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 JBBS  Vol.11 No.12 , December 2021
Borderline Personality Disorders by Dialectical Therapy
Abstract: This study aimed to discover the possibility of reducing the symptoms of borderline personality disorders (BPD) through the dialectical treatment of a sample group of individuals with BPD in Kuwait. To achieve this objective, a quasi-experimental approach was applied by dividing the study sample into two groups; the control group consisted of 75 individuals and the experimental group consisted of 75 individuals. In addition, a borderline personality disorder scale and program were developed based on American psychologist Marsha Linehan’s rules of dialectical behavioral therapy (DBT). Among the results, the study found statistically significant differences between members of the two groups due to the use of the counseling program based on dialectical treatment. This indicates a positive effect of using the counseling program to reduce the level of BPD among the members of the study sample, in favor of the experimental group.

1. Introduction

The analysis of personality occupied an important place in this study. What helped to confirm this position was to view personality as the outcome of several factors operating in an integrated unit, which results from the interaction of several gross and psychological features that determine the way the personality deals with environmental components. Therefore, personality is nothing but an integrated, dynamic organization of physical, mental, moral, and social characteristics. BPD is usually diagnosed when these different features overlap with clearly abnormal actions so that they are distorted. Each personality disorder is preceded by a set of pathological features that appear on the individual through his interaction with himself and the surrounding environment [1].

BPD is considered an overall pattern of instability in the human emotions system, which appears in the context of relationships with others, mood, and the person’s self-image. A person with BPD tries to control this unique type of tension in the intensity of his/her feelings or to act with what tools he/she has, but that in turn causes symptoms of this disease [2]. BPD is a group (B) personality disorder that makes it difficult for an individual to feel safe in his relationships with others, to have good beliefs about themselves, and to control their emotions. The individual may also suffer from distress in his/her family and social life, in his/her work, and the individual may harm himself/herself. Moreover, BPD is not the individual’s own fault, but rather a combination of biological factors or early traumas in life [3].

An individual with BPD has an intense fear of abandonment or instability and may have difficulty tolerating loneliness. In addition, the individual’s suffering from acute anger, impulsivity, and volatile moods push others to turn away from him/her despite his/her need to feel love and the presence of lasting relationships. BPD usually begins with the onset of adulthood, worsens in youth, and may gradually improve with age [4]. Many indicative and therapeutic approaches have been developed for the treatment of BPD, and these approaches have varied between medical treatment, cognitive therapy, and behavioral therapy [5]. In addition, dialectical behavioral counseling, with its many techniques, is considered one of the most effective approaches for treating BPD [6].

Reference [7] was the first to use the method of dialectical behavioral counseling in treating individuals with BPD, as Linehan treated individuals suffering from emotional fluctuations, chronic agitation of thoughts, suicide attempts, and unjustified anger. Dialectical behavior therapy (DBT) arose primarily to treat behaviors such as self-harm and suicidal thinking, evolved into treating adolescents and adults with BPD, and then expanded to include many other disorders such as depression and eating disorders. DBT aims to treat the symptoms of borderline personality disorder by replacing maladaptive behaviors with healthy coping skills, such as mental alertness, interpersonal effectiveness, and relationship regulation, and it is currently the only empirically supported treatment for BPD [8].

The current study represents a purposeful attempt to contribute to the research for reducing the symptoms of BPD through the method of dialectical treatment, as this topic is of great importance in the prospect of reducing the symptoms of borderline personality disorders. This study also stems from a desire to support the sample group covered by the study, who are individuals suffering from BPD in Kuwait in need of care and attention.

2. Research Problem

BPD is a mental health disorder that affects how one thinks and feels about oneself and others, which leads to problems in daily life. It includes issues with a person’s self-perception, difficulty in controlling feelings and behavior, and frequent relationship disturbances. Numerous studies [9] [10] have indicated that personality disorders represent one of the most important concerns of researchers in psychology, owing to their profound impact on all aspects of the lives of those who suffer from BPD. This includes disturbances in their perception, attitudes, emotions, and daily practices, which leads to many problems associated with impulsive behaviors, unconscious and unstable relationships with others, and even perceptions of situations and events are skewed. Consequently, the study of BPD is extremely important in the field of diagnosing and guiding many other disorders as well.

