Dialectical Behavioral Therapy

Dialectical Behavioral Therapy (DBT) was originally developed as a disorder-specific treatment program for patients with borderline disorder and is recommended in the new S3 guidelines for borderline disorders in Germany as the most scientifically proven treatment method.

DBT is based on clear principles and rules that provide good orientation, especially for complex disorders. Depending on the severity of the disorder, the focus of treatment is on teaching specific skills to deal with crises or on improving emotion regulation, self-concept and social interaction.

Methodologically, DBT covers a wide field of evidence-based interventions, each of which can be used on the basis of individual problem analysis.

In recent years, in addition to the standard DBT for borderline disorders, a variety of adaptations to other disorders and different settings have been developed.

There are now 24 randomized, controlled studies in outpatient and inpatient settings that clearly demonstrate the effectiveness of DBT: DBT improves overall psychopathology, reduces the frequency of self-harm and inpatient stays. Social integration, work and relationships also normalize. Today, DBT is considered the gold standard in the treatment of complex psychological disorders of emotion regulation. The AWP Freiburg is in close contact with the international developers of the DBT.

Accredited by and in close cooperation with Marsha Linehan and her team, we set ourselves the goal many years ago of spreading DBT in German-speaking countries, which we have largely succeeded in doing.

Our team consists of psychologists, doctors and nurses who have been trained by the DBT umbrella organization and are trainers or have received supervisor status.

We are also available for on-site training and further education as well as inpatient implementations and the development of outpatient networks.

Epidemiology and course:

According to a study published in 2010, the lifetime prevalence of borderline personality disorder (BPD) is around 3% ( Trull et al. 2010 ). If young patients are included, the lifetime prevalence is around 5%. Cross-sectionally, around 1–2% of the population suffers from BPD ( Lieb et al. 2004 ; Coid et al. 2006a, 2006b ). This means that this serious disorder is much more common than, for example, B. schizophrenic illnesses.

The gender ratio is roughly balanced. The widespread assumption of female gender preference for borderline disorders is probably primarily due to the clinical impression that predominantly female patients seek psychiatric/psychotherapeutic treatment. Compared to the normal population, borderline patients are significantly more likely to report current experiences of physical violence (OR = 5.6), sexual violence (OR = 5.5) and violence at work (OR = 2.7). In addition, there are often financial problems (OR = 3.5), homelessness (OR = 7.5) and contact with the youth welfare office (OR = 7), i.e. numerous problem areas that largely lie outside the scope of medical care. Only about half of those affected seek psychiatric treatment, although 66% reported suicide attempts. The most common reasons for psychiatric treatment are comorbid Axis I disorders such as depression and anxiety disorders and PTSD.

In retrospective analyzes by our working group, around 30% of the adult borderline patients examined stated that they had intentionally inflicted self-harm on themselves as early as primary school age . A recent meta-analysis based on 172 studies in 41 countries shows that the lifetime prevalence of self-harm is around 17% worldwide (around 20% in Germany). The average age at onset of self-harm is 13 years. Around 12% of those affected in Germany regularly cut themselves (Brunner et al., 2014). This must be seen as a strong predictor of future suicide attempts and the development of BPD (eg Groschwitz et al., 2015).

All data therefore indicate that borderline personality disorder begins in early adolescence, leads to a maximization of dysfunctional behavior and experiences in the mid-20s and then slowly subsides ( Winograd et al. 2008 ). Inpatient treatment for self-harming behavior also peaks between the ages of 15 and 24. The S2 guidelines for the treatment of personality disorders ( Bohus et al. 2008 ) indicate that the diagnosis of borderline disorder should also be made in adolescence (from 15 years). Especially in light of the fact that there are now excellent evidence-based therapy programs for adolescent borderline patients, the assumption that is still widespread in Germany that this diagnosis cannot be made before the age of 18 should be recognized as a historical error ( Kaess et al., 2014; Chanen et al. 2017; ). There is now a “Borderline Guide” written specifically for young people and their relatives ( Wewetzer and Bohus 2016 ).

