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Dialectical Behavior Therapy of borderline patients with and without substance use problems

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The aim of this article is to examine whether standard Dialectical Behavior Therapy (DBT) (1) can be successfully implemented in a mixed population of borderline patients with or without comorbid substance abuse (SA), (2) is equally efficacious in reducing borderline symptomatology among those with and those without comorbid SA, and (3) is efficacious in reducing the severity of the substance use problems. The implementation of DBT is examined qualitatively. The impact of comorbid SA on its efficacy, as well as on its efficacy in terms of reducing SA, is investigated in a randomized clinical trial comparing DBT with treatment-as-usual (TAU) in 58 female borderline patients with (n = 31) and without (n = 27) SA. Standard DBT can be applied in a group of borderline patients with and without comorbid SA. Major implementation problems did not occur. DBT resulted in greater reductions of severe borderline symptoms than TAU, and this effect was not modified by the presence of comorbid SA. Standard DBT, as it was delivered in our study, however, had no effect on SA problems. Standard DBT can be effectively applied with borderline patients with comorbid SA problems, as well as those without. Standard DBT, however, is not more efficacious than TAU in reducing substance use problems. We propose that, rather than developing separate treatment programs for dual diagnosis patients, DBT should be "multitargeted." This means that therapists ought to be trained in addressing a range of severe manifestations of personality pathology in the impulse control spectrum, including suicidal and self-damaging behaviors, binge eating, and SA.
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Dialectical Behavior Therapy of borderline patients
with and without substance use problems
Implementation and long-term effects
Louisa M.C. van den Bosch
a,
*, Roel Verheul
b,c
,
Gerard M. Schippers
a
, Wim van den Brink
a
a
Amsterdam Institute for Addiction Research, University of Amsterdam, Amsterdam, Netherlands
b
Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
c
Psychotherapy Institute ‘‘Viersprong’’, Halsteren, Netherlands
Abstract
Objective: The aim of this article is to examine whether standard Dialectical Behavior Therapy
(DBT) (1) can be successfully implemented in a mixed population of borderline patients with or
without comorbid substance abuse (SA), (2) is equally efficacious in reducing borderline
symptomatology among those with and those without comorbid SA, and (3) is efficacious in
reducing the severity of the substance use problems. Method: The implementation of DBT is
examined qualitatively. The impact of comorbid SA on its efficacy, as well as on its efficacy in terms
of reducing SA, is investigated in a randomized clinical trial comparing DBT with treatment-as-usual
(TAU) in 58 female borderline patients with (n= 31) and without (n= 27) SA. Results: Standard DBT
can be applied in a group of borderline patients with and without comorbid SA. Major implementation
problems did not occur. DBT resulted in greater reductions of severe borderline symptoms than TAU,
and this effect was not modified by the presence of comorbid SA. Standard DBT, as it was delivered in
our study, however, had no effect on SA problems. Conclusions: Standard DBT can be effectively
applied with borderline patients with comorbid SA problems, as well as those without. Standard DBT,
however, is not more efficacious than TAU in reducing substance use problems. We propose that,
rather than developing separate treatment programs for dual diagnosis patients, DBT should be
‘‘multitargeted.’’ This means that therapists ought to be trained in addressing a range of severe
0306-4603/02/$ – see front matter D2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 3 0 6 - 4 6 0 3 ( 0 2 ) 0 0 293-9
* Corresponding author. Academic Medical Center, University of Amsterdam, Tafelbergweg 25, 1105 BC
Amsterdam, Netherlands.
E-mail address: wiesvdbosch@wxs.nl (L.M.C. van den Bosch).
Addictive Behaviors 27 (2002) 911923
manifestations of personality pathology in the impulse control spectrum, including suicidal and self-
damaging behaviors, binge eating, and SA.
D2002 Elsevier Science Ltd. All rights reserved.
Keywords: Borderline personality disorder; Substance abuse; Dual diagnosis; Dialectical Behavior Therapy
1. Introduction
Borderline personality disorder (BPD) is a persistent and severe mental disorder. Studies
have shown significant comorbidity between BPD and substance use disorders (SUD) or
substance abuse (SA) (Akiskal, Chen, & Davis, 1985; Dulit, Fyer, Haas, Sullivan, & Frances,
1990; Links, Heslegrave, Mitton, & van Reekum, Patric, 1995; Loranger & Tulis, 1985;
Oldham et al., 1995; Trull, Sher, Minks-Brown, Durbin, & Burr, 2000; Zanarini, Gunderson,
Frankenburg, & Chauncey, 1989; Zimmerman & Coryell, 1989). The reported prevalence
rates of SUD among patients with BPD range from 39% to 84% with a median rate of 67%
(Dulit et al., 1990; Links et al., 1995; Zanarini et al., 1989, 1998; Zanarini, Gunderson,
Frankenburg, & Chauncey, 1990). Within SA populations, the prevalence of BPD ranges
from 2% to 66% with a median rate of 18% (Verheul, van den Brink, &Hartgers, 1995).