Several studies [11] [12] have indicated the existence of a wide range of disorders and problems that can be addressed through counseling programs based on DBT, such as aggression and anger, impulsive behavior, depression, and post-traumatic stress disorder. Despite the importance of the topic of borderline personality disorder and its treatment using dialectical therapy, which was considered a successful treatment by many researchers, this treatment has not been applied to people with borderline personality disorder in Kuwait (according to the researchers’ knowledge), and since societies differ in their components and lifestyles. Therefore, it is necessary to ascertain the effect of the argumentative treatment method on patients with borderline personality disorder in Kuwait.

Based on this, it is important to study the effect of the dialectical treatment method on individuals with BPD, especially since these individuals suffer from a set of disorders and problems that this method can treat. Therefore, the problem of the current research is determined by the following questions:

1. What is the effect of using the dialectical method of treatment in reducing the symptoms of BPD in a sample of individuals with BPD in Kuwait?

2. Are there statistically significant differences at the significance level (α ≤ 0.05) in the BPD scale prepared in this study among the experimental group students due to the gender variable?

3. Literature Review

3.1. Borderline Personality Disorder

Personality disorder, in general, is a pattern of feelings and behaviors that seem appropriate and justified for the individual who suffers from them, however, these feelings and behaviors in fact cause many problems in an individual’s life. There are nine other types of personality disorders besides borderline personality disorder: paranoid disorder, disorder dissociative personality disorder, schizotypal disorder, antisocial personality disorder, representational personality disorder, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder, selfish personality disorder, and obsessive-compulsive disorder [13].

Individuals with BPD may seek closeness, but their intense and unstable emotional responses tend to isolate them from others. This in turn causes feelings of isolation in the long term, which calls for seeking the correct and necessary help from doctors to try to control the development of the disorder and start living a normal, free life of complications. In addition, the term borderline refers to the fact that individuals with this condition tend to set limits in their lives, whether in their relationship with others or in the mental processes that take place within them [14].

Personality disorders, as a clinical concept, are simply the behavioral product of delayed, faltering, over-intensity, or deviation in the maturity process, and are considered maladjustments that affect a person’s social and functional performance. In addition, BPD is considered a mental illness and mental disorder in which the individual feels a state of depression and constant anxiety, affecting adolescents the most. This may cause him/her to make rash decisions, have mood swings, or feel sharp anger, and these fluctuations, in turn, affect his/her relationship with others [15].

Symptoms of BPD vary from person to person, and women are more likely to have this disorder than men. Common symptoms of BPD are [16]:

1) An unstable or dysfunctional self-image or distorted self-feeling.

2) Increasing feelings of isolation, boredom, and emptiness.

3) Difficulty feeling empathy for others.

4) Unstable relationships that can change drastically from intense love and idealism to intense hate.

5) Constant fear of abandonment and rejection.

6) Sudden mood change that can last for several days or only a few hours.

7) Strong feelings of anxiety and depression.

8) Impulsive, risky, and destructive behaviors including reckless driving, drug or alcohol abuse, and unprotected sex.

9) Violence and aggression toward others.

3.2. Dialectical Therapy

DBT is a psychological treatment method designed to treat people by altering their ineffective behavior patterns, such as self-harm, suicidal ideation, and substance abuse. This method of treatment aims to help people increase emotional and cognitive control by recognizing the things that generate emotions and active states in them; it also aims to help them evaluate which coping methods they should use during the sequence of events, thoughts, feelings, and behaviors that ultimately lead them to unwanted behavior. DBT assumes that people are doing their best to avoid this behavior, but that they lack skills or are affected by positive or negative reinforcements that interfere with one’s job performance [17].

