Borderline Personality Disorder is characterized by distinct features of hypersensitivity to rejection and fearful preoccupation with expected abandonment (5th ed.; DSM-5; American Psychiatric Association). Patients suffer a prolonged period of low self-worth, which could only be resolved through connection with a caregiver that usually requires unrealistic availability. While BPD has long been considered a chronic disorder that is mostly untreatable, data in recent studies indicated a high remission rate for BPD. Remission was defined as no more than two diagnostic criteria being met for at least 12 months, and a low relapse rate (about 15%) (Gunderson, 2011). This project intends to offer a brief overview of several empirically supported psychotherapies for BPD and analyze in detail one of the primary treatments. It’s worth noticing that impulsivity and the exaggerated fear of rejection sometimes lead the patients to attempt self-destructive behaviors. Emotional dysregulation could also severely disable patients from even starting the treatment. The importance of medication in adjuncts to psychotherapeutic treatment therefore shall not be underestimated despite the exclusive focus on psychotherapies in this project.
Major psychotherapies for BPD include (Gunderson, 2011) Dialectical Behavior Therapy (DBT), Mentalization-Based Therapy (MBT), and Transference-focused Psychotherapy (TFP). DPT derived from cognitive behavioral therapy but was specifically tailored towards the needs of BPD patients. It was customized with the incorporation of validation and mindfulness strategies that focuses directly on improving emotional regulation skills through group sessions. It has been empirically supported as the easiest to learn among psychotherapies with therapists being resources of consistent and extensive availability. During MBT, on the other hand, therapists adopt a “not-knowing” stance while insisting that the patient examine and label his or her own experiences and those of others (i.e mentalization process). This treatment arose from psychodynamic tradition but was similarly tailored for BPD in particular by laying an emphasis on emotional labeling in interpersonal contexts. MBT also differentiates from DBT in that the latter considers the reduction of self-destructive behaviors as one of its major goals during therapy and endorses explicit instruction to control suicidal and self-harm impulses whereas MBT achieved the same goal in a comparatively implicit way (Barnicot & Crawford, 2019). It’s therefore debatable whether the enrollment of MBT is itself a more selective process given admitted patients’ higher emotional and cognitive capacity in processing treatment materials. In addition to more widely practiced MBT and DBT, TFP came from a psychoanalysis tradition, which usually involves a twice-weekly individual therapy including interpretation of motives and feelings unknown to the patient and keeps a focus on the patient’s misunderstanding of others, especially of the therapists, thus known as transferences. Not much research has yielded supportive evidence for this treatment and the operation of the treatment itself is hard to manage as compared to the aforementioned two treatments.
Given the empirical success and prevalence of DBT in alleviating symptoms of BPD (Cristea et al., 2017), I am very interested in looking specifically into the individual components of the treatment as well as the potential challenges of implementation. DBT is a complex evidence-based psychotherapy with four treatment modes including weekly skills groups, individual therapy, therapists consultation team, and phone coaching. The weekly skills groups generally take place in a classroom setting, in which participants gather in groups to acquire skill sets mentioned in the previous paragraph. Following the skills groups, individual therapy encourages participants to make use of the skill sets acquired during group sessions in real life when they encounter rejection or separation that would usually result in severe distress if not anger. The therapists consultation team assists providers in doing DBT with a weekly affirmation of the following steps and prevention of practitioner burnouts. Phone coaching, based on prior agreement with the therapist, could occur at any time of the day based on the need of the client. The primary function of the last mode is to offer clients guidance to generalize acquired skills, which should in turn reduce suicidal and ineffective behaviors at moments of distress. Phone coaching, particularly its after hour functioning, is unique and helpful for it essentially serves as an extra channel of connection building, through which clients with BPD are reassured of their available support resources. Given the disabling dependent attachment that interferes with patients’ interpersonal relationships, clients with BPD could largely benefit from phone coaching as a pathway to regain independence. However, few implementations of DBT adopted all four modes of treatment. According to a 2019 report by Landes et al., the skills group was the most implemented treatment mode in Veterans Affairs settings, followed by individual therapies. Phone coaching listed the third followed by the therapist consultation team. Among the 35 sites that endorsed phone coaching, only four provided 24/7 phone coaching. Major challenges for the implementation of phone coaching included the absence of tools and policies, lack of compensation/fundings for phone coaching, clinicians’ unwillingness for providing the service, and the lack of consistent program and leadership support.
Consequential to the low rate of implementation, scant research focusing on the effectiveness of this treatment mode has been conducted. Oliveira and Rizvi (2018) examined the relationship between frequency of phone service use and demographic factors, baseline severity, suicidal behaviors, and therapeutic alliance. Results suggested that while BPD severity, a recent history of self-harm, and therapeutic alliance shared no significant correlation with the frequency of phone calls, lower income was significantly associated with higher frequency of phone service use. One possible explanation could be the lack of additional supportive networks including the limited awareness of local non-profit support organizations. Lower income families are also more likely to juggle multiple jobs, which leads to reduced availability around patients with BPD. Limited transportation and spare time also make phone calls more accessible compared to an in-personal meeting that more affluent clients might prefer.
