Patient experiences of therapy for borderline personality disorder: Commonalities and differences between dialectical behaviour therapy and mentalization‐based therapy and relation to outcomes

Abstract

Objectives Dialectical behaviour therapy (DBT) and mentalization‐based therapy (MBT) are widely used evidence‐based psychological treatments for borderline personality disorder (BPD). The study aimed to establish evidence on common and unique, and helpful and unhelpful, treatment processes. Design Mixed‐methods. Methods In‐depth qualitative interview data on patient experiences during treatment were combined with quantitative outcome measures in 73 patients diagnosed with a personality disorder and receiving DBT or MBT. Results Across both DBT and MBT, accounts of learning not to react impulsively, learning to question one’s thoughts and assumptions, learning to communicate more effectively, and exposure to painful emotions that may previously have been avoided were each associated with less baseline‐adjusted self‐harm at the end of treatment. Difficulties in interacting with other group members were more likely to be described by patients receiving MBT than DBT, whilst difficulties in the therapeutic relationship were equally common. Both of these types of difficult experience were associated with higher baseline‐adjusted levels of BPD traits and emotional dysregulation, at the end of the 12‐month study period. Conclusions The findings identify novel evidence of common therapeutic processes across DBT and MBT that may help to reduce self‐harm. The findings also highlight the potential iatrogenic effect of difficulties in the alliance with therapists or with other group members. This underscores the importance of listening to patients’ voices about what they are finding difficult during therapy and working to address these relational challenges, so that the patient is able to progress and make best use of the treatment. Practitioner points Regardless of whether dialectical behaviour therapy or mentalization based therapy is used, helping service‐users to learn not to react impulsively, to question their thoughts and assumptions, and to communicate more effectively, may be beneficial for reducing self‐harm. Across both types of therapy, exposure to painful emotions is a difficult experience for service‐users, but may also be beneficial for reducing self‐harm, if carefully managed. Whilst service‐users’ experiences across both types of therapy have much in common, accounts of mentalization based therapy stand out in more often describing both helpful and unhelpful experiences of interactions with therapy group members. Service‐users across both types of therapy report the benefits of learning intrapersonal mentalization skills, whilst recipients of mentalization based therapy uniquely extend this to learning interpersonal mentalization. Ruptures in the therapeutic alliance, and distressing interactions with group members, may be iatrogenic and must be carefully managed.

Compassion Focused Group Psychotherapy for attachment and relational trauma: Engaging people with a diagnosis of personality disorder

“…Engagement with the programme was encouraging, in that only 21% of participants dropped out, coupled with an 85% session attendance rate that was consistent across the duration of therapy. It is possible that the attendance level positively correlates with the sustained outcome data and specific attention to the cultivation of safeness in the therapeutic process in CFGP which has been cited as a missing component in other therapies (Barnicot et al, 2022). This attrition rate was lower than that of published literature reviews of treatments for people with a diagnosis of personality disorder which indicated 37% non-completion rate (Arntz et al, 2023;Hummelen et al, 2007;McMurran & Ward, 2010).…”

Perspectives on Dialectical Behavior Therapy and Mentalization-Based Therapy for Borderline Personality Disorder: Same, Different, Complementary?

“…A mixed-methods re-analysis of the previously mentioned non-randomized comparison of DBT and MBT 61 found that patients’ accounts of learning not to react impulsively, questioning one’s thoughts and assumptions, communicating more effectively, and exposing oneself to painful emotions were associated with less self-harm at the end of treatment across both therapies. 62 Also, difficulties in the therapeutic relationship or with group members were associated with more severe BPD severity and emotion dysregulation at end of treatment for both MBT and DBT. 61 , 62 …”

“… 62 Also, difficulties in the therapeutic relationship or with group members were associated with more severe BPD severity and emotion dysregulation at end of treatment for both MBT and DBT. 61 , 62 …”

Mentalizing the patient–Patient experiences with short-term mentalization-based therapy for borderline personality disorder: A qualitative study

“…Over the past decade, the use of qualitative methods to investigate patient experiences of psychotherapy for BPD is accumulating, with a significant number of studies focusing on DBT (10,11). To the best of our knowledge, four qualitative papers and one mixed-method paper focusing on patient experiences of MBT, primarily long-term, for BPD has been published (12)(13)(14)(15)(16). Lonargáin et al (15) explored seven outpatients' experiences with MBT for BPD (duration ranging from 3 to 14 months).…”

“…Even though patients perceived MBT as helpful, the patients did not feel like they were cured ( 14 ). In a mixed-method study, Barnicot et al ( 12 ) interviewed 73 outpatients with a personality disorder, primarily BPD, who attended either DBT (duration: 12 months) or MBT (duration: 18 months) ( 13 ). The study pointed to helpful and hindering common factors across DBT and MBT for BPD, but also elements unique to the different models.…”