ijcrb.webs.com INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS JANUARY 2012 VOL 3, NO 9

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A STUDY OF THE EFFECT OF COUPLE DIALECTICAL

BEHAVIORAL THERAPY ON SYMPTOMS AND QUALITY OF

MARITAL RELATIONSHIPS AND MENTAL HEALTH OF

IRANIAN BORDERLINE PERSONALITY COUPLES: A

CONTROLLED TRIAL

Mahnaz Joukar Kamalabadi

66

, Seyyed Ahmad Ahmadi

67

, Ozra Etemadi

68

Maryam Fatehizadeh

69

, Fatemeh Bahrami

70

, Ali Firoozabadi

71

Abstract

The aim of this study was to evaluate the effect of couple dialectical behavior therapy (CDBT) on symptoms and quality of marital relationships and mental health of Iranian borderline personality couples. Borderline personality disorder symptoms (BPDSI-IV), general mental health questioner (GHQ), perceived relationship quality components (PRQC)were assessed in 15 male patients and their partner who had participated in this program. Fifteen waiting list patients were participated as control group. Post-testing was conducted four months after the initial assessment (i.e. 1 month after discharge for the CDBT group). ANCOVA with pretest as covariate demonstrated that there was a significant difference between the groups in favor of the CDBT on 8 psychopathological variables and 3 subscale of GHQ and 5 subscale of PRQC. The results confirmed the efficacy of CDBT in redacting BPD symptoms, increasing mental health improvement and perceived relationship quality of patients.

Key words: Couple dialectical behavioral therapy, Quality of marital relationships, Mental health,

Iranian, Borderline personality disorder, Symptom

Introduction

Borderline personality disorder (BPD) is characterized by high levels of emotional distress, sensitivity, reactivity, impulsivity, suicidality and self harming behaviors, interpersonal difficulties, fear of abandonment and experiencing emptiness of self. Seven criteria of 9 DSM's criteria indicate on interpersonal relationship (Glick, and Loraas, 2001).

A first generation of research showed that BPD patients had lower probability of being married (Swartz, et al, 1990; Zimmerman, et al, 1990), greater number of breakups in marital relationships (Labonté, et al., 1993), shorter friendship ties, and absence of intimate partnership (Bernstein, et al 1996). Fruzzetti and Fruzzetti (2003) estimated that by using sub threshold criteria of BPD (at least three criteria met), close to 50% of distressed couples seekingtreatment have at least one member with borderline personality traits or the full syndrome of BPD. The results of early studies suggested that in axis II diagnosis, significantly decreased relationship satisfaction .This negative effect was more important for couples in which one partner suffered from a personality disorder than for couples in which one partner suffered from an axis I disorder (Reich, et al, 1989; Truant, 1994). Chen, et al. (2004) findings although suggested that borderline traits have a negative impact on relationship satisfaction and may be lasting and even increase over time. Self-reported relationship quality is lower in BPD patients than in patients with other personality disorders. The main findings of Zanarini et al. (2005) research revealed that compared with other patient groups, BPD was related to more romantic relationship dysfunction. BPD patients also evidenced elevated avoidant romantic relationship. Bouchard et al., (2009) showed both partners of BPD couples reported lowered dyadic satisfaction than community couples.

66_{Corresponding author, PhD student of family counseling ,Department of education and psychology,}

University of Isfahan, Iran

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Dailey and his colleagues (2000) found that the presence of borderline personality traits predicts decreases in partner satisfaction and increase romantic conflicts, and unwanted pregnancy. In a study Bouchard, et al. (2009) reported that the most of BPD couples reported a chronic pattern of episodic relationship, instability characterized by intermittent breakups and reunions approximately once every 6.5 months. In addition, 28.6% of clinical couples reported having broken up definitively before the end of a study.