The 2016 study by Rizvi, Hughes, and Thomas, instead of directly using phone calls as means of coaching, employed modern technology (i.e. phone app DBT Coach) to achieve the same after hour function without the restraint of staff shortage. Given that smartphones are becoming more and more prevalent in modern lives, personal devices became immediate sites of skill refreshing for BPD patients, particularly in threatening situations. Results from this 2016 study suggested that among the 16 patients, the frequency of using DBT Coach varied significantly from two to 107 times during a nine-month trial. While the overall frequency was not considered high, patients’ individual ratings suggested a decrease in distress and the urge to self-harm at the moment. Additionally, though the frequency of app use was not significantly correlated with treatment outcome, there is a significant correlation between greater frequency of non-suicidal self-injury and the frequency of service use. It’s therefore reasonable to infer that DBT coach and similar phone apps might have the potential to address in-the-moment suicidal and self-harm threat of patients with BPD in a similar manner relative to phone coaching.
App coaching, while alleviating challenges of staff shortage and presumably related funding issues faced by conventional phone coaching, is not a solution with no limitations. The prerequisite of its effectiveness is very closely tied to the patients’ socioeconomic status and preference for using technology. Patients from lower income backgrounds might not have the financial capacity to purchase a smartphone on which they could install the phone app, thus relying more on phone coaching for explicit guidance and after hour help. While DBT Coach provided at the moment support, the privilege of making use of smartphones does not extend to those who might have relatively lower IQ scores or are uncomfortable working with technology. Additionally, phone coaching and app coaching provided fundamentally different forms of service. While patients interact directly with a professional during phone coaching at a given moment of crisis, DBT Coach provides a visual list for crisis survival, from which patients choose and make use of the tool like a reference booklet. App coaching should thus not be understood as an equivalent to phone coaching but rather a different entity that attunes to clients’ identity and preferences and might even be coupled with phone coaching if needed. However, it is possible that skill coaching regardless of the format affects BPD patients in a positive way. To explore the mechanism behind skill coaching, I look into another study (Roman, 2017) focusing on the same app DBT Coach. The study hypothesized that on days with the help of skill coaching (i.e. app coaching and/or phone coaching), patients would have increased self-perceived self-efficacy as compared to the days when the app was not used.
Self-efficacy, defined as an individual’s belief in his/her ability to deal with a given situation through the execution of a series of actions, is a potential deficit among the population with BPD (Roman, 2017). The unhealthy boundary setting and the catastrophic thinking after rejection signify to some extent lowered self-efficacy in accomplishing tasks in life by oneself. The real-life application of emotional regulation and social interaction required not only the mastery of the aforementioned skills but also the confidence that one is equipped with effective skills to combat a difficult situation by oneself. DBT Coach might have allowed patients to gradually ease into the real-world application of skill sets through step-by-step practices that take form in quizzes, material readings, and role-playing. More generally, skill coaching allows patients to receive guidance and act accordingly on one’s own, thus experiencing the success that accompanies personal attempt. Roman operationalized self-efficacy through the ratings of skill effectiveness and the results showed an interesting deviation from the initial hypothesis. Among the four cases of patients with BPD, one participant gave higher skills effectiveness rating when using some type of skills coaching than no coaching while two others report the opposite. The final participant reported the lowest skills effectiveness on days using DBT Coach, with phone coaching being the highest rating. The variation in personal interpretation suggested alternative interpretation for self-efficacy in terms of using skill coaching resources. It is possible that patients made use of coaching resources on more “difficult” days when they faced more challenging issues, consequently resulting in the perception of lowered skill effectiveness. It’s equally possible that patients adopted varied interpretations of external assistance. Regardless of environmental factors (e.g. the challenging nature of the crisis), patients might interpret help-seeking as evidence against their independence and adequacy. Differences also existed in patients’ reactions towards phone coaching with a professional and the self-coaching app DBT Coach. The interactive nature of a patient-therapist conversation and the mere acknowledgment that the help came from a professional might alter the rating of skill effectiveness. The result of the study pointed towards the importance of reframing help-seeking behaviors in group or individual therapy sessions. Patients should be encouraged and informed to avoid internalizing help-seeking as proof of personal deficiency. Appropriate help-seeking and implementation of solutions to problems can instead be reframed as independent initiative taking. Mindfulness techniques can aid the reframing of such a mindset by encouraging clients to tune in the now-and-here. Patients shall try and practice neutral observation of the challenges involved in a given situation without making judgmental inferences about their own capability.
