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The Treatment of Borderline Personality Disorder with Dialectical Behavior Therapy
Catherine DuPuy
HSJ 5620.2
John F. Kennedy University
Spring 2012
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The term Borderline was originally coined as a descriptive for a disorder
considered to be on the ‘borderline’ between neurosis and psychosis. These clients are
notoriously difficult to treat in part because many display suicidal tendencies, are often
in crisis, and are emotionally dysregulated. They have a desire to seek help yet find it
difficult to commit to staying in therapy long enough for a treatment plan to work. In
addition, they are extremely sensitive to anything they perceive as criticism, making
working with this population often frustrating. For the therapist, it can lead to burned out
and at times, resentment toward the client. Dialectical Behavior Therapy was developed
to work to address these issues for both the therapist and client, and to date, is one of
the most effective modalities therapists have for working with this populations and the
issues they present, for themselves, and in the therapeutic environment.
Marsh Linehan developed dialectical Behavior Therapy, or DBT for short, in the
early 1980’s. She created what she termed the biosocial theory of emotional
dysregulation, proposing that BPD develops from a biological vulnerability and a
subsequent invalidating environment. According to Linehan, people who are
biologically vulnerable experience emotions more intensely than others, reacting more
frequently and with a higher sensitivity to their emotions. Lastly, they experience a
longer lasting arousal than others not so vulnerable. These are also the characteristics
of a someone suffering from PTSD.
Affect dysregulation is the hallmark of those suffering with Borderline Personality
Disorder. This is the inability to control one’s emotions, and those emotions then
overwhelm a BPD’s ability to think and reason. Emotions are often expressed in an
intense way, with little to no ability to moderate them. BPD’s suffer from a host of other
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issues, including identity problems, unstable relationships, poor impulse control, and
feelings of emptiness and little to no sense of self, frequenting leading to self-harming
behavior and suicide attempts. They fear abandonment and will go to any lengths to
avoid it, yet their emotional instability guarantees rocky and problematic relationships.
Relationship difficulty extends to all areas of their lives, including interpersonal, love or
work relationships. Research has been ongoing into the etiology of this disorder, and
many believe (van Dijke, Ford, J.D., van Son,M., Frank,L., van der Hart, O. ,2012) that
for many people with BPD, early childhood trauma is the root. Trauma can include the
following; dysfunctional family dynamics, caregivers (mom usually) depressed and
erratic, absent fathers or fathers with major character problems, and early losses
(Rathbun). Child sexual abuse plays a large part in the development of BPD, as victims
are at a higher risk for developing BDP, “childhood abuse and neglect are extremely
common among borderline patients: up to 87% have suffered childhood trauma of
some sort, 40–71% have been sexually abused and 25–71% have been physically
abused (Winston, para. 4, 2000).
For Linehan, environment plays as much a part in the development of BPD as a
biological vulnerability. And the evidence supports her in this, as it clearly indicates that
children who have been traumatized, be it sexual or physical abuse, or in repeated
hospital stays and operations, or other early childhood trauma, are at a much higher risk
to develop BPD. In a recent study of female inmates, it was found that trauma played a
critical role in the development of BPD. “Bpd has been linked to elevated rates of
trauma among female offenders” (Blonigen, D. Sullivan, E., Hicks, B., Patrick, C., para.
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7, 2012). Further, “ the majority… experienced at least one form of abuse in their
lifetimes” Blonigen, D. Sullivan, E., Hicks, B., Patrick, C., para. 12, 2012).
Perhaps one of the more tragic components of childhood trauma is it’s effect on
the developing brain. Research has shown that “chronic trauma interfers with
neurobiological development and the capacity to integrate sensory, emotional and
cognitive information in a cohesive whole” (van der Kolk, para. 7). It is a setup for the
development of many disorders, including BPD.
Research based on attachment theory is beginning to elucidate the links between
childhood trauma and the capacity to think about oneself and others. Borderline patients
are usually preoccupied with their disturbed early relationships and are unable to give a
coherent account of them. Severe childhood trauma in these patients appears to result
in a specific inability to think about their own thoughts and feelings, as well as those of
others. (Winston, para. 7, 2000). Children who are lucky enough to be raised by a
‘good enough’ caregiver are able to model their behavior after hers, and when the child
becomes emotionally distraught and dysregulated, Mom is there to calm and soothe the
child, and help them to restore a sense of safety and control, over both themselves and
their environment. They grow up trusting themselves and trusting that the environment
will meet their needs. These early patterns of attachment will affect the quality of
information processing throughout the child’s life (van der Kolk, para. 9) and allow the
child to learn to trust what they feel and what they think in any given circumstance.