Comorbidity of SUD and BPD can partly be accounted for by overlapping diagnostic criteria
(Dulit et al., 1990; Rounsaville et al., 1998), but prevalence rates of BPD remain high even
when SA is excluded as a diagnostic criterion of BPD (e.g., Dulit et al., 1990; Rounsaville et
al., 1998). Some have suggested that SUD and BPD are causally linked in some way(Verheul,
Ball, & van den Brink, 1997). For example, some have hypothesized that SUD and BPD may
share a common etiology and may be viewed best as being in the same domain of
psychopathology, i.e., affective dysregulation (Linehan, 1991, 1993) or impulse control
disorders (Siever & Davis, 1991; Zanarini, 1993). Many authors view substance use as a
manifestation of impulsivity, which is a core feature of BPD (Links, Heslegrave, & van
Reekum, 1999; van Reekum, Links, & Fedorov, 1994).
Since SA can be considered as a typical borderline manifestation rather than an
independent comorbid condition, it is interesting that borderline patients comorbid with
SA often are treated differently from those without SA. For example, it has been reported that
borderline patients with SA experience difficulties when applying for treatment. Anecdotal
data indicate that this group may be caught in a therapeutic ‘‘Catch-22’’ situation in which
they cannot enter the mental health service system until they stop using substances and cannot
enter SA treatment until their suicidal and self-damaging behaviors are under control (e.g.,
National Institute of Alcohol Abuse and Alcoholism (NIAAA), 1993; van den Bosch, 1996;
Verheul et al., 1997). Several factors may account for this phenomenon, including (1)
segregations in the mental health field, (2) the assumption that addictive behaviors should be
applied as an exclusion criterion for treatment programs and studies, and (3) program
differentiation.
First, mental health centers and addiction treatment programs in some countries exist
separately. This health care segregation has a strong tradition in the Netherlands, where the
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923912
financial support systems for mental health and SA are completely separate. Unfortunately,
this situation often prevents clinicians from undertaking integrated and collaborative treat-
ments for dual diagnosis patients. Only recently, we have observed some initiatives in this
direction often within the framework of research projects.
Second, scientific studies and clinical treatment programs often view addictive behaviors
as an exclusion criterion for treatment of BPD. For example, substance abusers tend to be
excluded from studies examining efficacy of treatments designed to target borderline
symptoms: four of five randomized controlled trials of psychosocial interventions for BPD
excluded borderline patients with SA (Bateman & Fonagy, 1999; Evans et al., 1999; Linehan,
Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Comtois, & Koerner, et al., 1998;
Linehan, Heard, & Armstrong, 1993; Marziali & Munroe-Blum, 1994). The practice of
excluding borderline patients with SA is questionable given recent findings pertaining to the
lack of clinical relevance of addictive behaviors among borderline patients. For example, one
study recently showed that the clinical and etiological differences between borderline patients
with and without SA are limited in number and size (van den Bosch, Verheul, & van den
Brink, 2001).
Third, rather than eliminating SA as an exclusion criteria for treatment programs, the
mental health field shows a tendency toward differentiation between symptom- and disorder-
specific modules. One example is DBT program designed to reduce SA problems in
substance-abusing borderline patients (DBT-S; Linehan et al., 1999). This type of differenti-
ation might be indicated if implementation of regular DBT in a population of borderline
patients with and without SA severely reduced the effectiveness of DBT within either one or
both subgroups—e.g., through interference with the group dynamic process—or, alterna-
tively, if treatment outcome data indicated that SA is a strong predictor of poor treatment
outcome for standard DBT. The most obvious disadvantage of treatment differentiation at a
symptom-specific level is the enormous organizational challenge resulting from the need for a
very large number of treatment modules to account for the whole clinical population.
We have described above some of the issues that might account for the observation that
borderline patients with SA experience difficulties when applying for treatment. In 1995, the
Jellinek Center for SA treatment and the Amsterdam Institute for Addiction Research (AIAR)
started a randomized clinical trial of DBT in a mixed population of borderline patients with
and without comorbid SA. Previous studies have shown that standard DBT compared to
treatment-as-usual (TAU) is effective in reducing severe borderline symptomatology in
borderline patients without SA (Linehan et al., 1993), and that a modified version of this
program (DBT-S) is effective in reducing SA in borderline patients with SA (Linehan et al.,
1999). Against the background of these findings, we initiated a study to evaluate whether
standard DBT would also be applicable and effective in the treatment of BPD pathology and
SA problems.
This paper aims to examine the following research questions:
1. Can standard DBT be implemented among a mixed group of borderline patients with and
without SA? What specific problems are encountered and what solutions to these problems
can be found?
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923 913
2. Is standard DBT equally efficacious in reducing borderline symptomatology among those
with and those without comorbid SA?
3. Is standard DBT efficacious in terms of reducing the severity of the substance use
problems?
2. Method
2.1. Aspects of implementation
A standard DBT program, focusing on life-threatening and suicidal behavior as primary
treatment targets, was implemented in the Jellinek Addiction Treatment Center in Amster-
dam. Female patients with BPD were recruited from both SA treatment centers and
psychiatric services in the greater Amsterdam area, irrespective of the severity of their
substance use problems. During a pilot phase, interviews at the beginning and the end of
treatment with both patients and therapists were held to obtain information about imple-
mentation issues.
