The Link between Borderline Personality Disorder and Treatment of Suicidality
In must be emphasized that dialectical behavioral therapy (DBT), while making use of the cognitive-behavioral approach, is aimed at a population (Borderline Personality Disorder – BPD) whose suicidal behavior rarely has death as a target (Kiehn & Swales, 1997), so the results cannot be generalized to all cases of suicidal behavior. However, a number of studies aimed at applying cognitive-behavioral therapy (CBT) for suicidal patients who do not necessarily suffer from BPD have been conducted over the last couple of decades.
The Role of CBT
In one such study, Salkovskis, Atha and Storer (1990) selected a group of 20 patients at high risk of repeat suicide attempt, through an assessment with the Beck Hopelessness Scale (Beck, 1988), the Scale of Suicide Ideation (Beck, Kovacs, & Weissman, 1979) and the Beck Depression Inventory (Beck, 1974). The subjects were divided into two groups. One was treated with standard medical treatment and the other was treated with cognitive-behavioral techniques focusing on problem-solving skills. At the end of treatment the group that received CBT showed statistically greater improvements on all indicators and a consistent decrease in suicide attempts; the benefits were maintained throughout the following year. The study did, however, have a number of limitations. There was no differentiation with respect to severity and lethality of suicidal behavior and the sample size (10 in each group) was insufficient to draw conclusions, especially for a population as diverse as the patients who attempt suicide.
Rotheram-Borus et. al (1994) conducted another study which investigated the application of cognitive-behavioral techniques to a population composed of people who had previously attempted suicide. Using a sample population of over 100 teenagers who had previously engaged in suicidal behavior, the authors administered a set of cognitive-behavioral techniques known collectively as Successful Negotiation Acting Positively (SNAP). This consisted of a series of structured tasks in order to create a positive family environment, while improving social and problem-solving skills. The authors considered the results to be very encouraging, but I believe that the characteristics of the selected population (only teenagers), the absence of a control group and the lack of positive results after two-year followup raise justified doubts to the application of results to other populations which engage in suicidal behavior.
In a replica of the SNAP study, Rudd et. al (1996) applied cognitive-behavioral techniques to a large group of youths who had previously attempted suicide and reported positive results with the use of such therapeutic techniques. The sample population, consisting of 256 young people, whose suicidal behavior was almost exclusively of low lethality, was distributed into two therapeutic groups. One group received standard treatment while the other received 8 to 12 sessions of CBT. Assessments were made at one month, 12 months, 18 months and 24 months after the end of treatment. Results indicate that both treatments were effective for prevention of repeat suicidal behavior, but CBT was significantly more effective in preventing cases of more serious suicidal behavior.
Other authors, such as McLean and Taylor (1994), Freeman and Reinecke (1995) as well as Ellis and Newman (1996), proposed applying cognitive-behavioral techniques in suicidal adolescents and their families. However, such proposed designs have so far, not been tested in controlled studies. Van der Sande et. al (1997) carried out a systematic review of controlled clinical trials of psychotherapy interventions in patients who had previously attempted suicide, and in their results, reported that out of the studies cited, only the four that used cognitive-behavioral techniques were effective in preventing future suicidal behavior.
These results suggest that CBT should be the therapeutic technique of choice in cases of suicidal behavior. However, it is well known that suicidal behavior is varied in nature and affects people from diverse backgrounds, many of who suffer from comorbid psychopathology. It is therefore necessary that these therapeutic techniques be tested on patients with different types of suicidal behavior and with different underlying psychiatric conditions, so that their effectiveness can be universally verified.
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