Despite DBT’s comprehensive and well-developed procedures, a study comparing the efficacy of DBT and MBT found a higher initial drop-out rate among patients in DBT (Barnicot & Crawford, 2019). Though there existed no significant difference between treatment dropout after adjusting for relevant confounds including age, baseline severity, and emotional dysregulation, such phenomenon required professional attention given that the effect of a treatment could be maximized only when patients are physically and emotionally capable of being present in the space. Little research has identified effective ways to improve the completion rate of treatments, particularly when patients of personality disorder experience difficulties with trust and conflict resolution. Chalker et al. (2016) found that increased contact with the therapist via phone coaching was associated with decreased odds of premature dropout, increased client and therapist satisfaction, and increased change of psychological symptoms. While the research suggested the significance of phone coaching in improving treatment completion, the experimental design did not differentiate phone coaching after and during work hours. Additionally, there was no significant association between the volume of phone coaching and emotion regulation despite the existence of a mild improvement in psychological symptoms. Frequency of phone coaching might have a threshold based correlation with skill acquisition for on the more extreme end of phone coaching service use, help-seeking became a form of personal life violation for the clinicians, partially explaining the reluctance of therapists working on phone coaching.
It’s however promising that, to address such challenges with regard to personal boundaries of therapists, multiple articles have been written with the intention of pushing forward a comprehensive guideline for phone coaching. Training for DBT (Chapman, 2019) included detailed information about the function of after-hour phone coaching, the brief nature of calls, information on how frequently calls generally occurred and ways to set personal boundaries for the practitioners. In addition to the publishing of comprehensive instruction, Landes et al. (2019) listed other possibilities in encouraging phone coaching implementation including the development of a clinical protocol for clinicians to use personal cell phones in response to the lack of tools, time-off rewards to compensate therapists and field education of the benefits and core principles of phone coaching to therapists to encourage participation. It’s exciting to see the growing attention of the field on phone coaching and the emerging policies in favor of its implementation. However, to achieve the optimal outcome for the patients in therapies, it’s crucial for the refinement of policy to couple with academic research. Thus, the effectiveness of after-hour phone coaching in trust-building as well as the way in which it could potentially increase the completion rate of DBT should be included in the agenda of further investigation.
In conclusion, the current project attempted to read closer into phone coaching and its variation as a crucial element of DBT. Based on both empirical research and literature reviews, I identify the following three aspects as crucial to the bettering of phone coaching in the future. First, forms of skill coaching grow in accordance with the development of smartphone technology. Yet, the implementation should be tailored towards individual preferences and the socioeconomic status of the patients so that this treatment mode generates more benefits than burdens. Second, it’s important to reframe the patients’ mindset around help-seeking as not an intrinsic inadequacy and dependency but rather a common difficulty shared by people with the same condition. Coaching as the language used in the name of this treatment mode is itself an indicator that practitioners shall try to situate themselves as partners with the clients in retrieving agency that has always been located internally in the client. By integrating this reframing practice in the group and individual sessions, therapists invite the patients to think of external help as resources allowing future independence rather than disapproval of their growth. Finally, future research should focus on the correlation between phone coaching and treatment completion rate in BPD, particularly the significance of after-hour phone coaching service and the role of phone coaching in mediating emotion regulation so as to keep on informing the refinement of policy regarding phone coaching implementation.
Work Cited: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Barnicot, K., & Crawford, M. (2019). Dialectical behavior therapy vs Mentalisation-based therapy for borderline personality disorder. Psychological Medicine, 49(12), 2060-2068. http://dx.doi.org/10.1017/S0033291718002878
Chalker, S. A., Carmel, A., Atkins, D. C., Landes, S. J., Kerbrat, A. H., & Comtois, K. A. (2015). Examining challenging behaviors of clients with borderline personality disorder. Behaviour Research and Therapy, 75, 11-19. http://dx.doi.org.libproxy.vassar.edu/10.1016/j.brat.2015.10.003
Chapman, A. L. (2019). Phone coaching in dialectical behavior therapy. The Guilford Press.
Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74(4), 319-328. http://dx.doi:10.1001/jamapsychiatry.2016.4287
Gunderson, J. G. (2011). Borderline personality disorder. The New England Journal of Medicine, 364(21), 2037-2042. http://dx.doi.org.libproxy.vassar.edu/10.1056/NEJMcp1007358
Landes, S. J., Matthieu, M. M., Smith, B. N., McBain, S. A., & Ray, E. S. (2019). Challenges and potential solutions to implementing phone coaching in dialectical behavior therapy. Cognitive and Behavioral Practice. http://dx.doi.org.libproxy.vassar.edu/10.1016/j.cbpra.2019.10.005
Oliveira, P. N., & Rizvi, S. L. (2018). Phone coaching in dialectical behavior therapy: Frequency and relationship to client variables. Cognitive Behaviour Therapy, 47(5), 383-396. http://dx.doi.org/10.1080/16506073.2018.1437469
Rizvi, S. L., Hughes, C. D., & Thomas, M. C. (2016). The DBT coach mobile application as an adjunct to treatment for suicidal and self-injuring individuals with borderline personality disorder: A preliminary evaluation and challenges to client utilization. Psychological Services, 13(4), 380-388. http://dx.doi.org/10.1037/ser0000100
Roman, K. M. (2017). Self-efficacy and its relation to skills coaching in the context of dialectical behavior therapy augmented with a mobile phone app. ProQuest. http://libproxy.vassar.edu/login?url=https://search-proquest-com.libproxy.vassar.edu/docview/1870296498?accountid=14824
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