However, for children raised in what Marsha Linehan calls an invalidating environment,
an environment that can be dismissive, neglectful, violent, inconsistent or abusive, the
child can become very distressed with no sense that their external environment can or
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will provide relief. “As a result, they experience feelings of anxiety, anger and the strong
desire to be taken care of” (van der Kolk, para. 15), note the Borderlines need for
relationship and fear of abandonment.
She does not learn safety and she cannot
control herself as it is not being modelled for her. Under these conditions, the child does
not learn to moderate her arousal and she is unable to
process, integrate and
understand what is happening. Children who grow up under these conditions
experience an insecure attachment and this same emotional instability is the foundation
for Borderline Personality Disorder. Like the suicide attempts of the teen ager and later
adult, for the child, their problems and their reaction to them can be seen as an attemp
to minimize the objective threat and regulate their emotional distress (van der Kolk,
para. 16).
For children like this, emotional dysregulation leads to a poor sense of self, poor
impulse control and agrression towards themselves or others. They have not been
given, by appropriate modelling, the tools to understand the cause and effect of their
behavior and/or what their relationship to their behavior and the environment around
them is. “Without internal maps to guide them, they act, instead of plan, and show their
wishes in their behaviors, rather then asking for what they want” (van der Kolk, para.
22). A traumatic childhood can be, and often is,
a set up for the development of
Borderline Personality Disorder.
The DSM–IV ‘s diagnostic criteria for borderline personality disorder is as follows:
At least five of:
Intense and unstable personal relationships
Frantic efforts to avoid real or imagined abandonment
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Identity disturbance or problems with sense of self
Impulsivity that is potentially self-damaging
Recurrent suicidal or -suicidal behavior
Affective instability
Chronic feelings of emptiness
Inappropriate intense or uncontrollable anger
Transient stress-related paranoid ideation or severe dissociative symptoms
DSM–IV (American Psychiatric Association, 1994)
Dialectical Behavior Theory proposes that people with BPD are attempting to
regulate their behavior, even if we see it as dysregulated, problematic and disordered.
Further, it states that invalidating behavior helps to further it and that common patterns
develop in attempting to both live and regulate behavior. These patterns become
problems unless treated (Koerner, p. 12, 2012). The theoretical framework for DBT is
dialectics, which is “both a view about the nature of reality and a method of persuasion.
It is an essential idea that any one position contains its antithesis” (Koerner, p 15,
2012). It is in simpler terms, a “way to achieve balance” (Linehan, 1995). Clients are
both accepted for who they are, where they are, and at the same time, encouraged to
change behavior that does not work for them. Validation is critical to DBT, as it sees
behaviors like suicide attempts as the best the client can do for now. In the film Girl,
Interrupted, Winona Ryder says to her therapist “I wasn’t trying to kill myself, I was
trying to make the shit stop” (Girl, Interupted, 2008). The “shit” in this case is an
emotional life out of control.
DBT is based on Cognitive Behavior Therapy, which is a therapy geared toward
change oriented strategies. DBT adds the element of mindfulness, as well as
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acceptance strategies, because, borderlines are so sensitive to criticism and negative
feedback, that simply working from a change strategy will meet with great resistance
and the client will likely leave therapy. Understanding that borderlines are coming from a
place of skills deficits – they do not know how to do things any other way, goes a long
way in working with them. If they are met where they are, if they are accepted for what
they have attempted in the past (even when it fails) and when the therapist understands
how hard it has been for them, and expresses that, then agreement to work toward
change becomes a possibility (Linehan, 1995).
This is the philosophical difference between DBT and other theoretical
perspectives, the notion of direct acceptance. Within the seed of that idea, comes the
notion of change. Hence the dialectic. Saying to a client “people who meet criteria for
borderline have skills deficits or capability deficiency, that they don’t have the ability to
engage in the behaviors that they need to dissolve their problems. What I’m thinking is
that what we have to do, is teach you something new to do, what do you think?”
