Examining challenging behaviors of clients with borderline personality disorder

Highlights

• Frequent phone contacts were associated with a decrease in dropout.

• Frequent phone contacts were associated with an increase in client satisfaction.

• Frequent phone contacts were associated with an increase in therapist satisfaction.

• Avoidance behavior was associated with a higher risk of SDV.

• Avoidance behavior was associated with a decrease in therapist satisfaction.

Abstract

Few studies have examined effects of challenging behaviors of clients with borderline personality disorder (BPD) on psychotherapy outcomes. Dialectical behavior therapy (DBT) is an evidence-based treatment designed to treat chronic suicidality, self-directed violence (SDV), and emotion dysregulation, while targeting challenging behaviors. DBT has been shown to be effective with clients with BPD. We evaluated whether therapist reported challenging behaviors, such as high volume phone contacts or violating the therapist's limits, during DBT would be associated with dropping out of DBT, severity and frequency of SDV, emotion regulation deficits, psychological symptom severity and client's and therapist's satisfaction of treatment. The current study examined challenging behaviors reported by therapists in a sample of 63 psychiatrically disabled outpatient DBT clients diagnosed with BPD (73% women, average age 37 years). More frequent phone contacts were associated with a decrease in dropout and psychological symptoms, and an increase in client and therapist satisfaction. More avoidance/disengagement behavior was associated with more than twice the risk of SDV and a decrease in therapist satisfaction. Findings suggest that the phone coaching might serve to maximize client satisfaction and reduce the likelihood of dropout.

Introduction

Borderline personality disorder (BPD) is a complex psychiatric disorder characterized by emotional instability and impulsivity. Clients with BPD are often high utilizers of acute psychiatric services, including inpatient admissions, crisis, and emergency services (Bateman and Fonagy, 2009, Bender et al., 2001, Comtois et al., 2007, Zanarini et al., 2004a). It is also common for clients with BPD to be diagnosed with one or more Axis I comorbidities, especially mood or anxiety disorders (Fyer et al., 1988, Grant et al., 2008, Zanarini et al., 1998, Zanarini et al., 2004b). A desire for more treatment is characteristic of clients with BPD (Goodman et al., 2010), and there is often over-treatment with minimally effective results (Gunderson et al., 2011, Linehan and Heard, 1999, Skodol et al., 2002).

At the same time, clients with BPD are more likely to dropout of treatment prematurely (American Psychiatric Association, 2001, Ben-Porath, 2004a, Ben-Porath, 2004b). Clients with BPD have a poor response to traditional community outpatient treatments, and research has found that they consume up to 40% of mental health services provided in a given setting even on an outpatient basis (Geller, 1986, Surber et al., 1987, Widiger and Weissman, 1991, Woogh, 1986).

There are many behaviors that can disrupt the course of psychotherapy and pose problems for both the therapist and client. These challenging behaviors, called therapy-interfering behaviors (TIBs) by Linehan (1993), have been defined as client or therapist behaviors that interfere with the client receiving or benefiting from the therapy offered. Clients with BPD tend to engage in multiple challenging behaviors that interfere with receiving therapy, such as calling the therapist at unreasonable hours outside of session (Dimeff & Linehan, 2001), behaving ineffectively on phone calls (Linehan, 2008), being non-collaborative (e.g., arguing with the therapist), and quitting therapy (Bados et al., 2007, Espinosa et al., 2009, Farrand et al., 2009, Oumaya et al., 2008). This, paired with emotional and behavioral dyscontrol, including suicidal and non-suicidal self-directed violence (SDV), results in these individuals being difficult-to-treat, BPD being a highly stigmatized disorder, and trepidation by clinicians to provide treatment for clients with BPD (Gunderson et al., 2011, Linehan et al., 2000, Paris, 2005).

Dialectical behavior therapy (DBT; Linehan, 1993) is the dominant evidence-based treatment for borderline personality disorder in the community (Koons et al., 2001, Linehan et al., 1991, Linehan et al., 2002, Linehan et al., 2006, Lynch et al., 2003, Telch et al., 2001, Verheul et al., 2003). DBT consists of five treatment components, including 1) weekly individual psychotherapy, 2) weekly skills training groups, 3) skills coaching via telephone, 4) therapist consultation team, and 5) ancillary treatments to help structure the environment (e.g., case management) as needed.

