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The use of DBT skills in the treatment of difficult patients in the General Hospital.

Received Sept. 19, 2002; revision received Feb. 24, 2003; acceptedMarch 17, 2003. From the Psychiatry Consultation Service, Massachusetts General Hospital; and the Harvard Medical School, Boston. Address reprint requests to Dr. Huffman, Massachusetts General Hospital, 55 Fruit St., Warren 605, Boston, MA 02114; jhuffman@partners.org (e-mail). Copyright 2003 The Academy of Psychosomatic Medicine. Dialectical behavior therapy (DBT) is a form of psychotherapy developed by Marsha Linehan in the 1980s to treat borderline personality disorder. Subsequent studies have found that DBT leads to less self-injury, fewer inpatient hospitalizations, and improved social adjustment in psychiatric outpatients with borderline personality disorder and also leads to less self-injury, depression, and anxiety among psychiatric inpatients with borderline personality disorder. Critical reviews of this literature have noted that these studies are limited by small numbers of subjects (less than 25 subjects in the active treatment groups), by the lack of a control group in the inpatient study, and by the fact that much of this research has been done by a single research group (led by Linehan). Despite these flaws, the studies do suggest that DBT can have a significant impact on psychiatric symptoms and quality of life for persons with borderline personality disorder. DBT relies upon principles of both cognitive behavior therapy and Eastern meditative philosophy to help patients with borderline personality disorder regulate their emotions. The treatment assumes that maladaptive behaviors, including self-injury, are attempts to manage intense affect. DBT emphasizes validation of a patient’s painful emotional experience and acceptance that the patient is doing the best that he or she can at that moment. DBT also emphasizes the need for change by teaching new coping skills. The skills training component of this treatment modality focuses on development of skills in four areas: mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation. While DBT has effectively treated individuals with borderline personality disorder in psychiatric settings, it appears that specific DBT skills could be adaptable to the treatment of difficult patients in the general hospital. Such skills can be introduced to help patients on medical units cope more effectively with stressful experiences. These skills can also be taught to staff to help them regulate their own emotional reactions to difficult patients. Here we present the hypothetical case of a patient on a medical service whose interpersonal style led to difficulties in management. Following the case vignette, we discuss how the principles of DBT and the skills that it teaches can be applied to medical patients in the general hospital.