Dialectical Behavior Therapy –
Adaptation for Family Physicians
Shelley McMain, PhD, C. Psych
Head, BPD Clinic
Centre for Addiction and Mental Health and Department of
Psychiatry
University of Toronto
UNIVERSITY OF TORONTO
Objectives
Be familiar with DBT’s biosocial theory of
BPD
 Identify two core DBT strategies used to
effectively engage individuals with BPD
 Be familiar with strategies to reduce
burnout and enhance self care

BPD: Diagnosis
Personality Disorder:
 enduring pattern of inflexible and
maladaptive traits which causes
impairment or distress
 arbitrary cutoff between BPD and traits: 5/9
 utility of diagnosis
 diagnosis not made by your own reaction to
the patient

Dialectical Behavior Therapy
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“Standard DBT” is a comprehensive,
multimodal treatment originally developed
for people with BPD
DBT has been adapted for various patient
populations and across a variety of
settings
Any professional can implement selected
strategies
Vignette #1
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42 year old single woman with chronic suicidal
and self harm behavior
Tx history includes numerous psychotropic
medications, lengthy hospital stays and repeated
ER visits, lengthy history of psychosocial
treatments
Patient frequently presents in a state of emotional
– often angrily demanding more time and
additional appointments
Clinical Consideration
How do you understand this patient’s
problems?
If you believe that this patient meets
criteria for BPD, should you
discuss the diagnosis?
How should you engage this patient?
Etiology of BPD:
DBT’s Bisosocial Theory
High
Emotion
Vulnerability
Emotion
Modulation
Deficits
Problematic
Behaviours (e.g. suicide,
substance use)
DBT’s Biosocial Theory
Fruzzetti et al. (2005)
Emotion
Vulnerability
Heightened
Emotional Arousal
Pervasive
History of
Invalidating
Responses
Inaccurate/Extreme
Expression
Invalidating
Responses from
Others
Fruzzetti et al, 2005
Educate Patients about BPD diagnosis
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Helps to de-stigmatize diagnosis
Helps to increase hopefulness about
possibility for change
Encourages active participation in treatment
planning
Education about the diagnosis has been
shown to reduce symptoms (Zanarini,2008)
Adopt a Clear Treatment
Structure

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Establish a treatment contract – clarify your roles,
responsibilities, treatment goals
Clarify structure of appointments – frequency of
appointments, expectations about attendance
Be clear about your limits and availability
Anticipate and plan for crises
APA, 2001
Guidelines on Concomitant
Treatments
Treatment by more than one clinician is
viable however good collaboration is
essential (APA, 2001).
 Someone should be identified as the
primary clinician

(APA, 2001; Oldhman et la., 2001; Gabbard, 2000;
Gunderson, 2001; Linehan, 2003; Kernberg, ).
Clinical Vignette #2
“I’ll kill myself if you don’t get me
admitted to the hospital for the weekend”
 Patient’s parting words to therapist who
indicated that she didn’t think that
hospitalization would be helpful

Clinical Considerations
Is this client being manipulative?
 How should you respond?
 If you attend to the suicide threat will you
reinforce this behavior?
 Should she be hospitalized?

Functions of Self-injurious
Behaviour
Function
% of patients
To feel physical pain – to overcome
psychic pain
59
To punish self for being “bad”
49
To control feelings
39
To exert control
22
To express anger
22
To feel-to overcome numbness
20
Gunderson, 2001 adapted from Shearer, 1994b
Opt For the Least Restrictive Safe
Treatment Setting
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Hospitalization may be iatrogenic
Hospitalization should be viewed as a vehicle for
maintaining safety
Hospitalization should be considered if the risk of
suicide outweighs the risk of inappropriate
hospitalization
Focus on helping patients cope in their natural
environment
Validate and Emphasize
Patient Control
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Move flexibly from validating kernal of truth and
helping patient take responsibility (APA, 2001)
Don’t rush in and “take care of” patient”
Don’t reinforce dysfunctional behavior with extra
attention (i.e., avoid scheduling extra
appointments in response to self-harm)
Validate patients capability of behaving
reasonably
Validation

Why Validate?

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an essential need of
people with BPD
the only way to build
alliance
reduces distress
reduces polarization
a prerequisite for
cooperation
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How to Validate?
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listen, reflect
make educated guesses
at what she’s not
saying (read her
thoughts and emotions)
normalise
remember where she’s
coming from
find what is valid, right
or understandable
Encourage Effective Coping
Always start by validating AND then
paradoxically
1. Cheerlead - validate her strength and
ability to cope/survive
2. Reinforce progress towards goal - reinforce
the small steps
3. Negotiate - offer the options you are willing
to offer and have clear limits
4. Suggest alternatives to the behaviour if
possible
Vignette #3
Thinking of your patient or seeing your
patient evokes the following response:
 hope that she’ll get admitted to hospital
 relief when she cancels
 daydreaming about transferring her care
 Wish that you’d chosen another career
 feeling angry or irritated with her
(comments to office staff)
Reducing Burnout
Validate yourself since stress is
understandable
 Validate your patient – remind yourself of
why she is doing the best she can
 Seek support from colleagues
 Assume responsibility for observing your
personal limits
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Observing Your Personal Limits
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Monitor your limits with your patients
Be honest with yourself and clear with your
patients about your limits
Observing limits is different than setting
boundaries
When your client exceeds your limits, validate and
problem-solve
 negotiate a better arrangement for yourself
(more resources for the patient?)
Summary
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DBT’s biosocial theoretical model can
increase understanding of symptoms.
Educate patients about the diagnosis
Treatment should be well structured
Emphasis on validation in addition to
helping the client control behavior
Observe your limits and get support