiatric hospital stays. Read more
here and
here
I was very suspicious about this at first, and still question the received wisdom of loading patients up on various pharmaceuticals but this approach can and does work. Also patients in fidelity DBT programs often remain on shedloads of drugs as well. Call them transitional objects, "gifts" from the doctor, or placebos if you will - but the outcomes speak for themselves
- there is even some "evidence" for using
seroquel - the first and last author of the paper are known to be ethically questionable, the numbers are small, the duration is short and could represent a "flight to health" we see in these patients - and you can't really do a fair comparison between inert placebo and quetiapine because the latter is so sedating you would need to give a sedating comparator to control for the active placebo effect, but the point is, these patients do respond (transiently as it might be) to pharmacotherapy. This may be more for psychological reasons but that is a large part of many of our drug and somatic treatments anyway. my point is, there has been a resurgence of interest and data suggesting that though not perhaps ideal, if part of a sensible team-based approach may have its place.
- also remember that depression, anxiety disorders, and even bipolar disorder are highly comorbid with borderline personality disorder and drug treatment may be indicated in that case. Curiously enough, good psychiatric management suggests starting borderline patients on an SSRI "to establish therapeutic alliance" haha. The fact is we use crude tools with most of our patients and we need to meet them where they are. the system is broken and evidence based treatments are not as widely available. Where I am we have more DBT programs than probably anywhere else and there are still major issues with engagement and getting people to agree to participate. You obviously have to weigh up risks and benefits and I certainly felt very frustrated with all these poor patients on multiple psychotropics but I am learning that they may have their place. At the same time we need to balance benefits against the potential for iatrogenic harm and use the fewest most benign medications at the lowest doses for the shortest duration, evaluating for changes and not falling prey to the psychotropic merry go round and paying attention to the countertransference enactments that can occur in your prescribing
- good supervision/process group/consultation/personal therapy is often essential in working with these challenging patients and maintaining your own sanity