The high utilization behavior of borderline patients places particular demands on care structures. The annual treatment costs in Germany amount to around 4 billion euros, which corresponds to around 25% of the total costs incurred for inpatient treatment of mental disorders ( Bohus 2007; Wagner et al., 2014; Priebe et al., 2017 ). 90% of these costs arise from inpatient treatment. The average length of stay in Germany is currently around 65 days.

In recent years, the data on the long-term course of borderline disorder has become somewhat more compact: two large-scale US long-term studies tracked the course of borderline symptoms over 10 and 16 years, respectively ( Gunderson et al. 2011; Zanarini et al. 2015 ). . In particular, the study by Zanarini et al., in which 79% of the initially 290 borderline patients included were examined after 16 years, found, based on careful calculation, that at least 60% of the study participants met the criteria for remission according to the DSM over a period of at least 8 years -IV (≤ 4 criteria) had been met (symptom remission). The relapse rate in this stable population is approximately 10%, so almost half of the patients examined achieved sustained symptom remission. The data from the study by Gunderson et al. (2011) confirm this: After 10 years (calculated conservatively) a stable symptom remission was found in around 40% of the study participants, although the criteria were stricter (12 months less than three criteria).

However, the findings are significantly worse in the area of ​​social integration: only around 15% achieve a value on the GAF scale (Global Assessment of Functioning Scale) > 60 over a period of 8 years ( Zanarini et al. 2015 ). Also in the study by Gunderson et al. Social integration proved to be extremely inadequate: only just under 20% achieved a GAF score of 70, even temporarily. This means that the majority of borderline patients (in the USA) are extremely poorly socially integrated even after 10 years.

However, when interpreting these data, it should be taken into account that they were collected from borderline populations served by the US health care system and who did not receive disorder-specific psychotherapy. The catamnesis data from a long-term study from London are therefore more optimistic (Bateman and Fonagy 2009). Five years after the end of mentalization-based psychotherapy (MBT), there is a clear difference to the non-specifically treated control group: only 13% continued to meet the diagnostic criteria after MBT (control group 87%) and 45% showed values ​​> 60 on the GAF (control group 10% ). This clearly speaks for the effectiveness of disorder-specific therapies, since 13 years after the start of the study, 87% of patients who received “normal” psychiatric treatment continued to meet the diagnostic criteria according to DSM-IV and 74% had made at least one suicide attempt. Social integration was also extremely poor: only 10% achieved a score above 60 on the GAF. Overall, these data are shocking and point to woefully inadequate psychiatric outpatient care (at least in the UK). A welcome exception is the study by Pistorello et al. (2012) , which showed an improvement in the mean GAF value from 50 to 75. The reason for these good findings may lie in the selection of study participants (exclusively students) or in the inclusion of partners and family members in the therapy. The risk analyzes by Zanarini et al. are also of clinical importance . (2003) , who identify comorbid alcohol and drug abuse in particular as a risk factor for chronicity, even before comorbid PTSD and depression. Further clinical predictors of a rather poor outcome include sexual abuse in childhood and particularly severe symptoms ( Zanarini et al. 2006; Gunderson et al. 2006 ).

Long-term studies on dialectical behavior therapy (DBT) demonstrate significantly improved social integration: after one year of outpatient therapy, at least 40% of patients were within the normal range (Wilks et al. 2016).

Diagnosis:

The diagnostic criteria of DSM-5 (301.83; American Psychiatric Association 2013 ) , which have been in effect since May 2013 and remain unchanged compared to DSM-IV, are summarized in › Table 24.2. The personality disorders are classified in Section 2 on the same axis as the other mental disorders, so the multiaxiality has been eliminated. To make a diagnosis, five of nine criteria as well as the general diagnostic criteria for a personality disorder must be met. The IPDE ( International Personality Disorder Examination ; Loranger et al. 1998 ) is currently the instrument of choice for the operationalized diagnosis of BPD. It integrates the criteria of DSM-5 and ICD-10. Interrater and test-retest reliability are good and significantly higher than for unstructured clinical interviews. Alternatives are the “ Diagnostic Interview for DSM-IV Personality Disorders ” (DIPD; Zanarini and Frankenburg 2001a) developed by Zanarini and the SKID II Structured Interview for DSM-IV Personality (SCID II; in the DSM-IV the personality disorders were classified on Axis II ; First et al. 1996 ). Since comorbid disorders such as addictions, post-traumatic stress disorders or affective disorders significantly influence the course and prognosis and thus also therapy planning ( Zanarini et al. 2003 ), their complete assessment using an operational instrument (SKID I) is urgently recommended.