Dialectical Behavior Therapy (DBT) is a manualized 12-month treatment that combines
four modules: (1) weekly individual cognitive behavioral psychotherapy sessions with the
primary therapist; (2) weekly skills training groups lasting 22.5 h per session; (3) weekly
supervision and consultation meetings for the therapists; and (4) phone consultation, where
patients are encouraged to get coaching in the appliance of new effective skills by phoning
their primary therapists either during or outside office hours. Individual therapy focuses
primarily on motivational issues, including the motivation to stay alive and to stay in
treatment. Group therapy teaches self-regulation and change skills, and self and other
acceptance skills. Among its central principles is DBT’s simultaneous focus on applying
both acceptance and validation strategies and change (behavioral) strategies to achieve a
synthetic (dialectical) balance in client functioning.
2.1.1. Therapists: recruitment and training
A core group of three therapists was sent to Seattle to be trained in DBT. Back in
Amsterdam, they recruited additional therapists from psychiatric hospitals in Amsterdam and
the Jellinek Addiction Treatment Center through introductionary lectures over a two month
period (van den Bosch, Egberts, Ingenhoven, & Kuipers, 1995). Therapists were invited not
only to refer their patients but also to take part in the project themselves as therapists. The
core group therapists provided training through in-service meetings and workshops. Ongoing
supervision and theoretical training were provided by the project manager (LMCvdB) in the
consultation team.
2.1.2. Recruitment of patients
The patient group in the pilot phase consisted of nine substance-abusing, (para)suicidal,
and self-mutilating female borderline patients. Exclusion criteria were the identical to those
used in standard DBT programs except that SA was not an exclusion criterion. The average
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923914
age of subjects in the pilot group was 37.5 years. The average number of days in residential
treatment in the last 4 years was 74 days per year. The average number of admissions in the
last 4 years ranged from 4 to 58.
2.2. Efficacy of standard DBT in a mixed group of borderline patients with or without SA
problems: effects on BPD symptomatology
We conducted a randomized clinical trial, comparing the efficacy of DBT with TAU in 58
female patients with BPD. Participants were clinical referrals from both substance use
treatment and psychiatric services. The inclusion criteria were: (1) DSM-IV diagnosis of
BPD; (2) currently in outpatient psychiatric or SA treatment; (3) age between 18 and 70; and
(4) residence within a 25-mile circle around Amsterdam. Exclusion criteria were: (1) a DSM-
IV diagnosis of bipolar disorder or (chronic) psychotic disorder; (2) insufficient command of
the Dutch language; and (3) severe cognitive impairments. Referred patients were requested
to fill out a screening device (PDQ-4+; Hyler, 1996). Subsequently, patients were diagnosed
using a semistructured interview (SCID-II; First, Spitzer, Gibbon, et al., 1996). SA problems
were assessed with the European version of the Addiction Severity Index (EuropASI;
Kokkevi & Hartgers, 1995). SA of the participants are presented in Table 1. Patients with
a severity score of 5 of higher on either the alcohol or drug section were considered substance
abusers (SA+) and those with severity scores of 4 or lower on both sections were considered
non substance abusers (SA ).
Table 1
Variation in SA behavior among the participants
EuropASI, N= 58 BPD SA + BPD SA
%n%n
Severity ratings
Cut-off score ASI 4 69403118
Cut-off score ASI 5 53314727
Cut-off score ASI 6 16 9 84 49
EuropASI, N= 58 BPD SA+, n=31
%n
Severity ratings ASI 5
Cannabis 30 9
Neroin 9 3
Cocain 17 5
Methadone 13 4
Alcohol 50 15
Medication (sedatives) 64 19
Poly drug abuse 56 17
Average number of years of SA 7.6
Average number of treatments 4
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923 915
The sample selection strategy, instrumentation, treatment conditions, and data analytic
strategy and first results has been described in detail elsewhere (Verheul et al., submitted).In
summary, intention-to-treat (ITT) analyses are available for 27 subjects assigned to DBT and
31 participants assigned to TAU. Outcome measures include (1) treatment retention and (2)
high-risk suicidal, self-mutilative, and otherwise self-damaging impulsive behaviors. The 12-
month efficacy data with respect to treatment retention and severe borderline symptomato-
logy are reported elsewhere (Verheul et al., submitted) and will be summarized below. Special
attention will be paid to the long-term effects of DBT on BPD symptomatology and on the
potential modification of the treatment effect of DBT on BPD symptoms by the presence of
comorbid SA problems.
2.3. Efficacy of standard DBT in a mixed group of borderline patients with or without SA
problems: effect on SA
The efficacy of DBT in terms of the course of substance use behaviors and borderline
symptomatology at 18-month follow-up will be presented.
3. Statistical analysis
The impact of SA problems on the 12-month efficacy data is analyzed using a general
linear mixed model (GLMM) approach (procedure Mixed from SAS version 6.12; SAS
Institute, Cary, NC). To test the hypothesis (i.e., substance use modifies impact of DBT on
borderline symptomatology), we used models with time, treatment, SA problems, and the
two-way and three-way interactions between these variables. In these analyses, we focused on
the Treatment SA and Time Treatment SA interactions (to inspect whether any of these
were statistically significant), as well as on the Treatment factor and Time Treatment
interaction (to inspect whether these were similar to the effects as observed in the models
without the addiction factor).
