Attention for borderline personality disorder (BPD) results from concern for its prevalence in clinical populations, as well as the serious and often dangerous nature of its symptoms. Six percent of those with BPD kill themselves, and there is a tendency to self-mutilation. In the clinical environment, expected behaviors include impulsive episodes, intense affective lability, and life-threatening behaviors. The patient, in turn, experiences an invalidating, controlling, and hence non-supporting environment.
Dialectic behavior therapy (DBT) is an adaptation of cognitive behavioral therapy that first focuses on preventing self-harm, or other damaging behaviors, and then attempts to embrace the client in a highly accepting, yet continually modifying, therapeutic relationship that is philosophically derived. The acceptance component is allows for an understanding of a presumably damaging behavior as something a client may have done to attempt to gain some benefit. For instance, drug use may be an attempt at self-medication to alleviate some mental anguish, an accepting approach to substance abuse, but the therapy dictates that the client make the necessary changes to move past this self-abuse. This describes the dialectic component of the DBT where the acceptance represents a thesis, the need for change represents antithesis, and the motion forward and away from harmful behaviors represents synthesis. The therapy includes a "devil's advocate" component that hinges on the antithetical approach; nothing is either validated or negated, everything is met with its antithesis so that the client approaches every thought and action in terms of its causes and consequences.
Skills training provides a framework for the "acceptance-change dialectic" (p. 12). Damaging emotional impulses and painful stress are handled in terms of "mindfulness," which is derived from Buddhism, and change is affected by improving emotional responses cognitively and by learning social skills. Insightful discussion is not a component of the therapy, which differentiates it from a humanistic approach; the therapeutic approach is based on CBT. It has been shown that when therapists do attempt open discussion among a group of patients (which is contrary to DBT strategy) such as an open discussion of self-harming, there is a tendency for self-harming episodes to increase and spread through the patient group as if it is a contagion because of this type of communication.
The therapy is comprehensive in that the entire clinical community moves in this process, and because of the stressful natures of the disorders being treated, a good deal of support goes to the therapeutic staff, and the support is in the context of the community. Staff may, for instance, give clients a home number to call in event a client feels a self-harming impulse; this is usually considered a therapeutic boundry violation, but in the case of DBT treatment of BPD, it is considered necessary for client safety.
DBT is considered effective; depending on how it is measured, its efficacy is 3 to 5 times greater than "treatment as usual" (Swenson, Sanderson, Dulit, & Linehan, 2001, p. 12). It should be noted that possibly more than 70% of borderline personality clients self-report childhood sexual abuse, which may help explain why the disorder does not respond to medication alone, and why it is so severely self-damaging (J. Dyce, personal communication, n.d.).
Clarkin, J., Hull, J., Cantor, J., & Sanderson, C. (1993). Borderline personality disorder and personality traits: A comparison of SCID-II BPD and NEO-PI. Psychological Assessment, 5(4), 472-476. doi:10.1037/1040-35188.8.131.522.
Swenson, C., Sanderson, C., Dulit, R., & Linehan, M. (2001). The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units. Psychiatric Quarterly, 72(4), 307. Retrieved from Academic Search Premier database.
acceptance-change dialectic occurs within skills training as well. These are four skills modules, core mindfulness and distress tolerance focusing on acceptance and emotion modulation and interpersonal effectiveness focusing on change.
highest probability of success
borderline - some hope
Among the 11 Axis II personality disorders, borderline personality disorder (BPD) has probably received more research attention than the others. This attention is generated by its prevalence in clinical populations and the serious nature of the behaviors involved in the diagnosis
Clarkin, J., Hull, J., Cantor, J., & Sanderson, C. (1993). Borderline personality disorder and personality traits: A comparison of SCID-II BPD and NEO-PI. Psychological Assessment, 5(4), 472-476. doi:10.1037/1040-35184.108.40.2062.
inpatient DBT staff creates a validating
treatment milieu and focuses on orienting and educating new patients and
identifying and prioritizing their treatment targets. p1
care of individuals meeting criteria for borderline personality
disorder (BPD) is notoriously difficult for all involved parties p2
staff, usually already stretched to its limits, faces life-threatening
behaviors, impulsive episodes, and intense emotional lability of patients
a myriad of restrictions and an overwrought, often invalidating environment.
staff comes to anticipate
“resistance,” “manipulation,” and “hostile behavior” from BPD patients
(3), and BPD patients with multiple hospitalizations come to expect
bias, mistrust, “punishment,” and “rigidity” from the staff (4).
Dialectical Behavior Therapy (DBT), a manualized outpatient cognitivebehavioral
therapy for BPD developed by Marsha Linehan (29
upon admission, DBT target priorities, individual therapy, group
skills training, self-monitoring with diary cards, unit-wide incorporation
of contingency management strategies, an emphasis on validation,
and behavioral chain analysis.