The most comprehensive treatment program for individuals meeting criteria for BPD is dialectical behavioral therapy (DBT) (Linehan, 1993). This therapy has repeatedly shown to be both effective (e.g., Linehan, 2002; Linehan, et al., 1999) and efficacious (Linehan, 1997). Fruzzetti and Fruzzetti (2003) applied Linehan’s dialectical behavior therapy with borderline personality disorder couples. These dialectics include (a) closeness versus conflict, (b) partner acceptance versus change, (c) one partner’s needs and desires versus the other’s, (d) individual versus relationship satisfaction, and (e) intimacy versus autonomy. DBT with couples emphasizes the role of deregulated emotions in the breakdown of communication and the escalation of conflict, and includes many interventions to help partners regulate emotion as a means (or mediator) to either acceptance or change. (Fruzzetti and Fruzzetti, 2010). In CDBT one of the treatment goals is reducing negative patterns and creating more constructive interaction patterns. Focusing more attention to skills needed to regulate emotions, to increase awareness of genuine or heartfelt goals ( e.g. having a better relationship) even when the urge to be nasty is present, and to match the form and function of communication, so that expression is more accurate, making it easier for partner to understand and validate each other. This approach focuses on creating a variety of effective ways to validate inherently valid things that partner express. In a study of two groups of couples (with and without a partner with BPD or significant BPD features) who participated in a pilot, DBT couple therapy showed a significant improvement in relationship satisfaction and communication (Hoffman, et al, 2007). In studies of parents and partners of people with BPD who participated in a time limited group program which called family connections showed a significant reduction in grief, depression, burden, and increase in mastery and empowerment (Hoffman et al.,2005; Hoffman, Fruzzetti, & Buteau, 2007). The effects of this couple intervention were evaluated and confirmed in another study (Kirby & Baucom, 2007).

The aim of this study was to examination the effect of couple dialectical behavioral therapy on symptoms and quality of marital relationships and mental health of Iranian borderline personality couples.

Method:

1. Participants:

This study was a randomized controlled trial, encluded 30 borderline patients and their couples. The patients were referred by psychiatrists of Hafez, Ebne Sina and Razy hospitals in Shiraz.

The inclusion criteria were that participants were married males, 18–50 years old and met borderline personality disorder symptoms. Exclusion criteria were that lifetime diagnosis of schizophrenia, bipolar disorder, dissociative identity disorder, antisocial personality disorder, drug addiction and mental retardation. Thirty men who met the inclusion and exclusion criteria were selected for this study (15 for experimental and 15 for control group).

2. Treatment plan:

The treatment plan consisted of 14 weekly sessions based on couple dialectical behavioral therapy (Fruzzetti & Fruzzetti, 2010). Sessions was included: accepting himself and his partner, training to stop making thing worse, being together in close relationship, reacting their relationship, accreting expression, validating responses, recovery from invalidation, managing problem and negotiating solutions and transforming conflict in to closeness. Mindfulness and relationship mindfulness are the first and key skills to effective implementation of these skills sets; they are also meant to specifically target identity disturbances.

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3. Instruments:

3.1. Borderline Personality Severity Index (BPDSI-IV): The BPDSI is a semi-structured interview (Arntz et al., 2003), assessing the frequency of borderline symptoms in the previous 3-month period. The BPDSI consists of nine sections, one for each of the DSM-IV criteria for BPD. The BPDSI-IV has been used in many trials (Bellino, et al, 2005, 2006; Giesen-Bloo et al., 2006; Rinne, et al, 2002; Rinne et al., 2003; Verheul, et al, 2003). It was translated at least into seven languages, and the published trials show high sensitivity for detecting change. It translated to Persian by researcher and ICC’s of the BPDSI-IV total and subscale scores were (0.89–1.00). Internal consistency of the BPDSI-IV total score was (α = 0.83) and the internal consistencies of the subscales ranged from moderate to high.

3. 2. Perceived Relationship Quality Components (PRQC) Inventory: The PRQC is designed to measure individuals’evaluations of their relationship satisfaction, commitment, intimacy, trust, passion, and love Partner evaluates their relationship on a seven-point Likert scale ranging from not at all (1) to extremely (7). The alpha reliability coefficient for this measure was .95. (Fletcher, Simpson, & Thomas, 2000). Cronbach’s alpha in an Iranian sample was .95 ( Nilforooshan, 2010).