The effect of DBT on the course of SA at 18-month follow-up is examined using an analysis
of variance (ANOVA) approach (SPSS version 8.0; General Linear Model Module). To test the
hypothesis that DBT results in greater reductions of SA problems than TAU, we used models
with SA severity as dependent variable, treatment as an independent variable, and initial SA
severity as a covariate. In these analyses, we focused, of course, on the Treatment factor.
4. Results
4.1. Aspects of implementation
4.1.1. Experiences of patients
From the beginning, both therapists and patients expected that it would be difficult to
combine substance-abusing and non-substance-abusing patients. Some even thought that the
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923916
two groups would not mix at all over time. In reality, the two subgroups appeared to get along
easily with each other by the second week. Through the discussion of homework, the
substance-abusing and non-substance-abusing participants realized that they shared most of
the essential borderline problems. Exit interviews showed that all patients judged the program
as validating and helpful. They felt acknowledged as borderline patients and judged the
treatment as very important. Session attendance for the total group was 81%. No difference in
attendance was found for patients with and without SA problems.
4.1.2. Experiences of therapists in individual therapies or sessions
In the beginning, therapists seemed to belong to different worlds. Therapists recruited
from the addiction field experienced difficulty staying focused on the hierarchy of
borderline pathology targets. They tended to immediately turn their attention to the SA
as soon as it showed up in sessions, even when suicidal and self-destructive behaviors were
present. Therapists recruited from the psychiatric field, however, had essentially no
experience with the treatment of substance abusers other than to refer them elsewhere.
Initially, these therapists did not consider (severe) alcohol and medication abuse—which
often lowers the threshold for (para)suicidal and self-mutilative behavior—as examples of
addiction, as is drug abuse. This realization was a shock to some of them. The gaps between
the two groups of therapists were closed in the consultation team meetings. At these
meetings, which were focused in part on providing support to therapists through behavioral
analysis, the individual therapists became aware of the many advantages of working with
colleagues with different types of expertise. In addition, the combination of individual
psychotherapy and group training was experienced as helpful. Phone consultation to the
patient—an essential ingredient of DBT—turned out to be a serious problem, because
therapists were unwilling to try this mode of treatment. Therapists were convinced that the
patients would abuse the possibility of calling 24 h a day, especially at night, and this would
result in therapist burnout. Fortunately, the patients opposed this reluctance and demanded
phone consultation because it was in the protocol. The concept of the patient being her own
case-manager proved to be of help here. Patients were encouraged to convince their in-
dividual therapists to give phone consultation a try and this approach turned out to be
successful.
Another problem resulted from the DBT rule that patients cannot be expelled from the
program. In particular, the experience of patients who relapsed to SA and were not referred
out of the program resulted in heated discussions in the consultation team. In the end, SA was
redefined as a problem behavior that needs to be addressed in individual therapy sessions in
order to prevent the patient from dropping out of the program. Over time, therapists
in individual therapies or sessions reported feeling less isolated and more competent and
also reported increased work satisfaction. The attendance rate for the consultation team
was 100%.
4.1.3. Experiences of the group skills trainers
All the problems in the skills group were related to an initial lack of clear rules, e.g.,
with respect to SA before or during the training meetings. The DBT framework does not
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923 917
actually provide explicit instructions to trainers on the question of whether a patient who
had used substance prior to a meeting should be sent home; instead, DBT encourages
trainers to rely on their own judgement. Some trainers, as well as some patients, expressed
concern about the lack of standardized procedures in this regard. In practice, however,
there were hardly any problems with this issue. In fact, a patient came to a session under
the influence of alcohol only once during the 20 pilot training sessions. The trainers
decided to let her stay because she could sit upright and utter understandable syllables and
she stayed the entire session. Two weeks later, this patient reported to the trainers that she
had visited her general practitioner to obtain antialcohol medication. She reported that the
experience of sitting drunk in the skills group for the whole session and not being sent
away had been a horrible experience. The fact that dealing directly with this patient had
prevented her from dropping out made the trainers see how ineffective traditional
procedures can be.
Another problem that turned up was related to the fact that all patients had been members
of dynamic and interaction-oriented groups. DBT involves concentrating on practicing skills,
rather than taking care of or discussing other patients’ problems. This guideline required
constant attention from the group skill trainers and a shift in attitude for most patients. For
some of them, this shift was difficult to learn and at times challenging and upsetting as it
made them conscious of their own judgmental behavior.
This study, which is the first clinical trial that was not conducted by the developer of DBT
and was conducted outside the US, supports the accumulating evidence that DBT can be
successfully disseminated in other settings and other countries, and that mental health
professionals outside academic research centers can effectively learn and apply DBT.
4.2. Efficacy of standard DBT in a mixed group of borderline patients with or without SA
problems: effects on BPD symptomatology
The efficacy study, which will be reported extensively elsewhere (Verheul et al.,
submitted), yielded three major results. First, DBT effectively retained patients in therapy.
The 12-month attrition rate was 37% in the DBT group compared with 77% in the control
condition. Second, DBT resulted in greater reductions of self-mutilating behavior and self-
damaging impulsive acts than TAU. Third, the beneficial impact on the frequency of self-
mutilating behaviors was far more pronounced among those who reported higher baseline
frequencies of these behaviors compared with those reporting lower baseline frequencies.
These results are highly concordant with previously published trials (Linehan et al., 1993).It
is also important to note that this study allowed for more rigorous statistical testing of DBT’s
efficacy than former trials due to a relatively large sample size (N= 58).
