Elsevier

Behaviour Research and Therapy

Volume 60, September 2014, Pages 46-52
Behaviour Research and Therapy

Reasons for premature termination of dialectical behavior therapy for inpatients with borderline personality disorder

https://doi.org/10.1016/j.brat.2014.07.001Get rights and content

Highlights

  • We studied 541 inpatients with borderline personality disorder seeking dialectical behavior therapy.

  • Non-parametric conditional inference trees were used to predict expulsion and dropout.

  • We found different risk factors for expulsion and dropout.

  • Several implications for inpatient programs were discussed.

Abstract

Although one of the main aims of dialectical behavior therapy (DBT) for borderline personality disorder (BPD) is to increase the retention rates, premature termination rates for DBT inpatient programs were found to be over 30%. The aim of the study was to identify the reasons for, and to analyze, patient characteristics that are associated with premature termination. We studied 541 inpatients with BPD, who were consecutively admitted for an open-door 3-month DBT inpatient treatment in Berlin, Germany. All participants completed several self-rating measures and participated in clinical interviews. Fourteen percent, who did not complete the full 84 days of assigned treatment, were expelled, mainly due to treatment-disturbing behaviors, or substance abuse or possession. Nearly 19% dropped out of treatment, mostly due to lack of motivation, arguments with others, and poor tolerance of emotional distress. Using non-parametric conditional inference trees, expulsion was associated with anorexia nervosa and alcohol abuse, whereas more than 9 suicide attempts, antisocial personality disorders, and more than 86 weeks in a psychiatric hospital were risk factors for dropout. We discussed measures and interventions that might lead to an adaptation of DBT inpatient programs. Future research should examine the symptom course and utilization of health-care services of non-completers.

Section snippets

Participants

The participants were admitted consecutively to an inpatient unit of psychiatry and psychotherapy from September 2001 to February 2012. As the Berlin area has a well-developed network of outpatient DBT facilities (www.borderline-netzwerk-berlin.de), only those BPD patients who could not be integrated into an outpatient setting due to severity of illness (i.e., severity of BPD symptoms, comorbidity, low social functioning) were admitted for inpatient DBT. The only exclusion criteria were: a) age

Sample description

Table 1 shows the socio-demographic data and clinical characteristics. The analysis included N = 541 BPD patients, of whom n = 489 were women (90.4%). All participants were Caucasian. Treatment was terminated before day 84 by 176 patients (32.5%). The treatment length for those who terminated treatment prematurely was, on average, 40 days (SD = 21.35). One-hundred participants dropped out and 76 were expelled.

For the total sample, the mean age lay at 29 years (SD = 8.237). Approximately 25.5%

Discussion

Considering different definitions of dropout and varying treatment lengths, the premature termination rate of 32.5% in the present study was lower compared to the median rate of 37% that was reported in a narrative review with regard to non-completion in personality disorder-specific treatments (McMurran et al., 2010). Moreover, the rate was comparable to the non-completion rate of 32% in the Rüsch et al. (2008) study, which also analyzed a 3-month DBT inpatient treatment. The risk of dropout

Acknowledgments

We would like to thank the following colleagues for their support: Carolin Schneider, BSc., and Melanie Stich, M.FA, outpatient clinic of the Technical University Brunswick, who extracted the data and reasons of premature termination; and Anke Banzhaf, Ph.D., Behnoush Behnia, M.D., Katrin Janke, Dipl.-Psych., Carla Palafox, Dipl.-Psych., Dimitris Repantis, M.D., and Sandra Strunz, Dipl.-Psych., all of whom were therapists at the Department of Psychiatry, Charité – Universitätsmedizin Berlin.

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