These instruments were primarily developed for the categorical diagnosis of BPD. Instruments for determining severity are now well established: Zanarini published a DSM-based external rating scale (ZAN-SCALE; Zanarini 2003) that has sufficient psychometric parameters. Arntz and colleagues developed the “Borderline Personality Disorder Severity Index” and published the first pre-post measurements (BPDSI; Kröger et al. 2013). Bohus and colleagues developed the Borderline Symptom List (BSL; Bohus et al. 2001, 2007) as a 90-item self-rating instrument. The psychometric parameters are very good, this also applies to the sensitivity to change. The instrument is also available as a well-established 23-item short version, which also allows classification into levels of severity. (Bohus et al. 2009; Kleindienst et al., 2020).

Phenomenology and etiology:

The currently favored etiological model postulates interactions between psychosocial variables and genetic factors. The psychopathology of borderline disorder can be divided into three domains: disorders of affect regulation, self-concept, and social cooperation. Most scientifically oriented working groups today focus on the disorder of affect regulation (Santangelo et al., 2018; Bohus et al. 2004b): The stimulus threshold for internal or external events that evoke emotions is low and the level of arousal is high. The patient only returns to the initial emotional level with a delay. The different feelings are often not perceived in a differentiated manner by those affected, but are often experienced as extremely distressing, diffuse states of tension with hypalgesia and dissociative symptoms. The self-damaging behavior patterns such as cutting, burning, drawing blood, but also aggressive breakthroughs that occur in 80% of cases can reduce the aversive states of tension, which can be referred to as negative reinforcement in the sense of instrumental conditioning. In recent years, a number of papers have been published that empirically support this initially purely clinical hypothesis (Kockler et al., 2020; Kleindienst et al. 2008; Reitz et al. 2015).

In the interpersonal area, difficulties dominate in regulating closeness and distance as well as in establishing trusting interactions (Liebke et al., 2018; ). Several studies indicate that borderline patients tend to overinterpret the emotional state of social partners and, in particular, to assume hostile intentions to neutral facial expressions. Under experimental conditions, BPD patients show a significantly increased sensitivity to social rejection, which can also be demonstrated in central imaging (for an overview, see Lis and Bohus 2013). Recent studies show pronounced experiences of loneliness and alienation in connection with limited social networks (e.g. Liebke et al., 2017)

The biosocial model (Bohus 2019; Fig. 1) attempts to integrate the empirical findings and contradictions on the genesis of BPD: Around 50% of those affected report experiencing serious interpersonal violence (sexual abuse) in childhood; about 95% about emotional neglect. On the other hand, many parents of borderline patients often credibly report that later borderline patients showed high emotional sensitivity even in childhood. There were also clear differences between the patients’ emotional neglect, which was subjectively experienced as traumatic, and the corresponding assessment of parental care by the parents

.

This model nevertheless places the early, formative experience of severe emotional rejection, disappointment or neglect (traumatically experienced invalidation) at the center of the pathogenesis. These experiences can occur within the family as well as caused by classmates or other peer groups. However, it seems important that these experiences do not always objectively have to reach the extent of interpersonal trauma. It is more about the subjectively perceived discrepancy between the expectations of the child or young person and the respective level of fulfillment of emotional support from parents or friends. Put more simply: Children with high emotional sensitivity genuinely show a very strong need for emotional exchange. Even an average level of emotional understanding can then be experienced as insufficient and rejecting. On the other hand, sexual trauma, for example, creates an intense need for emotional exchange in order to restore social security, support and internal consistency. If this emotional exchange is not possible, this is recorded as a second, additional social traumatic experience, which is often experienced as more serious than the trauma itself.