Those from the CC
group were more likely to believe that the skills would help them after
discharge, but in fact they “acted out” on the unit more than the control
group. In contrast to the recommendations of Linehan’s manual (29),
patients in the CC group were encouraged to openly discuss their selfinjurious
behaviors, which may well have created a contagion effect.
treatment incorporated behavioral analysis
of the targeted behavior, orientation to the basics of BPD and DBT,
skills training with a focus on skills to prevent future hospitalizations,
and contingency management of reinforcers following self-injurious behaviors
The investigators compared the month prior to hospitalization
and the month after and found significantly fewer parasuicidal acts and
significant improvements in ratings of depression, dissociation, anxiety,
and global stress
At its core, it balances
a relentless insistence on problem solving, informed by behavioral
principles and techniques, with an attitude of acceptance embodied in
validation, empathy, and a radical acceptance of things as they are
“in the moment.”
The characteristic maladaptive behaviors of BPD
(e.g., suicidal and impulsive behaviors) are viewed as direct sequelae
of emotion dysregulation or as efforts to regulate painful and chaotic
in DBT, the therapist provides a validating
environment, extinguishes maladaptive behaviors, teaches skills to
help with emotions and relationships, and ensures that skills are reinforced,
strengthened, and generalized to all relevant environments.
All therapists of BPD patients are seen as requiring support that is
partially provided for in a weekly DBT consultation team meeting (29).
Dialectical synthesis is a pervasive target throughout treatment.
One always looks for an opportunity to use DBT’s Dialectical Strategies
(29) to move the patient, the team, and the treatment from rigidity,
polarity, and stasis towards flexibility, synthesis, and change.
Many borderline patients enter
the hospital involuntarily, and considerable work may be required to
elicit a voluntary commitment to a set of goals.
orient them to the unit and DBT; validate their emotional pain and
difficulty; and structure preliminary problem solving, including a behavioral
analysis of the behaviors prompting hospitalization and an
introduction to crisis survival skills.
most relevant contingency management
principles include positive reinforcement, negative reinforcement, random
intermittent reinforcement, extinction, punishment, and shaping.
some patients get
“stuck” in pre-treatment, it is helpful for everyone involved to see that
as the problem rather than acting as if some agreement is in place when
it actually is not.
reinforce small skillful
steps in targeted directions with positive reinforcement, to extinguish
dysfunctional behaviors by withholding reinforcement and soothing
the patient, and to punish disturbing dysfunctional behaviors if
314 PSYCHIATRIC QUARTERLY
Immediate reinforcement is preferred over delayed
reinforcement, natural contingencies are preferred over artificial
ones, and extinction is preferred over punishment. Because of the necessity
of providing a controlled, safe environment for a large number
of highly distressed individuals, punishment (not punitiveness) plays
a larger role in inpatient treatment than it ordinarily does in outpatient
treatment. One wants an atmosphere permeated by positive reinforcement
for small gains while punishment is used effectively and
as sparingly as possible. Unfortunately, many inpatient units routinely
and inadvertently reinforce the very behaviors targeted for reduction
and extinguish and punish those behaviors targeted for increase.
inpatient DBT program is an ideal setting for the acquisition and
strengthening of DBT skills (33), most importantly the Distress Tolerance
“skills culture” that has certain benefits. The focus
is on pragmatism, concrete steps, “here-and-now” capabilities. This
“workshop” atmosphere not only provides a constructive focus on
change; it also implicitly counters a pejorative focus on “bad behavior”
and deep pathology that resonates with patients’ hopelessness about
being “fundamentally flawed,” “evil,” or “crazy.” The atmosphere helps
to reduce shame and to empower the patient with validation, respect,
and practical tools.
of peers for each patient, peers that may have similar behaviors and
issues and who are taking concrete steps together. The group participation
is supportive. Mutual criticism and processing of group issues are
The patient who
regularly dissociates prior to self-injury can be taught to use mindfulness
skills to increase voluntary attentional control at critical predissociation
skills training and generalization into the milieu
are the most natural and most common inpatient DBT applications
and can by themselves result in substantial benefits, the use of other
structures and strategies of DBT can further strengthen and focus the
treatment. These include the use of target priorities, contingency management
strategies, biosocial theory, consultation teams, and the functions
of the primary therapist. The inpatient unit can play a limited,
focused, and powerful role in the overall treatment of the patient with
BPD, especially if it is part of a larger, vertically integrated system.
Swenson, C., Sanderson, C., Dulit, R., & Linehan, M. (2001). The Application of Dialectical Behavior Therapy for Patients with Borderline Personality Disorder on Inpatient Units. Psychiatric Quarterly, 72(4), 307. Retrieved from Academic Search Premier database.
