Available online at www.sciencedirect.
com
ScienceDirect
Mechanisms of change in dialectical behaviour therapy for people
with borderline personality disorder
Lars Mehlum
This paper reviews current knowledge on mechanisms of
change targeted in dialectical behaviour therapy for people
with borderline personality disorder. Improvements in emotion
regulation capacity and the use of coping skills or mindfulness
skills helping patients to downregulate emotional reactions
and to cope with stressful situations seem to play important
roles. In addition, strong therapeutic relationships, where
therapists use high levels of validation, seem equally
beneficial for treatment outcomes. When therapists actively
install hope in their patients and foster the capacity of hopeful
thinking in other ways, long-term outcomes seem to improve.
A growing body of evidence shows us how neurobiological
and epigenetic change in brain regions important to emotion
regulation and behaviour control correspond with more
favourable treatment outcomes.
Address
National Centre for Suicide Research and Prevention, Institute of Clinical
Medicine, University of Oslo, Oslo, Norway
Corresponding author: Mehlum, Lars (lars.mehlum@medisin.uio.no)
Current Opinion in Psychology 2021, 37:89–93
This review comes from a themed issue on Personality pathology:
developmental aspects
Edited by Carla Sharp, Andrew Chanen and Marialuisa Cavelti
For a complete overview see the Issue and the Editorial
Available online 25th August 2020
https://doi.org/10.1016/j.copsyc.2020.08.017
2352-250X/ã 2020 The Author(s). Published by Elsevier Ltd. This is an
open access article under the CC BY license (http://creativecommons.
org/licenses/by/4.0/).
Introduction
With its high risk of suicide, substance abuse, violence
and high service usage borderline personality disorder
(BPD) was until fairly recently regarded as next to
untreatable by many clinicians. However, after exten-
sive research efforts we now have several evidence-
based psychosocial interventions leading to successful
treatment outcomes for people with BPD. Among these
interventions are dialectical behaviour therapy (DBT),
a comprehensive, principle-based, outpatient treat-
ment that was developed by Linehan [1] for adults
with BPD and repetitive suicidal and self-harming
behaviour. The treatment includes weekly individual
therapy using cognitive and behaviour change strate-
gies balanced with validation strategies to promote
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self-acceptance and capacity to regulate emotions
and reduce suicidal and self-harming behaviours and
other behaviours reducing quality of life. Patients also
participate in weekly skills training group sessions where
they learn coping skills such as mindfulness skills, emotion
regulations skills, distress tolerance skills and interpersonal
skills. Between therapy sessions patients may contact their
therapists to receive coaching as to how to use the skills in
challenging daily life situations. DBT therapists typically
work together in consultation teams to help maintain
treatment integrity over time and prevent therapist
burnout.
DBT has a very strong evidence base supported by
more than 40 randomized trials. Still, treatment
response rates in most of these trials are only moderate,
effect sizes are in the middle to low range, and dropout
rates are often high even when treatments are delivered
under highly favourable conditions. Clearly, we are in
need of more knowledge to optimize DBT and other
BPD specific treatments and enhance outcomes. Essen-
tial to this is to study predictors of treatment response
and mechanisms involved in therapeutic change. In a
seminal paper from 2006 [2] Linehan et al. put forward a
series of hypotheses on potential mechanisms and laid
out a framework for future clinical research in DBT.
Since then, the amount of relevant research has grown
substantially. The scope of this review is to highlight
and discuss recent discoveries and developments in the
field of mechanisms of therapeutic change in DBT with
people with BPD.
What is a mechanism of change?
Knowledge on mechanisms of change are important to
design and develop effective treatments, to refine them
(‘mine the gold’) to help boost treatment effects and to
prevent inadvertently eliminating or diluting essential
elements in the treatments as they are further developed,
adapted or adopted in new contexts and for new patient
populations. But what is really a mechanism of change?
Simply put it could be the pieces of information that tell
us how and why a treatment works, or put in the words of
Kazdin [3]: a ‘ . . . mechanism explains how the inter-
vention translates into events that lead to the outcome’.
Alternatively, we could define mechanisms of change in
statistical terms as the variables, or mediators, that
account for the association between the treatment and
the outcomes [4], although the mediator does not usually
explain how the change came about.