The primary emotions that accompany this traumatic invalidation, and thus also its memory, are usually disappointment, humiliation, powerlessness, abandonment, anger and fear. Since these emotions are very difficult to bear, especially for children and young people, those affected develop more tolerable explanatory concepts with the associated emotions: It’s all because of me, I did something bad, that all this is happening (guilt); I am somehow different or worse than the others (shame); I don’t deserve to be treated well (self-contempt); I am stupid and bad (self-hatred). There are also generalizations such as: Nobody likes me, I will always be excluded (expectation of social rejection); If I confide in someone, I will be destroyed (mistrust). These cognitive-emotional basic assumptions are relatively stable in the self-concept and therefore, together with the neurobiologically anchored affective hypersensitivity, control the three central domains of borderline pathology: emotional dysregulation, identity disorders and interpersonal cooperation disorders – each with the corresponding neurobiological, cognitive and behavioral dysfunctional specifics.

Most maladaptive behavior patterns are used either for short-term relief (e.g. to reduce tension) or to ensure internal consistency (e.g. with unexpected offers of social cooperation or praise). In the sense of negative feedback loops, these behavioral patterns not only lead to the stabilization of the problem, but often to its aggravation.

Psychotherapy for borderline disorder:

The effort to develop disorder-specific psychotherapeutic treatment concepts for mental disorders has also become established in the field of BPD. The following four disorder-specific treatment concepts are currently best established in the German healthcare system:

• Dialectical behavioral therapy (DBT) according to M. Linehan
• Mentalization-based therapy (MBT) according to A. Bateman and P. Fonagy
• Schema therapy for BPD according to J. Young

Before the respective study situation is discussed, the similarities between these disorder-specific forms of treatment should first be outlined:

• Diagnostics : The basic requirement for carrying out disorder-specific psychotherapy is an operationalized initial diagnosis that is disclosed to the patient. Forms of therapy whose diagnostics develop in the interactional clinical process are now considered obsolete.
• Time frame : The duration of the respective forms of therapy varies and is usually determined by the research design. Nevertheless, it has become common practice to agree on clear time limits at the beginning of therapy and to adhere to them.
• Therapy agreements : What all forms of therapy have in common are clear rules and agreements regarding how to deal with suicidality, crisis interventions and disruptions to the therapeutic framework. These are agreed at the beginning of therapy in so-called therapy contracts.
• Hierarchization of therapeutic foci : Whether explicitly agreed upon or implicitly anchored in the therapeutic code, all disorder-specific procedures for treating BPD have a hierarchy of treatment foci. Suicidal behavior or urgent suicidal ideas are always treated as a priority; behavioral patterns or ideas that endanger the maintenance of therapy or place a heavy burden on the therapist or fellow patient are also given priority. The principle of “dynamic hierarchy”, first formulated by M. Linehan, has become generally accepted today: the choice of treatment foci is based on the current circumstances of the patient. These are organized and structured within the framework of given heurisms. This means that the strategies for treating complex disorders (such as BPD) differ from therapy concepts for treating monosymptomatic disorders (such as obsessive-compulsive or anxiety disorders), the course of which is clearly defined in time.
• Multimodal approach : Most procedures combine different therapeutic modules such as individual, group and pharmacotherapy and, in particular, telephone counseling for crisis intervention.

The differences between the procedures lie in different etiological concepts, in the focus of the treatment and, in particular, in the selection of the treatment methodology.

DBT is organized modularly (i.e. in therapy modules) (Linehan 1993; Bohus and Wolf 2009). It integrates individual therapy, skills group training, telephone coaching and specific disorder-oriented modules such as trauma therapy, drug and alcohol abuse and eating disorders. DBT also has a specific treatment concept for children and adolescents as well as for inpatient, day-care and forensic settings. In the phased course of treatment, DBT initially focuses on acquiring behavioral control and improving emotion regulation, and then on improving social skills and the consequences of possible trauma-associated experiences.

MBT is based on the assumption that borderline patients have difficulty understanding or predicting the emotional reactions of others (mentalization; Bateman and Fonagy 2006) . The focus of the treatment is therefore on improving interpersonal skills, particularly the ability to place one’s own emotional experience in the social context and to decode emotional reaction patterns and intentions in others.

