Masters Thesis on Psychotherapy for Adult Survivors of Child Abuse: Qualitative Longitudinal Cohort Study of Dialectical Behaviour Therapy for Adult Survivors of Child Abuse with Borderline Personality Disorder (DBT for ASCA with BPD)

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Background:
A high proportion of people with Borderline Personality Disorder (BPD) who present to mental
health services for treatment, concurrently report a childhood history of abuse(1, 2) and neglect(3, 4).
Childhood abuse and neglect have negative “lasting neurobiological effects”(5) into adulthood(6-9), and
are strongly correlated with BPD(10-13). These people are often difficult to engage in treatment(14, 15)
as they find it difficult to trust others(16, 17) and are ill-equipped to cope with stress(18, 19).
Studies suggest that Dialectical Behaviour Therapy (DBT)(13, 20), originally developed to treat
people with BPD who engage in self harm behavior(21), is superior to other therapies in treating BPD
and promoting treatment engagement and completion(22, 23).
By extrapolation, Adult Survivors of Child Abuse (ASCA) with BPD(24) as a sub-set, are expected
to yield similar results. However, long-term evidence-based research investigating whether treating
ASCA with BPD using DBT significantly enhances professional therapeutic engagement is lacking.
Hence, in this qualitative study, we shall investigate the hypothesis that treating ASCA with
BPD using DBT(25) would significantly enhance professional therapeutic engagement(22, 26).
Methodology:
Designed as a prospective longitudinal Randomised Controlled Trial (RCT), informed consent
would first be obtained from all volunteers before screening for a history of childhood abuse and
neglect, and a psychological evaluation for BPD. Volunteers who are assessed to have both a history of
childhood abuse and neglect, and a diagnosis of BPD, would be invited to participate in 1 of 2 randomly
assigned arms of DBT or Treatment as Usual (TAU).
A questionnaire would be administered face-to-face by therapists upon enrollment of all
eligible and consenting subjects. The same questionnaire would be administered face-to-face again at
the final individual therapy session, then via telephone annually over 5 years post-treatment.
Recruitment would be by media blitz, referrals from social services, psychiatric and counselling
facilities, which would have access to potential volunteers(27). A hotline number would be provided for
volunteers to enquire about facility location, enrollment procedure, and other details about the study.

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Inclusion criteria: Volunteers must be aged 21 years and above as that is the legal age of
consent and official age of adulthood; have a history of childhood abuse and neglect; have a clinical
diagnosis of BPD; and agree to commit to 12 months of DBT and 5 years of annual follow up calls.
Exclusion criteria: ASCA with BPD referred by counseling and psychiatric facilities who decline to
participate in the study; have a criminal record of violence.
Therapists involved in this study are required to be licensed clinical psychologists specialising in
treating ASCA with BPD, and have been DBT practitioners for a minimum of 3 years. This is to ensure
that the therapists involved have the professional expertise to implement DBT and engage ASCA with
BPD in long-term therapy.
Measurements:
All volunteers would first be screened for a history of childhood abuse and neglect via the
Trauma Symptom Inventory (TSI) which has strong psychometric support and is also a good predictor of
BPD(28). Volunteers who obtain a T-score of 65 or above in the 100 item test are considered to have a
history of childhood abuse and neglect, as that is the established “clinically significant cutoff score” for
the TSI(29). Volunteers who meet the criteria would then be clinically evaluated for BPD by a therapist
via a thorough interview and discussion about BPD symptoms(30, 31).
Eligible subjects would then be randomly assigned to either the DBT or TAU study arm, where a
questionnaire would be administered face-to-face by a therapist to assess initial attitudes towards
professional engagement and gather feedback on subjects’ response towards professional engagement.
The 19-item Revised Helping Alliance Questionnaire (HAq-II) would be used to measure how the
subject feels or behaves towards the therapist, and vice versa. The HAq-II was selected for its high
internal consistency, test-retest reliability, and good convergent validity(32).
The HAq-II is first administered at Week 0 to assess baseline pre-treatment attitudes
towards professional engagement, then again at Week 52 to gather insight into the subjects’ attitudes
and responses toward professional engagement post-treatment. 5 years of follow up is projected to
provide long-term insight into, and extensive data on, participants’ evolving response to DBT compared

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to TAU. Changes in participants’ attitudes and receptiveness resulting from DBT would provide valuable
insight on the extent to which professional engagement by DBT therapists helped to overcome trust
issues borne out of abuse and BPD(33). Data gathered would then be subjected to thematic analysis.
Intervention:
DBT treatment would be offered as 52 weekly individual therapy (1-hour) and 52 group therapy
(2-hours) skills-training sessions, structured to encourage non-judgmental validation through acceptance
and adaptive strategies, while balancing heightened emotions(34). Functional stress-coping skills would
be taught, i.e.: mindfulness, distress tolerance, emotional regulation, interpersonal effectiveness(35), to
enable participants to manage distressing emotions, effectively handle abuse victimization encountered
in adulthood(36) and build healthy interpersonal relationships(37). This is projected to enhance trust
between the subject and therapist, and help the subject manage stress more effectively so as to stay in
therapy. Telephone counseling in crisis situations allows participants “a healthy way to reach out for
assistance”(23) and reinforces the therapeutic relationship, strengthening professional engagement.
TAU consists of 52 (1-hour) weekly Schema-focused Therapy or Cognitive–analytic therapy
sessions(13, 38), and / or psychotropic medications as routinely prescribed(39, 40), as the comparator
against which the effectiveness of DBT intervention would be measured(41).
Limitations:
Limitations of this intervention include costliness, in terms of human resources for manpower
staffing and financial expenditure(42). Participation may only consist of those willing to discuss their
traumatic experiences, while those severely trauamtised may be self-excluded . Attrition due to
migration, death, change of contact information or refusal for continual participation is a problem for
long-term studies. Finally, potential participants may not volunteer due to the stigma of undergoing
mental health therapy, skepticism at the workability of DBT after repeated disappointments and
frustrations with other mental healthcare therapies attempted, or the lack of a supportive social
environment (including stable housing, income, food arrangements) to allow potential participants to
fully commit to and focus on DBT, recognized to be both time-intensive and emotionally challenging(23).

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