Skills coaching via telephone is a component of DBT designed to help strengthen behavioral skills learned in DBT. Skills coaching is not “telephone therapy” (Linehan, 1993) but instead utilizes specific strategies to generalize skills use to the client's natural environment (Linehan, 1993, Linehan, 2008, Manning, 2011). Calls are generally brief and focused on helping clients use specific skills in the moment. As with many other DBT strategies, clients are oriented to the use of skills coaching and how to use it effectively (e.g., calling prior to engaging in SDV rather than after). DBT therapists are directed to observe their personal limits regarding the frequency, content, and timing of telephone calls (Ben-Porath, 2014). Limits around skills coaching in DBT are seen as fluid rather than static; that is, they may change throughout the course of treatment or differ between clients (Linehan, 1993). (For more information on skills coaching, see Linehan, 1993 and Ben-Porath, 2004a, Ben-Porath, 2004b).

The structure of DBT offers therapists strategies to directly address challenging behaviors, including suicidal behaviors and therapy-interfering behaviors (TIBs). DBT utilizes a treatment hierarchy of behavioral targets that explicitly includes TIBs as the second highest priority for treatment, following only suicidality, SDV, and violent behaviors. In DBT, TIBs can include behavior of both the therapist and the client. Therapist TIBs include behaviors such as having an imbalance of treatment strategies (e.g., too much change or too much acceptance), being disrespectful (e.g., being late, forgetting important information), or not knowing what to do in response to particular behaviors. Client TIBs include behaviors such as non-attendance, non-compliance, and non-collaboration, such as missing or arriving late to a therapy session, and not returning phone calls. Behaviors that do not follow therapist's observed limits, such as calling for coaching outside of agreed upon times, are also targeted as client TIBs (Dimeff & Linehan, 2001).

The broader treatment literature has focused on challenging client behaviors related to dropout and phone contacts between the client and therapist. Dropout is considered to be the most serious form of TIBs and research in this area has shown that DBT is more effective at reducing dropout than treatment as usual (Dimeff and Linehan, 2001, Harley et al., 2007, Koons et al., 2001, Linehan et al., 1991, Linehan and Heard, 1999, Linehan et al., 2002, Linehan et al., 2006, McMain et al., 2009, Verheul et al., 2003). Beyond dropout, few studies have examined what predicts challenging client behaviors or the effect of these behaviors on the outcome of psychotherapy. Within the first randomized controlled trial of DBT, no significant correlation was found between the number of telephone calls and frequency of SDV in the DBT condition, whereas clients who engaged in more SDV had more telephone calls with their therapist in the treatment-as-usual condition (Linehan et al., 1991, Linehan and Heard, 1993). One article offers case examples to explore the difficulties in problematic telephone consultation in DBT (Koons, 2011). Allen (1997) examined four diverse paradigms and suggested techniques of handling TIBs in a BPD population, though none of the techniques have been empirically tested. While not a challenging behavior itself, therapeutic alliance ruptures certainly can be an outcome of such behaviors. A review of the literature on therapeutic alliance and treatment outcome found evidence that repairing rupture therapeutic alliances is related to positive outcomes (Safran, Muran, & Eubanks-Carter, 2011). Other than the first randomized clinical trial of DBT (Linehan et al., 1991, Linehan and Heard, 1993), no published studies have examined the impact of challenging behaviors on key DBT outcomes such as suicidal behavior or emotion regulation.

There is a clear need to increase engagement, effectiveness, and efficiency and decrease dropout in treatments for clients with BPD, including in evidence-based treatments such as dialectical behavior therapy (DBT; Linehan, 1993). The current study examined how a wide range of challenging behaviors was associated with treatment outcomes.

The current study describes DBT therapists' report of challenging behaviors amongst a sample of psychiatrically disabled clients with BPD in an outpatient DBT program. Four types of potentially challenging client behaviors were examined: (1) interpersonal negativity (e.g., the client behaving in an inflexible or defiant manner toward the therapist) and avoidant/disengaged behaviors (e.g., missing a session without calling), (2) extreme behavioral dysregulation (e.g., engaging in SDV in a way that is not medically serious), (3) the frequency of out-of-session contacts, regardless of whether it was described as a challenging behavior by the therapist, and (4) whether the therapist's limits were observed in relation to each client. We examined the impact of these potentially challenging client behaviors on treatment outcomes. We hypothesized that more client challenging behaviors would be associated with seven outcomes: (1) premature dropout, (2) frequency of SDV, (3) severity of SDV, (4) emotion regulation deficits over the course of treatment, (5) the client's satisfaction of treatment, (6) the therapist's satisfaction of treatment, and (7) psychological symptom severity.