Schema therapy postulates dysfunctional automated cognitive-emotional experience patterns (schemas or modes) as the cause of the often contradictory and socially inadequate behavior of borderline patients (Jacob and Arntz 2011). The aim of therapy is to help those affected to recognize these often complex modes and to enable them to question and, if necessary, revise their respective meaning in the current social context.

Data on psychotherapy:

To date, evidence of effectiveness for defined symptom areas of the disorder has been provided for several forms of psychotherapy with different theoretical orientations and treatment durations. The consensus of all major guidelines is that patients with BPD should be offered psychotherapy as the procedure of choice (American Psychiatric Association 2001; National Collaborating Center for Mental Health 2009, 2018; National Health and Medical Research Council 2013). In a review of the effectiveness of psychotherapeutic procedures in reducing diagnosis-unspecific suicidal and self-harming behavior, Calati and Courtet (2016) found an absolute risk reduction for suicide attempts of 7%, corresponding to an NNT of 15. Treating 15 patients thus prevented one suicide attempt. In their review specifically on BPD, Cristea and colleagues (2017) even found an NNT of 4.10 for the prevention of suicide attempts for borderline-relevant target parameters (BPD symptoms, self-harming, parasuicidal and suicidal behavior) and an NNT of 5.56. In this respect, overall it can be assumed that BPD responds well to psychotherapy.

After a long time when reliable, meta-analytically integrated data from several high-quality studies were only available for DBT (Stoffers et al. 2012), this is now also the case for MBT. According to Chambless and Hollon (1998), there is evidence level Ia for both procedures.

DBT is by far the best researched and proven procedure. The effectiveness of DBT has been demonstrated by several independent working groups in numerous randomized, controlled therapy studies). The meta-analytic review of therapy effects in the Cochrane review (Storebø et al. 2020) showed confirmed, moderate to strong effects for DBT in terms of reducing suicidality, self-harming behavior, overall BPD severity, and improving psychosocial functioning and quality of life , with standardized mean differences (SMDs) between 0.36 and 0.94).

Recent research on DBT deals with effectiveness under non-ideal practical conditions, including with naturalistic, unselected patient groups or with nursing staff as therapists (“effectiveness studies”; including Feigenbaum et al. 2012, Flynn et al. 2017b, Priebe et al. 2012 ), with the identification of effective therapy elements (“dismantling studies”; Linehan et al. 2015), the development of DBT adaptations for patients with comorbid post-traumatic stress disorder (Bohus et al. 2013; Harned et al. 2014), forensic patients (Bianchini et al. 2019), young people (including Mehlum 2012, McCauley 2018), DBT in various therapeutic settings (Sinnaeve et al. 2018) and with work with relatives (Family Connections; Flynn et al. 2017a).

It has been shown that treatment effects can be achieved even under non-ideal, practice-typical conditions in heterogeneous patient samples (Feigenbaum et al. 2012; Flynn 2017b; Priebe et al. 2012). Two studies have further clearly demonstrated that patients with BPD and post-traumatic stress disorder (PTSD) can be treated well and, above all, safely, even before self-harming behavior has subsided. In a study on inpatient treatment with DBT-PTSD, a modular concept based on DBT and trauma-specific components, there were large effects (SMD 0.87–1.50) on the reduction of both BPD and PTSD (SMD 0 .70–0.96) as well as depression and psychosocial functioning (SMD 0.94–1.50) (Bohus et al., 2013). These effects were also evident under outpatient conditions in a large-scale multicenter study (Bohus et al., 2020). In a small Italian study with forensic patients, DBT found no significant effects on impulsivity and affective instability compared to usual rehabilitative measures, but there were clear pre-post effects. There are also RCTs on DBT-A, an adaptation for young people, from the children/adolescent sector. Compared with supportive individual and group therapy, DBT-A showed significant effects in the sense of less self-harming behavior and fewer discontinuations of therapy (McCauley et al. 2018). Mehlum et al. (2014) also found significant effects on overall BPD severity and suicidality. In their RCT, Sinnaeve and colleagues (2018) examined the question of the extent to which the combination of three months of inpatient DBT followed by six months of DBT in an outpatient setting is superior to standard DBT (12 months in an outpatient setting). With the exception of the dropout rate, which was lower in the combined therapy condition, there were no differences between the settings. A more intensive treatment does not necessarily appear to be more effective. Finally, the relatives of people affected by BPD are also becoming the focus of research because they themselves are under considerable stress (Bailey and Grenyer 2013, 2015). A quasi-randomized study (Flynn et al. 2017a) found positive effects for a DBT-based treatment program (Family Connections) on distress and grief.