(Linehan, 1995) is a welcoming and understanding perspective, one that encourages
possibilities. From here is possible to bring the client on board in the treatment, by
asking if they then want to learn something new.
DBT is based on a hierarchical structure with 4 primary components; individual
therapy, group skills therapy, telephone consults and therapist group therapy/support.
These 4 modes of treatment have been one of the most effective modalities for treating
those with Borderline Personality Disorder.
Individual Therapy
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Individual therapy begins with what is termed the ‘pretreatment stage, where the
client and the therapist agree (contract) to the essential goals and the methods of
treatment. The therapist explains (to the extent they can in this initial session) what DBT
is all about. The contract may not be written down, but it is essential that both parties
understand and agree to it. This agreement will take into consideration what precisely is
the current problem(s) for the client, and will include expected and set time frames for
treatment results as well as when scheduled sessions are, what they cost, etc. The
therapist will also include what he/she is agreeing to, which might include needing extra
training, abiding by the highest ethical standards and that they will be participating in a
BDT consult group. When this agreement is in place, formal treatment begins.
DBT has 4 stages, not all of which any one patient may go through. The first
stage is for the most critical clients, though given a borderlines resistance, most clients,
even if not suicidal, will start here. This stage targets behaviors that the client is doing
that are life threatening, for instance, suicide attempts, and cutting behaviors, or burning
themselves with cigarettes. DBT defines treatment goals as the desired end point for a
stage of treatment, for example, in Stage 1, a treatment goal would be choosing not to
kill oneself (or do other self-injurious behaviors). A ‘target” is defined as behaviors that
have been identified (by the therapist, therapist consult team, or the client) as needing
to change. That change may be either increasing the behavior (for example, learning to
sit with ambiguity) or decreasing behaviors (tolerating distress without blowing up or
raging at someone).
Stage 1

decrease life threatening behaviors
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
Decrease therapy-interfering

Decrease quality of life interfering behaviors (this can include Axis 1 disorders as
well as issues around housing, relationships, work, or legal problems.

Increase behavioral skills (some of these are taught in skills groups)
o Mindfulness
o Distress Tolerance
o Interpersonal effectiveness
o emotional regulation
o self-management
(Koerner, p. 25, 2012)
It should be no surprise that DBT starts targeting self-harm behaviors right away,
as DBT was created to deal with suicidal borderlines. Like many therapies, DBT expects
the client to commit to a no suicide pact, but in DBT, the contract is usually for a year,
and unlike most other therapeutic interventions, DBT therapists are available to their
clients (regardless of the stage) by telephone for consultation when the need arises. In
a 2003 study done in Sweden, borderline clients found the therapeutic contract
beneficial and supportive. The contract “postulates progress in therapy as a criterion to
continue”, pushing them to work on their issues. One (unnamed) study participant said
“If I’ve signed a paper it feels like more of a commitment not to let myself or the
therapist down” (Perseius, para. 23, 2003).
Identifying behaviors that can or do interfere with therapy is the second in this
hierarchy. DBT recognizes that borderlines have a tendency to shoot themselves in the
foot, and drop out of therapy when it’s gets hard, and this is where the acceptance and
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change model comes into play. Clients are helped (through individual, group and phone
calls) in their commitment to their own process. The therapy will target any of these
behaviors with specific goals to stop their occurrence.
The therapist is also involved in helping the client resolve life issues they may be
having, usually as a result of their skills deficit. To a borderline, a job interview may
seem overwhelming, and with the help of the therapist and the skills group, the client
can begin to try out new behaviors, because a critical component of DBT is the ability to
translate what one has learned in the rooms, to the outside world. This is where Linehan
sees other treatment modalities as failing the borderline. “Treatment programs fail
because they don’t pay enough attention to getting the behaviors learned in therapy into
the real world, where they have got to have them” (Linehan, 1995).
Lastly, the therapist and client begin to identify and work on a set of skills that will
help the client begin to be a bit more comfortable in the world. It is this step in the stage
one hierarchy that also sets DBT apart from other evidence based methods. Here
mindfulness is introduced. Linehan is not talking about asking a client to learn to sit in
meditation, though she is a student of Zen herself. Rather, what is asked of the client is
that they begin to inculcate an awareness into their lives that they begin to question, in
the moment, what they are feeling or doing. As the therapist has worked in the room on
acceptance of the client where they are, so now the client begins that same process of
acceptance “by practicing mindfulness skills, clients become increasingly able to
willingly and nonjudgmentally engage with their immediate experience” (Koerner, p. 20,
2012). Because this population can be difficult and triggering to work with, DBT expects
that it’s therapists are practicing all the elements itself, including mindfulness.