The currently described RCT is the first study that examined the influence of comorbid SA
on the efficacy of standard DBT on borderline symptomatology. The hypothesis that
comorbid SA modifies the impact of DBT on borderline symptomatology was rejected by
the additional statistical analyses. The Treatment SA and Time Treatment SA inter-
actions appeared to be nonsignificant, and adding substance use in the statistical model did
not significantly alter the Treatment and Time Treatment interaction parameters. Thus, the
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923918
observed favorable impact of DBT on borderline symptomatology occurred among non-
substance-using as well as substance-using borderline patients.
4.3. Efficacy of standard DBT in a mixed group of borderline patients with or without SA
problems: effect on SA
Table 2 shows the impact of DBT, as compared to TAU, on measures of SA at 18-month
follow-up, corrected for initial substance use severity scores. The results indicate that no
differential treatment effects were found. This is true for the number of days of alcohol,
medication, and cannabis use in the past month, as well as for the overall severity scores for
both alcohol and drug problems. Based on these findings, the second hypothesis (i.e., DBT
results in greater reductions of substance use problems than TAU) should be rejected.
Inspection of the findings reveals that in both treatment conditions, the course of the
substance use problems is rather stable with almost no change over the 18-month follow-
up period. This implies that the substance use problems were not effectively targeted in the
TAU nor in the DBT condition.
Table 2
Impact of DBT on severity of substance use problems at 18-month follow-up
EuropASI item
a
Treatment condition
DBT, M± S.D. TAU, M± S.D. Comparison
at 18-month
follow-up corrected
for baseline
b
Baseline,
n=27
fu
c
,
n=20
Baseline,
n=31
fu
c
,
n=24
FP
Days 5 drinks past
Months 0 30
7.1 ± 10.3 6.1 ± 9.8 6.2 ± 9.2 3.8 ± 7.8 0.9 .34
Days medication use past
Months 0 30
14.2 ± 14.0 7.9 ± 12.2 13.5 ± 14.5 11.5 ± 13.9 0.4 .54
Days cannabis use past
Months 0 30
6.5 ± 11.2 9.2 ± 13.3 2.3 ± 5.8 5.9 ± 11.5 0.1 .73
Days alcohol problems past
Months 0 30
8.7 ± 12.3 7.0 ± 11.3 9.0 ± 12.9 6.7 ± 11.3 0.0 .89
Days drug problems past
Months 0 30
8.1 ± 11.4 9.5 ± 13.2 9.0 ± 12.6 4.5 ± 10.0 2.0 .17
Severity alcohol
problems 0 9
2.7 ± 2.3 2.8 ± 2.6 3.0 ± 2.5 2.4 ± 2.1 1.1 .31
Severity drug
problems 0 9
3.3 ± 2.0 2.8 ± 2.2 3.6 ± 2.3 2.3 ± 1.8 0.5 .47
a
European version of the Addiction Severity Index (Kokkevi & Hartgers, 1995).
b
Using the General Linear Model Module of Statistical Package for Social Sciences (SPSS 8.0), with
EuropASI scores at 18-month follow-up as dependent variables, treatment condition as fixed factor, and baseline
scores on EuropASI as covariaties.
c
Follow-up scores at 18 months since start of treatment.
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923 919
5. Discussion
This article is aimed at examining whether standard DBT can be applied to a dual diagnosis
population, i.e., whether standard DBT can be implemented in regular mental health or
regular SA treatment settings for borderline patients with and without SA problems. Our
results indicate (1) the implementation process occurred without major problems, (2) standard
DBT is as effective for substance abusing borderline patients as for non-substance-abusing
borderline patients when suicidal and self-destructive behavior are focus of treatment, and (3)
standard DBT does not seem to affect the SA problems in these patients.
Linehan et al. (1999) developed a modified, intensified, and extended version of DBT,
including all the standard components, targeting SA. Specific training of DBT therapists in
the additional SA module was a prerequisite. Koerner and Linehan (2000) found DBT-S had
significantly lower dropout rates and showed significantly more reductions in drug abuse
throughout the treatment year and at follow-up (16 months) compared to subjects in TAU. No
differences, however, were reported for the medical or psychiatric inpatient treatment
received by DBT-S and TAU subjects, nor for rates of parasuicidal behavior. Examination
of the DBT-S treatment program shows that it was primarily focusing on the SA rather than
on high-risk suicidal and self-damaging behaviors. The focus on one target group of behavior
seems to be a common trait of the other DBT programs aimed at other severe dysfunctional
behaviors, such as binge eating (Koerner & Dimeff, 2000; Koerner & Linehan, 2000).
In the DBT trials published thus far, we recognize an interesting pattern: DBT is effective
in terms of the specific ‘‘behavioral’’ target that is focused on, but this impact does not seem
to generalize to behavioral domains that have not been targeted. In this sense, DBT is an
example of an excellent behavior therapy program that can be effective for the treatment of
severe symptomatology of serious personality pathology. This conclusion has a number of
implications.