DBT was developed as a pivotal form of cognitive-behavioral therapy by psychologist [7] to treat people with BPD and individual cases of chronic suicidal thinking. Although research on the effectiveness of this method in treating other conditions is very limited, DBT has been used in addition to other therapeutic approaches to treat mental disorders such as eating disorders, mood disorders, or those that occur due to traumatic brain injury. This method of treatment has also been found effective in cases of sexual abuse survivors, as well as in cases of drug addiction [8].

DBT is a type of cognitive-behavioral therapy. Its main goal is to teach people how to live in the present time, deal with healthy stress, regulate emotions, and improve relationships with others by transforming negative thinking patterns into positive behavioral change. It was originally developed to treat BPD and suicidal thoughts (in other words, severe and chronic psychological problems), but has since been adapted for other conditions including self-harm, eating disorders, addiction, and post-traumatic stress disorder [18].

DBT combines standard cognitive-behavioral techniques for regulating emotions with a realistic appraisal of concepts such as distress tolerance, receptivity, and rational thinking, largely derived from Buddhism. DBT, based on a biosocial theory describing mental illness, is the first treatment to be empirically shown to be effective in treating BPD in general. The first randomized clinical trial of DBT showed lower rates of suicidal gestures, psychiatric hospital admission, and dropout compared with standard treatment methods [14].

4. Methodology

The study population consisted entirely of individuals with BPD at the Kuwait Center for Mental Health, which totaled 5212 patients. As a result of the Kuwaiti government’s measures to limit the spread of the COVID-19 virus, which is represented in not making large gatherings, in addition to the reluctance of many patients to participate in this experiment, whether because they are ashamed of this disease or because they are afraid of contracting the Covid-19 virus, the researchers were only able to choose 150 individuals to conduct this study.

Therefore, the study sample comprised of 150 patients, who were randomly selected from the total, and the quasi-experimental approach was used by dividing the study sample individuals into two groups; the control group consisted of 75 individuals and the experimental group consisted of 75 individuals. Table 1 shows the distribution of the study sample according to their demographic variables.

To achieve the objectives of this study, the researcher used two instruments, as follows.

4.1. Borderline Personality Disorder Scale

To prepare this scale, the researcher conducted the following steps: (A) review of previous studies and research on BPD, and (B) view the available tools related to BPD.

The Borderline Personality Disorder Scale, a preparation for [19], is a self-assessment method consisting of 51 items that measure a group of sub-phenomena (loss of identity, primitive defense mechanisms, weakness of

Table 1. Characteristics of the study sample according to the demographic variables.

reality test, and fear of vanishing). The Borderline Personality Disorder Scale prepared by [10] included 145 statements distributed across eight dimensions: lack of evidence of feelings of fear of abandonment, fluctuation of feelings, disturbance of self-image, self-harm and impulsivity, a marked decrease in mood activity, emotional revolution, paranoid thoughts, and cognitive excitement of stressful events.

In light of the above, the Borderline Personality Disorder Scale was prepared in its initial form, which consisted of 50 statements distributed across four dimensions: emotional instability, identity disorder, impulsivity and abuse, and negative relationships with others. These were answered using the Quadrant Response Scale (Always, Sometimes, Rarely, Never).

The validity of the scale was verified by presenting it to a group of referees from among faculty members in Kuwaiti universities. After reviewing the opinions of the referees and their suggestions, the scale was revised by amending or deleting statements based on the majority of referees’ opinions, until the scale in its final form consisted of 45 statements.

The reliability of the BPD dimensions was verified by internal consistency (by calculating the Cronbach alpha coefficient) and the values of the reliability coefficient for the dimensions of the borderline personality disorder scale ranged from (0.75 - 0.82). These values are considered acceptable for the purposes of the current study.

4.2. Program Based on the Rules of Dialectical Behavioral Therapy

The program was based on the rules of DBT by the American psychologist Marsha Linehan with four skills: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. These skills are among the group of skills trained in DBT, and they have been referenced in many studies by [8] [10].

