Lisa Davies
Consultant Forensic Psychologist
Malta, October 2012

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What is Borderline Personality Disorder
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How to treat BPD effectively
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Pink Elephants
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Principles of Dialectical Behaviour Therapy

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BPD is: a major health problem
Prevalent – severe, chronic and persistent
High mortality rate
10% of BPD patients will die by suicide
Much higher rate of suicide in the 36-65% who have attempted suicide or intentionally injured themselves in the past
The emotional costs are enormous

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BPD individuals describe:
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Anger, Emptiness, Depression and Anxiety
Extreme Frustration
They experience:
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Brief psychotic episodes
They have:
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Chaotic Relationships and Confused Identities
Suicidal ideation is common
Quality of Life ratings are low
Few treatments with proven efficacy

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Emotional dysregulation
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Inappropriate intense or uncontrollable anger
Affective Instability
Interpersonal dysregulation
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A pattern of intense and unstable interpersonal relationships
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Frantic Efforts to avoid abandonment
Self dysregulation
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Identity disturbance
Emptiness
Behavioural dysregulation
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Recurrent suicidal or para-suicidal behaviour
Impulsive behaviours
Cognitive dysregulation
Transient stress-related paranoid ideation
Severe dissociative symptoms

Biological and environmental factors account for BPD
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BPD individuals are born with an emotional vulnerability
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BPD individuals grow up in invalidating environments
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Reciprocal influences between biological vulnerabilities and an invalidating environment lead to a dysfunction in the emotion regulation system.

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High sensitivity to emotional stimuli – low threshold for an emotional response and quick reaction which results in responding to even low levels of stress
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Emotional intensity – emotional reactions are seen to be extreme and difficult to regulate
Slow return to emotional baseline – emotional attention (to emotionally congruent information) and reactivation of memories.

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The individual is told that they are wrong in both their description and reflections of their own experiences. In other words, their private experiences and expressions of emotions are not viewed as valid responses to events around them.
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The environmental messages are that the individual feels something that they state they don’t, that they like something that state they don’t like or that they have done something which they state they haven’t.

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Dialectics
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Walking the middle path
Out of extreme ways of thinking and behaving
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Things can both be true and not true
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Achieving synthesis
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See the validity in their statements
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Search for the truth
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I feel bad because I am ugly,
If I felt ugly I would feel bad too.

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Therapists see suicide as a problem
Patients see suicide as the solution
Perceptions are diametrically opposed
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Solutions in DBT include:
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Solve the problem
Change your emotional reaction to the problem
Tolerate the problem
Stay miserable
Make things worse….

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Behaviour Therapy
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Behaviour is learned.
Basic principles of reinforcement or punishment
Define behaviour in behavioural terms
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Shouted at me
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Preparing to overdose by storing pills
Burst into tears when criticised
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Vulnerability factors
Precipitating factors
Understanding the link
Explore consequences
Explore alternative solutions

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Stage 1 Therapy – Achieving behavioural control
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Aim is to stabilise the client
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Gain Commitment before entering therapy
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Pro’s and cons
Devils Advocate
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I’m going to ask you not to kill yourself whilst you are in this treatment. This is going to be difficult - so why would you do that?
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Freedom to choose
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You can choose not to do this, but will your life get better?

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Highly structured
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Group based Skills Training
Weekly individual therapy
Telephone consultation
Consultation Team Meeting for Therapists
 do all members agree to be responsible for the outcomes of all patients treated by the team, not just the ones they treat individually?
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Life threatening behaviours
Imminent treatment drop out
Team interfering behaviours

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Who needs consultation?
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Life threatening behaviour in our clients
Risk of imminent treatment drop out
Team interfering behaviours
 lateness, not asking for help, lack of motivation,
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What do I need from consult meeting?
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A clearer case conceptualisation, help with a treatment plan?
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Trouble finding empathy
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Sharing successes
A feeling of dread when the phone rings
What’s getting in the way? What’s going well?
What can we do to help?

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Dialectical Strategies
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Core Strategies
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Validation
Problem Solving
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Stylistic Strategies
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Irreverent communication
Reciprocal Communication
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Case Management
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Therapist supervision / Case consultation
Consultation to the patient
Environmental interventions

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BPD clients often feel invalidated when:
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Others focus on change (they feel blamed), but they also insist that their pain ends now
Or
When others try to get them to tolerate and accept their situation
BPD clients need to
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 build a better life and accept life as it is feel better and tolerate emotions better
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Only striving for change is doomed to fail

 The most caring thing a therapist can do is help clients change in ways that bring them closer to their ultimate goals
 Clarity, precision and compassion are of the utmost importance in the conduct of DBT
 The therapeutic relationship is a real relationship between equals
 Principles of behaviour are universal
 DBT therapists can fail
 DBT therapy can fail even when therapists do not
 Therapists treating borderline patients need support

 Patients are doing the best they can
 Patients want to improve
 Patients need to do better, try harder, and be more motivated to change
 Patients may not have caused all of their problems, but they have to solve them anyway
 The lives of suicidal, borderline individuals are unbearable as they are currently being lived
 Patients must learn new behaviours in all relevant contexts
 Patients cannot fail in DBT.