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The rate of completed suicide among individuals diagnosed with borderline personality disorder (BPD) is between 3% and 9%,1-3 comparable to the rate in other high-risk diagnostic groups such as major depression and schizophrenia. However, individuals with BPD are more likely than individuals with these other disorders to make nonlethal suicide attempts and repeated threats, to engage in nonsuicidal self-injury, and to experience chronic suicidal ideation. It is estimated that up to 75% percent of individuals with BPD have made suicide attempts, with nearly 50% making at least one severe attempt.4,5 Furthermore, approximately 80% of hospitalized patients with BPD have engaged in self-mutilation (usually cutting or burning the skin, or hitting oneself without the intention to die).6"11 The unpredictability of suicide risk within the context of other less lethal forms of self-injurious behavior causes much suffering and presents a major challenge to these individuals, their families, and the clinicians who treat them.
Dialectical behavior therapy (DBT) is a cognitive-behavioral psychotherapy treatment developed by Dr. Marsha Linehan for the treatment of BPD.12 Dialectical behavior therapy was designed as an outpatient treatment to reduce self-mutilation and suicidal behavior in the most severe subgroup of patients with BPD.
Dialectical behavior therapy aims to provide increased support for patients to stay safe on an outpatient basis, as well as support for therapists working with chronically suicidal outpatients. This is achieved through capability and motivation enhancement of both the patient and therapist. Patient capability is enhanced through the teaching of adaptive skillful behaviors, and motivation is enhanced through the reinforcement of progress and nonreinforcement of maladaptive behaviors. For the therapist, a DBT outpatient consultation team is a source of support and guidance as well as an aid to keep the therapist focused on treatment goals and format.
Dialectical behavior therapy has three stages of treatment:
* stage 1: decreasing life-threatening behaviors,
* stage 2: reducing post-traumatic stress, and
* stage 3: increasing self-respect and achieving individual goals.
Stage 1 specifically targets the reduction of lifethreatening behavior and therefore has been the most researched. In addition, this first stage of treatment is of particular interest to the clinician who treats the chronic suicidality of BPD patients on an outpatient basis. Within the context of treating self-injury, other behavioral, interpersonal, cognitive, and emotional...