Dialectical Behavior Therapy (DBT) for Borderline Personality Disorder

Psychologist Marsha Linehan developed dialectical behavior therapy (DBT) especially for the treatment of borderline personality disorder. Linehan based this innovative approach to therapy on the idea that borderline personality disorder arises from a combination of biological and social factors. She theorizes that emotionally vulnerable individuals who grow up in an invalidating environment (a term coined by Linehan) most frequently develop the condition.

Linehan defines an emotionally vulnerable person as one who has excessive reactions to relatively low levels of stress and who takes much longer than the typical person to return to normal once the stress is reduced. The term, invalidating environment, refers to a situation where parents or other significant people invalidate a child’s experiences and feelings throughout childhood or adolescence. This situation results in the child’s inability to trust her own responses to events in everyday life. Eventually, this environment results in the development of a persistent, negative behavior pattern and inappropriate coping mechanisms known as borderline personality disorder.

Dialectical Behavior Therapy for Borderline Personality Disorder

Dialectical behavior therapy for borderline personality disorder uses a variety of psychosocial therapies during treatment. DBT therapy differs from traditional cognitive behavioral therapy (CBT) in that it emphasizes personal validation. This means the therapist and client work together to accept uncomfortable thoughts. Once the client identifies and validates a particular thought, changing the thought and its behavioral consequences is seen as a real possibility. The client begins to see the goal of transformation as a reality.

The individual learns to accept disturbing or stressful thoughts without entering the downward spiral of self-criticism, which is one of the symptoms of borderline personality disorder. She or he also learns to acknowledge, yet resist, self-harming urges.

The Dialectical Behavior Therapy Methodology

Standard dialectical behavior therapy has four parts:

• Individual (one-on-one) therapy
• Group skills lessons
• Remote coaching (i.e. by phone or video conference) to address crises between sessions
• Consultation between various health care providers for continuity of care

As with CBT, the DBT therapist may assign "homework" for clients to do between sessions. The homework may include practicing new interpersonal and stress management skills. Some clinicians ask clients to keep a daily journal to track their emotions, urges, behaviors (i.e. lying, self-injury, risky behaviors), and positive outcomes. This unique therapy approach seeks to enhance life skills like:

• Emotional regulation
• Mindfulness
• Effective interpersonal interactions
• Stress tolerance

During the DBT therapy sessions, the therapist trains the client in the concept of mindfulness and self-awareness, so she can address situations and negative thoughts as they occur. For example, a client might start to think things like, "I'm the worst," "I always screw everything up," or similar all-or-nothing, unfounded thoughts. DBT therapy can teach the person to validate the thought, but to then work through a mental process that pulls her back into the moment.

Here's a good way to think about it: Imagine you're tidying up the family room in your home. While you're doing this, your mind takes a detour from the actual task. You begin to have thoughts like, "If the kids would just pick up after themselves, this would be so much easier," or "Why is my spouse such a slob? He's always so lazy," or similar thoughts that have nothing to do with the actual task.

The concept of mindfulness would have you validate the thoughts, but then get right back to focusing on the chore of picking up socks, shoes, vacuuming and noticing how nice everything looks. Validating the thoughts doesn't mean they're right or wrong. It simply allows you your feelings and responses, but mindfulness pulls you away from the negativity surrounding them and into the present.

The American Psychiatric Association endorses dialectical behavioral therapy as effective for treating borderline personality disorder. People who stick with treatment may see a number of improvements, including:

• Less hostility and anger
• More peaceful inner experience
• Improved social function
• Shorter hospitalizations
• Less frequent bouts of suicidal thoughts and behavior
• Higher level of commitment to treatment

Many people with BPD abuse drugs or alcohol. While DBT reduces the abuse of substances among this group, it hasn't proven effective in treating actual addictions.

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