Rethinking BPD: A Clinician's View

So I want to start with something only because I'm afraid that I'll talk too long and won't get to tell you this.

So I'm gonna tell a little story just to start, which is this fabulous patients that I had for many years who had been in and out of hospitals forever and was at in New York at a hospital for two years. And they sent her to me on an ambulance plane of all things. And she came and I said, Okay, I'd see her as long as she was in a halfway house in Seattle, and because she's very suicidal, and many other things, and running down streets and night gowns with knives and being found behind dumpsters and alleys almost dead.

So I treated her for quite some time. And finally, we got through college, which was a big thing.

This is more than my usual research, one year treatment, but we got through, she actually got through college. And she went, moved and got a job in San Francisco, sorry, Los Angeles as a teacher and would call me because she wanted to be able to teach some of the skills to her students. I love her so much.

And so I was down not too long ago. She calls me every once in a while, and we talk and so I gone down, we were having lunch. And she was telling me about how awful her life was because she also was not only borderline personality sorter, but also Schizoaffective.

And so she was saying how hard it was to be psychotic and teach and that it was problematic. And so that she had had take a leap, she was tutoring now.

I was so sad that I was in tears because I was just so sad. This is sad happened to her. And she said to me said Marsha, don't be so upset. This is a lot better than being borderline was.

And I think that says a lot. You know that being psychotic Schizoaffective beats out borderline personality disorder.

So I'm going to talk a little bit about people talking about my treatment, dialectical behavior therapy, just to give you you know, someone said to me, Marsha, your job is to give us hope. So I'm going to give you hope, because I'm not alone anymore. I was for years, the only person doing treatment research on borderline personality disorder, and most of my life, the only person doing a non suicidal behavior.

But now we've managed to get other people out there doing data, there's mentalization treatment, all these young people are doing things. So there's a lot of hope. And I'm I know this about so I'm going to talk about dialectical behavior therapy, where it started and tell you what I ran into, I hope I guess an apple. Okay, good.

So I started, I was always wanted to work with suicide.

And so I decided that I was going to work with suicide at NIMH, and those days, helped young investigators enormously, they talk to come run by your research with them in place, you know, I really feel to be honest with you. And I NIMH is like the co author of most of what I've done, they've been so helpful all the time. So I want to deal with high risk for suicide when multiple suicide camp and self injury and I call it all the hospitals in Seattle.

And I said I want the very worst that you've got, because I wanted to be sure that if my people got better, you know, I would be able to tell the difference between them and that control condition.

And so I got a little grant to do treatment development for suicidal behavior. And I just learned behavior therapy, and I was totally sure it would cure everybody. I had not the slightest doubt. But I ran into a bunch of problems.

My first problem was the people I was treating had this extreme sensitivity to rejection, and invalidation. And that made a change-focused treatment, which definitely behavior therapy in 1980 was untenable.

So I switched to an acceptance based treatment, that was a disaster to them. Because the extreme suffering made that an acceptance based approach untenable, the patient's would say, you're not hearing my suffering, you're not going to help me change. I say, No, no, I'll help you change, I'll help you change. They say you're saying I'm wrong. You're saying I'd say no, I'm not saying that.

So that's sort of how it went.

So I came up with an approach really by accident just working with all these people, which ultimately got called dialectical.

Dialectical is walking the middle path in many ways, where it's a synthesis of change strategies, this on the part of the therapist, the change on the part of the therapist and acceptance strategies on the part of the therapist where that's my job.

The next problem though, was I was dealing with people had an extraordinarily low distress tolerance, and it made focusing on any one problem marry or one part of a problem or one disorder is you know, they have multiple disorders, or one syrupy topic impossible, with frequent crises, overtaking any ability for cities to sit down and work on change.

So we're constantly every topic you go through 10 topics because of avoidance and inability to tolerate.

So the solution there was to develop an approach that taught the patients in effect, acceptance skills, which included within their distress tolerance.

And there's a whole teaching that I do module called distress tolerance, how to tolerate both crises and not make them worse, but also how to radically accept a life that may not be the life you want. But that doesn't mean you had to be miserable your whole life, and change skills, which all came from behavior therapists stole every one of them.

But then I had another problem, which was the ever changing clinical presentation together with frequent crisis resulted in like, all the therapists being confused and chaotic, and therapy got very chaotic.

You've got to remember this is back in the 80s, when all the behavioral treatments were protocol based treatments, you do this, the first session is the second session is the third session, that was all of the only one treatment manual, literally one.

