DBT and Psychiatry for Borderline; Equally Poor at 2 years, But Long-Term Remission is Common

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A prospective study in the American Journal of Psychiatry compares Dialectical Behavior Therapy (DBT) with psychiatric management for borderline personality disorder, founding that outcomes after two years were equivalent for both groups. Both groups exhibited poor functional outcome after 36 months (53% neither employed or in school, 39% receiving disability). However, an editorial in the same issue reports that clinicians over-react to the immediate clinical presentations of borderline, but that the long-term outcomes are positive nonetheless.

Abstract → 

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected].

18 COMMENTS

  1. ” …one important finding that replicates previous research is that participants continued to exhibit high levels of functional impairment. The effectiveness of adjunctive rehabilitation strategies to improve general functioning deserves additional study.”

    Life in the “fix me” workshop that does not have a concurrent skills, talents, gifts and abilities assessment and development focus will not ever produce a functional, employable robot – oops – human being.

    At some point in the mental health patient’s “career”, they need to stop being a “mental health patient” if they’re ever going to build and live a life – or else being a “mental health patient” IS their life and will always be. For those people, nothing else exists.

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    • “Life in the “fix me” workshop that does not have a concurrent skills, talents, gifts and abilities assessment and development focus will not ever produce a functional, employable robot – oops – human being.”

      I need to clarify.

      One of the biggest problems is not knowing what’s right & good about yourself. Those things often go overlooked, ignored and unknown (undiagnosed). The focus is strict; every flaw, every trauma and “boo-boo”, every “disease”. Find the natural right & good in a person and you just might actually save their life.

      Try this: when you “evaluate”, don’t devalue (validate negatives and invalidate positives). Value (validate positives). Can you understand that?

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      • Trauma informed care demands the use of “strength based” approaches, recognizing that the individual survivor of truama has a number of strengths to work with, otherwise they wouldn’t be a survivor! It sounds like this is what you’re talking about here. The wonderful “medical model” that the psychiatrists tought all of the time now seems to be based totally on deficits. No wonder nothing works, considering mental illness is a fabrication in the first place and then you “treat” it by looking at all the deficits. And we continue to ask what’s wrong with this picture?

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        • “Trauma informed care demands the use of “strength based” approaches, recognizing that the individual survivor of truama has a number of strengths to work with, otherwise they wouldn’t be a survivor!”

          That might suggest a value in trauma, because without it – we’d have no skill or ability? Or the only skills and abilities a person has is *because* of trauma?

          Actually, there is a value in survivor stories – we love them, to be honest.

          A “boo-boo” of a person will ALWAYS be a “boo-boo” if you don’t ever see their natural talent, skill, gift or ability which has NOTHING to do with their traumas or “disease” or the way they survived, healed, recovered.

          John Nash is *more* than a worthless schizo; he is a prized mathematician! See what I’m getting at?

          What if inside a person is a sleeping dream that they know nothing about, because they’re so preoccupied with (negatives) that they invest all of their resources in that? What if a good “treatment” is to invest at least *some* effort into looking for the sleeping dream?

          There are distinct states of being:

          Those who exist
          Those who survive
          Those who live

          Some might say that surviving *is* living. Maybe for some people, it is. My point is, if you aren’t oriented to “living”, you’ll ALWAYS be existing and surviving. If you aren’t looking for a right & good thing, you’ll always see the “bad & wrong”.

          What if someone like John Nash was prevented from being a prized mathematician, forced to spend his life “treating” his “disease”?

          How often does that happen to people – their lives are cut off and cut short – because they’re commanded to live in the “health care system” that is NEVER going to “help” them get in touch with that which is NOT diseased, broken or ailing.

          Stephen Hawking! Why does his SUCCESSFUL ability have NOTHING to do with his (negatives)?

          Huge Prather says, “see the sanity in people”.

          If someone has a “functional impairment” – look for the Stephen Hawking or John Nash in them, will you please? THANKS.

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    • It is a bit ridiculous. I was given the diagnosis at 16 or 17 years old. It was nothing other than adding insult to injury.

      There is an unspoken criminality to “borderline personality disorder”.

      Typo correction above: Hugh Prather, not Huge. haha

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        • Her book was an impossible read for me. Couldn’t get past the first pages.

          “she was quickly labelled ‘borderline personality disorder’ – a label, reflected in the findings of Beyond Trauma, which some, though not all, mental health professionals, seem to use as a way of saying ‘we have no idea what to do with this person’ or ‘untreatable’ and pass them on to yet another service which responds in a similar way.”

          The case example where this statement is found is in excess of horrific, but it goes right back to my original point which is that there HAS to come a time when people find *something* in themselves that is NOT trauma and has nothing to do with their trauma, and that focusing on and building on that could be, for some, the very thing that truly saves their life.