The program was prepared to suit the developmental characteristics of the ages of the study sample, which ranged between 18 - 28 years, and the behavioral therapy prepared in this study passed through four basic stages:

The first stage involved moving from a state of lack of control over the behavior to placing the behavior under control, to achieve four goals. These included reducing and eliminating life-threatening behaviors (e.g., suicidal thinking), reducing and protecting behaviors that negatively affect treatment (e.g., psychological burnout and absenteeism from attending sessions), reducing behaviors that destroy life and erase it (e.g., depression and fear), and finally teaching individuals the skills that help them understand emotions and how to get rid of them. The second stage involved moving from a state of suppressing emotions to fully expressing them, with the aim of helping individuals overcome their emotions without negatively affecting them. The third stage involved building regular life and solving daily life problems, such as family conflict and job dissatisfaction. The fourth stage involved moving from a state of incompleteness to a state of maturity, with the aim of developing awareness among individuals to search for specific clues using spiritual means and places of worship.

The counseling program consisted of 30 group counseling sessions; each session lasted 90 minutes, occurred on average twice per week, and ran for a period of 10 weeks. The program was based on the following principles:

1) Program should be relatively short to suit application in academic settings, where sessions can be passed within free time.

2) Application of the program should be through group counseling sessions

3) Counseling sessions should be formulated according to the behavioral therapy skill training model.

4) Participants should be trained in mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills.

5) Program implementation techniques should include lecturing, dialog, and discussion.

6) The Homework method should be utilized (i.e., each session ends and is reviewed in the next session, with feedback provided to the participants).

The data and material used in this study are not available, because it’s considered private information for respondents.

5. Data Source and Analysis

Two sources of data were utilized in this study:

Primary sources: Also referred to as field sources, these sources are directly related to the subject of the study. The data of the study community were collected directly using the Borderline Personality Disorder Scale. Secondary Sources: Data collected by the researcher from periodicals, books and reports, master’s theses, doctoral dissertations, and other reliable sources.

For the analysis of the study, data were analyzed using the Statistical Package for the Social Sciences software (SPSS. 25) [20] [21], through:

1) Descriptive statistics (frequency, percentage, mean, and standard deviation).

2) T-test for two independent samples.

6. Study Results

To ensure the validity of the results and to avoid any other factors that may impact the outcome, a set of tests were conducted for members of the study sample prior to answering the study questions. To ensure that the two groups of the study (experimental and control) were equal, as well as ensuring that members of the experimental group in particular were equal with no differences due to the variable of gender, the following steps were taken prior to starting the counseling program:

First, a parity of control group members with experimental group members on the Borderline Personality Disorder Scale was performed by applying the scale to the members of the groups prior to the start of the counseling program. This was to ensure that members of the two groups were equal, and Table 2 shows the results.

Data from Table 2 indicated that the mean of responses from the experimental group on the Borderline Personality Disorder Scale reached 3.07, with a standard deviation (0.514). The mean of the control group was (3.05) with a standard deviation (0.470), which indicated that the means converge and the levels of both the control and experimental groups are close. This was confirmed by the value of (T) of (0.342), which meant there were no statistical differences at the level of significance (α ≤ 0.05) in the answers of the groups on the Borderline Personality Disorder Scale. Therefore, it can be said that the two groups are equivalent and suitable for study purposes.

Second, a parity of experimental group members on the Borderline Personality Disorder Scale was conducted due to the gender variable. This was done by applying the scale to experimental group members before using the counseling program; then, the scores were collected for all members of the study sample and a (T) test was performed for the results of the experimental group members. Table 3

Table 2. (T) test results between members of the experimental group and the control group in the borderline personality disorder scale before starting to use the counseling pro-gram based on dialectical treatment.

Table 3. (T) test results between members of the experimental group in the borderline personality disorder scale before starting to use the counseling program based on dialectical treatment.

shows the results.