Linehan (1993) has suggested that the DSM-IV criteria for BPD criteria can be organised according to various systems, or subsystems, of dysregulation:
emotion or affective dysregulation mood reactivity, anger, fights
behavioral dysreg -- impulsivity, spending, sex, binging
interpersonal dysregulation -- pattern of unstable intense relationships alternating between extremes of idealisation and devaluation, frantic efforts to avoid abandonment
self-dysreg -- identity disturbance unstable self-image feelings of emptiness
cognintive dysreg -- transitory stress-related paranoid ideation, severe dissociative symptoms
The DBT therapist attends vigilantly to how the therapist and client reciprocally influence each other. For example, one can easily imagine that if a client became verbally aggressive every time the therapist tried to address a presenting problem, the therapist might stop trying to target that problem. In this scenario the client would have punished the therapist's therapeutic behaviour, and the therapist may have reinforced the client's aggressive behaviour.
reality is not static but is comprised of opposing forces, the thesis and antithesis, from which a synthesis emerges only to evolve into a new set of opposing forces. In DBT the primary tension that arises is the tension created by trying to accept the client as she is while simultaneously trying to change her.
(a) acceptance by the client of current life circumstances but also (b) acceptance of the him or herself as he/she is within the moment, (c) acceptance by the therapist of the client as the client is in the moment and (d) acceptance of the therapeutic relationship as it is in the moment. But this acceptance must be combined with a demand for change because without some degree of change, no matter how small, there is a risk of treatment termination.
structuring the treatment may be particularly important when working with borderline clients because one rarely encounters a client who presents with only one problem. More typically, these clients present with some combination of substance abuse, eating disorders, criminal activity, dissociative disorders, depression, unemployment, poor physical health, post traumatic stress disorder, etc
due to the difficulty of this population and the frequency with which borderline patients punish therapeutic behaviour and reward non-therapeutic behaviour, the treatment must also address the capabilities and motivation of the therapist. Therapists require a modality that will enable them to remain in therapy with clients and to work effectively with them. In standard DBT these treatment tasks are addressed by group skills training, individual psychotherapy, phone consultation with the individual therapist, ad hoc meetings with relevant others in the environment and the consultation team, respectively.
Validation is the main acceptance strategy of the treatment. Validation contains yet goes beyond the empathy in most forms of psychotherapy. When a DBT therapist validates his or her client they communicate not only that they understand why the patient thought felt or acted as they did (empathy) but that there was a degree of wisdom, accuracy and truth in the client's responses.
The final level of validation, radical genuiness, requires the DBT therapist to respond and validate the inherent capacity of the client to improve and overcome her difficulties, while at the same time retaining an empathic understanding of the level of the difficulties.
a radically genuine response would require the therapist to share the hypothesis as a hypothesis. The therapist would help the client cope with any emotional response to the feedback. In a dialectical manner, the therapist may validate both the client's 'right' to wear short skirts, her distress at unwanted stares and the normative response of those who do stare.
DBT assumes that individuals with BPD lack critical skills. Hence the programme aims to teach these skills to clients. The acceptance-change dialectic occurs within skills training as well. These are four skills modules, core mindfulness and distress tolerance focusing on acceptance and emotion modulation and interpersonal effectiveness focusing on change.
mindfulness skills from aspects of Zen Buddhism, although the skills are equally compatible with other meditative religious traditions. These skills teach clients a particular way of becoming aware of the activity of their mind and to find their 'wise mind', the intersection of 'reasonable' and 'emotion minds'
Empirical evidence of efficacy -- 3 to 5 times more effective than "treatment as usual"
Swales, M., Heard, H., & Williams, J. (2000). Linehan's Dialectical Behaviour Therapy (DBT) for borderline personality disorder: Overview and adaptation. Journal of Mental Health, 9(1), 7-23. doi:10.1080/09638230016921.
over-representation of borderline personality disorder in female prisons has lead to pilots of dialectical behaviour therapy in three such establishments in the UK
cognitive behavioural therapy underpinned by classical and
Core mindfulness is fundamental to the programme and
incorporates Eastern mindfulness practices.
The central dialectic in DBT is
that of acceptance versus change. Patients diagnosed with BPD have great
difficulty in accepting themselves and others, and DBT leads to the
development of acceptance skills as well as the change skills typically seen in
Cognitive Behaviour Therapy (CBT).
Linehan (1993) hypothesizes that any comprehensive psychotherapy must meet five critical functions. The therapy must:
a) enhance and maintain the client’s motivation to change;
b) enhance the client’s capabilities;
c) ensure that the client’s new capabilities are generalized to all relevant environments;
d) enhance the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities; and,
e) structure the environment so that treatment can take place.
It is typically the individual therapist who maintains the client’s motivation for treatment, since the individual therapist is the most salient individual for the client.