First, there is now substantial evidence that DBT is an excellent choice for patients with
severe, life-threatening, or health-threatening impulse control disorders (e.g., high-risk
suicidal, self-damaging, and otherwise self-damaging behaviors) that have proven to be
relatively resistant to change in standard or short-term treatments. There is no empirical
support that the core pathology of many patients with BPD (i.e., chronic emptiness and
boredom, unstable relationships associated with primitive defenses, identity disorder, etc.) is
affected by DBT (applied during 1 year). Perhaps, these intrapsychic elements of the
pathology might benefit more from insight or psychodynamically oriented psychotherapeutic
approaches (e.g., Bateman & Fonagy, 1999; Young, 1994).
The second implication is that standard DBT can be modified such that multiple targets can
be focused on, depending on the specific behavioral problems of individual patients. Our
experiences in Amsterdam made clear to us that in our standard DBT program, a focus was
missing—SA. Therefore, we would strongly recommend integrating these potential mod-
ifications within standard DBT, rather than developing different treatment programs for
distinct patients group. In particular, we would recommend that the hierarchy used in the
treatment program be modified. SA should be prioritized next to or just below suicidal and
self-damaging behaviors. In addition, the education of DBT therapists should include training
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923920
in counseling techniques for substance abusers and strategies for modifying addictive
behaviors. There are two good reasons for this recommendation:
1. Patients with impulse control disorders tend to have multiple problems simultaneously or,
alternatively, tend to shift from one to another type of problem behavior.
2. The development of symptom-specific programs would introduce an undesirably high
degree of differentiation that poses an enormous, if not impossible, organizational
challenge for the mental health field.
This study has a number of limitations. The sample size is rather small for studying three-
way interactions; thus, the analyses with respect to the possible differential impact of
substance use severity on DBT’s efficacy should be regarded with some caution. Further-
more, the recommendation mentioned above, i.e., to develop multitarget DBT, is basically
derived from indirect evidence. Future randomized trials are required to test the relative
efficacy of that approach.
In conclusion, the current study provides evidence that standard DBT can be implemented
and is efficacious among both non-substance-abusing and substance-abusing borderline
patients, but it does not seem to affect SA behaviors. We have recommended developing a
multitargeted DBT program for a broad patient population including several specific impulse
control disorders and combinations of these disorders.
Acknowledgements
This work was supported by the Province of Noord-Holland and ZAO Health Insurance
Company in Amsterdam. We acknowledge the assistance of Eveline Rietdijk and Wijnand
van der Vlist with the collection of the data.
References
Akiskal, H. S., Chen, S. E., & Davis, G. C. (1985). Borderline: an adjective in search of a noun. Journal of
Clinical Psychiatry,46, 41– 48.
Bateman, A., & Fonagy, P. (1999). The effectiveness of partial hospitalization in the treatment of Borderline
Personality Disorder: a randomised controlled trial. American Journal of Psychiatry,156, 1563– 1569.
Dulit, R. A., Fyer, M. R., Haas, G. L., Sullivan, T., & Frances, A. J. (1990). Substance use in borderline
personality disorder. American Journal of Psychiatry,147(8), 1002 1007.
Evans, K., Tyrer, P., Catalan, J., Schmidt, U., Davidson, K., Dent, J., Tata, P., Thornton, S., Barber, J., &
Thompson, S. (1999). Manual-assisted cognitive behaviour therapy (MACT): a randomised controlled trial
of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm. Psychological
Medicine,29, 19 25.
First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B. W., & Benjamin, L. (1996). The structured clinical
interview for DSM-IV Axis II personality disorders (SCID-II, Version 2.0). New York, NY: Biometrics
Research Department, New York State Psychiatric Institute (Dutch translation by Weertman, A., et al., 1996).
Hyler, S. E. (1994). Personality diagnostic questionnaire, DSM-IV version (PDQ-4+). New York, NY: New York
State Psychiatric Institute (Dutch translation by Akkerhuis, G. W., et al., 1996).
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923 921
Koerner, K., & Dimeff, L. A. (2000, Spring). Further data on dialectical behaviour therapy. Clinical Psychology:
Science and Practice, 104 112.
Koerner, K., & Linehan, M. M. (2000). Research on dialectical behaviour therapy for patients with borderline
personality disorder. Psychiatric Clinics of North America,23, 151167.
Kokkevi, A., & Hartgers, C. (1995). EuropASI: European adaptation of a multidimensional assessment instrument
for drug and alcohol dependence. European Addiction Research,1, 208– 210.
Linehan, M. M. (1993). Cognitive behavioural treatment of borderline personality disorder. New York, NY:
Guilford Press.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive behavioural
treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry,48, 1060– 1064.
Linehan, M. M., Comtois, K. A., & Koerner, K. (1998). University of Washington study of Dialectical Behaviour
Therapy: a preliminary report. Paper presented at the meeting of the Association of Advancement of Behaviour
Therapy, Washington, DC, 1998.
Linehan, M. M., Heard, H. L., & Armstrong, H. E. (1993). Naturalistic follow-up of a behavioural treatment for
chronically parasuicidal borderline patients. Archives of General Psychiatry,50, 971– 974.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical
behaviour therapy for patients with borderline personality disorder and drug-dependence. American Journal
of Addiction,8(4), 279 292.
Links, P. S., Heslegrave, R., & van Reekum, R. (1999). Impulsivity: core aspect of borderline personality disorder.
Journal of Personality Disorders,13, 1–9.