Current Opinion in Psychology 2021, 37:89–93
90 Personality pathology: developmental aspects
Emotion regulation
BPD is commonly viewed as a disorder of emotion
regulation. Therefore, according to Linehan’s biosocial
theory [5], to improve the capacity to regulate emotions
and enable individuals to respond appropriately to stress-
ful situations and experiences through the use of various
strategies are essential treatment targets. Several studies
of DBT have indeed shown that improvements in emo-
tion regulation and behaviour control are linked to more
favourable outcomes. Axelrod et al. reporting on females
with BPD and substance dependence who received
20 weeks of outpatient DBT, found that improvement
in emotion regulation mediated the association between
treatment and reductions in substance use frequency [6].
Reductions in depressive symptoms did, however, not
explain any of the variance in substance use frequency at
the end of treatment. In an exploratory study of patients
receiving either DBT or general psychiatric management
McMain et al. [7] also found evidence that improvements
in emotion regulation capacity was associated with greater
reductions in general symptom distress and with greater
improvements in interpersonal functioning even though
they were not able to break down their results on treat-
ment conditions. In a more recent study Kramer et al. [8]
found that participants who received 20 sessions of DBT
skills training, had a significantly stronger symptom
reduction than participants receiving treatment as usual
(TAU) and that this symptom reduction seemed to be
linked to an increase in the level of adaptive assertive
anger in the participants.
These studies, and several more studying emotion regu-
lation indirectly or in association with other factors, pro-
vide a fairly good indication that making progress in the
capacity to regulate one’s emotions is at least part of the
answer to how patients with BPD recover through DBT.
Improved emotion regulation is, however, more of an
outcome in itself, and not a treatment strategy or thera-
peutic modality or tool.
Skills training and skills use
The Linehan group was the first to study what role the
treatment modality skills training and skills use might play
in relation to treatment outcomes in DBT. In an early
study, Neacsiu et al. [9] found that skills use fully medi-
ated the association between time in DBT treatment and
reductions in suicide attempts and depressive symptoms
and increases in the control over anger in women with
BPD who received either DBT or a control treatment. In
another early study O’Toole et al. [10] found that
improvements in mindfulness skills were associated with
increased levels of emotional well-being and less frequent
use of health care services among women with BPD who
received DBT. In an additional study of the role of
mindfulness skills, Perroud et al. [11] found that the
mindfulness skill acceptance without judgement increased
significantly over time and this increase was correlated
Current Opinion in Psychology 2021, 37:89–93
with an improvement in BPD symptoms in BPD subjects
receiving one year of standard DBT. Linehan also found
support for the important role of skills training in her
2015 study of women with BPD who were randomized to
receive either standard DBT, DBT skills training without
individual therapy or DBT individual therapy without
skills training. The two interventions incorporating skills
training were significantly more effective in reducing
frequency of self-harm episodes [12]. Barnicot et al.
[13] similarly found that more frequent use of DBT skills
was associated with less frequent self-harm and treatment
dropout in adults with BPD and repetitive self-harm
receiving standard DBT.
After these initial studies, recent research has confirmed
the mediating role of DBT-skills acquisition in the asso-
ciation between baseline levels of predictors such as
difficulties of emotion regulation and outcomes such as
BPD-symptoms [14], depressive symptoms [14], alcohol
and substance abuse [15] or self-harm [16] among
others. Some studies have focused more in-depth on what
skills, among the four main types in DBT, seem to play
the most important role for different outcomes. That
increases in the above mentioned mindfulness skill accep-
tance without judgement seem to play an important role [11]
has been confirmed by several recent studies. In a sample
of adults attending a DBT-informed partial hospitaliza-
tion programme, Mochrie et al. [17] found that increases
in this particular skill accounted for reductions in depres-
sion scores. In a randomized trial of 20 weeks of DBT
skills training versus wait list control Krantz et al. [16]
found a significant effect of skills training on the fre-
quency of NSSI episodes and where the mindfulness skill
acceptance without judgement mediated this association.
Finally, in a recent randomized trial of 20 weeks of
DBT skills training against a wait list control by Zeifman
et al. [18] in patients with BPD, improvements in mind-
fulness, and particularly acceptance without judgement,
was again a significant mediator between the treatment
and improvements in general psychopathology. From
these studies it seems clear that improvements in mind-
fulness skills, notably acceptance without judgement, seem to
have a significant impact on several treatment outcomes
in patients with BPD receiving DBT. These mediational
studies do not, however, provide answers to the question
of how the changes come about. One possibility is that
acceptance without judgement helps patients counteract
feelings of shame, or it may help them reduce their strong
tendency to judge their own experience as either good or
bad and then take action to avoid this experience, for
example through self-harm [16].
There are a wide range of skills taught in DBT, and when
successfully used, they influence many different cogni-
tive, behavioural and emotional functions. An example of
this comes from the study of Euler et al. [19], a random-
ized trial of 20 sessions of DBT skills training and TAU
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versus TAU alone for BPD outpatients, where overall
defence functioning was found to be significantly more
improved in patients receiving DBT skills training sug-
gesting that a change in defence mechanisms is a poten-
tial mechanism of change. How different individuals
respond to and benefit from skills training in DBT
may vary and this response may be predictive of treat-
ment outcomes. As shown in a naturalistic study by Yeo
et al. [20] of adolescents with BPD features and self-harm
behaviour receiving DBT adapted for adolescents [21],
higher pre-treatment levels of adaptive skills were linked
to increased DBT skills use at post-treatment, suggesting
that patients’ baseline use of coping skills is predictive of
psychotherapy outcomes. If this finding is confirmed in
randomized trials, it could be important to tailor treat-
ments and treatment dosages to different patients’ needs
informed by baseline assessments.
Therapeutic alliance
Some potential mechanisms of change are typically inter-
personal, such as the therapeutic alliance. This dimension
has been studied repeatedly over the years, from the very
first small study by Shearin and Linehan [22] demonstrat-
ing that therapeutic strategies fostering a more favourable
therapeutic relationship were associated with a drop in
suicidal behaviour in women with BPD and a history of
repeated suicidal behaviour. In a randomized trial of
female patients with BPD who received either DBT or
community treatment by experts, patients who received
DBT reported a significantly stronger association
between therapist affirmation and protection and reduc-
tions in self-harm behaviour [23] and, later in the same
sample, an association between patient rated alliance and
reductions in self-harm behaviour [24]. Another aspect of
the therapeutic relationship was investigated by Carson-
Wong et al. [25] examining the association between
therapists’ use of validation strategies and change in
patients’ emotions, where the use of high levels of vali-
dation lead to increases in positive emotion and reduc-
tions in negative emotion. Findings in studies of the
therapeutic relationship seem, however, not to be entirely
consistent. Therapeutic alliance was not found to be a
mechanism of change in DBT the previously mentioned
study of Uliaszek et al. [14] of subjects receiving DBT
skills training for 12 weeks.
Neurobiological changes
Well in line with Linehan’s biosocial theory [5] there would
be good reason to expect changes in neurocircuitry in brain
regions involved in emotion reactivity and regulation to
ultimately be essential to therapeutic change in DBT.
Schnell and Herpertz [26] were the first to demonstrate a
decreased activation of the amygdala and other brain
regions involved in emotion regulation after negative sti-
muli among DBT responders in a small fMRI study among
individuals with BPD who had received 12 weeks of in-
patient DBT. Later Goodman et al. [27] were able to
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Mehlum 91
demonstrate a reduced amygdala activation after negative
stimuli from pre-treatment to post-treatment among
patients with BPD following 12 months of standard
DBT; this reduction was significantly associated with
reductions in emotion dysregulation. Schmitt et al. used
[28] functional magnetic resonance imaging to investigate
neural correlates of emotion regulation capacity before and
after 12 weeks of inpatient DBT in females with BPD
compared with women who had not received DBT and
with healthy controls. During an emotion regulation task,
treatment responders displayed reduced activation in the
amygdala, anterior cingulate cortex, orbitofrontal, and dor-
solateral prefrontal cortex and increased fronto-limbic con-
nectivity. The same group also found that DBT leads to an
increased volume of grey matter in brain regions critical to
emotion regulation such as the anterior cingulate cortex,
inferior frontal gyrus and superior temporal gyrus [29].
People with BPD frequently use self-harm to regulate
emotions, a learned behaviour, and to reduce this behaviour
is a highly prioritized treatment target in DBT. A third
study from the same group provided important knowledge
on the mechanisms involved in this behaviour, and in
recovery from it, through DBT [30]. Adults with BPD
showed a marked activation of the amygdala and dorsolat-
eral prefrontal cortex following negative visual stimuli, but
this activation was significantly reduced after participants
having received 12 weeks of DBT. A similar reduction of
activation of the amygdala could be achieved in response to
painful stimuli. However, this amygdala deactivation was
no longer present after completion of the treatment in those
participants who received DBT, in contrast to those who
received treatment as usual. These studies will need to be
replicated, but the first insights they provide in the patho-
physiological and — psychological processes involved in
repetitive self-harming behaviour among people with
BPD, and the role played by DBT in the recovery from
repetitive self-harm are extremely promising.
