Using Dialectical Behavior Therapy to Treat Borderline Personality Disorder
Developed by Marsha Linehan, Dialectical Behavior Therapy was initially designed to treat Borderline Personality Disorder (BPD). Often called DBT, it is rooted in the same principles as Cognitive Behavior Therapy (CBT) along with Eastern meditative practices. DBT aims to help clients change their typical patterns of thinking and acting, so that they can feel better and behave in ways that are more adaptive.
For a complete overview of Dialectical Behavior Therapy, see the previous article in this series. This article will further discuss the nature of Borderline Personality Disorder and the way in which DBT can help to reduce the symptoms of the disorder. Learn more about the application of DBT for BPD:
Diagnosis of Borderline Personality Disorder
Being diagnosed with a personality disorder can seem more daunting than some other diagnoses. In general, the presence of a personality disorder indicates that a person has some rigid psychological features that persist across settings and contexts, despite often being maladaptive. Personality disorders take various forms and are thought to be long lasting. However, many view BPD a bit differently.
BPD is marked by a pattern of unstable moods, behavior, and self-image. It was named in part because individuals with this diagnosis seem to shift back and forth across a border. At times, they may be on one side of the border—happy, feeling good about themselves, and able to easily maintain their behavior. At other times, they may quickly shift to unhappy, self-critical, and somewhat out of control.
As people with BPD, sit on or shift across the border, they may behave impulsively and without thinking things through. Intense emotions can drive them to act out, sometimes even lashing out at others. This can have deleterious effects on their relationships. It can also hurt their relationships and performance at work and in other settings. In turn, this can leave them feeling poorly and worsen the symptoms.
Aside from instability and impulsivity, the diagnostic symptoms of BPD include:
Reactive mood and affective instability.
Intense and perhaps inappropriate anger along with difficulty controlling anger.
Sometimes frantic efforts to avoid abandonment.
A pattern of intense and unstable interpersonal relationships.
Persistently unstable self-image and sense of self.
Chronic feelings of emptiness.
Impulsivity in areas such as spending money and substance use.
Transient, stress-related paranoid ideation.
Dissociative symptoms such as feeling disconnected from themselves or their surroundings.
Recurrent self-harm behavior and suicidal ideation or gestures.
There is a great deal of variance among people with BPD, in that they may have some but not all the symptoms and to different degrees of severity.
Marsha Linehan and others in the field view emotion dysregulation as a core problem in BPD. Essentially, individuals with BPD have such a difficult time managing and regulating their emotions, that many of these other symptoms occur as a result.
Causes of Borderline Personality Disorder
Many in the field of psychology view BPD as being the result of certain, difficult life circumstances. Research indicates that many people with this disorder have a history of neglect, abuse, or other trauma. In many cases, they experienced at least some history of invalidation. With this, caregivers neglected their emotions or told them (directly or in subtle ways) that their emotional reactions were wrong.
Having your emotions neglected by caregivers or being told that your emotions were unimportant or being told that your assessment/identification of your emotions is incorrect would leave most people quite confused. Invalidation interferes with learning how to identify, attend to, and manage emotions.
As a child, adolescent, or young adult showing intense emotions, may feel like the only way to get needed attention and one’s needs met.
By viewing the core feature of BPD as emotion dysregulation and by seeing it as a result of life’s circumstances, Linehan saw a possibility to help those who suffered from the disorder. Her belief was that individuals with these behaviors could learn new ways of thinking and acting. By teaching them skills, they could better manage their emotions and get their needs met in more adaptive ways.
Application of DBT to Borderline Personality Disorder
As noted in the previous article in this series, DBT consists of four modules, each of which is designed to teach clients skills in a particular area to address associated symptoms.
The first module, mindfulness, helps clients learn to slow their thinking and observe, rather than react to their thoughts. The second module helps clients to learn skills for managing and reducing their distress. The third module helps clients better recognize their emotions and regulate their emotional reactions. The fourth module teaches skills for interpersonal effectiveness, so that clients can improve their relationships.
Here, I want to elaborate on the skills that would be taught in each module and how each module can help individuals with Borderline Personality Disorder to better manage their symptoms.
One of the key symptoms of BPD is that tendency to sit on the border, bouncing between intense reactions and actions. Also recall that some of this occurs because of black-or-white thinking. Mindfulness skills teach people how to relax and observe thoughts or experiences, without jumping to judgments and impulsive behaviors.
Mindfulness skills teach awareness of the present moment with acceptance. Clients are taught to engage with deep breathing to calm their body and mind. They are taught to observe their surroundings without engaging or reacting. They are also taught to observe thoughts rather than immediately engaging with them. This all allows more space to just be in the gray-zone, and respond thoughtfully rather than react.
Distress tolerance skills are often taught second in the sequence so that clients will have these tools to better manage their most intense emotional reactions. Clients are taught many skills that they can use during times of distress. For example, clients are taught to distract themselves when appropriate. They are also taught how to self-soothe or engage with techniques to calm themselves down.
Such skills are helpful because clients with BPD often experience distress during intense moments where they become extremely dysregulated. This could be caused by a difficult situation or simply feeling that the emotions they have are intolerable (much like feeling distress about their distress). Individuals learn how to create their own sense of calm.
The emotion regulation skill-set module contains the key information all humans need in order to analyze, identify, and manage their emotions.
In this module, clients are taught about the various emotional reactions they might experience and the varying degrees to which those emotions can occur (i.e. happiness versus sadness, and sadness versus despair). Then, clients are taught how to reduce their emotional vulnerability, to ensure that they put themselves in the best state possible for dealing with emotions.
Emotional vulnerability occurs when people simply do not take good care of themselves. Every human needs food and sleep, time for fun, time for friends, time to relax, etc. When a person lacks these, they become worn out and more vulnerable to feeling emotionally upset. This is because they simply lack the resources and “fuel” to power through those emotions. Instead, the emotions can overtake them.
Woven throughout the distress tolerance and emotion regulation modules is the concept of acceptance. One thing that people with BPD may struggle with, is a struggle against or even anger about their circumstances, emotions, and reactions (sort of wishing that things were different and being even more upset that things are the way that they are). By learning to accept, but not necessarily approve of, those things they do not like, they are able to more effectively deal with their reality.
Finally, recall that individuals with BPD often have relationship difficulties. This is due in part to the various symptoms and also to deficits in interpersonal skills. The interpersonal effectiveness module teaches individuals with BPD how to make more effective choices in their relationships. This can allow them to improve their interpersonal relationships and social support.
Evidence Supporting DBT for Borderline Personality Disorder
DBT is an evidence based treatment for BPD. Research supports the use of DBT for BPD and numerous studies have confirmed its efficacy.
Linehan updated her original DBT manual. Many of her materials can be found online.
With the right help, your symptoms and quality of life can improve.
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