Dialectical Behavioral Therapy (DBT) and Borderline Personality Disorder (BPD)

1. Summary of the DBT Method and application, including Borderline Personality Disorder

2. General presentation of the DBT Technique

3. The 4 modules of the DBT Technique

4. DBT tools

1. Summary of the Method

Marsha Linehan developed Dialectical Behavioral Therapy in the late 1980s and early 1990s, originally created for suicide and self-harm cases in patients with psychiatric histories and multiple hospitalizations or who met criteria for Borderline Personality Disorder (BPD).

Linehan has been using Cognitive Behavioral Therapy (CBT) for many years on this population but had found that there were aspects unsuitable for them, especially the unrelenting focus on change (changing one’s thoughts, behavior and beliefs), otherwise invalid for much money. These demands and pressures to change proved difficult to tolerate for this client category, with consequences of emotional exhaustion, self-harm, more frequent suicide attempts and/or threats of withdrawal from treatment.

Four components to treat Borderline Personality disorder

Linehan realized that individual therapy was not adequate for high-risk treatment including Borderline Personality disorder and developed a multifaceted approach that included four components:

• individual and group therapy

• coaching

• collateral contact between sessions

• group supervision

• support for therapists dealing with such clients

The author’s idea was that a comprehensive psychotherapy must fulfill five critical functions:

1. It must maintain and increase the client’s motivation to change

2. It must increase the client’s capabilities (through skills groups, telephone coaching, face-to-face coaching and homework);

3. It must encourage the generalization of acquired capacities;

4. It must structure the environment so that treatment can take place in a safe and effective way (it may be necessary to involve families to ensure that they also work therapeutically with the patient).

Linehan adopted some standard cognitive-behavioural techniques for emotion regulation and reality testing. She then combined these with concepts derived from Buddhist meditative practice, including suffering tolerance, acceptance, and mindful awareness. DBT may be the first proven effective therapy in treating BPD. Research indicates that DBT is also effective in treating patients who exhibit a variety of symptoms and behaviours associated with mood disorders and recently showed effectiveness with survivors of sexual abuse and chemical dependency.

2 General presentation of the DBT Technique

Linehan’s first basic insight was to recognize that the studied suicidal patients were raised in deeply disabling environments. These environments can take the form of neglect or abuse, but they could also take more benign forms, such as discouraging, punishing, or invalidating a child’s emotional responses. These clients, therefore, required a climate of unconditional acceptance in which to develop a successful therapeutic alliance.

Linehan also believed that certain clients were born with a biological inclination toward stronger emotional responses than their peers. Because these children had stronger emotional responses, it is more likely that these responses were invalidated by their environment, so the dysfunction was the result of the child’s interaction with the environment.Her second insight involved the need for commitment from patients, who had to be willing to accept their level of emotional dysfunction and engage in treatment. Linehan observed that achieving this acceptance of reality and commitment to treatment helped decrease therapist burnout when working with Borderline Personality disorder and/or extremely demanding or suicidal customers.

DBT strives for the patient to view the therapist as more of an ally an opponent. Consequently, the therapist aims to accept and validate the client’s feelings at some point, while nevertheless informing the client that some feelings and behaviours are maladaptive and there are better alternatives.

Linehan has also accumulated a number of skills for emotional self-regulation drawn from Western psychological traditions such as cognitive behavioural therapy, assertiveness training, and Eastern Buddhist meditation (mindfulness).

3. The four modules of DBT that have proved successful in treating Borderline Personality disorder:

Module 1: Mindfulness

Mindfulness is one of the core concepts behind all elements of DBT. This is considered a foundation for the other skills taught in DBT because it helps individuals accept and tolerate the strong emotions they may feel when they self-harm or expose themselves to distressing situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, however the version taught in DBT does not involve any religious or metaphysical concepts. In DBT mindfulness is the ability to pay attention, without judgment, to the present moment.

Mindfulness skills divide into “What” and “How,” which teaches participants to non-judgmentally observe their inner and outer environments. They are then taught to describe their experiences and observations without using judgmental statements or qualifying opinions. In addition, they are taught skills to participate fully in a moment, with focused attention, rather than drifting and navigating distractedly through life.

How skills teach clients to act without judgment and focus the mind on one thing at a time. Using these skills, clients learn to move more effectively through life and not be swayed by their emotions.

Module Two: Suffering Tolerance

Dialectical behavior therapy emphasizes learning to cope with pain skillfully.

