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Introduction
The prevalence of borderline personality disorder (BPD) in the general population is 1.6% [1]. The criteria can be summarized into five categories: Self-dysregulation, dysregulation of behavior, emotional dysregulation, interpersonal dysregulation, and dysregulation of thought [2]. It is crucial to develop effective therapeutic models that can reduce the symptoms of BPD, prevent the loss of clients, and lower the cost of treatment [3].
Dialectical behavior therapy (DBT), which was developed as borderline patients’ treatment, consists of a combination of individual psychotherapy and group skills training [4]. DBT, in comparison with other therapeutic approaches, has demonstrated efficacy in reducing symptoms of BPD, such as suicide, self-mutilation, substance abuse, eating disorder, and mood disorder [5-8]. One limitation of the prolonged dialectical behavior approach is increasing the possibility of missing patients [9-11]. The DBT skills training (DBT-ST), first introduced by Soler in 2009 includes mindfulness techniques (2 sessions), interpersonal skills (4 sessions), emotion regulation (4 sessions), distress tolerance skills (3 sessions), and relapse prevention (1 session). He found the efficacy of dialectical behavioral skills training in reducing symptoms of BPD as a short-term method [11].
Instead of using different methods separately, it can be used as an integrated treatment model [12, 13]. Another psychological model proposed for borderline patients is family education. According to the etiology of BPD, an invalidating family environment is a major contributing factor that increases the risk of developing BPD. This treatment includes the method by Gunderson and Singer, which is based on psychological education for patients and their families, Hoffman DBT, couple therapy, and family therapy [14]. It uses several techniques, including mindfulness, problem-solving, and psychological education [15]. The present study examines the effectiveness of DBT-ST and the modification of family members’ interactions in the reduction of BPD. The hypothesis in this study is dialectical behavior skills training based on the Soler model, either alone or in combination with family education, will reduce the BPD’s symptoms. This study is done because of limited research in Iran based on the effectiveness of integrated therapy for BPD, as well as the lack of family education studies on this particular group.

Materials and Methods
In this single-blind case study, eight cases were assessed using the structured clinical interview for the diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) and the structured clinical interview for DSM-5 personality disorders in 2017 at the clinic of Shahid Ayatollah Taleghani Hospital. The diagnostic criteria were based on DSM-5 guidelines. The inclusion criteria were the absence of bipolar disorder, substance abuse, and psychosis, a score of >10 in the BDP questionnaire, scoring of Sansone self-harm inventory of >5. Meanwhile, the exclusion criterion was non-cooperation with medication. The participants were randomly divided into two groups. Informed consent was obtained at the beginning of the research. The manual of dialectical behavior skills training based on the Soler model was implemented for both groups and families of the second group (parents of single members and spouses of married ones) [16]. Members of both groups were assessed before the intervention, three weeks after starting treatment, at the end of treatment, and three months after the end of intervention with borderline personality inventory, Sansone self-harm inventory, and Barratt impulsivity scale (BIS). After the completion of the project, the data were analyzed using the SPSS software, version 21.
The dialectical behavior skills training based on the Soler model was used as the manual for this study. The training consists of 13 sessions, each lasting 120 min, and focuses on teaching four main skills (Table 1) [15, 16].




Results
The age of the samples in this study was between 20 and 31 years, with mean ages of 25 years and a standard deviation of 3.85 years. In this study, 37.5% of the patients (3 persons) were single and 62.5% were married (5 subjects). The results of the Mann-Whitney U test indicate that the members had no significant difference before the intervention; therefore, the difference in the post-test stage is the result of DBT-ST. Patients who had non-threatening suicidal thoughts only received a psychotherapy program, but others were referred to a psychiatrist for medication (Table 2). Significant differences were not shown on the pre-test in all measurements of these eight patients.



Significant differences were shown between the pre-test and post-test of both groups in all measurements (Table 3). Therefore, the first and second assumptions of the research on the effectiveness of the solar method, individually and with the family were confirmed.