Data from Table 3 indicated that the mean of responses of male members on the Borderline Personality Disorder Scale reached (3.11) with a standard deviation (0.514), while the mean of female members was 3.00, with a standard deviation of 0.516. This indicated that the means converge and the levels of both the male and female members are close. This was confirmed by the value of (T) of 0.873, which meant there were no statistical differences at the level of significance (α ≤ 0.05) in the answers of experimental group members on the Borderline Personality Disorder Scale. Therefore, it can be said that experimental group members are equivalent and suitable for study purposes.

Answer the study questions

First question: What is the effect of using the dialectical method of treatment in reducing the symptoms of BPD in a sample of individuals with BPD in Kuwait?

To answer this question, arithmetic means, standard deviations and a (T) test of two independent samples were extracted to indicate the differences between the performance of the experimental group and the control group on the depression scale prepared in this study. This occurred after training experimental group members through the counseling program. Control group members were not trained, and the results are shown in Table 4.

It should be noted from Table 4 that the mean of the experimental group in the borderline personality disorder scale is (2.80) with a standard deviation of (0.526), while the mean of the control group is (2.90) with a standard deviation (0.372), as indicated by the value of (T) of (2.373) and the level of significance (0.005). This means there are statistically significant differences at the level of significance (α ≤ 0.05) between the means of the experimental and control groups in the borderline personality disorder scale. The inequality between the two groups indicates a positive effect of using the counseling program on reducing the level of BPD among the members of the study sample.

This was attributed to the fact that DBT helps individuals increase emotional and cognitive control by identifying the things that generate emotions and active states in them, and aims to assist them in evaluating which coping methods they should use during the sequence of events, thoughts, feelings, and behaviors, which ultimately lead to unwanted behavior.

The results were also attributed to the benefits of using DBT, which included teaching individuals how to live in the moment, develop healthy ways to deal

Table 4. T-test results between experimental group and control group members in borderline personality disorder scale after starting to use the counseling program based on dialectical treatment.

with stress, regulate their emotions, and improve their relationships with others. DBT also included helping individuals pay attention to what is happening inside them (thoughts, feelings, sensations, and impulses), using their senses to control what is happening around them, and not make judgments. As a result, individuals reduce suicide and self-harm behaviors, improve tolerance, control and regulate emotions, reduce symptoms of anxiety, depression, trauma, and hardship. They also learn to set rational goals to improve the quality of life, reduce non-adaptive behaviors and thoughts that affect quality of life and relationships, and improve belief in self and self-esteem.

Second Question: Are there statistically significant differences at the significance level (α ≤ 0.05) on the Borderline Personality Disorder Scale among experimental group members due to the gender variable?

To answer this question, arithmetic means, standard deviations and a (T) test of two independent samples were extracted to indicate the differences between the performances of experimental group members on the depression scale prepared in this study. This occurred after training experimental group members through the counseling program, due to the gender variable. Table 5 explains the results of this.

It should be noted from Table 5 that the mean of male members in the Borderline Personality Disorder Scale is 2.87, with a standard deviation of 0.486; the mean of female members is 2.68, with a standard deviation of 0.580, as indicated by the value of (T) of (1.504). The level of significance is (0.158), indicating that there are no statistically significant differences at the level of significance (α ≤ 0.05) between the means of male and female experimental group members, which indicates there are no statistically significant differences due to gender.

7. Recommendation

In the light of the results, the study recommends:

1) The necessity of using DBT techniques in treating BPD cases in psychotherapy centers in Kuwait, due to their clear effect on reducing symptoms of this disease.

2) Conducting similar studies on different age groups and other sectors of society who suffer from psychological and behavioral disorders and problems.

3) Further study of the effectiveness of dialectical behavioral counseling in reducing reproductive personality symptoms.

Table 5. T-test results between experimental group members in borderline personality disorder scale after starting to use the counseling program based on dialectical treatment due to gender variable.

Acknowledgements

The authors would like to thank the anonymous referees for constructive comments on the earlier version of this paper.

Cite this paper: Al-Khalidi, N. and Al-Tayyar, H. (2021) Borderline Personality Disorders by Dialectical Therapy. Journal of Behavioral and Brain Science, 11, 301-312. doi: 10.4236/jbbs.2021.1112025.
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