Links, P. S., Heslegrave, R. J., Mitton, J. E., van Reekum, R., & Patric, J. (1995). Borderline psychopathology and
recurrences of clinical disorders. Journal of Nervous and Mental Disease,183(9), 582 586.
Loranger, A. W., & Tulis, E. H. (1985). Family history of alcoholism in borderline personality disorder. Archives
of General Psychiatry,42, 153– 157.
Marziali, E., & Munroe-Blum, H. (1994). Interpersonal group psychotherapy for borderline personality disorder.
New York: Basic Books.
National Institute of Alcohol Abuse and Alcoholism (NIAAA) (1993). Psychiatric comorbidity with alcohol use
disorders. Eighth special report to the US congress on alcohol and health (pp. 37 59 ). Washington, DC:
NIAAA.
Oldham, J. M., Skodol, A. E., Kellman, H. D., Hyler, S. E., Doidge, N., Rosnick, L., & Gallaher, P. E. (1995).
Comorbidity of axis I and axis II disorders. American Journal of Psychiatry,152(4), 571 578.
Rounsaville, B. J., Kranzler, H. R., Ball, S., Tennen, H., Poling, J., & Triffleman, E. (1998). Personality disorders
in substance abusers: relation to substance use. Journal of Nervous and Mental Disease,186(2), 87 95.
Siever, L. J., & Davis, K. L. (1991). A psychobiological perspective on the personality disorders. American
Journal of Psychiatry,148, 1647– 1658.
Trull, T. J., Sher, K. J., Minks-Brown, C., Durbin, J., & Burr, R. (2000). Borderline personality disorder and
substance use disorders: a review and integration. Clinical Psychology Review,20(2), 235– 253.
van den Bosch, L. M. C. (1996). Dialectische gedragstherapie bij verslaafden met een BPS. Handboek verslaving
(B 4375-1). Houten: Bohn Stafleu Van Loghum.
van den Bosch, L. M. C., Verheul, R., & van den Brink, W. (2001). Substance abuse in borderline personality
disorder: clinical and etiological correlates. Journal of Personality Disorders,15(5), 416 424.
van den Bosch, W., Egberts, T., Ingenhoven, Th., & Kuipers, H. (1995). Tussen Amsterdam en Seattle: de
methode Linehan. MGV,50(10), 1096 1103.
van Reekum, R., Links, P. S., & Fedorov, C. (1994). Impulsivity in borderline personality disorder. In K. R. Silk
(Ed.), Biological and neurobehavioural studies of borderline personality disorder ( pp. 1 – 22). Washington,
DC: American Psychiatric Press.
Verheul, R., Ball, S., & van den Brink, W. (1997). Substance abuse and personality disorders. In H. R. Kranzler, &
B. J. Rounsaville (Eds.), Dual diagnosis and treatment: substance abuse and comorbid medical and psychi-
atric disorders (pp. 317– 363). New York, NY: Marcel Dekker.
Verheul, R., van den Bosch, L. M. C., Koeter, M. W. J., de Ridder, M. A. J., Stijnen, T., & van den Brink, W.
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923922
(submitted). A 12-month randomized clinical trial of Dialectical Behaviour Therapy for women with borderline
personality disorder in the Netherlands.
Verheul, R., van den Brink, W., & Hartgers, C. (1995). Prevalence of personality disorders among alcoholics and
drug addicts: an overview. European Addiction Research,1, 166 177.
Young, J. E. (1994). Cognitive therapy for personality disorders: a schema-focused approach. (Revised ed.).
Sarasota: Professional Resource Press.
Zanarini, M. C. (1993). Borderline personality disorder as an impulse spectrum disorder. In J. Paris (Ed.), Border-
line personality disorder: etiology and treatment (pp. 67 86). Washington, DC: American Psychiatric Press.
Zanarini, M. C., Frankenburg, F. R., Dubo, E. D., Sickel, A. E., Trikha, A., Levin, A., & Reynolds, V. (1998).
Axis I comorbidity of borderline personality disorder. American Journal of Psychiatry,155(12), 1733– 1739.
Zanarini, M. C., Gunderson, J. G., Frankenburg, F. R., & Chauncey, D. L. (1989). The revised diagnostic inter-
view for borderlines: discriminating borderline personality disorder from other axis II disorders. Journal of
Personality Disorders,3(1), 10– 18.
Zanarini, M. C., Gunderson, J. G., Frankenburg, F. R., & Chauncey, D. L. (1990). Discriminating borderline
personality disorder from other axis II disorders. American Journal of Psychiatry,147, 161 167.
Zimmerman, M., & Coryell, W. (1989). DSM-III personality disorder diagnoses in a non-patient sample. Archives
of General Psychiatry,46, 682– 689.
L.M.C. van den Bosch et al. / Addictive Behaviors 27 (2002) 911–923 923
... The study population included six studies with a total of 400. Five of the six of studies in this review included adult populations aged between (18-45) Gregory et al., 2008); (18-65) (Van Den Bosch et al., 2002;Morley et al., 2014) and one included only adolescents (aged 13-17) (Esposito-Smythers et al., 2011). All studies included at least 50% or more participants that reported problematic use of alcohol, with only two studies that included 100% of the sample with problematic alcohol use (Gregory et al., 2008;Wilks et al., 2018). ...
