DIALECTICAL BEHAVIOR THERAPY: RESPECTFUL AND EFFECTIVE NEW APPROACH FOR TREATING THOSE WITH BORDERLINE PERSONALITY DISORDER AND OTHER DIFFICULT-TO-TREAT MENTAL DISORDERS
By Libba Carpenter Wells, MSN, PBHCNS-BC
Recently, during a moment of quiet reflection, I thought about the major paradigm shifts that have been occurring in our culture in the past 10 to 15 years. One shift is away from victim consciousness toward individual affirmation, accountability, and empowerment. Another is the change in focus away from the needs of the individual toward the “greater good” of all in our world community. There has also been a growing spirituality that embraces all peoples and all beliefs. During this period of time, a new treatment approach has evolved that has caused a paradigm shift in my approach to treating clients with severe distress. My purpose in writing this article is to share that treatment approach with you.
My First Client with Severe Borderline Personality Disorder
About two years after opening my private practice in early 1984, a young woman was referred by a local family practice. She was pregnant with a second child, and she was referred because of concerned about her anxious, hyper-vigilant manner of parenting her one-year-old daughter and her deep distress over this second, unplanned pregnancy. The first time we met I sensed in her a degree of terror that I have never sensed with any other client. My first focus was to support her and her young family through the delivery and integration of a second child into their family system. There was relief when her son was born, but little did I realize that the greatest challenges lay ahead. Her fragile self shattered into psychosis during the delivery and hospitalization process, and serious self-mutilating behaviors began. To maintain her safety, she had to be hospitalized four or five times over the next few years. For days on end she reported wanting to die. She fantasized about ways to kill herself and brought me clay models of nude women hanging from trees. I kept showing up, with compassion, care, and consistent limits, but felt my best efforts which were consistent with my training were inadequate to help me understand and handle her behavior and unrelenting distress.
This client’s primary diagnosis was borderline personality disorder (BPD) and was on the severe end of the diagnostic continuum. The work that I did with her and with other clients in the late 80s and early ‘90s with sexual, physical, and emotional abuse issues was based on the premise that painful experiences must be remembered in the presence of a caring other in order to be resolved. It became apparent after awhile, however, that this process of “digging,” to get to the symbolic “bottom” of the trauma often resulted in clients becoming exhausted, overwhelmed, and less able to function effectively in their everyday lives. A lesson learned from Imago Relationship Therapy while attending a couples workshop in 1989 and completing certification training in 1990 was that individuals can learn behavioral skills which allow them to respond more effectively to present-day conflicts. While I was a well-trained professional, it impressed me that I learned new skills and further developed pre-existing skills through the Imago training. In the mid 1990s, as I continued to work with Imago, I also became introduced to the revolutionary work of Dr. Marsha Linehan who was getting very positive results with BPD clients through the approach she developed and called Dialectal Behavior Therapy (DPT). It was at this point that my ideas about how to work with clients who have suffered severe trauma began to take a dramatic shift.
The Evolution of DBT as a Treatment for BPD
After completing her doctoral studies in psychology in the early 1970s, Dr. Linehan did her internship in a suicide prevention clinic. There she got her first experience working with severely distressed and suicidal clients. She now says that she “came to the work with a blank slate—knowing only that she wanted to work with the most miserable people in the world” (Butler, 2001, p. 32). She used her knowledge as a behavioral scientist to observe client behaviors and how clients change. Negative behaviors were seen as attempts at problem-solving and communication. Realizing that her strategies at that point were only partially effective, she got further training in cognitive-behavioral therapy (CBT) at the State University of New York at Stony Brook. In 1977, she took a faculty position at the University of Washington. There her research on therapy for suicidal clients began in earnest with the support of NIMH grants. She worked with clients in front of one-way mirrors while her graduate students observed and videotaped. Later she and her students coded and critiqued the therapy. The treatment now known as DBT evolved from that collaborative process (which continues) of “experimenting” to see what works. With the publication of her landmark 1991 article in Archives of General Psychiatry (Linehan, Armstrong, Suarez, Allman, & Heard), she was able to share the results of her first randomized clinical trial. The 22 clients in DBT treatment for a year had fewer episodes of parasuicide or self-harm behaviors, fewer days of hospitalization, and less premature termination from therapy than 23 clients who got usual treatment. These findings, subsequently replicated by Dr. Linehan and others, validated that she was developing an approach which could actually help these difficult-to-treat clients get better.
A Definition of DBT
On her website, Dr. Linehan describes DBT as “a comprehensive cognitive-behavioral treatment for complex, difficult-to-treat mental disorders.” While originally developed to treat chronically suicidal individuals, DBT has evolved into a treatment for those with BPD. It has been adapted for use with other disorders and clinical problems in a variety of settings.
“DBT…is based on a dialectical and bio-social theory of BPD” (Linehan, 1993b, p. 1). A key feature is the emphasis on “ ‘dialectics’—that is the reconciliation of opposites in a continual process of synthesis” (Linehan, 1993a, p. 19). A dialectical, both/and view allows for the therapist to say to the client “On the one hand, I accept you just as you are and, on the other, I believe there be some ways in which you can learn to live your life more effectively.” This principle of dialectics, with the “emphasis on acceptance as a balance to change” (Linehan, 1993b, p. 19), comes from Dr. Linehan’s own practice of Zen meditation and her integration of this world view, which has been integrated in most social and natural sciences today.
