18b
Nicholas Salsman and Laurence Y. Katz
The chapter from Fonagy, Bateman, Luyten, Allison, and Campbell (this volume) on psychoanalytic/psychodynamic approaches to personality disorder and their description of mentalization-based treatment (MBT) delineates a number of striking similarities with the principles of dialectical behavior therapy (DBT, Linehan, 1993). These two treatments are very different and there is no evidence suggesting equivalence, but the common principles may be indicative of areas of shared understanding of best practices in the treatment of individuals with borderline personality disorder (BPD). The differences between the two treatments may also illuminate empirical questions needing further exploration. The amassed empirical support for each of these approaches reflects that these treatments can work for individuals with BPD. Examining the commonalities and differences among them may offer ideas about critical elements of any effective treatment of BPD.
Common Structural Properties of MBT and DBT
Fonagy et al. describe nine structural properties of MBT, which have significant overlap with structural properties of DBT. The first principle describes maintaining client engagement through the use of a combination of validation with “the need to address behaviors that interfere with therapy such as alcohol or substance abuse or self-harm” (p. 434 in the previous chapter). In their MBT manual, Bateman and Fonagy (2016) elucidate how from the initial sessions, the therapist and client work together to agree to reduce self-harm and consistently target this behavior through analysis of self-harm behavior and generation of ways to change. This first structural property of MBT suggests that it is important for treatment providers to combine two distinct approaches. DBT practitioners strive to continually synthesize acceptance and change. Treatment providers are expected to synthesize these two distinct approaches in every moment of the treatment. On the acceptance side DBT practitioners utilize validation, teach and practice acceptance skills, and employ mindfulness. These acceptance-based techniques are balanced with change-focused interventions, such as change oriented skills, contingency management, and cognitive modification, to help clients change their destructive behaviors. Both treatments emphasize the importance of validating clients’ experiences while also helping them to change critical actions.
The second structural property of MBT is to have a model of pathology that is described to the patient. Adherents of DBT follow this principle as well through the utilization of the biosocial model (see Crowell, Beauchaine, & Linehan, 2009 for an explanation of this theory). In DBT, this model, based in research, guides therapist action, helps to remove blame and judgment, and increases the likelihood of validation of self and others. The biosocial model describes how problems like the symptoms of BPD develop as an individual’s biologically based emotional vulnerability transacts with an invalidating environment, i.e., the person does the best that they can to adapt within the environment. Similarly, Fonagy et al. state that from the MBT perspective, “personality disorders are not seen as disorders of personality, but as understandable adaptations to the environment, even if they ultimately are counterproductive in terms of the functioning of the individual” (p. 432 in the previous chapter). Both of these models offer validating and non-judgmental explanations for the problems experienced by people with BPD, which effectively inform treatment.
The third structural property of MBT described by the authors is that therapists actively develop a strong therapeutic relationship with validation. The relationship between therapist and a chronically suicidal client in DBT is considered critical. Linehan (1993, p. 154) states, “Indeed, the strength of the relationship is what keeps such a patient (and often the therapist as well) in the therapy. At times, if all else fails, the strength of the relationship will keep a patient alive during a crisis.” Validation strategies are considered to be a critical set of strategies that are used consistently throughout DBT to engage the client, maintain the relationship, and re-regulate emotion. There is an assumption in DBT that the therapeutic relationship is a real relationship between equals. Linehan (1997) describes six levels of validation, with the highest level being radical genuineness, where the therapist engages with the client as their genuine self, not adopting a persona or playing a role with insincere mannerisms of how a therapist should act. Fonagy et al. (this volume) list the sixth structural property of MBT as, “adoption of a structure of treatment that suggests increased activity, proactivity, and self-agency (avoiding the use of an expert stance, and encouraging collaboration with the patient and a ‘sit side-by-side’ therapeutic attitude)” (p. 434 in the previous chapter). The importance of a collaborative relationship built with validation highlights that having a human-to-human connection may be a critical element of treatment. The seventh structural property of MBT describes the importance of a robust relationship between therapist and client. DBT therapists are called to explicitly target behaviors of the client or therapist that interfere with the treatment. This principle creates a structure that is explicitly designed to foster a robust relationship. Thus, both MBT and DBT place immense importance on actively building a therapeutic relationship that is genuine, validating, and able to withstand significant tension.
