Evaluation of inpatient Dialectical-Behavioral Therapy forBorderline Personality Disorder Ð a prospective studyMartin Bohus*, Brigitte Haaf, Christian Stiglmayr, Ulrike Pohl, Renate BoÈhme,Marsha LinehanDepartment of Psychiatry, University of Freiburg, Hauptstrasse 5, 79104 Freiburg im Breisgau, GermanyReceived 19 April 1999AbstractDialectical-Behavioral Therapy for Borderline Personality Disorder (DBT) developed by M. Linehanis speci®cally designed for the outpatient treatment of chronically suicidal patients with borderlinepersonality disorder. Research on DBT therapy, its course and its results has focused to date ontreatments in an outpatient setting.Hypothesizing that the course of therapy could be accelerated and improved by an inpatient setting atthe beginning of outpatient DBT, we developed a treatment program of inpatient therapy for thispatient group according to the guidelines of DBT. It consists of a three-month inpatient treatment priorto long-term outpatient therapy. In this pilot study 24 female patients were compared at admission tothe hospital, and at one month after discharge with respect to psychopathology and frequency of self-injuries. Signi®cant improvements in ratings of depression, dissociation, anxiety and global stress werefound. A highly signi®cant decrease in the number of parasuicidal acts was also reported. Analysis ofthe average eect sizes shows a strong eect which prompts the development of a randomized controlleddesign. 7 2000 Elsevier Science Ltd. All rights reserved.1. IntroductionDBT is a cognitive-behavioral therapy, developed by M. Linehan originally for theoutpatient treatment of chronically suicidal patients with borderline personality disorder. AsBehaviour Research and Therapy 38 (2000) 875±8870005-7967/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved.PII: S 0005 - 7 9 6 7 ( 9 9) 00 10 3- 5www.elsevier.com/locate/brat* Corresponding author. Tel.: +49-761-270-6822; fax: +49-761-270-6619.E-mail address: [email protected] (M. Bohus).with standard behavior therapies, DBT presumes that attention to both skills acquisition andbehavioral motivation is essential for change. Taking into account the characteristic features ofpatients with borderline personality disorder, several modi®cations to standard behavioraltherapy were made (Linehan, 1993). First, a number of treatment strategies that re¯ectacceptance and validation of the patients' current capacities and behavioral functioning weregathered and added to the treatment. The dialectical emphasis of the treatment ensures thebalance of acceptance and change within the treatment as a whole and within each individualinteraction. Second, treatment of the patient was split into three components: one that focusesprimarily on skill acquisition, one that focuses primarily on motivational issues and skillsstrengthening, and one designed explicitly to foster generalization of skills to everyday lifeoutside the treatment context. Third, a consultation-team-meeting with speci®c guidelines forkeeping the therapist within the treatment frame was added. In standard outpatient DBT,treatment consists of structured psychosocial individual or group therapy (for skills training),individual psychotherapy (addressing motivational and skills strengthening), telephone contactwith the individual therapist (addressing generalization), and peer supervision meetings (tomonitor the therapist). DBT is further characterized by a clear hierarchy of treatment targets(the behavior identi®ed for change), and a set of treatment strategy groups (tactics andprocedures of the therapist used to achieve change). In contrast to many behavioralapproaches, DBT also places great emphasis on the therapeutic relationship.Reliable data are available for an outpatient treatment period of one year. During thisperiod and in the framework of a controlled randomized study, DBT proved to be superiorwith regard to several factors compared to experienced therapists following an unspeci®ed`treatment as usual` approach. Frequency and severity of parasuicidal acts were signi®cantlyreduced in the group of patients treated according to DBT; the same is true for thefrequency of premature treatment termination, as well as for the frequency and length ofstays in psychiatric hospitals (Linehan, Armstrong, Suarez, Allmon & Heard, 1991;Linehan, Heard & Armstrong, 1993). Meanwhile, data from replication studies are available(Koons, 1998).As discussed above, DBT was originally developed as a form of outpatient therapy andemphasizes the potential risk of nonspeci®c inpatient treatment. One of the main risk factorsseems to be the (unintended) reinforcement of dysfunctional patterns of behavior such as self-injury, suicide attempts, and/or suicide communications by the therapeutic milieu. This notionis similar to the views of numerous depth psychology-oriented authors who particularlyemphasize the distinct tendency towards `regression' on the part of borderline inpatients, aswell as `manipulatory behavior' and dicult transference and counter-transference phenomena.A deterioration of the symptoms and a tendency towards long-term hospitalization are themost frequent results (Nurnberg & Suh, 1978; Rosenbluth & Silver, 1992).Nonetheless, several reasons speak for the development of a speci®c module of inpatienttreatment according to the guidelines of DBT. First, the number of patients who meet thecriteria for borderline personality disorder is estimated at 30% of all inpatients worldwidewho are treated for personality disorders, thus ranking in ®rst place (Loranger et al., 1994).Second, the probability of requiring psychiatric or psychosomatic inpatient treatment atsome point in one's lifetime is unusually great for persons with a borderline disorder. Westudied a representative population of 40 female patients in Germany with borderlineM. Bohus et al. / Behaviour Research and Therapy 38 (2000) 875±887876personality disorder according to DSM-IV and DIB-R (Gunderson, Kolb & Austin, 1981)and discovered this to be the case for 84% of these patients. Following initialhospitalization, 80% of them returned annually for an average annual inpatient stay of 70days (Jerschke, Meixner, Richter & Bohus, 1998). On the basis of these ®ndings, inpatientstays seem to increase the probability of readmission or at least they do not contributesubstantially to outpatient stabilization. A third argument does not rely
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