An increasing body of research has shown us that the
human brain has a pronounced learning dependent struc-
tural plasticity; this is involved in the acquisition of all
types of skills and capacities and in new experiences and
learning from interactions with other people, such as in
psychotherapy. Hence, we may expect that our knowl-
edge on how the brain changes as a consequence of
psychotherapy will grow tremendously in years to come.
This will involve all levels of study, from molecules to
neurocircuitry. An example of this comes from a recent
study of possible epigenetic biomarkers of DBT outcome
in patients with BPD where Knoblich et al. [31] found
that higher levels of methylation of the genes APBA3 and
MCF2 was predictive of better treatment response.
Other factors
In real life interactions between people a multitude of
emotions, cognitions and behaviours are simultaneously
involved and in very complex ways. Disentangling these
Current Opinion in Psychology 2021, 37:89–93
92 Personality pathology: developmental aspects
in research is not easy, but nevertheless important. In a
series of experimental studies in non-clinical samples Lu
et al. [32] demonstrated how dialectical thinking may
influence outcomes when subjects attempt to use positive
emotion under negative and provoking interpersonal
situations with anger and despair. Individuals with high
levels of dialectical thinking were significantly more
successful at tolerating the tension between positive
emotions and negative situations and had less adverse
consequences of negative intergroup encounters. Meh-
lum et al. similarly investigated the potential role of
hopeful thinking versus hopelessness in a randomized
trial of 19 weeks of DBT versus enhanced usual care for
self-harming adolescents with BPD features [33]. A
reduction in adolescents’ levels of hopelessness during
the treatment period was a mediator of long-term (three-
year) outcomes in terms of frequency of self-harm
episodes. DBT includes several interventions to treat
hopelessness, for example the use of cognitive strategies
such as psychoeducation helping patients link problem-
behaviours to their goals, and the use of commitment
strategies and helping patients clarifying the pros and
cons of choices they make about their treatment and
future life. An important aspect of this study was the
linking of mechanisms of change during treatment with
long-term outcomes. Ultimately, what psychotherapy
attempts to achieve is lasting and favourable change in
the lives of those who receive the treatments. In this case
patients were young suicidal teenagers for whom much
was at stake in terms of survival as well as having a life
worth living.
Conclusions
As will hopefully be demonstrated by the brief review
above, the search for the how and why DBT works is
starting to bear fruit, but we must admit it is still in its
early stages. Most studies so far have been conducted in
adult patient samples and the vast majority of patients
have been female. Future research will need to clarify
whether mechanisms of change vary according to age,
gender or other salient population characteristics. Our
current evidence seems, however, to suggest that
improvements in emotion regulation capacity in general
play important roles as mechanisms of change in DBT.
Frequently, these changes are elicited through the use of
coping skills or mindfulness skills helping patients to
downregulate emotional reactions, to tolerate emotions
or to be able to respond to or behave appropriately in
stressful or precarious situations. A strong therapeutic
relationship where therapists use high levels of validation
seems equally beneficial for treatment outcomes. And
when therapists actively install hope in their patients and
foster the capacity of hopeful thinking, long-term out-
comes seem to improve, particularly with respect to
suicidal and self-harming behaviour. A growing body of
evidence shows us how neurobiological and epigenetic
change in brain regions important to emotion regulation
Current Opinion in Psychology 2021, 37:89–93
and behaviour control correspond with improved treat-
ment outcomes.
In the time to come, an increasing number of discoveries
and insights will probably help us to understand better
what we are really doing in psychotherapy and help us
deliver treatments in more specific and targeted ways.
This research is both intriguing and challenging and not
for the faint of heart [34], but nevertheless necessary to
make us able to offer effective and tailored treatments
to larger proportions of people with BPD and other
disorders linked to emotion dysregulation.
Conflict of interest statement
Nothing declared.
Funding
None.
CRediT authorship contribution statement
Lars Mehlum: Conceptualization, Methodology, Writing
- original draft, Writing - review & editing.
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Current Opinion in Psychology 2021, 37:89–93