The fourth structural property of MBT is, “a focus on emotion processing and the connection between actions and feelings” and the fifth structural property is “a genuine inquiry into patients’ mental states (behavioral analysis, clarification, confrontation)” (Fonagy et al., this volume, p. 434 in the previous chapter). DBT is an emotion-focused treatment and it conceptualizes BPD as a disorder of emotion regulation. The treatment teaches individuals to practice experiencing their emotions without avoidance or holding on to their emotions. Actions such as self-injury and suicidal behaviors are assessed through a process of behavioral chain analysis and these behaviors and their determinants are understood through examining links consisting of emotions, thoughts, actions, physical sensations, and environmental events. Through the therapist and client developing a mutual understanding of the behaviors and their determinants, solutions specifically targeting problematic links can be developed. The centrality of emotions and systematic analysis of how actions, internal experiences and the environment transact are principles that are shared by both treatments.
The eighth structural property of MBT described by the authors is that treatment providers structure their interventions based on a manual and supervision is used to sustain adherence to the manual. The ninth structural property of MBT is that everyone involved with the therapeutic milieu is committed to MBT and strengthens validation of the patient’s emotions and thoughts. These structural properties highlight a team approach to MBT. In DBT, all DBT providers including individual therapists and group leaders meet weekly for a consultation team. This consultation team is set up to accomplish two main goals: (1) to monitor and maintain the adherence of the members of the team to the DBT principles described by Linehan (1993, 2015) and (2) to enhance therapist motivation. The team approach in DBT is sometimes thought of as a community of providers treating a community of clients. In the weekly team meeting, providers remind themselves of the mutual agreements of the team members, including an agreement called the phenomenological empathy agreement, where therapists are called to understand patients’ and each other’s behaviors from a non-pejorative and validating perspective. Both MBT and DBT build structures into treatment in order to increase adherence to the treatment principles and utilize a community of providers to reinforce the principles with clients.
Skills Training in the Treatment of Individuals with Personality Disorders
The authors cite Fonagy and Luyten (2016) in hypothesizing about three communication systems that are present in effective treatments for individuals with personality disorders. These three systems are “the teaching and learning of content,” “the re-emergence of robust mentalizing,” and “the re-emergence of social learning.” These systems point to the central importance of skills training in effective treatment. Language, methodology, and content of skills training differ greatly in MBT and DBT and these differences may point to empirical questions about the impact of different skills and the need to study mechanisms of change in these treatments to inform necessary treatment components. Nonetheless, the underlying principle of engaging in skills training as a critical part of treatment is present in both therapies. Linehan (2015) describes three phases of learning in skills training: knowledge acquisition, skills strengthening, and skills generalization. These three phases have some striking parallels with the three communication systems. Knowledge acquisition involves using didactic strategies to convey the information that is a necessary, but not sufficient, prerequisite of practicing the skills. This phase has parallels to the system of “teaching and learning content.” The second phase of learning, skills strengthening, involves practicing the skills in order to translate knowledge into action. This practice is necessary to allow skills to become more robust, as indicated by Fonagy et al. (this volume). Bateman and Fonagy (2016) indicate that the setting of therapy serves the function of increasing skills. The third phase of learning, skills generalization, involves learning to apply skills in all relevant contexts. Fonagy et al. (this volume) say of the third communication system, “This allows the patient to apply his/her new mentalizing and communicative capabilities to wider social encounters, outside the consulting room” (p. 436 in the previous chapter). Thus, what clients learn in treatment must then be generalized to life outside of treatment.
The Role of Insight in MBT and DBT
In both MBT and DBT, insight is not prioritized as an outcome that needs to come first. Fonagy et al. (this volume) state:
In MBT, the aim and the actual outcome of an intervention on the patient’s immediate emotional and cognitive state is thought to be more important than the insight gained from interpreting particular defenses or understanding aspects of the transference relationship, although of course such insights emerge during treatment. (p. 434 in the previous chapter)
In DBT, an emphasis often is placed first on changing behavior and then having insight follow. In response to criticism that DBT focuses only on symptoms and does not treat underlying causes, Bedics, Atkins, Comtois, and Linehan (2012) conducted an analysis to examine if and how DBT produces intra-psychic change in comparison to treatment by non-behavioral experts in the context of a randomized controlled trial with suicidal individuals with BPD. Their analyses revealed that individuals in DBT had significantly greater increases on the introject affiliation measure from Lorna Benjamin’s Structural Analysis of Social Behavior (Benjamin, 1974) than individuals in treatment by non-behavioral experts. These analyses revealed that in DBT, although emphasis may often be placed first on behavioral change, the process of change leads to significant changes in how people perceive themselves. This de-emphasis of insight as a primary agent of change then frees the therapeutic dyad to prioritize elements of treatment such as emotional experiencing. As Fonagy et al (this volume) state, when there are breaks in mentalizing, the therapist attends to those moments and, “explores the current emotional context in the session by identifying the momentary affective state between patient and therapist” (p. 435 in the previous chapter).