According to Dr. Linehan, the core disorder of BPD is emotion dysregulation. BPD develops in those who have a biological predisposition to the disorder (high sensitivity to emotional stimuli) and who grow up in environments where their thoughts and feelings (their “private experience,” Linehan, 1993b, p.3) are not appropriately validated. Consequently these individuals are not able to label, validate, and regulate their own experience adequately. Given that a high percentage of these clients are victims of sexual abuse and often experience physical abuse and neglect as well, it makes sense they would have difficulty with healthy Self development and tend to live their lives careening from one extreme to another.
The intensive treatment approach of DBT occurs in stages. In Stage 1, the first year of therapy, clients attend a weekly skills training group, have individual therapy for help in applying the skills, and use phone consultations for validation of their experiences and for skills coaching. Their individual therapist is a part of a consultation team with other therapists to learn the model, help therapist be optimally effective, and help them stay motivated.
The general goal of skills training in that first year is “to learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems in living, that is, those causing misery and distress” (Linehan, 1993b, p. 107). Four skills modules are taught: 1) core mindfulness skills, which address confusion about the self, getting more control of one’s mind, and how to go within; 2) interpersonal effectiveness skills, to address intense, unstable relationship patterns; 3) emotion regulation skills, for affect lability of and helping clients experience and modulate emotions without extremes of emotional inhibition or intensity; and 4) distress tolerance skills, for learning to tolerate uncomfortable feelings without engaging in impulsive, hurtful behaviors.
Stages 2, 3, and 4 build on these Stage 1 skills to help clients feel better and hopefully eventually experience joy and transcendence (Linehan, 2001, www.behavioraltech.com under “DBT: Behavioral targets and stages of treatment in DBT”). Trauma resolution is not attempted until sometime after the first year, when the skills are learned.
WHAT I ESPECIALLY LIKE ABOUT DBT:
It makes sense to me, especially given my experiences with the client I described, that it is beneficial to for the client to learn skills before attempts at trauma resolution. DBT also seems so deeply respectful and validating of the client and her experience, without being judgmental. The dialectical approach, with the balance of validation and acceptance, allows for a clear, gentle way to talk to sensitive clients about areas of needed growth. Clients intuitively know that they need to live more skillfully. If we let them continue blaming others and failing to address areas of needed change, a crucial part of therapy is omitted. I have also been impressed with the success of DBT in our area. Dr. Meggan Moorhead, a local psychologist heard Dr. Linehan speak in 1991 and participated in the first intensive DBT training. She then began teaching DBT to eight inpatients at a local state psychiatric hospital. Women who had been part of the revolving door syndrome were able to manage outside the hospital (Butler, 2001, p. ).
IMPLICATIONS FOR IMAGO THERAPISTS:
- Considerable research data support the effectiveness of DBT for those with BPD and chronic suicidality. It is also being used for treatment resistant depression, bipolar disorder, adolescent behavioral problems, substance abuse, and eating disorders. Consideration of this therapy for deeply distressed clients makes sense.
- DBT principles may be useful for all of us who seek to live balanced lives and probably congruent with principles that we already find useful. The handouts used in skills training are available in the skills handbook (Linehan, 1993b) and may be photocopied. Since my first training in 1996, I have used the skills personally and have integrated them in varying degrees with most individuals and couples I have seen.
- Many of us have found mindfulness useful in our own lives. The DBT mindfulness modules and distress tolerance are an additional resource in helping couples and individuals to have a clear sense of self and manage old brain reactivity.
- The dialectical world view resonates deeply with our intentional dialogue process. In guided those in dialogue, we have been saying, overtly and covertly, that the thoughts, feelings, and behaviors make sense Or, their own perceived and expressed experience). We have asked them to speak “their truth.” We have implied or said that both perspectives are “right” or “true.” Then we support them in bringing the tension of the opposites together. In dialectical theory, “the ends of the teeter-totter represent the opposites (‘thesis’ and ‘antithesis’); moving to the middle and up to the next level of the teeter-totter represents the integration or ‘synthesis’ of these opposites, which immediately dissolves into opposites again” (Linehan, 1993b, p. 30). This beautifully validates the power of our tool of dialogue. The dialectical world view, if we let it sink deeply into our souls and psyches, can be a powerful, transforming tool for us in the Imago community now as we are forging a new way with the proposed reorganization. Those on opposite ends of the symbolic teeter-totter can hang on and “ride” until the synthesis of the opposites occurs.
Dr. Linehan’s website (www.behavioraltech.com) delineates training options from individual self-study to DBT program development. One can buy the books and then study alone or form a study group with other professionals. The skills training manual, with the handouts which can be copied, is probably the easiest place to start. The Butler articles in Psychotherapy Networker also provide a current and thorough review of the material, with a moving story of the work Dr. Megan Moorhead has done with one of those first women she taught at the state hospital.
Butler, K. (2001a). DBT in a nutshell. Psychothery Networker, 25(3), 34-35.
Butler, K. (2001b). Revolution on the horizon. Psychotherapy Networker, 25 (3), 26-39.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.
Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
Linehan, M. M. (2001) www.behavioraltech.com.
Books and videos may be purchased through Guilford Press at 1-800-365-7996 or through the website.