Treatment differences in the therapeutic relationship and introject during a 2-year randomized controlled trial of dialectical behavior therapy versus nonbehavioral psychotherapy experts for borderline personality disorder.

Evidence has continued to accumulate supporting the efficacy of dialectical behavior therapy (DBT; Linehan, 1993) for the treatment of borderline personality disorder (BPD; APA, 1994; Morey & Zanarini, 2000). DBT has been shown to be superior to treatment as usual and treatment by expert clinicians across a variety of domains of functioning including suicide attempts, emergency/inpatient treatment, intentional self-injury, anger, depression, and social and global adjustment among others (Kliem, Kroger, & Kosfelder, 2010; Lynch, Trost, Salsman, & Linehan, 2007). A critique of DBT, and these associated findings, has been DBT's perceived emphasis on symptomatic change as opposed to elements of patients’ experience that represent internal or intrapsychic change (e.g., Scheel, 2000). Similarly, behavioral approaches have historically been perceived as underemphasizing the use of the therapeutic relationship for the sake of technique (Lejuez, Hopko, Levine, Gholkar, & Collins, 2006). Broadly speaking these critiques speak to issues of the underlying mechanisms of change in DBT (e.g., Neacsiu, Rizvi, & Linehan, 2010). The current study sought to test these critiques by examining intrapsychic change and the role of the therapeutic relationship in DBT compared to a community treatment by experts (CTBE) control condition. According to interpersonal theory (Sullivan, 1953), the concept of the introject can be defined as an aspect of an individual's personality that consists of self-directed actions including cognitive self-appraisals, and verbal and physical actions directed toward the self (Henry, 1996; Henry, Schacht, & Strupp, 1990). These internal, self-directed actions are thought to be fairly stable across the lifespan, reflective of the actions of early caregivers, and conceptually related to one's self-concept (Pincus, Gurtman, & Ruiz, 1998a). The concept of the introject has been particularly useful in furthering our understanding of BPD. Benjamin and Wonderlich (1994) found BPD patients to have an overall attacking and abandoning introject when compared to patients diagnosed with major depressive disorder and bipolar disorder. Additional studies have suggested that a hostile internal relationship with the self may act as a regulatory strategy for managing aversive experiences related to overall BPD symptom severity (Rosenthal, Cukrowicz, Cheavens, & Lynch, 2006) and that BPD patients value their negative self-concept as a desired part of their identity (Janis, Veague, & Driver-Linn, 2006). Based on a biosocial model of BPD (Linehan, 1993), DBT treats the development of a positive self-concept as a primary target of therapy. Although not using the term introject per se, patients are taught methods of appropriate self-evaluation, methods of tolerating disapproval, and ways of decreasing self-invalidating behaviors that are antithetical to patient goals. In an exploratory test of introject change during DBT, Shearin and Linehan (1992) showed that patients who perceived their therapist as providing more control and instruction were in turn perceived by their therapist as having an introject that was more self-caring. Despite DBT's theoretical emphasis on patient self-concept, critics have suggested that behavioral treatments, such as DBT, fail to incorporate important personality factors, such as the introject (Benjamin, 1997; Scheel, 2000; Shedler, 2010). These same critiques suggest that the effectiveness of DBT in the treatment of BPD can be accounted for by symptom reduction rather than intrapsychic changes in patient factors considered more relevant to improvement when treating personality disorders. In light of the theoretical importance of the self-concept in DBT, and as a response to critiques, a goal of the present study was to examine the nature of introject change in DBT during the course of a randomized controlled trial of DBT. One mechanism hypothesized to result in intrapsychic change during DBT is the therapeutic relationship (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). The therapeutic relationship is a common treatment factor that has been shown to have a consistent effect on outcome across a variety of therapeutic modalities (Castonguay, Constantino, & Grosse Holtforth, 2006). Although historically perceived as underemphasized in behavior therapy, recent work has begun to more fully explicate the role the therapeutic relationship in cognitive and behavioral interventions (Gilbert & Leahy, 2007; Grosse Holtforth & Castonguay, 2005; Lejuez et al., 2006). In DBT, a positive therapeutic relationship is considered essential to treatment and serves two functions (Linehan, 1993; Robins & Koons, 2000). First, the relationship between the therapist and patient is considered therapeutic as the therapist provides an accepting, nonjudgmental, and compassionate stance toward the patient. Second, the therapeutic relationship also provides an avenue for the therapist to help the patient regulate their affect and behavior. Thus, the relationship also allows the therapist to exert control and influence where the patient might be initially lacking the skills to do so themselves. During the course of treatment the therapist attempts to balance the two poles of acceptance and change as a method of simultaneously validating the patients’ experience and also correcting dysfunctional behaviors – a dialectic of DBT. In a preliminary analysis of this dialectical style, Shearin and Linehan (1992) examined the therapeutic relationship in four therapist-patient dyads during DBT. Results showed patients’ perceptions of simultaneous control, autonomy, and warmth to be predictive of an overall decrease in suicidal behavior (i.e., non-suicidal self-injury, urges to self-harm, and suicide ideation) in two of the four cases. An overall significance test supported the dialectical hypothesis and results were maintained while controlling for non-dialectical hypotheses including therapists’ behavior that was purely autonomous or purely controlling. Although based on a few cases, these results provided preliminary data supporting the importance of acceptance and control in the interpersonal stance of the DBT therapist. Based on these initial impressions, the current study attempted to examine the therapeutic relationship in DBT using a much larger treatment sample in the context of a randomized controlled trial of DBT. The present study had the following five hypotheses. First, we explored introject change during the course of DBT. Given DBT's emphasis on self-concept change, our first hypothesis predicted DBT patients to show a more affiliative introject during the course of treatment. In light of DBT's emphasis on therapists’ warmth and control, our second hypothesis predicted DBT therapists to be perceived by patients as emphasizing greater levels of affirmation, protection, and control during treatment. Our third and fourth hypotheses explored the association between therapist affiliation with introject and non-suicidal self-injury (NSSI) in DBT. We expected higher ratings of overall therapist affiliation to be related to increased introject affiliation (hypothesis three) and less frequent NSSI (hypothesis four) for DBT patients. Our fifth hypothesis predicted that the simultaneous use of emancipating, affirming, protecting, and controlling behavior, the DBT dialectic, to predict improved outcome. With each hypothesis, DBT was compared to CTBE. Although there were not specific hypotheses about how these two treatments would differ, CTBE practitioners were notably psychodynamic and eclectic in orientation and hence provides a meaningful comparator relative to our hypotheses about DBT.