          If borderline equals “we have no idea what to do with this person” – now you have an idea.

          “Women, and children for that matter, want and need access to a range of resources at different points in their struggles to escape from or deal with the consequences of sexual violence.” To *escape from*.

          It’s almost like saying that once the trauma has impacted, TWO new lives have to begin:

          1. care & treatment
          2. an entirely new life

          Care and treatment should NOT be the person’s only lifestyle and orientation.

          If the person always wanted to learn to play the guitar, learn how to speak french, had a dream of becoming a veterinarian … If they have a natural skill, gift, talent or ability …

          Incorporating those things *immediately* into the care & treatment plan will allow them to make a connection that will help to “unsolidify” being condemned into the trauma and near-endless treatment of it.

          I feel like I’m not expressing my concept sufficiently. Sigh…

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          • You have expressed yourself perfectly! I totally get what you’re saying. Trauma is one part of someone’s history or story but they are not their trauma, they are so much more than that.

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  2. Hi Kermit,
    I’m wondering why M.I.A. is reporting ‘news’ of a study by Joel Paris (a psychiatrist who has built his entire career on a misogynistic hate label that pathologises women in distress) giving commentary on Linehan’s money spinner DBT (a psychologist/Uncle Tom who has built her entire career throwing survivors under the bus). It seems a little out of keeping with the ethos of the site. Unless of course validity is being given to the ‘diagnosis’ (label).

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    • I see my job as being to post things that stimulate thought and debate. My influence extends to what it is that I find interesting to stimulate thought and debate about. The fact that I post something has more to do with thinking that there’s something worth thinking about, than what I might believe about the “validity” of any one construct that the item is based on. Often, when I post things, I actually think that the construct is invalid, and that an honest reading of the article cannot help but leave an observant reader to that conclusion. Almost always, there are astute commenters who get the ball over the goal line in this regard. Occasionally they might assume one way or another about what I believe, which is ok; it’s better than me being too explicit about what I believe. I think it’s my job to keep any overt beliefs I may have out of it, and instead try to keep coming up with grist for the conversation mill. As Clinton once said about his detractors on the other side of the political aisle; they don’t want you to talk about it, because when you talk about, we win. I like to believe that if the conversation is open enough, and full enough, it will end up where I happen to believe it should. On MIA, I’ve rarely been disappointed.

      As long, of course, as the conversation doesn’t get shut down by people being too reactive, and demanding expressions of fealty to one ideology or another. That’s the death knell for a living conversation. That’s where madness begins, in my opinion.

      I will say, though, that one thing I found interesting about the article is that, whatever approach one is using to approach the situation in which someone is being referred to as “borderline,” one can expect that a few years later the person has a reasonable expectation of the situation being resolved. This squares with the research I’m aware of that it’s the overreaction to the situation that causes more harm; that as long as people get through it, they generally go on to do well. My take=away is; then try not to over-react, and try not to do anything that is going to just further damage a person who has been injured.

      So; no. I guess I don’t accept the “validity” of the label. And that’s why I put the article up. So that perceptive people such as yourself would point out its flaws.

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    • Isis Thank you so much for this comment and your perspective. One of my not so great therapist against the psych doc advice advise to do a DBT day treatment program in the summer when all the kids were home.I hated hated hated it. I found it to be simplistic daycare and of no value. I tried to tell my husband and family but they just didn’t get it. How can one suddenly become borderline when they have been functioning above and beyond average? Trauma renders everyone in need of some sort of support. However in today’s’ mental health system the support and understanding of trauma just isn’t there.
      I am glad I really was on target with my thoughts and frustrations. What a waste of money.
      See it was so worth posting this. I now finally have validation that Linehan is not the great and good as some people think.
      Thanks Kermit. And I do like dialogue that is nonreactive though if one is triggered or feels strongly it is hard not to speak out and not just take a breath.
      Maybe a delay one could use for 8 hours then a reread and then a posting!
      Trauma informed posting! Maybe?

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  3. This hit the spot for me; this is what I have needed all these years instead of drugs, labels and med checks.

    “It’s almost like saying that once the trauma has impacted, TWO new lives have to begin:

    1. care & treatment 2. an entirely new life

    Care and treatment should NOT be the person’s only lifestyle and orientation.

    If the person always wanted to learn to play the guitar, learn how to speak french, had a dream of becoming a veterinarian … If they have a natural skill, gift, talent or ability …

    Incorporating those things *immediately* into the care & treatment plan will allow them to make a connection that will help to “unsolidify” being condemned into the trauma and near-endless treatment of it.” mjk

    I hope you are well, mjk. Your input on this site is sorely missed.

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