The Importance of Flexibility among Treatment Providers
In MBT and DBT emphasis is placed on adherence to the principles of the treatment manuals, and nonetheless both treatments emphasize the need for flexible application of these principles. In principle-based treatment, there are few if any situations where there is only one correct intervention. Thus, practitioners of these principle-based treatments should be able to apply principles without rigidity. Fonagy et al. (this volume) state, “The psychoanalytic approach encompasses a uniquely sophisticated model of the mind, which, if applied with intellectual openness rather than rigid orthodoxy, can tolerate the categorical complexity of personality-disordered states” (p. 436 in the previous chapter). In DBT, flexibility is critical in the delivery of treatment. Responding in the moment to a client who is struggling with intense emotion dysregulation requires mindfulness on the part of the therapist and effective problem-solving. In describing dialectical strategies in DBT using the metaphor of ballroom dancing, Linehan (1993) states:
“Dancing” with the patient often requires the therapist to move quickly from strategy to strategy, alternating acceptance with change, control with letting go, confrontation with support, the carrot with the stick, a hard edge with softness, and so on in rapid succession. (p. 203)
Rigid orthodoxy will prevent a person from engaging effectively and genuinely in the therapeutic process with individuals with BPD.
Conclusion
The psychoanalytic approaches, including MBT, are quite distinct from DBT. The differences range from key divergence in overarching theory to significant variation in the interventions utilized in moment-to-moment interactions. It is our belief that having distinct, empirically validated approaches to treating individuals with BPD will serve the greatest good. There is no one treatment that works for everyone suffering from BPD. Therefore, the availability of varied treatments is likely to increase the proportion of individuals with BPD who are treated with an effective intervention.
Nonetheless, the goal of this commentary is to identify some commonalities in principles shared between MBT and DBT, which may be indicative of best practices when treating individuals with BPD. Some candidates for what may be best practices include approaching treatment with a balanced combination of validation and change-based strategies which directly target severe behaviors such as suicidal behaviors and non-suicidal self-injury; providing a compassionate model of the pathology; actively building a strong, genuine, and validating therapeutic relationship; a central focus on emotions and how they are related to actions; use of a team-based approach that promotes adherence to the treatment model; teaching skills that address the model of pathology; and promoting flexibility within the treatment approach to address the complexities of the clients’ problems. We would hypothesize that within these commonalities are some necessary, but not sufficient conditions for effective treatment of individuals with BPD. Further research on mechanisms of change is needed to develop a more complete understanding. Examining other empirically supported treatments may help to clarify if they too include these commonalities. It may also be helpful to understand how and why other treatments deviate from these principles.
References
Bateman, A., & Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders. New York: Oxford University Press.
Bedics, J., Atkins, D. C., Comtois, K. A., & Linehan, M. M. (2012). Treatment differences in the therapeutic relationship and introject during a 2-year randomized controlled trial of Dialectical Behavior Therapy versus nonbehavioral psychotherapy experts for borderline personality disorder. Journal of Consulting and Clinical Psychology, 80, 66–77.
Benjamin, L. S. (1974). Structural analysis of social behavior. Psychological Review, 81, 392–425.
Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory. Psychological Bulletin, 135, 495–510.
Fonagy, P., & Luyten, P. (2016). A multilevel perspective on the development of borderline personality disorder. In D. Cicchetti (Ed.), Developmental Psychopathology, Volume 3: Maladaptation and Psychopathology (3rd ed., pp. 726–792). New York: John Wiley.
Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, M. (1997). Validation and psychotherapy. In A. C. Bohart & L. S. Greenberg (Eds.), Empathy Reconsidered: New Directions in Psychotherapy (pp. 353–392). Washington, DC: American Psychological Association.
Linehan, M. (2015). DBT Skills Training Manual (2nd ed.). New York: Guilford Press.