3.3. General Mental Health Questioner (GHQ): The GHQ is a well-known screening instrument for measuring current mental health (Goldberg, et al., 1992). This instrument had a good psychometric characteristic in Iranian samples. The GHQ has been translated into 38 languages and interrater and intrarater reliability have both been shown to be excellent (cronbach's alpha 0.89–1.00)( Makowska, et al., (2002). In the present study the GHQ was used as a measure of current degree of illnesses.

Results:

In this study it was hypothesized that couple dialectical behavioral therapy has a positive effects on decreasing symptoms and increasing quality of marital relationships and mental health of Iranian Borderline Personality Couples.

Findings demonstrated that there was no significant differences between treatment conditions regarding age, educational level and number of children. As it was shown in table 1, differences of BPD symptoms at pretest between two groups were no significant. As hypothesized, one month after the end of the couple DBT, ANCOVA demonstrated that there was a significant difference between the groups in favor of the couple DBT (CDBT). Specifically, the treatment group had significantly lower scores one month after the end of sessions of measures of BPD symptoms (BPDSI-IV), low score in 3 subscales of general mental health questioner (GHQ) and higher scores of 5 subscales of PRQC in treatment group.

The positive treatment effect was repeated for partner of treatment group in the scores of PRQC. An additional ANCOVA was conducted to examine the subscale scores of the BPDSI-IV. Table 1 presents the subscale results at pretest and posttest. There were no significant differences between the CDBT and control group on any subscale at pretest. At posttest points, the CDBT-group had significant improvement almost in all subscales of BPDSI-IV (except dissociation) and PRQC (except trust).

ANCOVA in all GHQ subscales showed no difference between two groups almost all (except depression) subscales, (Table 1).

Discussion:

The results showed a range of psychopathometric and interpersonal changes in male patients with borderline personality disorder at one month after the end of three-month couple dialectical behavior therapy. CDBT seems to have a sustained effect on some of the core symptomsof BPD. Participants treated with CDBT reported using skills throughout treatment significantly more than participants in the control group.

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Although much progress has been made in the development and availability of treatments for BPD in the last years, available approaches have demonstrated differential effectiveness for various symptoms. Self-injurious behavior, suicidal behavior, and impulsivity are the symptoms treated most effectively and by the largest number of treatments. However, quality of marital relationship issues, mental health and function are treated less successfully by most treatments.

The results provided additional support for the efficacy of couple dialectical behavior therapy in mental health improvements (increasing health function and decreasing of anxiety and psychosomatic pains) of patients and their partners. It was synchronized with Soler et al (2009) who suggest DBT seems to have an impact on depression, anxiety, psychoticism, irritability and general psychiatric symptom reduction. This mood improvement was consistent with the core target of DBT intervention, which aims at the dysregulation of emotions (Linehan, 1993a, 1993b),

PRQC result resembles the findings of a case study in which CDBT was successfully used as treatment for couple dysfunctions (Oliver, et al, 2008). Family psycho education and family education models documents suggested that family member participation is related to positive patient outcome as well as to increased family member well-being (McFarlane et al., 1995; Miklawitz & Coldstein, 1997). Not surprisingly results of this article also demonstrated that Partner participassion in intervention can improve relationship quality components of patients and their partners.

Unlike other psychiatric disorders, in which services exist to support patients and family member relationship satisfaction and well-being, the families of BPD persons are frequently neglected (Glick & Loraas, 2001; Harman & Walso, 2001; Hoffman, et al 2005). Family members with BPD often experience burden, depression, loss, grief, and other kinds of distress and unstable relationship (Berkowitz & Gunderson, 2002; Hoffman & Hooley, 1998; Hoffman et al., 2005, Fruzzetti, 2010; Porr, 2010; Buchard et al, 2009). There were not researches to alleviate the impact of suggested treatment programs on relatives. The results of this research were compared with those found about family programs for relatives of persons with psychiatric disorders other than BPD, when available (Dixon et al., 2001), result of this research is also synchronized with them and confirmed that these programs can take a valued role in treatment settings.

