Professor Goldberg
PSY 101
October 25, 2011
Treatment of Borderline Personality Disorder
With Dialectical Behavior Therapy
Borderline personality disorder (BPD) is a chronic and severe mental illness that
is becoming more common among teens and young adults. It is estimated that about 25% of the general population are affected by this disorder (Selby, Joiner 219).
Frequently patients with borderline personality disorder meet the DSM criteria for other
psychiatric illness as well, such as major depression, anxiety disorders, post-traumatic
stress disorder, and eating disorders (Lieb et al. 454). This usually makes it more
challenging to diagnose BPD and the illness remains untreated. The American
Psychiatric Association defines BPD as “a pervasive pattern of affective instability and
identity disturbance characterized by frantic efforts to avoid loss and diminish chronic
feelings of emptiness that often takes the form of impulsivity and recurrent suicidal or
self-mutilating behaviors” (Sneed, Balestri, Belfi 265). These persistent suicidal thoughts
and behaviors along with self-mutilation are often referred to as parasuicidal and are
most often associated with borderline personality disorder. Other common forms of
impulsivity associated with BPD include substance abuse, disordered eating, spending
sprees, verbal outbursts, and reckless driving. Along with impulsivity other criteria for
borderline personality disorder include affective disturbance, disturbed cognition, and
intense unstable relationships (Lieb et al. 453).
There are several factors that can cause borderline personality disorder to
develop. Genetics has been said to play a role in the onset of BPD, most particularly in
twins. BPD can also be inherited from a parent who has borderline personality disorder.
Events during childhood can also induce the onset of BPD, especially ongoing
experiences of abuse or neglect. It is reported that “the most frequent of these is
childhood sexual abuse, which is reported by 40-71% of inpatients with borderline
personality disorder” (Lieb et al. 454). In 1993, Marsha Linehan, who later created
dialectical behavior therapy, proposed a theory stating that individuals who are
surrounded by an invalidating environment are more susceptible to developing BPD.
When communication of emotional experience is met by erratic, inappropriate,
judgemental, and extreme responses by others, individuals with BPD then develop an
emotional vulnerability that results in heightened sensitivity to emotional stimuli,
experiences emotions as extremely intense and a slow return to emotional baseline
(Selby, Joiner 219). Linehan also pointed out that
This development of emotion dysregulation resulted in the development of
subsequent behavioral dysregulation (defined as behaviors that are difficult to
control and result in impairment in the affected individuals functioning) …, these
behaviors provide a way for an individual to shift attention away from unpleasant
emotional states.” (Selby, Joiner 219)
Because individuals with BPD constitute for a large group among suicide attempters
and they tend to repeat their self-destructive behaviors, it is necessary for them to seek
treatment.
It is evident that because of the high risk behaviors associated with borderline
personality disorder, psychotherapy is a necessity. Unfortunately many medical
professionals are unaware of the challenges presented by this disorder. Joan Wheelis,
M.D., who graduated from the Boston Psychoanalytic Society and Institute, stated that
“My psychoanalytic training led me to focus on a patient’s resistances to insight rather
than on the patient’s maladaptive responses to overwhelming affect..., When I felt
ineffective at helping my patients I sought consultation and I was relieved and excited to
learn about dialectical behavior therapy.” (325). Dialectical behavior therapy (DBT)
focuses on manipulation the contingencies, which maintain problematic behavior in the
present, which they may have been learned in the past. Like Cognitive behavior therapy
(CBT), DBT does not recognize dynamic unconscious meanings or forces. Instead
these theories try to understand behavior by studying its occurrence over time, what
events precede and what follows a particular behavior. When Dr. Marsha Linehan
developed DBT she added three important components to the standard CBT protocol.
1. A dialectical philosophy and methodology of treatment emphasizing the
importance of acceptance and validation of behavior while promoting its
change.
2. Mindfulness as a set of skills to focus attention as well as a philosophy
borrowed from the Zen tradition to stay connected to the present
3. Significant attention is focused on the development and on the maintenance
of a working therapeutic alliance.
(Wheelis 328)
Dialectical behavior therapy is currently the most frequently used psychotherapy for
borderline personality disorder. The DBT program consists of multiple forms of therapy
including individual therapy twice a week, a skills group once weekly, telephone
coaching and case management, and supporting therapists’ motivation and skills with a
consultation team once weekly. Individual therapy is focused on “promoting the
motivation for change by detailed chain analyses, [teaching] validation strategies, and
management of reinforcement contingencies” (Kliem, Kröger, Kosfelder 936). DBT
therapists use a treatment target hierarchy to help determine the problem focus for each
session. The reduction of suicidal gestures and self-injurious behaviors is given the
highest priority, considering that these behaviors predict completing suicide. Therapyinterfering behaviors such as skipping appointments or lying are addressed next,
followed by reduction in quality-of-life interfering behaviors, such as drug/alcohol use,
and binge eating (Kliem, Kröger, Kosfelder 936). The primary goal of the weekly skills
group is to increase target-oriented and appropriate behavior by teaching over 50 skills
grouped into four separate modules, each designed to target a different area of skills
deficits in BPD. (Neacsiu et al. 564).