There are four randomized-controlled studies on standard MBT (Bateman and Fonagy 2006), two from the day-care setting (Bateman and Fonagy 1999; Laurenssen et al. 2018), two from the outpatient setting (Bateman and Fonagy 2009; Jørgensen et al. 2013). The pooled effects from these four RCTs show a significant, moderate effect in terms of an improvement in psychosocial functioning, as well as significant effects for self-harming and suicidal behavior. Smits et al. (2019) compared day-care and outpatient MBT in another RCT. Here the former proved to be superior, with significantly better treatment results in terms of BPD overall severity and interpersonal problems. Like DBT, MBT research is now also focusing on adolescents, patient groups with specific comorbid disorders and family members. An adaptation of MBT for adolescents (MBT-A) was developed by Rossouw et al. (2012) investigated. Significant effects were found here in the sense of a reduction in self-harming behavior and depression. Beck et al. (2019) examined the effects of an MBT adapted for young people and held primarily in groups with additional appointments for caregivers. No significant effects were observed here compared to the control treatment, which consisted of at least monthly individual sessions with counseling, psychoeducation and crisis management. A short version of the MBT in the form of an introductory group was published by Griffiths et al. (2019), but no significant effects were found. Two other RCTs, each of which examined an MBT adaptation for specific comorbidities, did not show any significant effects in a direct comparison with the respective control treatments for BPD symptoms (Philips et al. 2018: MBT for BPD + substance dependence; Robinson et al . 2016: MBT for BPD + eating disorders, here limited effects were found on eating disorder-associated outcome variables). In contrast, significant positive effects were found for an MBT-based family program (MBT-FACTS), which is aimed at relatives and is also guided by relatives. Compared to a waiting list control, there were significant effects on the frequency of negative incidents with the affected family member as well as an improvement in family functioning and general well-being (Bateman and Fonagy, 2018).

There is no randomized controlled study on schema therapy (Young et al. 2005) that examines the effectiveness compared to a non-specific control condition. In a direct comparison with TFP, Giesen-Bloo and colleagues (2006) found a significant superiority of schema therapy in terms of severity and discontinuation rates. In a strictly scientific sense, however, there is still no fundamental proof of effectiveness, as this requires direct comparison with a non-specifically treated control group. This comparison is being examined in another study with inpatient forensic patients (Bernstein et al. 2012), the final results of which are not yet available. In a one-year cohort study with BPD patients who received combined group and individual regimen therapy, positive effects regarding BPD symptoms and functional level were observed for the pre-post comparison (Fassbinder et al. 2016). Furthermore, a so-called dismantling study showed no additional effects for a variant of SFT in which the therapists are always available by telephone in emergencies (Nadort et al. 2009). There are positive findings for an eight-month short form of schema therapy in a group format: In a small study (Farrell et al. 2009), the developers of the therapy program found very large effects, which have yet to be replicated by an independent research group. A large multicenter study is currently investigating the effects of longer-term schema group therapy (two years of treatment) versus TAU (Wetzelaer et al. 2014). The question is also examined here as to whether isolated schema group therapy shows comparable effects to the combination of group and individual therapy. An RCT to directly compare SFT and DBT is currently being carried out at the University Hospital of Lübeck (Fassbinder et al. 2018).

There are currently two randomized controlled studies on the question of the combination of psychotherapy and pharmacotherapy , in each of which the administration of fluoxetine alone with a combined therapy of fluoxetine and interpersonal psychotherapy (IPT; Bellino et al. 2006) or a combined therapy of fluoxetine and a form of IPT adapted for BPD (IPT-BPD; Bellino et al. 2010d) was compared. In BPD patients with a current depressive episode, treatment combined with psychotherapy was shown to be superior in terms of depression, quality of life and interpersonal functioning (Bellino et al. 2006). Borderline-specific outcome measures were not collected. The second study also indicated better results in terms of BPD pathology, depression, anxiety and general level of functioning with simultaneous psychotherapy (Bellino et al. 2010d).