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Stage 1 can last for a year or more, depending entirely on the client, therapist
and the peer consult group.
Below is a diagram of how DBT views the development of BPD.
AN ETIOLOGICAL MODEL OF BORDERLINE PERSONALITY DISORDER
(Winston, 2000)
The next stage, Stage 2, is completely dependent on the stability of the client. It
is possible that the client will move in and out of this stage as their work with their own
trauma begins. Stage 2 involves a good deal of exposure therapy, and for many
borderlines, that can be quite difficult. Starting small and building on successes is the
best way to approach this and understanding that the client may move back to stage
one (anywhere on the hierarchy) is critical. Continuing to meet the client with
acceptance (validation for the difficulties they are experiencing) and change (giving
them the skills they need to work through their trauma) is what this stage entails.
Estimates are that 36-58% of people with borderline personality disorder are also
suffering from PTSD. Because of the reactivity of clients with BPD, assessing the
readiness of the client is critical at this stage. Stage 2 is not hierarchical, but is
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prioritized based on the individual client needs, and it is about decreasing symptoms
like emotional dysregulation, invalidating the self, and avoiding situations or feelings that
have been troublesome in the past.
Clients may or may not stay in therapy for the last 2 stages and Linehan herself
has written and researched little about them. In stage 3, she sees the therapist helping
the client to synthesize all the work that has gone before, helping the client to begin to
take her place in the world, to develop a sense of respect for herself and her process
and to work on any remaining issues around living. Stage 4 dips down again into the
client’s inner world, focusing on “the sense of incompleteness” (Koerner, p. 24, 2012)
that many people with BPD experience. Mindfullness continues to be helpful at this
stage, and for clients reaching stage 4, developing a spiritual life becomes possible as
they begin to work with and perhaps give up, notions about the ego.
Dialectical Behavior Therapy is not an easy methodology, especially for the new
trainee. There are fail points within it, not the least is the notion of ‘peer group support’.
The theory is that a team of experienced DBT therapists meets once a week to support
each other in working with their borderline patients. However, this presupposes a
number of things; that a therapist needing help will speak up in the group, and speak up
consistently. But what happens if the therapist feels they are taking up too much of the
group time, week after week, or if the therapist is simply unwilling to speak up for fear of
being judged (some may have a supervisor in this group) or just not wanting to appear
ignorant? And the question must be asked; do all who practice DBT have such a group?
It is a major component of practicing BDT, but it seems that that would be dependent on
geography and the number of DBT therapists near you.
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Further, it remains unclear exactly how to help resistant clients. The DBT rule is if
you miss 4 sessions you are out, but how do you deal with those clients who show up
late, who do not pay, who are disruptive within the session? Clearly getting by in from
the client is critical, but that may not be an easy thing to accomplish with borderlines.
Telephone support, another critical component of this therapy that helps build essential
skills, may also prove difficult. Borderlines by definition have difficulty with boundaries
and giving them free access to their therapists, especially new therapists, could be
fraught with problems. How does one manage the client who calls in such emotional
dysregulation that she/he cries for 20 minutes (Rizvi, 2010)? It may be difficult to
validate a client when they are so dysregulated you have trouble understanding what
they are saying The phone calls are (according to the manual) to last between 5 – 10
minutes. But if you are concerned the person is going to kill himself or herself, or they
are saying they are going to kill themselves, where do you draw the line? And if these
calls come once a day or several times per day, how is that to be managed? Which of
course can lead to a greater issue, that of remaining (as the therapist) in a positive
frame of mind to work with such clients.
DBT currently has the best track record for decreasing suicidality among the
borderline population, but it is by no means (as is true of all theoretical systems)
foolproof. Expanding the model for instance, perhaps simplifying it or integrating it with
other models being developed (IFS – internal family systems) might be worth
investigating. Keeping an open mind to what works as this disorder becomes more
understood, especially from a trauma perspective, seems a good approach.
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Contact Information for Catherine: cdupuy3@me.com