Treating Borderline Personality Disorder

Dialectic Behavioral Therapy, 1 Treating Borderline Personality Disorder: A Dialectical Approach Jill W. Coxen May 3, 2002 Clinical Psychopathology Treating Borderline Personality Disorder Dialectic Behavioral Therapy, 2 Many mental health professionals would say that working with individuals who meet the diagnostic criteria for Borderline Personality Disorder (BPD) is very challenging, making them one of the most difficult populations to treat. Many clinicians choose not to work with these people who are unable to find solutions to their problems and often resort to unpredictable and dangerous behaviors to deal with their everyday problems. Their belief system had become distorted, often from a very young age and they often don’t see any other options to relieve pain than to harm themselves. These patients often participate in self-mutilation, including cutting on their skin or burning themselves. They often think of suicide as a viable solution to any problem and often require inpatient hospitalization. Although there is yet to be a perfect treatment for BPD, Dialectic Behavioral Therapy (DBT) has been shown to be the most effective so far. Pioneered by Marsha Linehan, M.D., this therapy is broken down using a dialectic approach; dialectic meaning to achieve balance. This therapy revolves around learning new skills and applying them to everyday life. The role of the therapist is to orient the patient to this type of therapy and agree on goals. These goals include replacing maladaptive behaviors with appropriate responses and improving motivation to change (Linehan, 1993). Linehan (1993) believes that this type of treatment is different from others in that it focuses on what she calls a technology of acceptance rather than a technology of change. It concentrates on validating the problems of these individuals and teaching them how to solve them using new skills. She also states that it is important not to invalidate the invalid but to always find the valid in every situation. It is often said by individuals meeting the criteria for BPD, that outside of mental health facilities they are not taken seriously and they do not receive Dialectic Behavioral Therapy, 3 attention for their behaviors. However, in a facility, their suicidal behavior gets the attention they are seeking, which often ensures that they will keep threatening to take their lives or harm themselves. According to Linehan (1993), DBT applies a broad array of cognitive and behavioral therapy strategies to the problem of BPD, including suicidal behaviors. Like standard cognitive behavioral therapy programs, DBT emphasizes on going assessment and data collection on current behaviors, clear and precise definition of treatment targets; and a collaborative working relationship between client and therapist. This therapy strategy works well in both inpatient and outpatient settings. However, in an inpatient setting, the group would have to be open with a continuous flow of patients entering and exiting the group. As previously mentioned, a large number of this population eventually wind up in an inpatient setting. For this to type of treatment to work in an outpatient setting, it would be necessary to find a group of people who want to learn these skills and have them agree to stay together for a period of time. Linehan (1993) feels that open groups work better, in part because they must learn to constantly adjust to change in a stable environment. In addition, she adds that in a closed group, it becomes easier to deviate from the skills training agenda. DBT is broken down into four skills training modules, including (1) core mindfulness skills, (2) interpersonal effectiveness skills, (3) emotion regulation skills, and (4) distress tolerance skills. These skills are most effective if patients stay in skills training for one year and go through eight-week sessions of each module twice. Higher functioning individuals might benefit from only six months of skills training. Although DBT is often started on an inpatient basis, patients are eventually discharged from the hospital and continue therapy on an outpatient basis, usually in the form of a day treatment at the same facility. Dialectic Behavioral Therapy, 4 The following are a list of the basic goals of skills training taken from the Skills Training Manual for Treating Borderline Personality Disorder, Linehan (1993): Behaviors to Decrease: (1) Interpersonal Chaos, (2) Labile emotions and moods, (3) Impulsiveness, (4) Confusion about self, cognitive dysregulation. Behaviors to Increase are: (1) Interpersonal effectiveness skills, (2) Emotion regulation skills, (3) Distress Tolerance Skills, and (4) Core mindfulness skills, i.e., the basic skills of DBT. There are nine basic guidelines for Skills Training (Linehan, 1993): 1. Clients who drop out of therapy are out of therapy. 2. Each Client has to be in ongoing individual therapy. 3. Clients are not to come to sessions under the influence of drugs or alcohol. 4. Clients are not to discuss past (even if immediate) parasuicidal behaviors with clients outside of sessions. 5. Clients who call one another for help when feeling suicidal must be willing to accept help from the persons called. 6. Information obtained during sessions, as well as the names of clients, must remain confidential. 7. Clients who are going to be late or miss a session should call ahead of time. 8. Clients may not form private relationships outside of skills training sessions. 9. Sexual partners may not be in skills training together. Attached are several handouts that make it easier to understand the skills training process and how to perform skills training with reproducible client handouts from the Skills Training Manual for Treating Borderline Personality Disorder, By Marsha Linehan (1993). Also included is information to order videos, textbooks, and a skills training manual with more handouts and homework Dialectic Behavioral Therapy, 5 Works Cited Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press. www.guilford.com Videos: Linehan, M.M. (1994). Treating Borderline Personality Disorder: A Dialectical Approach. Kevin Dawkins Productions. Linehan, M.M. (1994). Understanding Borderline Personality Disorder: A Dialectical Approach. Kevin Dawkins Productions.