The usage of CDBT approach to Increase marital satisfaction, commitment, intimacy, passion and love needs to new research intervention with BPD movement beyond symptomatic remission to the next phase of recovery – a meaningful life, with a positive sense of healthy relationships. In other hand, partner supportive and genuine relationship that provides a safe environment for the patient to be vulnerable and express emotions can be, especially for BPD patients, beneficial in intervention process.

Finding of this study didn't show significant between-group differences in reductions of dissociation (subscale of BPDSI) trust (subscale of PRQC), and depression (subscale of GHQ). It is likely due to a large standard error.

There were also several potential limitations in this study which limit their generalizability. There were no data to show that CDBT is more effective than DBT, and short term duration of intervention.

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Annexure

Post test Pre test measure Power estimate d P value F SD Mean d P value F SD Mean 1.00 0.80 0.000 109.3 3 12.4 2 27.15 .02 .41 .67 11.3 9 33.66 BPDSI 0.86 0.76 0.010 3.88 0.63 .86 .01 .50 .47 1.62 4.52 Abandonme nt 0.86 0.76 0.019 3.87 1.36 1.98 .00 .77 .08 1.58 4.80 Interpersonal 0.99 0.89 0.000 10.05 0.93 2.44 .00 .72 .127 1.00 2.69 Identity 1.00 0.91 0.000 12.45 .60 .51 .06 .172 1.96 .83 2.22 Impulsivity 0.99 0.85 0.002 7.00 0.85 .94 .02 .82 .05 1.21 1.92 Parasuiside 0.86 0.76 0.019 3.89 1.61 4.01 .01 .52 .41 1.49 8.16 Affect 0.92 0.79 0.009 4.47 1.51 3.54 .00 .97 .001 2.18 4.14 Emptiness 0.88 0.77 0.015 4.12 0.84 1.42 .00 .79 .072 2.13 5.03 Anger 0.57 0.63 0.116 2.15 1.50 1.92 .01 .50 .47 1.95 2.34 Dissociation PRQC 0.87 0.57 0.013 9.63 2.94 15.66 .00 .95 .04 6.23 10 Satisfaction 0.94 0.63 0.004 4.95 1.91 18.4 .07 .14 2.19 4.58 13.26 Commitment 0.92 0.61 0.007 4.45 2.69 18.00 .00 .95 .03 3.06 11.33 Intimacy 1.00 0.77 0.000 9.76 5.16 15.13 .06 .17 1.94 6.44 12.16 Passion 0.92 0.61 0.007 4.52 2.92 17.60 .00 .97 .001 5.52 9.93 love 0.47 0.36 0.195 1.64 3.78 13.00 .01 .57 .32 3.24 9.46 trust GHQ 0.99 0.55 0.000 29.89 3.16 11.06 .00 .85 .035 2.88 12.03 psychosomat ic 1.00 0.66 0.000 47.84 3.28 11.06 .24 .41 .67 3.16 11.06 anxiety 0.96 0.39 0.001 15.34 4.50 10.7 .00 .44 .004 3.17 11.32 function 0.36 0.10 0.105 2.84 4.01 10.43 .02 .45 .57 3.72 13.32 depression Partner PRQC 0.90 .59 0.009 4.17 3.87 16.86 0.041 0.28 1.21 4.22 9.80 Satisfaction 0.87 .57 0.013 3.87 1.47 19.26 0.006 0.68 0.17 2.05 18.66 Commitment 0.99 .71 0.001 7.15 2.91 15.33 0.013 0.54 0.37 3.55 10.26 Intimacy 1.00 .90 0.000 26.01 3.23 17.26 0.008 0.63 0.22 4.87 7.93 Passion .99 .72 0.000 7.56 1.85 19 0.001 0.89 0.01 5.20 12.33 love .90 .59 0.009 4.19 5.30 10.33 0.002 0.80 0.06 4.37 3.86 trust

Table1: Means and Standard Deviations on Dependent Measures Pre- and Post test for DBT Group and control group