And that was a psychodynamically oriented, treatment manual. And that didn't do that. And so I modeled after that, I had patients who are meeting criteria both for loads of access one disorders, but also access to, although I didn't know that they were meeting criteria for that stuff at that time, because remember, I was focusing on suicide.

So my solution was to develop an approach to treatment that combined protocol based interventions. In other words, our all of our patients get skills training, which is this week, you get the skillet we're teaching this week, and next week, the one we're teaching next week, and combine that with a target based agenda, where the target Bay said, we're going to organize ourselves into this problem.

First, this problem. Second, this problem, life threatening behavior, of course, was first life threatening, at that time was suicide.

But since it's DBT, is now in so many prisons, you have to look at homicide, also as a life threatening behavior. So that brought those two things together. But the next problem that I had was therapists got emotionally dysregulated, treating these patients, and that led to excessive fear, excessive anger hostility, the therapist would get angry at the patients, they try to control the patient is very frightening to have a person could be dead at any moment.

And that you're out of you can't keep them from being fed. And so the therapist would then try to get in control, they would reject the patient or a taxi patient. This is group one of the therapist and group two therapists were the ones who had excessive empathy. And they would fall into the pool of despair with the client and just abandoned therapy all together, and everyone was sort of crying together. So I had to solve them.

And the way I started out was by defining a treatment team. As part of the treatment, I didn't really create a treatment team, I define a treatment team as part of the therapy because I am going to say something to you may not be aware of I don't think many people are.

To my knowledge, there's never been one single randomized clinical trial that has ever been conducted without a team as part of the therapy where the role of the team is to keep all the therapists doing the treatment that they are studying. And that clinical trial. As far as I know, there are two things that are always done assessment of outcomes.

And some group you have either one supervisor or a team that keeps you doing the therapy. And then we wonder why when you take a therapy to the community, it does not work. Why because we don't take the entire therapy to the community. We take all kinds of things, but we leave the team that keeps you doing the therapy and assessment out of was translated. So I just said to myself, fine. I'll just redefine therapy. And I will say if we did a team in the research, we'll call it team part of the therapy. Since I developed the therapy, you can't say you're doing the therapy if you don't have a team. And so that's essentially how that was dealt with in the role of the team is to treat the therapist and keep the therapist in the model.

Do I believe it's important all the time? Possibly not do I believe it's important with high risk out of control, difficult to treat? multi diagnostic suicidal patients? Yes, I do.

Therapists get burned out. The next problem to solve was that I wanted to get another grant to study what I was doing, but I couldn't get a grant was had a mental disorder. And I was doing suicide and I didn't have a mental disorder.

So I figured Okay, someone told me at a review, actually that I was studying borderline personality sorter my entire manual was written without the word borderline personality disorder and even want because I had never heard of the disorder.

So then I heard of a disorder, and I had to choose borderline personality disorder major depression. So since most of the people appear to meet criteria for borderline, I said, I do borderline and My, my advocate at the NIMH told me, I'll never forget it because he says, Okay, I'll go with borderline and not depression, he said, Marsha, you are making the biggest mistake of your entire career. on there. Forget, I said, Well, I'm doing it anyway.

So turned out not to be a huge mistake. But that was obviously a problem. That, but once I did that, I had to have a model of the disorder. And there wasn't any model that behaviors can live with.

Because of course, I found out at that point, but the only people who thought there was borderline personality or psychoanalysts, of course, good behaviors do not read psychoanalytic stuff. And when I read, it didn't make a lot of sense, because the model, the theory was so completely divergent from any theory that I could deal with, or what I think of is behavioral science.

So I but you do have to have a theory to do treatment, I have a theory of suicide. But now I need a series of board on and I need one capable of I have three criteria, only three, capable of guiding effective therapy has to be non pejorative, and inter inter compassion has to be compatible with current research data. So my theory does all of that because when the data changes, I just changed the theory. The basic model, which I fought all my career for this model, but I think I'm really winning the data, but I'm not going to give you data on it, because it's not part of this talk.

But I could, is borderline personality disorder is a pervasive regulation disorder, basically. And it's a pervasive disorder of emotion regulation system, where you look at emotion as a system not feeling but a total system, that is a full person response, but it's an emotional response.

And therefore it has action as part of that thought and physiology etc. And that borderline personality, sort of criteria and behaviors, if you actually look at them, and really study them function to regulate emotions has a number of suicidal behavior, for example, is extraordinarily effective at regulating emotion in the average person, I kid you not actually believes that they kill themselves, they will not feel as bad when they're dead.

