You obviously champion the cause of protecting the patient from the potentially harmful effects of labeling - while at the same time you're interested in developing a helpful and workable treatment formulation. This, above all, I'll attempt to not lose sight of - as it remains very important. What if, however, Gary truly does suffer from delusions in the absence of other schizophrenia symptoms? What protective contigencies must we begin to formulate while remaining validating and solution focused? Are we so uncertain of the power of our own biases for those exhibiting the behaviors described as criteria for personality disorders that we can't entertain the possibility that he could have this problem. That does not mean that his Dr., in the confidential confines of his office will now begin to treat his patient poorly. The presence or absence of delusions simply serve as one of many hypotheses to either be validated objectively or dismissed.
I would be thrilled to read the studies authored by other CBT clinicians - demonstrating results as significant as those replicated in the DBT literature. It is always good to hear of CB success stories.
The inmate/patients we've been discussing did not suddenly learn to exhibit self-mutilating behaviors as a result of being incarcerated. They typically have a long history of self-harm prior to incarceration. They are few in numbers (40 of 550). To NOT acknowledge that they meet criteria outlined in the DSM-IV (personality disorders) is a dangerous bias itself. The stress of prison will get worse once they leave the hospital. As with Linehan's priority - our job is to teach them how to (1) not die by their own hand (2) learn to decrease their behaviors that lead them away from therapy.
I hope we can at least agree with what I feel is the most important notion from all this - As clinicains, we must objectively consider multiple hypotheses and formulations. We can't be so biased for or against the concept of personality disorders that we either view the patient negatively (untreatable, all his fault...)or miss important issues requiring priority attention (is it too risky to dig into abuse issues now...).
Finally, I appreciate your views - especially today as I rethink my own biases. I don't stand a chance of decreasing my biases if I only talk with those who agree with me.