... All studies included at least 50% or more participants that reported problematic use of alcohol, with only two studies that included 100% of the sample with problematic alcohol use (Gregory et al., 2008;Wilks et al., 2018). Problematic alcohol use was indicated either by meeting criteria for an alcohol use disorder (DSM V) as in (Esposito-Smythers et al., 2011), alcohol dependence or abuse (DSM-III-R, DSM IV) as in studies Gregory et al., 2008), the Addiction Severity Index (ASI; (Mclellan et al., 1992)) (Van Den Bosch et al., 2002;Gregory et al., 2008) or alcohol consumption of five or more standard drinks for men and four or more for women per occasion within the prior 30 days (Gregory et al., 2008;Morley et al., 2014;Wilks et al., 2018). Three studies Van Den Bosch et al., 2002;Gregory et al., 2008) were targeted for individuals with borderline personality disorder (BPD). ...
... Problematic alcohol use was indicated either by meeting criteria for an alcohol use disorder (DSM V) as in (Esposito-Smythers et al., 2011), alcohol dependence or abuse (DSM-III-R, DSM IV) as in studies Gregory et al., 2008), the Addiction Severity Index (ASI; (Mclellan et al., 1992)) (Van Den Bosch et al., 2002;Gregory et al., 2008) or alcohol consumption of five or more standard drinks for men and four or more for women per occasion within the prior 30 days (Gregory et al., 2008;Morley et al., 2014;Wilks et al., 2018). Three studies Van Den Bosch et al., 2002;Gregory et al., 2008) were targeted for individuals with borderline personality disorder (BPD). ...
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Objective We aimed to provide a synthesis and evaluation of psychosocial interventions to prevent suicide and reduce self-harm, as well as alcohol intake, for patients with alcohol problems. Methods The systematic review was carried out according to the PRISMA guidelines and considered articles published in English from all countries. Terms relating to suicidality and alcohol problems were used to search Medline, EMBASE and PsycINFO databases. Randomized controlled trials of psychosocial interventions targeted for outpatient settings were included. Results Six studies with a total of 400 participants were included. Two investigated dialectic behavioural therapy (DBT), one internet-delivered DBT, one dynamic deconstructivist psychotherapy (DDP) and two integrated cognitive behavioural therapy (CBT). Face to face and online DBT was significantly associated with abstinence and reductions in consumption with only a trend for a reduction in suicide attempts in one study relative to treatment at usual (TAU). DDP yielded significant reductions in alcohol consumption and suicide attempts versus community care. CBT was significantly effective relative to TAU in reducing alcohol use and suicide attempts in one trial with adolescents but not in another trial in an adult population. Conclusion Integrated CBT has promise for adolescents, DBT may be helpful for alcohol patients with borderline personality disorder and iDBT may be useful for the wider community with heavy alcohol use. However, given the paucity of studies and the exploratory nature of these trials, there is currently no strong evidence for an effective psychosocial intervention to reduce alcohol consumption and suicidal behaviour in adults with problematic alcohol use.
... Individuals with cognitive challenges (here defined as intellectual disability or borderline intellectual functioning) have difficulties understanding, processing, and generalizing new knowledge (American Psychiatric Association 2013). They show an increased vulnerability to other psychiatric conditions, such as depression (Reiss and Rojahn 2008), mood swings (Tyrer et al. 2006, Barnicot et al. 2012, personality disorders and post-traumatic stress disorder (Peña-Salazar et al. 2018), but also to high levels of frustration (Tyrer et al. 2006). Challenging behaviors such as aggression, destructive behavior and self-harm are found in 10-20% of all individuals with intellectual disability (Davies and Oliver 2013). ...
... Individuals with cognitive challenges (here defined as intellectual disability or borderline intellectual functioning) have difficulties understanding, processing, and generalizing new knowledge (American Psychiatric Association 2013). They show an increased vulnerability to other psychiatric conditions, such as depression (Reiss and Rojahn 2008), mood swings (Tyrer et al. 2006, Barnicot et al. 2012, personality disorders and post-traumatic stress disorder (Peña-Salazar et al. 2018), but also to high levels of frustration (Tyrer et al. 2006). Challenging behaviors such as aggression, destructive behavior and self-harm are found in 10-20% of all individuals with intellectual disability (Davies and Oliver 2013). ...
... Individuals with BPD have a high prevalence of self-injurious as well as suicidal behaviors (90% and 75% respectively; Goodman et al. 2017). A number of studies have shown beneficial effects of DBT, such as reduced self-harm and psychiatric symptoms, reduced duration of hospitalization and increased global level of functioning (Linehan et al. 2006, van den Bosch et al. 2002, Verheul et al. 2003, Cristea et al. 2017, Storebø et al. 2020. DBT has also proven to be effective in treating other psychiatric disorders where difficulties in managing emotions and problem behaviors are a part of the symptomatology, such as substance abuse (Linehan et al. 2002, Linehan et al. 1999) and eating disorders (Safer et al. 2001). ...
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... The Suicide Attempt and Self-Injury Count, a brief version of the Suicide Attempt Self-Injury Interview [44], has been widely used to determine suicide attempts in clinical trials [45][46][47][48][49] and was used to identify dates of suicide events and categorize events into suicide attempts and nonsuicidal acts. ...
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