I point out to my clients, there's no evidence of that particular point of view, or suicidal behaviors, a natural consequence of emotion dysregulation, you cannot have good relationships, if you are not regulated, if you hate a person one day, love them, the next want to go to a movie with one night don't want to go the next etc, etc.

In other words, relationships, a sense of self, most of the criteria they're in there have to do with the fundamentals of emotion.

So the solution was to develop a treatment of the pathogenesis. This, I have to say, the bio is a biological regulation disorder, I don't have the slightest doubt that there's the biological basis of this disorder.

And I don't believe you could create a borderline personality disorder without the biology, I could be wrong on that. But that's my, my experience and just watching all this time, combined with what I call the invalidating social environment. Now whether there are other characteristics of the environment. Besides In fact, validating covers a lot of territory.

So so far, I haven't had to change the theory. But that's because I changed the definition of invalidation as needed. But by by my real point is it so we need more research on that, that we're very, very, very limited on our research here.

But it's much like the Patterson like other research on the development of other disorders where this the same, and that therefore, the disorders transactional, transactional and dialectics are incompatible with blank just to be clear, because it is that that person a creates Person B, but Person B creates person. So it's not like the family creates the disorder.

The disorder creates the family and the family creates the disorder, the disorder, not the family, but the environment.

And so you'll have this transactional over time, creation of a disorder based on both characteristics, not necessarily the family, by the way.

So what did I add to standard kinds of behavior therapy, I'm just going to go because I'm looking at the time and realize I'm supposed to be finished in a minute.

So synthesis acceptance to change this remember, I started way back Well, most of the stuffs in there now but it wasn't principle based integration of evidence based treatments. I'm a big believer in bringing protocols into a principle based approach, as opposed to developing new therapies all the time.

Focus on insertion, behavior, staging, targeting by severity and threat. DBT is organized in stages of treatment based on control, suicide risk and assessment protocol. there's reason to believe now that this actually may be controlling a lot of our findings much to my disbelief, skill space to evidence based treatments. In other words, I stole all my skills Evidence Based treatments and mindfulness definition team is part of therapy and therapists self disclosure.

So what are the clinical trials say? There's really no one disagrees right now this treatments effective so that's not the fight at the moment so that you've lucify for years but it's no longer the fight.

Everybody agrees the treatment works. The question now is why it works.

We have nine randomized trials on borderline personality disorder DBT is going so far away from borderline now to other disorders. That is unclear that it's actually a treatment for borderline as it is a treatment for for substantial dysregulation.

Said for low level non serious stuff, you would never need DBT there plenty of good treatments for that. DBT is real strength is when you have really serious dysregulation, DBT works that are high risk, difficult to treat multiple diagnosis multiple stuff, that's when DBT sort of comes into its own otherwise it becomes something else. It we our data is that we just suicide attempt self entry, depression, hopelessness, anger, substance dependence, impulsiveness.

Now the psychoanalytic people fought for years with me saying that only treated symptoms, behaviors, of course, don't even use the construct, but nonetheless, so I used one of the psychoanalytic measures and made them promise that they would stop saying that if I got the findings, and I did, so it also changes, the interject, which is a psychoanalytic construct.

This is just a suicidal behavior. Just this is suicidal behavior plus self injury, the yellow is the people who didn't get DBT. And there, there been a lot of internal validity controls. For in these studies. This is set percent attempting suicide. Well, I want to talk about for a moment as what matters. In other words, do you need the whole treatment, the standard treatment is individual DBT plus skills training, plus phone calls to the individual therapist for coaching, behavioral coaching, plus a team. All the research I'm going to talk to you about now every single one of them have a team and they have coaching of some sort, but not necessarily with the individual therapists.

First thing I want, Oh, whoops. Okay, what happened was the slides didn't get put on here, I'm gonna tell you our data. This is a fabulous study with hitch which NIMH funded, this is very important. What we did was we did a study looking at DBT standard dialectical behavior therapy, what's a better B over here standard, but dialectical behavior therapy, sort of the ordinary one, and we took highly suicidal people to suicide attempt last year, and self injury or suicide attempt, and the eight weeks before they came in, and borderline personality, so most of them meet between eight and nine criteria.

Okay, most of them aren't working, etc. So we did that 1/3 of them went to standard to hit behavior therapy, that same stuff, they tell everyone they have to do to say they're doing DBT, the other one went in to a treatment where we wanted to see our skills, his skills training important.