Clients learn skills to accept, find meaning within, and tolerate suffering.

Distress tolerance skills are a natural development in DBT after the development of mindfulness skills. They strengthen the ability to accept, in a non-evaluative way and without judgment, both for oneself and for the current situation.

Since this is a non-judgmental position, this means it is not one of approval or resignation. The goal is to become able to calmly recognize negative situations and their impact, rather than becoming overwhelmed or hidden by them. This allows individuals to make wise decisions about whether and how to act, rather than falling in intense, desperate or destructive emotional reactions.

Teaching skills for Borderline Personality disorder

DBT uses several acronyms to help clients easily remember these skills. For example, the distress tolerance skill is taught with the acronym ACCEPTS:

• Activities—Engage in a positive activity that you enjoy.

• Contribute—Help others or your community.

• Comparisons—Compare yourself either to people who are less fortunate, or to yourself when you were in a less fortunate situation

• Emotions —Make yourself feel something different by provoking your sense of humor or happiness

• Push—Put your situation in the background of time. The situation is temporary

• Thoughts — Force your mind to think about the situation differently

• Sensations — Do something that gives an intense feeling other than what you feel. (like a cold shower or a spicy candy)

Self-soothing is a basic distress tolerance skill and involves helping participants to be kind and gentle to themselves, primarily by engaging in soothing activities such as prayer, music, walks outside.

Other skills taught include enhancing the moment, thinking about the pros and cons of tolerating this suffering in the present moment, and being willing to do what is effective.

All suffering tolerance skills are taught in a framework called “Radical Acceptance”. It means that clients must stop fighting reality and accept their current situations exactly as they are.

Module Three: Emotional Regulation

Individuals with BDP and suicidal individuals are intensely emotional and unstable. These clients may be angry, fearful, depressed or anxious and generally benefit from learning to regulate their emotions. Skills taught include identifying and labeling emotions, identifying obstacles to changing emotions. They also include reducing vulnerability to acting out when “the mind is emotional,” taking the opposite action of what the emotion seems to encourage. Clients are taught to do chain analysis of situations to better understand what triggers their emotions, how they experience those feelings in mind and body, and how they might choose more productive outcomes in the future.

Clients are also taught basic self-management skills to limit vulnerability to the emotional mind, such as getting enough sleep, eating healthy, and avoiding mood-altering chemicals.

Module Four: Interpersonal Effectiveness

The interpersonal response patterns taught in DBT are similar to those taught in many assertiveness groups. They include effective strategies for asking for what he needs, saying no, and coping with interpersonal contact. People with Borderline Personality disorder often possess good interpersonal skills. The problems arise in applying these skills to specific situations. A person may be able to effectively instruct another person in coping behaviours but may be unable to generate or perform similar behaviours when analysing their own situation. Interpersonal effectiveness focuses on situations where the goal is to change something (e.g., asking someone to do something) or to resist changes that someone else is trying to make (e.g., saying no). The skills taught intend to maximize the chances that a person’s meets their goals in a specific situation, while not harming either the relationship or the person’s self-esteem.

4. DBT tools

DBT uses a number of support tools, below:

-journal cards track weekly progress. They identify behaviours that interfere with therapy or on which days they chose to practice which skills.

– chain analysis is a form of functional behavioural analysis with increased focus on sequential events that form the behavioural chain. It has strong roots in behavioural psychology. Behavioural chains examine how emotions predict actions. Clients then understand where they might break the chain and use more productive skills, closer to their goals.

-The environment or culture of the group involved plays a key role in the effectiveness of DBT. The environment provides support to therapists by providing gentle social pressure on clients to help them better meet their goals. Groups are generally led by 2 therapists. Successful environment creates positive accountability while still tolerating the behavioural slips the client might experience.

Bibliography:

• Borderline Personality Disorder Brochure
• Dykstra, E., Charlton M., (2003), Dialectical Behavior Therapy Skills Training
• Read K., (2013), Instructors Manual for Dialectical Behavioral Therapy  with Marsha Linehan, publicat de Psychotherapy.net
• McKay M., Wood J., (2007), The Dialectical Behavior Therapy Skills Workbook, New Harbinger Publications, Inc
• Pederson L., (2017), The Expanded Dialectical Behavior Therapy Skills Training Manual: DBT for Self-Help and Individual & Group, PESI Publishing & Media
• Van Dijk, S., (2012), DBT made simple, A step-by-step guide to Diealectical Behavior Therapy, New Harbinger Publications, Inc