According to Table 4, significant differences were found between the pre-test and post-test of all scales and subscales, except the primitive defense mechanism in the group that was treated with individual DBT-ST. However, no significant differences were reported between the post-test and the 3-week follow-up or post-test and the 3-month follow-up.



Significant differences between all overall scores of scales and subscales were reported in a group that received DBT with family education (Table 5).



Meanwhile, The two groups did not show a significant difference (Table 6).



Discussion
DBT-ST is effective in symptom reduction of BPD in both groups with a 95% confidence level. In addition, treatment reduced self-dysregulation, behavior dysregulation, emotional dysregulation, interpersonal dysregulation, and dysregulation of thought. Also, post-test and 3-month follow-up results did not show significant differences (P>0.05) which indicates the stability of the results during 3 months. The Mann-Whitney U test results do not show any significant difference between the first and second groups (P>0.05). Therefore, the third hypothesis of the study, which states that DBT-ST with family education is more effective than individual DBT-ST, has been rejected.
As discussed before, the most effective DBT-ST strategies in emotional dysregulation treatment are comprehensive mindfulness and distress tolerance skills [11]. To the best of our knowledge, no study has assessed the effectiveness of this treatment on BPD and their families in Iran. In this study, DBT-ST is effective for decreasing symptoms, affective instability, impairment in social interaction and communication, identity disturbances, depressive symptoms, and suicide attempts in BPD. Compared to studies by Soler [11], Stepp [3, 18], Linehan [19] and Neacsiu [7, 20], these impacts are not low. On the other hand, the low efficacy of this intervention on some symptoms like defense mechanisms and identity diffusion may be associated with severe disability and the use of avoidant mechanisms [4]. 
The difference between the two groups is not significant, and this matter needs to be explained. Focusing on family psycho-education will not be sufficient. It is not recommended as the sole treatment for borderline personality patients [1]. Although family and couple education are useful adjuncts to individual therapy, improvement in interactions between couples and family members does not lead to treating the main problems of a person with BPD, including primitive defense mechanisms, emotional dysregulation, suicide, and self-destructive behaviors [21]. In other words, it is more useful to have family education based on schema therapy, DBT, or psychoanalysis as complementary methods along with individual therapy [22, 23]. It is necessary to use different methods as well as other approaches to family and couple therapy and compare their effectiveness with individual interventions to obtain a reliable treatment for BPD. What had been lacking is evidence of the effectiveness of an intervention designed to address family problems of BPD.

Conclusion
Teaching DBT skills based on the Soler model as a short-term intervention is an effective method to reduce symptoms of BPD, non-suicidal self-harm behaviors, impulsivity, and improving self-regulatory skills. Also, in the second group, the training of DBT based on the Soler model, along with family education decreased the symptoms of BPD. Given that the difference between the two groups is not significant indicates the priority of individual therapy. Family education based on the Soler model is recommended as an additional and complementary treatment with individual therapies. 

Study limitations
In interpreting the findings, it is important to note its limitations. The generalization of results must be made cautiously because of the small sample size and loss of the control group. Although psychoeducation promotes empathy and validation among family members, it has limitations in providing elaborative information like childhood abuse or information about destructive behaviors to parents and spouses of BPD due to confidentiality commitment. It is suggested to adopt other complementary approaches with individual treatment which focuses on improving interpersonal patterns. Different eclectic methods should be considered and their effectiveness compared to individual interventions to obtain a fairly reliable result about the necessity and priority of treatment for BPD.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.MSP.REC.1395.449). 

Funding
This article was extracted from PhD dissertation of Atiyeh Safarzadeh, approved by Shahid Beheshti University of Medical Sciences.

Authors' contributions
Conceptualization and supervision: Atiyeh Safarzadeh and Maryam Bakhtiari; Methodology: Mohammad Reza Shaeiri; Data collection: Atiyeh Safarzadeh; Data analysis: Ali Kheradmand and Mohsen Saberihaji; Investigation and writing: Atiyeh Safarzadeh, Bonnie Bozorg and Zahra Ahmadvand. 

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors are grateful to the individuals who participated in this project as sample groups at the Clinic of Shahid Ayatollah Taleghani Hospital in Tehran.




References