Okay, so we gave one group the entire treatment, except they didn't get skills training, we gave them as psychoeducation activities group, like you get in communal health. So that's group two, we'll call that the the individual therapy only group because they didn't get sales and no skills group. And then we took another group, and we want to say is the individual DBT the way it is? Run? Is that important?

Maybe we could get rid of that and just give people skills training. So we did but because people were so highly suicidal, we've I thought I had to have somebody who could deal with crisis.

So we gave them intensive case management, Washington State case management treatment, man, it was important to get that part. Why should I say it was manualized. And we had a supervisor and they had a team. And but they had so they had skills training, case intensive case management. But the intensive case managers only took calls during office hours, this big ticket item, but we gave a really good suicide crisis management plan to the crisis clinic in Seattle, which is one of those phone lines that every town has.

Now, the other thing that happened in the study was I was very worried that I thought, I just can't let people die. Just because I want to do a study. So I gave the University of Washington, which is really DBT actually, risk assessment Management Protocol, which is a treatment now designed to get people to want to treat suicidal people by giving you something that says after a session, you check off whether you did it, and it makes you verify Do you have risk and should you think of hospitalization and but the way it's set up is it tells you every reason not to hospitalized, which you can check off to say, I didn't do it and I give you your reasons. I didn't do something else and I give you your reason.

So the whole thing sort of set up is to get therapists not to hospitalized and to do top of the line risk management, mainly because I didn't think that was why the treatment was working. If I'd known when I know now, I might not have done this. So what happened one, all the treatments were effective for reducing suicidal behavior, and they were equally effective, suggesting more than likely that the commonality across is what team and the Risk Management Protocol and some characteristics of having someone who could handle a crisis, okay, and sort of crisis management, it was top of the line first admit, however, when you look at mental health outcomes, something different happened.

This is the biggest one of my bigger life shocks, is what counts is the skills has a big effect on reducing depression, big effect on reducing anxiety in the individual therapy is useless.

For that not useless, but not as good. So in other words, since I was certain standard therapy would be the best, it never occurred to me to think anything else. But what the only place that's good is it has half the drop out. So if you want to keep people in therapy, it's great.

But why keep them in if you don't have to, if you can get them better without keeping them in as well look at this. So we're still analyzing the data.

The outcome of this is two things. One, the skills probably are critical. And you've heard this from your from our colleagues over here who said teach me how to live.

And that's exactly what it's designed for. There's now since they're designing it to go into eighth grade now, we've got the skills vol been translated down for five to seven year old five to 12 year olds, there's kindergarten, mindfulness training, now, we run friends and family skills training.

So I think that I underestimated this enormous value of the skills training. Now the other thing that we do in DBT, is we take them mostly taper them off psychotropic medication, and we keep them out of hospitals. And so it's possible that really, the treatment that we have for suicidal behavior has been reducing hospitalization, you know, there's not a single shred of evidence that any hospitalization ever kept anybody alive five extra minutes. And but we all hospitalized and off treatment, as usual, therapists are terrified not to housewives because they're afraid of being sued.

So we have this unbelievable fear, and our therapists. And when you can get therapists secure, which I obviously have been able to do, you can get that down.

Now, I'm not saying standard might not be better, in some ways, it's looking that during follow up, maybe you know, it's coming back to life again. But the point I'm making to you is that without rigorous research, that that focuses on component analysis and tearing treatments apart, we're not going to get anywhere, and horse race therapy isn't going to help us manage care should do help health insurance companies should do it.

But science has to figure out how to improve and make treatments better. I have a lot on training, but I'm gonna skip it because I think my time is up and I don't want to go over. But we're now looking at skills training is being used it treats treatment resistant depression, we have studies on eating disorder or skills training, and so it's going widely across. And so we need to look at that because even in our study with borderline drug addicts, what we found was that DBT was a little bit better on drugs, but it didn't. It is I don't know if it's worth of money on drugs.

But it's really better on depression and anxiety. So let me tell you one thing, future just one more last little thing.

Here's where we're not good at. Just to be clear, in case you thought we're good at everything. DBT standard DBT is really good at most disorders, except it's terrible anxiety disorders, unless you target anxiety disorders specifically. And DBT does that but only after you get suicidal behavior down.

So we're now at our lab, Melanie Harnett, a research scientists working with me. And Martin Bo has been in the Mannheim Institute of psychiatry in Germany, head of that we're collaborating and working on bringing prolonged exposure into DBT.

And  the data we have so far suggests that this is going to then we can move way up and deal with anxiety disorders. So that says also that we've got to have these principal based treatments and then the research on what how to bring a module in for this that in the other. So thank you. Thank you. Thank you very much. Thank you.

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