In recent years, a shift towards care practice has been observed in relevant research. On the one hand, procedures that have now been established, such as B. DBT has been examined in the course of so-called feasibility studies in everyday care (Priebe et al. 2012; Feigenbaum et al. 2012), i.e. for example with multimorbid patients and nursing staff as therapists, whereby positive effects have continued to be confirmed in the case of DBT. Leppänen et al. (2016) in turn examined the extent to which an open training series, which was aimed at interested practitioners from different professional groups (doctors, psychotherapists, nursing) and included elements from DBT, ST and attachment theory, influenced the treatment results for outpatient BPD patients in everyday care. There were encouraging effects in terms of better health-related quality of life. Andreoli and colleagues (2016) also address the question of the extent to which “abandonment psychotherapy”, a psychotherapeutic crisis intervention, achieves different effects when carried out by licensed psychotherapists or experienced nursing staff. For this very limited intervention, there were no differences between the patients treated by the different professional groups. Both therapy groups were superior to a TAU comparison group in terms of suicidality.

Antonsen et al. (2017) examined to what extent a combination of a total of two years of treatment in inpatient individual and group settings was superior to treatment of the same length in an individual setting, but without finding any difference effects. The study already presented by Sinneave et al. (2018) supports the finding that additional inpatient treatment does not provide any further advantage over outpatient treatment. There are still numerous so-called dismantling studies for DBT that aim to “filter out” actually effective individual components of more complex therapies through systematic comparisons (including Feliu-Soler et al. 2016; Kramer et al. 2016; Linehan et al. 2015; Soler et al. 2016). An RCT that compared standard DBT (including individual and group/skills training) with standard individual therapy (plus non-specific control group) or group/skills training (plus non-specific individual control treatment) pointed to the skills group as a central treatment element: both treatment groups, Those who took part in a specific DBT skills group (plus DBT or control individual therapy) were superior to DBT individual therapy (plus control group therapy) (Linehan et al. 2015).

Interestingly, after almost three decades of developing disorder-specific approaches, a shift towards BPD-unspecific short-term interventions has recently been observed, see e.g. B. Jahangard et al. (2012; Emotional Intelligence Training); Kramer et al. (2011, 2013, 2014; plan analysis), Pascual et al., 2015 (cognitive training) or Schilling et al. (2015; metacognitive training). However, which of these short-term interventions are actually effective and useful can only be seen against the background of an overall treatment concept.

The development of group therapy procedures that can be used alone or in combination with individual therapy will continue to be interesting in the future. They are of particular importance for the care system, as it remains difficult to find suitable individual therapists for all BPD patients. In addition to the well-documented DBT skills training (see, among others, Linehan et al. 2015; McMain 2017), the best-known group program is the “Systems Training for Emotional Predictability and Problem Solving” (STEPPS; Blum et al. 2009), which is complementary to individual therapies Group program based on psychoeducational elements and DBT. STEPPS has broad evidence (Blum et al. 2008; Bos et al. 2010), but is currently relatively less widespread in the German-speaking world. Another very well-researched group program is the so-called Emotion Regulation Group according to Gratz and Gunderson, which integrates elements of DBT and Acceptance and Commitment Therapy (ACT) (Gratz and Gunderson 2006; Gratz et al. 2014; Schuppert et al. 2012) . Three RCTs provide integrable outcome measures and, taken as a whole, show significant effects on BPD overall severity, self-harming behavior, affective instability, impulsivity, interpersonal problems and depression. A group program for acceptance and commitment therapy is also promising (Morton et al. 2012; › Table 24.3). Recent studies have examined the effectiveness of creating crisis intervention plans coordinated with patients by therapists and caregivers. Even if such crisis plans seem understandably sensible, a smaller RCT did not show a reduction in self-harm 6 months after the crisis plans were drawn up (Borschmann et al. 2013).

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Standard DBT for Borderline Disorders