To aide the DBT therapist in helping the patient during individual session diary
cards are used to monitor urges to engage in target behaviors as well as what skills the
client practiced throughout the week. They are then reviewed in therapy each week and
are used to determine the targets to be addressed in that session. Diary cards are also
kept on file throughout treatment as a guide to the therapist on progress being made
(Neacsiu et al. 566). During individual sessions, skills from the four modules are also
reviewed to help reinforce them with the client. The four modules consist of core
mindfulness, distress tolerance focusing on acceptance, interpersonal effectiveness
focusing on change and finally emotion regulation (James et al. 149). Perhaps the most
important module of skills in DBT is mindfulness. Marsha Linehan added mindfulness
to the program because she believes that “an important element is the attention the
therapists pay to the dialectic between validation and acceptance of the patients as they
are, and at the same time helping them change” (James et al. 149). Mindfulness helps
the individual be more in control of their thoughts and actions because it emphasizes
staying in the present and focusing attention in the moment (Wheelis 329). This helps
facilitate the experience of validation as well as tolerance and acceptance of change.
The skill of validation is also focused on during DBT skills groups, which is “the process
by which patients are given support for their experiences as their therapists convey their
understanding of a patients behavior in view of a current situation or past experience”
(Wheelis 329). Validation does not mean agreement, it simply states that you
understand where the person is coming from or they are being heard. An example of
this could be used with an individual who suffers from recurrent self-injurious behaviors.
The therapist may validate this behavior by saying “I can understand how you could get
to point” or “It must be really difficult to deal with those feelings so I can see why you
would want to cut yourself”.
Although dialectical behavior therapy was originally developed for treatment of
borderline personality disorder, it has now been conceptualized as a useful treatment
for a wider range of difficult to treat or multiple disordered patients. These include but
are not limited to paranoid personality disorder, obsessive-compulsive personality
disorder, avoidant personality disorder, non-BDP anorexia-nervosa, and chronic
depression (Lynch, Cheavens 155). In general, “Dialectical behavior therapy is the
most empirically supported treatment available for suicidal behaviors and nonsuicidal
self-injury” (Harned et al. 421).
Works Cited
Harned, Melanie S.Jackson, Safia C.Comtois, Katherine A.Linehan, Marsha M.
"Dialectical Behavior Therapy As A Precursor To PTSD Treatment For Suicidal And/Or
Self-Injuring Women With Borderline Personality Disorder." Journal Of Traumatic Stress
23.4 (2010): 421-429. Psychology and Behavioral Sciences Collection. Web. 4 Nov.
2011.
James, Anthony C.Taylor, Annie Winmill, Louise Alfoadari, Kielly. "A Preliminary
Community Study Of Dialectical Behaviour Therapy (DBT) With Adolescent Females
Demonstrating Persistent, Deliberate Self-Harm (DSH)." Child & Adolescent Mental
Health 13.3 (2008): 148-152. Psychology and Behavioral Sciences Collection. Web. 4
Nov. 2011.
Kliem, Sören, Christoph Kröger, and Joachim Kosfelder. "Dialectical Behavior Therapy
For Borderline Personality Disorder: A Meta-Analysis Using Mixed-Effects Modeling."
Journal Of Consulting And Clinical Psychology 78.6 (2010): 936-951. PsycARTICLES.
Web. 4 Nov. 2011.
Lieb, Klaus Zanarini, Mary C.Schmahl, ChristianLinehan, Marsha M.Bohus, Martin.
"Borderline Personality Disorder." Lancet 364.9432 (2004): 453-461. Psychology and
Behavioral Sciences Collection. Web. 4 Nov. 2011.
Lynch, Thomas R.Cheavens, Jennifer S. "Dialectical Behavior Therapy For Comorbid
Personality Disorders." Journal Of Clinical Psychology 64.2 (2008): 154-167.
Psychology and Behavioral Sciences Collection. Web. 4 Nov. 2011.
Neacsiu, Andrada D.Rizvi, Shireen L.Vitaliano, Peter P.Lynch, Thomas R.Linehan,
Marsha M. "The Dialectical Behavior Therapy Ways Of Coping Checklist: Development
And Psychometric Properties." Journal Of Clinical Psychology 66.6 (2010): 563-582.
Psychology and Behavioral Sciences Collection. Web. 4 Nov. 2011.
Selby, Edward A., and Thomas E. Jr. Joiner. "Cascades Of Emotion: The Emergence
Of Borderline Personality Disorder From Emotional And Behavioral Dysregulation."
Review Of General Psychology 13.3 (2009): 219-229. PsycARTICLES. Web. 4 Nov.
2011.
Sneed, Joel R., Massimo Balestri, and Brian J. Belfi. "The Use Of Dialectical Behavior
Therapy Strategies In The Psychiatric Emergency Room." Psychotherapy: Theory,
Research, Practice, Training 40.4 (2003): 265-277. PsycARTICLES. Web. 4 Nov. 2011.
Wheelis, Joan. "Mending The Mind." Psychoanalytic Dialogues 20.3 (2010): 325-336.
Psychology and Behavioral Sciences Collection. Web. 4 Nov. 2011.