Skills are acquired, strengthened, and generalized through the combination of
phone coaching (clients are instructed to call therapists for coaching prior to engaging in self harm),
in vivo coaching, and
To repeat, the first stage of treatment focuses, in order, on decreasing life threatening behaviors, behaviors that interfere with therapy, quality of life threatening behaviors and increasing skills that will replace ineffective coping behaviors
he goal of Stage I DBT is for the client to move from behavioral dyscontrol to behavioral control so that there is a normal life expectancy.
In Stage II, DBT addresses the client’s inhibited emotional experiencing. It is thought that the client’s behavior is now under control but the client is suffering “in silence”. The goal of Stage II is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.
Stage III DBT focuses on problems in living, with the goal being that the client has a life of ordinary happiness and unhappiness. Linehan has posited a Stage IV specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.
Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.
DBT is a modification of standard cognitive behavioral treatment. As briefly stated above, Marsha Linehan and
her team of therapists used standard CBT techniques, such as skills training, homework assignments,
symptom rating scales, and behavioral analysis in addressing clients’ problems
notice new strategies that helped clients
tolerate their pain and worked to make a “life worth living.” (p. 4)
e balance between acceptance and change strategies in therapy formed the fundamental “dialectic” that
resulted in the treatment’s name. “Dialectic” means ‘weighing and integrating contradictory facts or ideas with a
view to resolving apparent contradictions.’ (p. 4)
CBT and DBT therapists do not think that clients can be helped through insightful discussions, although insight
can be helpful at times. Learning new behaviors is critical in DBT and is a focus in every individual session,
skills group or phone call (for coaching)
Clients track and record their problem
behaviors with a weekly diary card.
work with their
therapist to identify how they are rewarded for maladaptive behavior or punished for adaptive behavior.
: Skills Training, Exposure Therapy, Cognitive Therapy, and Contingency Management.
stand-alone interventions, they caused clients a great deal
pushing for change invalidating (patients feeling pain me)
validate that: a) her behavior makes sense as the only way she’s ever
gotten her anxiety to go down; b) her parents always got drunk at parties; and c) sometimes when she’s drunk
and does something impulsive, the impulsive behavior can be “fun.” In this case, the therapist can validate that
the substance abuse makes sense, g
helping the client regain confidence both by assuming that her behavior makes perfect sense
validation. In treatment and in life, it is important to know what about ourselves we can change and what
about ourselves we must accept (whether short term or the long term).
1) every thing is connected to everything
else; 2) change is constant and inevitable; and 3) opposites can be integrated to form a closer approximation
to the truth (which is always evolving)
dynamically alter therapy me
means recognizing that all points of view—yours, the other members – have validity and yet all may also be
wrong-headed at the same time.
skills group me
. If the group is working together dialectically, the group leaders and the
members are in constant flux, looking at how opposing points of view can be in play and yet be synthesized.
a client makes a strong initial
commitment to do a year’s worth of DBT. Rather than simply saying “Hey, that’s terrific!” the therapist would
gently turn the tables on the client by asking, “Are you sure you want to? It’s going to be very hard work.” This
strategy, called “Devil’s advocate,” p6
1997-2008 Cindy Sanderson
Behavioral Tech, LLC ● 2133 Third Ave., Ste. 205, Seattle, WA 98121 ● Ph. (206) 675-8588 ● Fax (206) 675-8590 ● www.behav
- schizoid - introverted bland
- schizotypal - introverted eccentric
- antisocial - no hope at all
- borderline - some hope
Dialectical Behaviour Therapy (DBT) for Borderline Personality Disorder:
Linehan, M.M., Schmidt, H., Dimeff, L.A., Craft, J.C., Kanter, J., & Comtois, J.A. (1999). DBT for patients with BPD and drug-dependence. The American Journal on Addictions,
Blennerhasset, R.C., & O'Raghallaigh, J.W. (2005). Dialectical behaviour therapy in the treatment of borderline personality disorder. The British Journal of Psychiatry, 186, 278-280. retrieved from doi:10.1192/bjp.186.4.278
Verheul, R., Van Den Bosch, L.M.C., Koeter, M.W.J., De Ridder, M.A.J., Stijnen, T., & Van Den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. The British Journal of Psychiatry, 182, 135-140. retrieved from doi:10.1192/bjp.182.2.135
overview websites (not scholarly articles):
http://www.apa.org/monitor/mar04/treatment.aspx -- personality disorders in general, but focuses on DBT and BPD (good general description)
components of DBT:
McKay, M., Wood, J., & Brantley, J. (2007) The Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance. Oakland: New Harbinger Publications.
cognitive-behavioral techniques for emotion regulation
mindfulness (derived from Buddhist meditative practice)
interpersonal effectiveness/assertiveness training
meta analysis -- The Effectiveness of Psychodynamic Therapy
and Cognitive Behavior Therapy in the Treatment
of Personality Disorders: A Meta-Analysis: