Borderline Pd And Self Injury


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Borderline Pd And Self Injury

  1. 1. What Is Borderline Personality Disorder ?DefinitionBy Mayo Clinic staffBorderline personality disorder can be a distressing medicalcondition, both for the people who have it and for thosearound them. When you have borderline personality disorder(BPD), you have difficulty controlling your emotions and areoften in a state of upheaval — perhaps as a result of harmfulchildhood experiences or brain dysfunction.With borderline personality disorder your image of yourself isdistorted, making you feel worthless and fundamentallyflawed. Your anger, impulsivity and frequent mood swingsmay push others away, even though you yearn for lovingrelationships.Increasing awareness and research are helping improve thetreatment and understanding of borderline personalitydisorder. Emerging evidence indicates that people withborderline personality disorder often get better over time andthat they can live happy, peaceful lives.Borderline personality disorder affects how you feel aboutyourself, how you relate to others and how you behave.When you have BPD, you often have an insecure sense ofwho you are. That is, your self-image or sense of self oftenrapidly changes. You may view yourself as evil or bad, andsometimes may feel as if you dont exist at all. An unstableself-image often leads to frequent changes in jobs,friendships, goals, values and gender identity.Your relationships are usually in turmoil. You oftenexperience a love-hate relationship with others. You mayidealize someone one moment and then abruptly anddramatically shift to fury and hate over perceived slights oreven minor misunderstandings. This is because people withthe disorder have difficulty accepting gray areas — things areeither black or white. For instance, in the eyes of a personwith BPD, someone is either good or evil. And that sameperson may seem good one day and evil the next. 1
  2. 2. Other signs and symptoms of borderline personality disordermay include: Impulsive and risky behavior, such as risky driving, unsafesex, gambling sprees or taking illicit drugs Strong emotions that wax and wane frequently Intense but short episodes of anxiety or depression Inappropriate anger, sometimes escalating into physicalconfrontations Difficulty controlling emotions or impulses Suicidal behavior Fear of being aloneCausesBy Mayo Clinic staffAlthough definitive data are lacking, its estimated that 1percent to 3 percent of American adults have borderlinepersonality disorder. As with other mental disorders, thecauses of borderline personality disorder are complex. Thename arose because of theories in the 1940s and 1950s thatthe disorder was on the border between neurosis andpsychosis. But that view doesnt reflect current thinking. Infact, some advocacy groups have pressed for changing thename, such as calling it emotional regulation disorder.Meanwhile, the cause of borderline personality disorderremains under investigation, and theres no known way toprevent it. Possible causes include: Genetics. Some studies of twins and families suggest thatpersonality disorders may be inherited. Environmental factors. Many people with borderlinepersonality disorder have a history of childhood abuse,neglect and separation from caregivers or loved ones. Brain abnormalities. Some research has shown changesin certain areas of the brain involved in emotion regulation,impulsivity and aggression. In addition, certain brain 2
  3. 3. chemicals that help regulate mood, such as serotonin, maynot function properly.Most likely, a combination of these issues results inborderline personality disorder.Self-Injury:Types, Causes and Treatment Approximately 1% of the population has, at one time or another, used self-inflicted physical injury as a means of coping with an overwhelming situation or feeling. ASHIC - the American Self-Harm Information Clearinghouse - strives to increase public awareness of the phenomenon of self-inflicted violence and the unique challenges faced by self-injurers and the people who care about them. Self-harm scares people. The behavior can be disturbing and difficult to understand, and it is often treated in a simplistic or sensational manner by the press. As a result, friends and loved ones of people who self-injure often feel frightened, isolated, and helpless. Sometimes they resort to demands or ultimatums as a way of trying to regain some control over the situation, only to see things deteriorate further. The first step toward coping with self-injurious behavior is education: bringing reliable information about who self-injures, why they do it, and how they can learn to stop to people who self-injure and to their friends, loved ones, and medical caregivers. ASHIC was founded to meet this need for honest, accurate information. About Self-harm Self-harm, also known as self-injury, self-inflicted violence, self-injurious behavior, or self-mutilation, can be defined as the deliberate, direct injury of ones own body that causes tissue damage or leave marks for more than a few minutes and that is done in order to deal with an overwhelming or distressing situation. 3
  4. 4. Its important to remember that, even though it may not beapparent to an outside observer, self-injury is serving afunction for the person who does it. Figuring out whatfunctions it serves and helping someone learn other ways toget those needs met is essential to helping people who self-harm. Some of the reasons self-injurers have given for theiracts include: Affect modulation (distraction from emotional pain, endingfeelings of numbness, lessening a desire to suicide, calmingoverwhelming/intense feelings) Maintaining control and distracting the self from painfulthoughts or memories Self-punishment (either because they believe they deservepunishment for either having good feelings or being an "evil"person or because they hope that self-punishment will avertworse punishment from some outside source Expression of things that cant be put into words (displayinganger, showing the depth of emotional pain, shocking others,seeking support and help) Expression of feelings for which they have no label -- thisphenomenon, called alexithymia (literally no words feeling), iscommon in people who self-harmSee Osuch, Noll, & Putnam, Psychiatry 62 (Winter 99), pp:334-345Zlotnick et al, Comprehensive Psychiatry 37(1) pp:12-16.People who self-injure often never developed healthy ways tofeel and express emotion or to tolerate distress. Studies haveshown that self-harm can put a person at a high level ofphysiological arousal back to a baseline state.Its natural to want to help people who self-injure develophealthier ways of coping when they feel overwhelmed, but itsimportant not to let your discomfort with the concept of self-harm cause you to issue ultimatums, punish self-harmingbehavior, or threaten to leave if the person self-harms again.Ideally, you should set boundaries to keep yourself feelingsafe while respecting the persons right to make his or herown decisions about how to deal with stress. 4
  5. 5. Common Myths about Self-InjurySelf-harm is usually a failed suicide attempt.This myth persists despite a wealth of studies showing that,although people who self-injure may be at a higher risk ofsuicide than others, they distinguish between acts of self-harm and attempted suicide. Many, if not most, self-injuringpeople who make a suicide attempt use means that arecompletely different to their preferred methods of self-inflictedviolence.People who self-injure are crazy and should be locked up.Tracy Alderman, Ph.D., author of The Scarred Soul,addressed this:"Fear can lead to dangerous overreactions. In dealing withclients who hurt themselves, you will probably feel fear. . . .Hospitalizing clients for self-inflicted violence is one such formof overreaction. Many therapists, because they do notpossess an adequate understanding of SIV, will use extrememeasures to assure (they think) their clients best interests.However, few people who self-injure need to be hospitalizedor institutionalized. The vast majority of self-inflicted woundsare neither life threatening nor require medical treatment.Hospitalizing a client involuntarily for these issues can bedamaging in several ways. Because SIV is closely related tofeelings of lack of control and overwhelming emotional states,placing someone in a setting that by its nature evokes thesefeelings is very likely to make matters worse, and may lead toan incident of SIV. In addition, involuntary hospitalization oftenaffects the therapeutic relationship in negative ways, erodingtrust, communication, rapport, and honesty. Caution shouldbe used when assessing a clients level of threat to self orothers. In most cases, SIV is not life threatening. . . . BecauseSIV is so misunderstood, clinicians often overreact andprovide treatment that is contraindicated.People who self-harm are just trying to get attention.A wise friend once emailed me a list of attention-seekingbehaviors: wearing nice clothing, smiling at people, saying"hi", going to the check-out counter at a store, and so on. Weall seek attention all the time; wanting attention is not bad orsick. If someone is in so much distress and feel so ignoredthat the only way he can think of to express his pain is by 5
  6. 6. hurting his body, something is definitely wrong in his life andthis isnt the time to be making moral judgments about hisbehavior.That said, most people who self-injure go to great lengths tohide their wounds and scars. Many consider there self-harmto be a deeply shameful secret and dread the consequencesof discovery.Self-inflicted violence is just an attempt to manipulateothers.Some people use self-inflicted injuries as an attempt to causeothers to behave in certain ways, its true. Most dont, though.If you feel as though someone is trying to manipulate you withSI, it may be more important to focus on what it is they wantand how you can communicate about it while maintainingappropriate boundaries. Look for the deeper issues and workon those.Only people with Borderline Personality Disorder self-harm.Self-harm is a criterion for diagnosing BPD, but there are 8other equally-important criteria. Not everyone with BPD self-harms, and not all people who self-harm have BPD(regardless of practitioners who automatically diagnoseanyone who self-injures with BPD).If the wounds arent "bad enough," self-harm isntserious.The severity of the self-inflicted wounds has very little to dowith the level of emotional distress present. Different peoplehave different methods of SI and different pain tolerances.The only way to figure out how much distress someone is in isto ask. Never assume; check it out with the person.Only teen-aged girls self-injure.In five years of existence, the bodies-under-siege email listhas had members of both genders, from six continents, andranging in age from 14-60+. Its a person-who-has-no-other-way-to-cope thing, not a teenage (or female or American orwhatever) thing.ASHICs goalsThe American Self-Harm Information Clearinghouse strives toeducate the general public and medical and psychologicalprofessionals about the phenomenon of self-harm. We hopethat by disseminating clear, concise, and accurate informationabout self-harm, we can improve the treatment that those who 6
  7. 7. cope with distress by injuring themselves receive fromhospitals, physicians, therapists, and their own families andfriends.The more people know about the realities of self-inflictedviolence, the less fearful and stigmatizing they will be whenconfronted with it. ASHICs main project to date has beenNational Self-Injury Awareness Day (March 1, 2002). Otherservices we offer now are: Sending out fact sheets, brochures, copies of the Bill ofRights for those who self-harm, and other materials onrequest Acting as a media liaison -- putting writers and reporters incontact with self-injury experts and self-injuring people Helping with research in special situations (recently, wehelped someone put together a package explaining whyinvoluntary commitment to a state hospital might be harmful toa person who self-injures Operating a limited Speakers Bureau Producing press kitsWe are working on an informational booklet to be released insummer 2002, as well.Contact informationMaterials can be requested by sending a stamped, self-addressed envelope to:ASHIC521 Temple PlSeattle, WA 98122E-mail inquires should be sent to andtelephone inquiries should be directed to Deb Martinson at206-604-8963. 7
  8. 8. The number of young people who participate in acts of self-mutilationis growing. Although self-harm is rarely a suicidal act, it must be takenseriously because accidental deaths do occur. It’s difficult to see thelight at the end of the tunnel but breaking the cycle of self-abuse ispossible if you reach out to someone you trust. Finding new ways ofcoping with your feelings can help to tone down the intense urges youfeel which results in you hurting yourself. Recovery is a continuousprocess and learning how to stop this addictive behavior is within yourreach if you work at it.Who engages in self-injury?The numbers are staggering…about two million people in the U.S. areself-injurers and approximately 1% of the population has inflictedphysical injury upon themselves at some time in their life as a way tocope with an overwhelming situation or feeling. Those numbers aremost likely an underestimation because the majority of acts of self-injury go unreported. In other parts of the world the numbers areconsiderably higher. Self-injury does not discriminate against race,culture, or socio-economic strata, but there is conflicting dataregarding demographics. Some reference sites indicate that themajority of people who engage in this type of addictive behavior arepredominately female teenagers and young adults, while other sitesindicate that both genders, ranging in age from 14 to 60 self-injure.However, there is consistent agreement that self-harm has more to dowith having poor coping mechanisms than anything else.Types of self-injuryDefinition of self-injurySelf-injury, self-inflicted violence, self-injurious behavior or self-mutilation is defined as a deliberate, intentional injury to one’s ownbody that causes tissue damage or leaves marks for more than a fewminutes which is done to cope with an overwhelming or distressingsituation. 8
  9. 9. The most common self-injurious behaviors are: Cutting - involves making cuts or scratches on your body with anysharp object, including knives, needles, razor blades or evenfingernails. The arms, legs and front of the torso are most commonlycut because they are easily reached and easily hidden under clothing Branding – burning self with a hot object, Friction burn – rubbing apencil eraser on your skin Picking at skin or re-opening wounds (dermatillomania) - is animpulse control disorder characterized by the repeated urge to pick atones own skin, often to the extent that damage is caused whichrelieves stress or is gratifying Hair-pulling (trichotillomania) – is an impulse control disorder, whichat times seems to resemble a habit, an addiction, or an obsessive-compulsive disorder. The person has an irresistible urge to pull outhair from any part of their body. Hair pulling from the scalp oftenleaves patchy bald spots on their head, which they hide by wearinghats, scarves and wigs. Abnormal levels of serotonin or dopaminemay play a role in this disorder. The combined treatment of using ananti-depressant such as Anafranil and cognitive behavioral therapy(CBT) has been effective in treating this disorder. CBT teaches you tobecome more aware of when you’re pulling, helps you identify yourpulling habits, and teaches you about what emotions and triggers areinvolved in hair pulling. When you gain awareness of pulling, you canlearn to substitute healthier behaviors instead. Hitting (with hammer or other object), Bone breaking, Punching,Head-banging (more often seen with autism or severe mentalretardation) Multiple piercing or tattooing - may also be a type of self-injury,especially if pain or stress relief is a factor Drinking harmful chemicalsReasons for self-injuryWhy do they do it?Even though it is possible that a self-inflicted injury may result indeath, self-injury is usually not suicidal behavior. The person who self-injures may not recognize the connection, but this act usually occursafter an overwhelming or distressing experience and is a result of nothaving learned how to identify or express difficult feelings in ahealthy way. Sometimes the person who deliberately harmsthemselves thinks that if they feel the pain on the outside instead offeeling it on the inside, the injuries will be seen, which then perhapsgives them a fighting chance to heal. They may also believe that thewounds, which are now physical evidence, proves their emotional pain 9
  10. 10. is real. Although the physical pain they experience may be the catalystthat releases the emotional pain, the relief they feel is temporary.These coping mechanisms in essence are faulty because the paineventually returns without any permanent healing taking place.Self-harm serves a function for the person who does it. If you canfigure out what function the self-injury is serving then you can learnother ways to get those needs met which will reduce your desire tohurt yourself.It is difficult to understand the motivations behind self-injuriousbehavior, but a clearer picture develops when you hear the commonexplanations self-injurers give for doing it: “It expresses emotional pain or feelings that I’m unable to put intowords. It puts a punctuation mark on what I’m feeling on the inside!” “It’s a way to have control over my body because I can’t controlanything else in my life” “I usually feel like I have a black hole in the pit of my stomach, atleast if I feel pain it’s better than feeling nothing” I feel relieved and less anxious after I cut. The emotional pain slowlyslips away into the physical pain”Self-injury can regulate strong emotions. It can put a person who isat a high level of physiological arousal back to a baseline state.Deliberate self-harm can distract from emotional pain and stopfeelings of numbness.Self-inflicted violence is a way to express things that cannot be putinto words such as displaying anger, shocking others or seekingsupport and help.Self-injurious behavior can exert a sense of control over your bodyif you feel powerless in other areas of your life. Sometimes magicalthinking is involved and you may imagine that hurting yourself willprevent something worse from happening. Also, when you hurtyourself it influences the behavior of others and can manipulatepeople into feeling guilty, make them care, or make them go away.Self punishment or self-hate may be involved. Some people who self-injure have a childhood history of physical, sexual and emotionalabuse. They may erroneously blame themselves for having beenabused, they may feel that they deserved it and are now punishingthemselves because of self-hatred and low self-esteem. 10
  11. 11. Self-abuse can also be a self-soothing behavior for someone who does not have other means to calm intense emotions. Self-injury followed by tending to one’s own wounds is a way to express self-care and be self-nurturing for someone who never learned how to do that in a more direct way. People who self-injure have some common traits:o Expressions of anger were discouraged while growing upo They have co-existing problems with obsessive-compulsive disorder, substance abuse or eating disorderso They lack the necessary skills to express strong emotions in a healthy wayo Often times there is a limited social support network Self-injury as an addiction BECOMING A HABITUAL SELF INJURER IS A PROGRESSIVE PROCESS The first incident of self- The next time a similar injury may occur by strong feeling arises, the accident, or after finding person has been out about others who “conditioned” to seek relief engage in this behavior in the same way The person has strong The person feels compelled feelings such as anger, fear to repeat self-harm, which is or anxiety before an injuring likely to increase in frequency event and degree These feelings build, and The person hides the tools the person has no way to used to injure, and covers up express or address them the evidence, often by directly wearing long sleeves Cutting or other self-injury Endorphins, specifically provides a sense of relief; enkephalins, contribute to a release of the mounting the addictive’ nature of tension self-injury A feeling of guilt and shame When a person injures usually follows the event themselves endorphins are The feelings of shame released in the body and paradoxically lead to function as natural pain killers continued self-injurious The behavior may become behavior addictive because the person learns to associate the act of self-injury with the positive feelings they get when 11
  12. 12. BECOMING A HABITUAL SELF INJURER IS A PROGRESSIVEPROCESS endorphins are released in their system The use of SSRI medications (selective serotonin reuptake inhibitors) such as Prozac and Zoloft, may be helpful in increasing brain serotonin levels and reducing self-injury in cases of moderate to severe depressionFDA Suicide WarningIn May 2007, the U.S. Food and Drug Administration (FDA)recommended a new warning label for all antidepressant medications.The current “black box” label includes a warning about the increasedrisk of suicidal thinking and behavior in children and adolescents. TheFDA wants to expand this warning to include young adults from ages18 to 24. Children and young adults should also be monitored for theemergence of agitation, irritability, and unusual changes in behavior,as these symptoms can indicate that the depression is getting worse.The risk of suicide is particularly great during the first one to twomonths of treatment.Self-injury and suicideSelf-injury is usually not suicidal behavior but rather a way to reducetensions. Inflicting physical harm on oneself is a poorly learned copingmechanism which is used to communicate feelings and self-soothe.Self-injury is strongly linked to a poor sense of self-worth, and overtime, that depressed feeling can spiral into a suicidal attempt.Sometimes self-harm may accidentally go farther than intended, and alife-threatening injury may result which is why intervention andprofession help is required sooner rather than later.Helping a friend or family member who is a self-injurerNo matter how you look at it, self-harm scares people. It is very hardcoming to terms with the fact that someone you care about isphysically harming themselves. From the depths of your own fear andhelplessness you may feel frustrated if you are unable to get the 12
  13. 13. person to stop hurting themselves which can further drive the personaway.Some helpful tips in dealing with someone who self-injures Understand that self-harming behavior is an attempt to maintain acertain amount of control which in and of itself is a way of self-soothing Let the person know that you care about them and are available tolisten Encourage expressions of emotions including anger Spend time doing enjoyable activities together Offer to help them find a therapist or support group Don’t make judgmental comments or tell the person to stop the self-harming behavior – people who feel worthless and powerless areeven more likely to self-injure If your child is self-injuring, prepare yourself to address the difficultiesin your family. Start with expressing feelings which is a common factorin self-injury – this is not about blame, but rather about learning newways of dealing with family interactions and communications whichcan help the entire familyHow can a self-injuring person stop this behavior?Self-injury is a behavior that over time becomes compulsive andaddictive. Like any other addiction, even though other people think theperson should stop, most addicts have a hard time just saying no totheir behavior – even when they realize it is unhealthy.What you can do to help yourselfAcknowledge You are probably hurting on the insidethis is a and need professional help to stop thisproblem addictive behaviorRealize this is This is about recognizing that a behaviornot about being that helped you handle your feelings hasa bad person become a big problemFind one Maybe a friend, teacher, rabbi, minister,person you counselor, or relative. Tell them you needtrust and get to talk about something serious that isprofessional bothering youhelpGet help in Ask for help in developing ways to eitheridentifying what avoid or address those triggers“triggers” yourself-harmingbehaviors 13
  14. 14. What you can do to help yourselfRecognize that Learn how to develop better ways to calmself-injury is an and soothe yourselfattempt to self-sootheFigure out what Replace the act of self-harm with learningfunction the how to express anger, sadness, and fearself-injury is in healthy waysservingTreatments for self-injuryOne danger connected with self-injury is that it tends to become anaddictive behavior, a habit that is difficult to break even when theindividual wants to stop. As with other addictions, qualifiedprofessional help is almost always necessary. It is important to find atherapist who understands this behavior and is not upset or repulsedby it. Call your doctor or insurance company for a referral to a mentalhealth professional who specializes in self-injury. Cognitive-behavioral therapy may be used to help the person learnto recognize and address triggering feelings in healthier ways Because a history of abuse or incest may be at the core of anindividual’s self-injuring behavior, therapies that address post-traumatic stress disorder such as EMDR may be helpful (seeHelpguide’s article on Eye Movement Desensitization andReprocessing) Hypnosis or other self-relaxation techniques are helpful in reducingthe stress and tension that often precede injuring incidents (seeHelpguide’s article on Yoga, meditation and other relaxationtechniques) Group therapy may be helpful in decreasing the shame associatedwith self-harm, and help to support healthy expressions of emotions Family therapy may be useful, both in addressing any history offamily stress related to the behavior, and also in helping other familymembers learn how to communicate more directly and non-judgmentally with each other In cases of moderate to severe depression or anxiety anantidepressant or anti-anxiety medication may be used to reduce theimpulsive urges to self-harm in response to stress, while other copingstrategies are developed. In severe cases an in-patient hospitalization program with a multi-disciplinary team approach may be requiredAlternatives to avoid self-harm 14
  15. 15. If you self-injure to…Deal with anger that you cannot express openly,try working through those feelings by doing something different –running, dancing fast, screaming, punching a pillow, throwingsomething, ripping something apartIf you hurt yourself in order to…Feel something when you feel numbinside, hold ice cubes in one hand and try to crush them, hold apackage of frozen food, take a very cold shower, chew something witha very strong taste (like chili peppers, raw ginger root, or a grapefruitpeel), wear an elastic rubber band around your wrist and snap it (inmoderation to avoid bruising) when you feel like hurting yourselfIf you inflict physical pain to…Calm yourself, try taking a bubble bath,doing deep breathing, writing in a journal, drawing, or doing someyogaIf you self-mutilate to…See blood, try drawing a red ink line whereyou would usually cut yourself, in combination with the othersuggestions aboveTo Learn More: Related Helpguide Articles Understanding Anxiety Obsessive-Compulsive- Symptoms, Types and Disorder (OCD) –Treatment Symptoms, treatment Medications for Anxiety options, and support for- Drug Benefits, Risks OCDand Side Effects Post-traumatic Stress Stress Management: Disorder (PTSD):Skills to Reduce, Symptoms, Help, andPrevent, and Cope with TreatmentStressReferences and resources for self-injuryGeneral Self-injury ResourcesS.A.F.E. alternatives (Self-Abuse Finally Ends) – Blog and news forindividuals who cause self-injuries. Information Line: 1-800-DONTCUT ( about self injury – Provides simple and clear definitions ofwhat self-injury is, myths and information about why people injurethemselves. (American Self-Harm Information Clearinghouse) 15
  16. 16. Self-injury coping skills – Describes many things you can do to helpcope with the self-injuring tendencies and provides helpful resourcesfor recovery, information, and support. (Self-injury support)Adolescent self-harm – Provides a brief overview and also includessuggestions for parents on addressing self-injury with their child.There is also a list of books available on the subject. {AmericanAssociation of Marriage and Family Therapists (AAMFT)}Help for family and friends – Lets self-injurers know that they are NOTalone and provides information to help their friends and family ( Cutter, Psy.D., Jaelline Jaffe, Ph.D., and Jeanne Segal,Ph.D., contributed to this article. Last modified: February 08.Self Injury Coping SkillsA person who has developed self-injury as a coping method obviouslyneeds to learn to develop new healthy coping methods. Not allhealthy coping skills work for everyone. Below is a list of manyalternatives to self-injury. The key to being able to utilize many ofthese methods is to identify when you are escalating to a crisissituation. The ability to do this is a learned skill in itself but onceachieved your alternatives to self-injury become abundant. If you are able to identify that you are escalating in anxiety, becomingoverwhelmed with emotion or detaching from your feelings and areentertaining the idea of self-injury, here are some good alternatives: Get rid of any sharp objects around that you have access to Go to a public place Read a book/magazine Journal (identify the trigger) Take a shower Listen to music Take a walk Draw/Color Watch TV. Get grounded Visualize your safe scene Talk to a parent, pastor or friend Pray Play sports Make crafts 16
  17. 17. Get on the computer (stay away from triggering web sites) Talk into a tape recorder Shred paper Hold ice cubes in your hands until they melt and then use warm water Call your therapist Make a no-harm contract with yourself or someone you trust Clean the house Take a bubble bath Do relaxation exercises Do deep breathing exercises Go shopping Wear a rubber band around a wrist and snap it tightly when the urge arises Make marks (washable red marker) where you want to hurt yourself (sometimes self-injurers like the sight of blood) If you are unable to utilize the above methods and self-injuryideation becomes imminent then “deal making” is used by many self-injurers as a last resort and can be very affective. “Deal making” isthe process where you basically make a no harm contract withyourself or with someone you trust that you will not harm yourself for adesignated amount of time. Once the time elapses you positivelyacknowledge the fact that you did not act out on your urge, re-assessyour feeling state and make another contract or “deal” if necessary.Here’s an example:“The Fifteen Minute Rule” One of the most effective things that can precede anything elseon this list is the 15-minute rule. Make a contract with yourself thatyou will wait 15 minutes before hurting yourself. During this time, usewhatever coping skills work for you (this is best), or just do somethingto pass the time. After the 15 minutes are over, recognize the fact thatyou were able to successfully complete the contract and immediatelymake another, realizing you have the power within to not reactimpulsively (you’ve already shown that). If you still want to hurtyourself, make another 15-minute contract making sure to giveyourself credit for not acting impulsively. If at any time you believeyou are in jeopardy of not continuing the self-contracting skill,reach out for assistance immediately. When the desire to self-injure finally passes, maybe you can tell a friend who knows aboutyour self-injury that you made it through. Even looking forward to 17
  18. 18. saying, "I made it!" is an incentive, and can make you feel good aboutyourself.An Overview of Dialectical Behavior Therapy in the Treatment ofBorderline Personality Disorderby Barry Kiehn and Michaela SwalesPatients showing the features of Borderline Personality Disorder asdefined in DSM-IV are notoriously difficult to treat (Linehan 1993a).They are difficult to keep in therapy, frequently fail to respond to ourtherapeutic efforts and make considerable demands on the emotionalresources of the therapist, particular when suicidal and parasuicidalbehaviors are prominent.Dialectical Behavior Therapy is an innovative method of treatment thathas been developed specifically to treat this difficult group of patientsin a way which is optimistic and which preserves the morale of thetherapist.The technique has been devised by Marsha Linehan at the Universityof Washington in Seattle and its effectiveness has been demonstratedin a controlled study, the results of which will be summarized later inthis paper.BORDERLINE PERSONALITY DISORDERDialectical Behavior Therapy is based on a bio-social theory ofborderline personality disorder. Linehan hypothesizes that the disorderis a consequence of an emotionally vulnerable individual growing upwithin a particular set of environmental circumstances, which sherefers to as the Invalidating Environment.An emotionally vulnerable person in this sense is someone whoseautonomic nervous system reacts excessively to relatively low levelsof stress and takes longer than normal to return to baseline once thestress is removed. It is proposed that this is the consequence of abiological diathesis.The term Invalidating Environment refers essentially to a situation inwhich the personal experiences and responses of the growing childare disqualified or "invalidated" by the significant others in her life. Thechilds personal communications are not accepted as an accurateindication of her true feelings and it is implied that, if they were 18
  19. 19. accurate, then such feelings would not be a valid response tocircumstances. Furthermore, an Invalidating Environment ischaracterized by a tendency to place a high value on self-control andself-reliance. Possible difficulties in these areas are not acknowledgedand it is implied that problem solving should be easy given propermotivation. Any failure on the part of the child to perform to theexpected standard is therefore ascribed to lack of motivation or someother negative characteristic of her character. (The feminine pronounwill be used throughout this paper when referring to the patient sincethe majority of BPD patients are female and Lineman’s work hasfocused on this subgroup).Linehan suggests that an emotionally vulnerable child can beexpected to experience particular problems in such an environment.She will neither have the opportunity accurately to label andunderstand her feelings nor will she learn to trust her own responsesto events. Neither is she helped to cope with situations that she mayfind difficult or stressful, since such problems are not acknowledged. Itmay be expected then that she will look to other people for indicationsof how she should be feeling and to solve her problems for her.However, it is in the nature of such an environment that the demandsthat she is allowed to make on others will tend to be severelyrestricted. The childs behavior may then oscillate between oppositepoles of emotional inhibition in an attempt to gain acceptance andextreme displays of emotion in order to have her feelingsacknowledged. Erratic response to this pattern of behavior by those inthe environment may then create a situation of intermittentreinforcement resulting in the behavior pattern becoming persistent.Linehan suggests that a particular consequence of this state of affairswill be a failure to understand and control emotions; a failure to learnthe skills required for emotion modulation. Given the emotionalvulnerability of these individuals this is postulated to result in a state ofemotional dysregulation’, which combines in a transactional mannerwith the Invalidating Environment to produce the typical symptoms ofBorderline Personality Disorder.Patients with BPD frequently describe a history of childhood sexualabuse and this is regarded within the model as representing aparticularly extreme form of invalidation.Linehan emphasizes that this theory is not yet supported by empiricalevidence but the value of the technique does not depend on thetheory being correct since the clinical effectiveness of DBT does haveempirical support. 19
  20. 20. PATIENTS CHARACTERISTICSLinehan groups the features of BPD in a particular way, describing thepatients as showing dysregulation in the sphere of emotions,relationships, behavior, cognition and the sense of self. She suggeststhat, as a consequence of the situation that has been described, theyshow six typical patterns of behavior, the term behavior referring toemotional, cognitive and autonomic activity as well as externalbehavior in the narrow sense.Firstly, they show evidence of emotional vulnerability as alreadydescribed. They are aware of their difficulty coping with stress andmay blame others for having unrealistic expectations and makingunreasonable demands.On the other hand they have internalized the characteristics of theInvalidating Environment and tend to show self-invalidation. Theyinvalidate their own responses and have unrealistic goals andexpectations, feeling ashamed and angry with themselves when theyexperience difficulty or fail to achieve their goals.These two features constitute the first pair of so-called dialecticaldilemmas, the patients position tending to swing between theopposing poles since each extreme is experienced as beingdistressing.Next, they tend to experience frequent traumatic environmentalevents, in part related to their own dysfunctional lifestyle andexacerbated by their extreme emotional reactions with delayed returnto baseline. This results in what Linehan refers to as a pattern ofunrelenting crisis, one crisis following another before the previousone has been resolved. On the other hand, because of their difficultieswith emotion modulation, they are unable to face, and therefore tendto inhibit, negative affect and particularly feelings associated with lossor grief. This inhibited grieving and the unrelenting crisis constitutethe second dialectical dilemma.The opposite poles of the final dilemma are referred to as activepassivity and apparent competence. Patients with BPD are active infinding other people who will solve their problems for them but arepassive in relation to solving their own problems. On the other hand,they have learned to give the impression of being competent inresponse to the Invalidating Environment. In some situations they mayindeed be competent but their skills do not generalize across differentsituations and are dependent on the mood state of the moment. This 20
  21. 21. extreme mood dependency is seen as being a typical feature ofpatients with BPD.A pattern of self-mutilation tends to develop as a means of coping withthe intense and painful feelings experienced by these patients andsuicide attempts may be seen as an expression of the fact that life isat times simply does not seem worth living. These behaviors inparticular tend to result in frequent episodes of admission topsychiatric hospitals. Dialectical Behavior Therapy, which will now bedescribed, focuses specifically on this pattern of problem behaviorsand in particular, the parasuicidal behavior. DIALECTICALBEHAVIOUR THERAPY The term dialectical is derived from classicalphilosophy. It refers to a form of argument in which an assertion is firstmade about a particular issue (the thesis), the opposing position isthen formulated (the antithesis ) and finally a synthesis is soughtbetween the two extremes, embodying the valuable features of eachposition and resolving any contradictions between the two. Thissynthesis then acts as the thesis for the next cycle. In this way truth isseen as a process, which develops over time in transactions betweenpeople. From this perspective there can be no statement representingabsolute truth. Truth is approached as the middle way betweenextremes. The dialectical approach to understanding and treatment ofhuman problems is therefore non-dogmatic, open and has a systemicand transactional orientation. The dialectical viewpoint underlies theentire structure of therapy, the key dialectic being acceptance on theone hand and change on the other. Thus DBT includes specifictechniques of acceptance and validation designed to counter the self-invalidation of the patient. These are balanced by techniques ofproblem solving to help her learn more adaptive ways of dealing withher difficulties and acquire the skills to do so. Dialectical strategiesunderlie all aspects of treatment to counter the extreme and rigidthinking encountered in these patients. The dialectical world view isapparent in the three pairs of dialectical dilemmas already described,in the goals of therapy and in the attitudes and communication stylesof the therapist, which are to be described. The therapy is behavioralin that, without ignoring the past, it focuses on present behavior andthe current factors, which are controlling that behavior. THERAPISTCHARACTERISTICS IN DBT The success of treatment is dependanton the quality of the relationship between the patient and therapist.The emphasis is on this being a real human relationship in which bothmembers matter and in which the needs of both have to beconsidered. Linehan is particularly alert to the risks of burnout totherapists treating these patients and therapist support andconsultation is an integral and essential part of the treatment. In DBTsupport is not regarded as an optional extra. The basic idea is that thetherapist gives DBT to the patient and receives DBT from his or her 21
  22. 22. colleagues. The approach is a team approach. The therapist is askedto accept a number of working assumptions about the patient that willestablish the required attitude for therapy: 1. The patient wants tochange and, in spite of appearances, is trying her best at anyparticular time. 2. Her behavior pattern is understandable given herbackground and present circumstances. Her life may currently not beworth living (however, the therapist will never agree that suicide is theappropriate solution but always stays on the side of life. The solutionis rather to try and make life more worth living). 3. In spite of this sheneeds to try harder if things are ever to improve. She may not beentirely to blame for the way things are but it is her personalresponsibility to make them different. 4. Patients can not fail in DBT. Ifthings are not improving it is the treatment that is failing. In particularthe therapist must avoid at all times viewing the patient, or talkingabout her, in pejorative terms since such an attitude will beantagonistic to successful therapeutic intervention and likely to feedinto the problems that have led to the development of BPD in the firstplace. Linehan has a particular dislike for the word "manipulative" ascommonly applied to these patients. She points out that this impliesthat they are skilled at managing other people when it is precisely theopposite that is true. Also the fact that the therapist may feelmanipulated does not necessarily imply that this was the intention ofthe patient. It is more probable that the patient did not have the skillsto deal with the situation more effectively. The therapist relates to thepatient in two dialectically opposed styles. The primary style ofrelationship and communication is referred to as reciprocalcommunication, a style involving responsiveness, warmth andgenuineness on the part of the therapist. Appropriate self-disclosure isencouraged but always with the interests of the patient in mind. Thealternative style is referred to as irreverent communication. This is amore confrontational and challenging style aimed at bringing thepatient up with a jolt in order to deal with situations where therapyseems to be stuck or moving in an unhelpful direction. It will beobserved that these two communication styles form the opposite endsof another dialectic and should be used in a balanced way as therapyproceeds. The therapist should try to interact with the patient in a waythat is: 1. accepting of the patient as she is but which encourageschange. 2. centered and firm yet flexible when the circumstancesrequire it. 3. nurturing but benevolently demanding. The dialecticalapproach is here again apparent. There is a clear and open emphasison the limits of behavior acceptable to the therapist and these aredealt with in a very direct way. The therapist should be clear about hisor her personal limits in relations to a particular patient and should asfar as possible make these clear to her from the start. It is openlyacknowledged that an unconditional relationship between therapistand patient is not humanly possible and it is always possible for the 22
  23. 23. patient to cause the therapist to reject her if she tries hard enough. Itis in the patients interests therefore to learn to treat her therapist in away that encourages the therapist to want to continue helping her. It isnot in her interests to burn him or her out. This issue is confronteddirectly and openly in therapy. The therapist helps therapy to surviveby consistently bringing it to the patients attention when limits havebeen overstepped and then teaching her the skills to deal with thesituation more effectively and acceptably. It is made quite clear thatthe issue is immediately concerned with the legitimate needs of thetherapist and only indirectly with the needs of the patient who clearlystands to lose if she manages to burn out the therapist. The therapistis asked to adopt a non-defensive posture towards the patient, toaccept that therapists are fallible and that mistakes will at timesinevitably be made. Perfect therapy is simply not possible. It needs tobe accepted as a working hypothesis that (to use Linehans words) "alltherapists are jerks". PATIENTS AND THERAPISTS AGREEMENTSThis form of therapy must be entirely voluntary and depends for itssuccess on having the co-operation of the patient. From the start,therefore, attention is given to orienting the patient to the nature ofDBT and obtaining a commitment to undertake the work. A variety ofspecific strategies are described in the Linehans book (Linehan1993a) to facilitate this process. Before a patient will be taken on forDBT she will be required to give a number of undertakings: 1. To workin therapy for a specified period of time (Linehan initially contracts forone year). and, within reason, to attend all scheduled therapysessions.2. If suicidal or parasuicidal behaviors are present, she must agree towork on reducing these.3. To work on any behaviors that interfere with the course of therapy(therapy interfering behaviors).4. To attend skills training.The strength of these agreements may be variable and a "take whatyou can get approach" is advocated. Nevertheless a definitecommitment at some level is required since reminding the patientabout her commitment and re-establishing such commitmentthroughout the course of therapy are important strategies in DBT.The therapist agrees to make every reasonable effort to help thepatient and to treat her with respect, as well as to keep to the usualexpectations of reliability and professional ethics. The therapist doesnot however give any undertaking to stop the patient from harmingherself. On the contrary, it should be make quite clear that the 23
  24. 24. therapist is simply not able to prevent her from doing so. The therapist will try rather to help her find ways of making her life more worth living. DBT is offered as a life-enhancement treatment and not as a suicide prevention treatment, although it is hoped that it may indeed achieve the latter. MODES OF TREATMENT There are four primary modes of treatment in DBT :1. Individual therapy2. Group skills training3. Telephone contact4. Therapist consultation Whilst keeping within the overall model, group therapy and other modes of treatment may be added at the discretion of the therapist, providing the targets for that mode are clear and prioritized. The individual therapist is the primary therapist. The main work of therapy is carried out in the INDIVIDUAL THERAPY sessions. The structure of individual therapy and some of the strategies used will be described shortly. The characteristics of the therapeutic alliance have already been described. Between sessions the patient should be offered TELEPHONE CONTACT with the therapist, including out of hours telephone contact. This tends to be an aspect of DBT balked at by many prospective therapists. However, each therapist has the right to set clear limits on such contact and the purpose of telephone contact is also quite clearly defined. In particular, telephone contact is not for the purpose of psychotherapy. Rather it is to give the patient help and support in applying the skills that she is learning to her real life situation between sessions and to help her find ways of avoiding self-injury. Calls are also accepted for the purpose of relationship repair where the patient feels that she has damaged her relationship with her therapist and wants to put this right before the next session. Calls after the patient has injured herself are not acceptable and, after ensuring her immediate safety, no further calls are allowed for the next twenty four hours. This is to avoid reinforcing self-injury. SKILLS TRAINING is usually carried out in a group context, ideally by someone other that the individual therapist. In the skills training groups patients are taught skills considered relevant to the particular problems experienced by people with borderline personality disorder. There are four modules focusing in turn on four groups of skills: 24
  25. 25. 1. Core mindfulness skills.2. Interpersonal effectiveness skills.3. Emotion modulation skills.4. Distress tolerance skills. The core mindfulness skills are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment. The interpersonal effectiveness skills which are taught focus on effective ways of achieving ones objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people. Emotion modulation skills are ways of changing distressing emotional states and distress tolerance skills include techniques for putting up with these emotional states if they can not be changed for the time being. The skills are too many and varied to be described here in detail. They are fully described in a teaching format in the DBT skills training manual (Linehan, 1993b). The therapists receive DBT from each other at the regular THERAPIST CONSULTATION GROUPS and, as already mentioned, this is regarded as an essential aspect of therapy. The members of the group are required to keep each other in the DBT mode and (among other things) are required to give a formal undertaking to remain dialectical in their interaction with each other, to avoid any pejorative descriptions of patient or therapist behavior, to respect therapists individual limits and generally are expected to treat each other at least as well as they treat their patients. Part of the session may be used for ongoing training purposes. STAGES OF THERAPY AND TREATMENT TARGETS Patients with BPD present multiple problems and this can pose problems for the therapist in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organized into a number of stages and structured in terms of hierarchies of targets at each stage. 25
  26. 26. The PRE-TREATMENT STAGE focuses on assessment, commitment and orientation to therapy. STAGE 1 focuses on suicidal behaviors, therapy interfering behaviors and behaviors that interfere with the quality of life, together with developing the necessary skills to resolve these problems. STAGE 2 deals with post-traumatic stress related problems (PTSD) STAGE 3 focuses on self-esteem and individual treatment goals. The targeted behaviors of each stage are brought under control before moving on to the next phase. In particular post-traumatic stress related problems such as those related to childhood sexual abuse are not dealt with directly until stage 1 has been successfully completed. To do so would risk an increase in serious self injury. Problems of this type (flashbacks for instance) emerging whilst the patient is still in stages 1 or 2 are dealt with using distress tolerance techniques. The treatment of PTSD in stage 2 involves exposure to memories of the past trauma. Therapy at each stage is focused on the specific targets for that stage, which are arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy but it is essential for therapists working in each mode to be clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking. The hierarchy of targets in individual therapy for example is as follows:1. Decreasing suicidal behaviors.2. Decreasing therapy interfering behaviors.3. Decreasing behaviors that interfere with the quality of life.4. Increasing behavioral skills.5. Decreasing behaviors related to post-traumatic stress.6. Improving self esteem.7. Individual targets negotiated with the patient. In any individual session these targets must be dealt with in that order. In particular, any incident of self harm that may have occurred since the last session must be dealt with first and the therapist must not allow him or herself to be distracted from this goal. The importance given to therapy interfering behaviors is a particular characteristic of DBT and reflects the difficulty of working with these patients. It is second only to suicidal behaviors in importance. These 26
  27. 27. are any behaviors by the patient or therapist that interfere in any way with the proper conduct of therapy and risk preventing the patient from getting the help she needs. They include, for example, failure to attend sessions reliably, failure to keep to contracted agreements, or behaviors that overstep therapist limits. Behaviors that interfere with the quality of life are such things as drug or alcohol abuse, sexual promiscuity, high risk behavior and the like. What is or is not a quality of life interfering behavior may be a matter for negotiation between patient and therapist. The patient is required to record instances of targeted behaviors on the weekly diary cards. Failure to do so is regarded as therapy interfering behavior. TREATMENT STRATEGIES Within this framework of stages, target hierarchies and modes of therapy a wide variety of therapeutic strategies and specific techniques is applied. The core strategies in DBT are validation and problem solving. Attempts to facilitate change are surrounded by interventions that validate the patients behavior and responses as understandable in relation to her current life situation, and that show an understanding of her difficulties and suffering. Problem solving focuses on the establishment of necessary skills. If the patient is not dealing with her problems effectively then it is to be anticipated either that she does not have the necessary skills to do so, or does have the skills but is prevented from using them. If she does not have the skills then she will need to learn them. This is the purpose of the skills training. Having the skills, she may be prevented from using them in particular situations either because of environmental factors or because of emotional or cognitive problems getting in the way. To deal with these difficulties the following techniques may be applied in the course of therapy:1. Contingency management2. Cognitive therapy3. Exposure based therapies4. Pharmacotherapy 27
  28. 28. The principles of using these techniques are precisely those applyingto their use in other contexts and will not be described in any detail. InDBT however they are used in a relatively informal way andinterwoven into therapy. Linehan recommends that medication beprescribed by someone other than the primary therapist although thismay not be practical.Particular note should be made of the pervading application ofcontingency management throughout therapy, using the relationshipwith the therapist as the main reinforcer. In the session by sessioncourse of therapy care is taken to systematically reinforce targetedadaptive behaviors and to avoid reinforcing targeted maladaptivebehaviors. This process is made quite overt to the patient, explainingthat behavior, which reinforced can be expected to increase. A cleardistinction is made between the observed effect of reinforcement andthe motivation of the behavior, pointing out that such a relationshipbetween cause and effect does not imply that the behavior is beingcarried out deliberately in order to obtain the reinforcement. Didacticteaching and insight strategies may also be used to help the patientachieve an understanding of the factors that may be controlling herbehavior.The same contingency management approach is taken in dealing withbehaviors that overstep the therapists personal limits in which casethey are referred to as observing limits procedures.Problem solving and change strategies are again balanceddialectically by the use of validation strategies. It is important at everystage to convey to the patient that her behavior, including thoughtsfeelings and actions are understandable, even though they may bemaladaptive or unhelpful.Significant instances of targeted maladaptive behavior occurring sincethe last session (which should have been recorded on the diary card)are initially dealt with by carrying out a detailed behavioral analysis.In particular every single instance of suicidal or parasuicidal behavioris dealt with in this way. Such behavioral analysis is an importantaspect of DBT and may take up a large proportion of therapy time.In the course of a typical behavioral analysis a particular instance ofbehavior is first clearly defined in specific terms and then a chainanalysis is conducted, looking in detail at the sequence of events andattempting to link these events one to another. In the course of thisprocess hypotheses are generated about the factors that may becontrolling the behavior. This is followed by, or interwoven with, asolution analysis in which alternative ways of dealing with the 28
  29. 29. situation at each stage are considered and evaluated. Finally onesolution should be chosen for future implementation. Difficulties thatmay be experienced in carrying out this solution are considered andstrategies of dealing with these can be worked out.It is frequently the case that patients will attempt to avoid thisbehavioral analysis since they may experience the process of lookingin such detail at their behavior as aversive. However it is essential thatthe therapist should not be side tracked until the process is completed.In addition to achieving an understanding of the factors controllingbehavior, behavioral analysis can be seen as part of contingencymanagement strategy, applying a somewhat aversive consequence toan episode of targeted maladaptive behavior. The process can also beseen as an exposure technique helping to desensitize the patient topainful feelings and behaviors. Having completed the behavioralanalysis the patient can then be rewarded with a heart to heartconversation about the things she likes to discuss.Behavioral analysis can be seen as a way of responding tomaladaptive behavior, and in particular to parasuicide, in a way thatshows interest and concern but which avoids reinforcing the behavior.In DBT a particular approach is taken in dealing with the network ofpeople with whom the patient is involved personally andprofessionally. These are referred to as case management strategies.The basic idea is that the patient should be encouraged, withappropriate help and support, to deal with her own problems in theenvironment in which they occur. Therefore, as far as possible, thetherapist does not do things for the patient but encourages the patientto do things for herself. This includes dealing with other professionalswho may be involved with the patient. The therapist does not try to tellthese other professionals how to deal with the patient but helps thepatient learn how to deal with the other professionals. Inconsistenciesbetween professionals are seen as inevitable and not necessarilysomething to be avoided. Such inconsistencies are rather seen asopportunities for the patient to practice her interpersonal effectivenessskills. If she grumbles about the help she is receiving from anotherprofessional she is helped to sort this out herself with the personinvolved. This is referred to as the consultation-to-the-patientstrategy’, which, among other things, serves to minimize the so-called"staff splitting" which tends to occur between professionals dealingwith these patients.Environmental intervention is acceptable but only in very specificsituations where a particular outcome seems essential and the patient 29
  30. 30. does not have the power or capability to produce this outcome. Suchintervention should be the exception rather than the rule.EMPIRICAL EVIDENCEThe effectiveness of DBT has been assessed in two major trials. Thefirst (Linehan et al, 1991) compared the effectiveness of DBT relativeto treatment as usual (TAU). The second (Linehan et al, in press)examined the effectiveness of DBT skills training when added tostandard community psychotherapy.In the first randomised controlled trial, there were three main goals:Firstly, to reduce the frequency of parasuicidal behaviors. This isclearly of importance because of the distressing nature of the behaviorbut also because of the increased risk of completed suicide in thisgroup (Stone, 1987).Secondly, to reduce behaviors that interfere with the progress oftherapy (therapy interfering behaviors), as the attrition rate fromtherapy in borderline women with a history of parasuicidal behaviors ishigh.Finally, to reduce behaviors that interfere with the patients quality oflife. In this study this latter goal was interpreted more specifically as areduction in in-patient psychiatric days, which is hypothesized tointerfere with the patients quality of life.Participants all met DSM-IIIR criteria for BPD, and were matched fornumber of lifetime parasuicide episodes, number of lifetimeadmissions to hospital, age and anticipated good or poor prognosis.There were 22 patients in each group. The experimental groupreceived standard DBT as outlined above. The experience of thepatients in the treatment as usual group was variable; some receivedregular individual psychotherapy, others dropped out of individualtherapy whilst continuing to have access to in-patient and day-patientservices. All participants were assessed on number of parasuicidalepisodes and a range of questionnaire measures of mood. Patientswere blindly assessed at pre-treatment, 4, 8 and 12 months andfollowed up at 6 and 12 months post-treatment. Measures of treatmentcompliance and other treatment delivered (e.g. in patient psychiatricdays) were also taken. At pre-treatment there were no significantdifferences on any of the measures between the control andexperimental groups including demographic criteria. 30
  31. 31. With regard to the first aim of the trial (i.e. the reduction of suicidalbehavior), during the year of treatment patients in the control groupengaged in more parasuicidal acts than DBT patients at all timepoints. The medical risk for parasuicidal acts was higher in the controlgroup than in the DBT group.Patients in the DBT group were more likely to start therapy and weremore likely to remain in therapy than those in the control group. Theone year attrition rate in the DBT group was 16.7% compared to 50%for those in the control group who commenced the year with a newtherapist. The DBT patients reported more individual and grouptherapy treatment hours per week than the TAU group, which reflectsthe intensive nature of DBT treatment. However, the control patientsreported more day treatment hours per week.With regard to the third goal of the trial, patients in the control grouphad significantly more inpatient psychiatric days per person than thosereceiving DBT (38.6 days per year as compared to 8.46 days per yearfor the DBT group).These results were considered to indicate the superiority of DBT overtreatment as usual. However, one major criticism of the trial is that thevariable and patchy therapeutic experience of the control group maybe considered to favor DBT. This criticism can be challenged,however, since one of the treatment aims of DBT is to keep the patientin therapy. This it seems to have succeeded in doing. However, it isstill pertinent to enquire how well DBT would compare to a consistenttreatment alternative. An attempt was made to explore this bycomparing the DBT patients with those in the TAU group who receivedregular individual therapy. It was found that the gains of the patients inthe DBT group over the TAU group remained even using this morerigorous comparison.Despite the more intensive nature of DBT it remained cheaper thanTAU, largely because of the reduction in the number of in-patient andday-treatment days received by the DBT patients.It is of interest that, although the DBT patients showed significantgains across the three areas of interest (number of parasuicides,treatment compliance and inpatient days), there were no between-group differences on any of the questionnaire measures of mood andsuicidal ideation. During the follow-up year, patients in the DBT grouphad higher Global Assessment Scores and a better work performancethan the patients in the TAU group. In the first 6 months, DBT patientshad fewer suicidal acts, lower anger scores and better self-reportedsocial adjustment than TAU patients. In the final 6 months, DBT 31
  32. 32. patients had fewer in-patient days’ treatment and better interviewerrated social adjustment than TAU patients.The second trial had two parts. Firstly, it compared standardcommunity psychotherapy (SCP) plus the group skills component ofDBT with SCP alone without added skills training. Secondly, itcompared the SCP group from the first part of the present study withthe experimental group in the previously described randomised controltrial. In this latter comparison, assignment to conditions was notrandom. However, all subjects were screened in the same way, duringthe same time frame and were all subject to blind assessment.The results of the first part of this study indicated that the addition ofDBT skills training to SCP for this group of parasuicidal borderlinewomen did not confer any additional therapeutic benefit. In this part ofthe study the skills training was truly ancillary in that there were nomeetings between the individual therapists and the group therapists,nor were any attempts made to assist the patient to generalize theskills learnt in the group to her everyday life.In the second part of the study there were some pre-treatmentdifferences between the two groups. The DBT patients were lessdepressed than the control group and reported higher levels ofunemployment. These differences were not considered to beparticularly important for three reasons. Firstly, depression was notcorrelated with any of the outcome variables. Secondly, although thelower depression scores favored the DBT group, the lowerunemployment favored the SCP group. Finally, the levels ofdepression did not differ between the two groups after the pre-treatment point.During the treatment year there were no significant differencesbetween the groups with regard to staying in therapy. There weresome slight differences in the distribution of therapeutic hours, withDBT patients reporting more group treatment hours than the SCPgroup. Most importantly, however, there were no significantrelationships between number of treatment hours and any of theoutcome variables. Over the treatment year, standard DBT patientscompared to SCP patients had fewer parasuicidal episodes, fewerepisodes leading to medical treatment and fewer psychiatric in-patientdays. DBT patients also reported less anger than the SCP patients.This research then provides some evidence for the therapeuticefficacy of DBT. This evidence is primarily derived from onerandomised control trial in which DBT was found to be superior on anumber of variables to treatment as usual. Clearly this finding requires 32
  33. 33. replication. There is also some evidence to suggest that DBT issuperior to other forms of psychotherapy with this group of patients.However, this result comes from a comparison made using only a sub-sample of patients in the randomised trial (Linehan et al, 1991) andfrom a further comparison between two groups from different studies(Linehan et al, in press). Consequently, the effectiveness of DBTcompared to other alternative treatments awaits further exploration.This will remain a challenge, particularly given the high drop-out ratesfrom treatment of this group of patients.SUMMARY AND CONCLUSIONSDialectical Behavior Therapy then is a novel method of therapyspecifically designed to meet the needs of patients with BorderlinePersonality Disorder and their therapists. It directly addresses theproblem of keeping these patients in therapy and the difficulty ofmaintaining therapist motivation and professional well-being. It isbased on a clear and potentially testable theory of BPD andencourages a positive and validating attitude to these patients in thelight of this theory. The approach incorporates what is valuable fromother forms of therapy, and is based on a clear acknowledgement ofthe value of a strong relationship between therapist and patient.Therapy is clearly structured in stages and at each stage a clearhierarchy of targets is defined. The method offers a particularly helpfulapproach to the management of parasuicide with a clearly definedresponse to such behaviors. The techniques used in DBT areextensive and varied, addressing essentially every aspect of therapyand they are underpinned by a dialectical philosophy thatrecommends a balanced, flexible and systemic approach to the workof therapy. Techniques for achieving change are balanced bytechniques of acceptance, problem solving is surrounded byvalidation, confrontation is balanced by understanding. The patient ishelped to understand her problem behaviors and then deal withsituations more effectively. She is taught the necessary skills toenable her to do so and helped to deal with any problems that shemay have in applying them in her natural environment. Generalizationoutside therapy is not assumed but encouraged directly. Advice andsupport available between sessions and the patient is encouraged andhelped to take responsibility for dealing with lifes challenges herself.The method is supported by empirical evidence, which suggests that itis successful in reducing self-injury and time spent in psychiatric in-patient treatment.REFERENCES 33
  34. 34. Linehan, M.M. (1993a) Cognitive Behavioral Treatment of BorderlinePersonality Disorder. The Guilford Press, New York and London.Linehan, M.M. (1993b) Skills Training Manual for Treating BorderlinePersonality Disorder. The Guilford Press, New York and London.Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. & Heard, H.L.(1991) Cognitive-behavioral treatment of chronically parasuicidalborderline patients. Archives of General Psychiatry, 48, 1060-1064.Linehan, M.M., Heard, H.L. & Armstrong, H.E. (in press) Dialecticalbehavior therapy, with and without behavioral skills training, forchronically parasuicidal borderline patients.Stone, M.H. (1987) The course of borderline personality disorder. InTasman, A., Hales, R.E. & Frances, A.J. (eds) American PsychiatricPress Review of Psychiatry. Washington DC; American PsychiatricPress inc. 8, 103-122.Barry Kiehn, Consultant Child and Adolescent Psychiatrist,Gwynfa Adolescent Service, Pen-y-Bryn Road, Upper ColwynBay, Clwyd, North Wales, LL29 6AL.e-mail: Swales, Chartered Clinical Psychologist, GwynfaAdolescent Service and Lecturer in the Psychology ofAdolescence, University College of North Wales, Bangor,Gwynedd, LL57 2DG.e-mail: Movement Desensitization and Reprocessing (EMDR)1 is acomprehensive, integrative psychotherapy approach. It containselements of many effective psychotherapies in structured protocolsthat are designed to maximize treatment effects. These includepsychodynamic, cognitive behavioral, interpersonal, experiential, andbody-centered therapies2.EMDR is an information processing therapy (When a traumatic or verynegative event occurs, information processing may be incomplete, perhaps becausestrong negative feelings or dissociation interfere with information processing. Thisprevents the forging of connections with more adaptive information that is held inother memory networks. For example, a rape survivor may “know” that rapists areresponsible for their crimes, but this information does not connect with her feelingthat she is to blame for the attack. The memory is then dysfunctionally storedwithout appropriate associative connections and with many elements stillunprocessed. When the individual thinks about the trauma, or when the memory is 34
  35. 35. triggered by similar situations, the person may feel like she is reliving it, or mayexperience strong emotions and physical sensations. A prime example is theintrusive thoughts, emotional disturbance, and negative self-referencing beliefs ofposttraumatic stress disorder (PTSD)). and uses an eight phase approach toaddress the experiential contributors of a wide range of pathologies. Itattends to the past experiences that have set the groundwork forpathology, the current situations that trigger dysfunctional emotions,beliefs and sensations, and the positive experience needed toenhance future adaptive behaviors and mental health.During treatment various procedures and protocols are used toaddress the entire clinical picture. One of the procedural elements is"dual stimulation" using either bilateral eye movements, tones or taps.During the reprocessing phases the client attends momentarily to pastmemories, present triggers, or anticipated future experiences whilesimultaneously focusing on a set of external stimulus. During thattime, clients generally experience the emergence of insight, changesin memories, or new associations. The clinician assists the client tofocus on appropriate material before initiation of each subsequent set.Eight Phases of TreatmentThe first phase is a history taking session during which the therapistassesses the clients readiness for EMDR and develops a treatmentplan. Client and therapist identify possible targets for EMDRprocessing. These include recent distressing events, current situationsthat elicit emotional disturbance, related historical incidents, and thedevelopment of specific skills and behaviors that will be needed by theclient in future situations.During the second phase of treatment, the therapist ensures that theclient has adequate methods of handling emotional distress and goodcoping skills, and that the client is in a relatively stable state. If furtherstabilization is required, or if additional skills are needed, therapyfocuses on providing these. The client is then able to use stressreducing techniques whenever necessary, during or betweensessions. However, one goal is not to need these techniques oncetherapy is complete.In phase three through six, a target is identified and processed usingEMDR procedures. These involve the client identifying the most vividvisual image related to the memory (if available), a negative beliefabout self, related emotions and body sensations. The client alsoidentifies a preferred positive belief. The validity of the positive belief israted, as is the intensity of the negative emotions. 35
  36. 36. After this, the client is instructed to focus on the image, negativethought, and body sensations while simultaneously moving his/hereyes back and forth following the therapists fingers as they moveacross his/her field of vision for 20-30 seconds or more, dependingupon the need of the client. Athough eye movements are the mostcommonly used external stimulus, therapists often use auditory tones,tapping, or other types of tactile stimulation. The kind of dual attentionand the length of each set is customized to the need of the client. Theclient is instructed to just notice whatever happens. After this, theclinician instructs the client to let his/her mind go blank and to noticewhatever thought, feeling, image, memory, or sensation comes tomind. Depending upon the clients report the clinician will facilitate thenext focus of attention. In most cases a client-directed associationprocess is encouraged. This is repeated numerous times throughoutthe session. If the client becomes distressed or has difficulty with theprocess, the therapist follows established procedures to help the clientresume processing. When the client reports no distress related to thetargeted memory, the clinician asks him/her to think of the preferredpositive belief that was identified at the beginning of the session, or abetter one if it has emerged, and to focus on the incident, whilesimultaneously engaging in the eye movements. After several sets,clients generally report increased confidence in this positive belief.The therapist checks with the client regarding body sensations. Ifthere are negative sensations, these are processed as above. If thereare positive sensations, they are further enhanced.In phase seven, closure, the therapist asks the client to keep a journalduring the week to document any related material that may arise andreminds the client of the self-calming activities that were mastered inphase two.The next session begins with phase eight, re-evaluation of theprevious work, and of progress since the previous session. EMDRtreatment ensures processing of all related historical events, currentincidents that elicit distress, and future scenarios that will requiredifferent responses. The overall goal is produce the mostcomprehensive and profound treatment effects in the shortest periodof time, while simultaneously maintaining a stable client within abalanced system.After EMDR processing, clients generally report that the emotionaldistress related to the memory has been eliminated, or greatlydecreased, and that they have gained important cognitive insights.Importantly, these emotional and cognitive changes usually result inspontaneous behavioral and personal change, which are furtherenhanced with standard EMDR procedures. 36
  37. 37. 1 Shapiro, F. (2001). Eye Movement Desensitization andReprocessing: Basic Principles, Protocols and Procedures (2nd ed.).New York: Guilford Press.2 Shapiro, F. (2002). EMDR as an Integrative PsychotherapyApproach: Experts of Diverse Orientations Explore the ParadigmPrism. Washington, DC: American Psychological Association Books.Thought stopping Techniques > Conversion > Thought stopping Undesirable thoughts | Preventing thoughts | See alsoThe principle of thought stopping is first to stop people thinking aboutthose things which will distract or dissuade them from what they aresupposed to be thinking.Undesirable thoughtsDistractionUndesirable thinking can come in two forms. First, the person may bedistracted by innocuous thoughts when they should be concentratingon a particular area. When I am reading or meditating, for example,someone talking nearby would be a distraction and cause my mind towander onto the subjects about which they are talking. Distraction isthus just a block to conversion, slowing it down.People may also be taught thought-stopping methods as ways ofblocking out dissuasive arguments when they meet them. Just as achild puts their hands over their ears and makes da-da-da noises toblock out what they do not want to hear, so a group member maydistract their conscious, for example by reciting some form of litany tothemselves or otherwise avoiding having to experience the tension ofcontradictory arguments.Dissuasion 37
  38. 38. The second form of unwanted thoughts are when the person isthinking about something that will dissuade them and persuadeotherwise from the thoughts that they should be having. This is farmore serious that distraction as it can cause a reversal in the processof conversion, rather than a temporary pause.Dissuasion may occur accidentally or deliberately. Accidentaldissuasion occurs, when the person reads, hears or sees somethingthat is not targeted directly at them, but causes them to think thewrong thoughts.Preventing thoughtsIsolationIsolation from distractions is commonly used at least at two levels.First, when practices such as meditation and prayer are used, thenindividual isolation removes immediate distractions. At the secondlevel, individuals and groups may be isolated from the world, either toavoid any dissuasion of individuals or to remove distractions.OccupationAnother simple way of limiting undesirable thoughts is to keep peoplebusy with all kinds of physical and mental activities that gives themlittle time for any action, talk or reflection that may lead to wrongthoughts.Carrot and stickOperant Conditioning says that rewards causes behavior to berepeated, whilst punishment leads to extinction of behavior. Reward ofright thinking and punishment of wrong thinking may thus be used topersuade and dissuade.Grounding Techniques Grounding techniques are those that help you focus on the here andnow and remind you that you are not in the past traumatic experience.Listen to music: Listen to your favorite type of music. Concentrate onthe lyrics. It may help to sing along with the lyrics as well.Touch the things around you: Touch things in your surroundingsand name each thing as you touch it either in your head or aloud. 38
  39. 39. Doing so will help you concentrate on your current circumstances and reminds you that you are not in the past. Repetitive phrases: Sometimes, repeating certain phrases will help you come back to the present. You might tell yourself, "I am safe now" or, "That was then, this is now." Keep repeating these phrases until you feel better. Talk/write it out: If someone is with you, and you can trust that person, talk to him or her about what you are feeling. Call a trusted friend and talk to him or her about what you are experiencing. Alternatively, call your therapist to talk. If no one is available, try writing down how you feel and what you are experiencing. Remind yourself that while you feel you are in the past traumatic experience, you are safe now. Pets: Brush, pet, or play with your dog or cat if you have one. Animals can be extremely therapeutic. Even being near your pet may help you feel better. Read: When you read, you must focus on the here and now. Read a book you enjoy. Do not read something that may remind you of the past trauma or could make you upsetSelf-Soot heIn DBT, there are four categories of Distress Tolerance strategies. These are: Distracting Self-Soothing Improving the Moment Focusing on the Pros and ConsThese are strategies that short circuit or help you to cope with overwhelming negativeemotions or intolerable situations. They take a lot of practice, but as you get the hang ofusing some of these techniques, you will see your relationship to the negative emotionsand intolerable feelings change. (This was the most amazing thing about DBT for me,that things I though could never change or that I could never learn to deal with didbecome better.) 39
  40. 40. It takes time and practice, and so I urge you to give the techniques plenty of practice.You will find some things work better than others for you. And you will find that somethings dont work at first, but over time and practice you will see some results.Self-Soothing TechniquesSome of us may recognize these techniques as things that we already use. But many of ushave never learned how to self-soothe, how to do those often simple things that makes us feelbetter. These are mostly very physical techniques, that use different body senses. Some of ushave never had the feeling that we could do things to make ourselves feel better, calmer, feelrelaxation or pleasure. I urge you to experiment with these techniques until you find some thatare comfortable and helpful for you. And when you find these, practice them. Use them whenyou are feeling distressed, when emotions feel overwhelming, when situations feel like youcant stand them any more. Instead of doing something that hurts you, try something thatgives you pleasure and comfort,SELF-SOOTHING has to do with comforting, nurturing and being kind to yourself. One wayto think of this is to think of ways of soothing each of your five senses: Vision Hearing Smell Taste TouchCheck p. 167 in the manual, Distress Tolerance Handout 1, for lots of suggestions ofthings that you can do to soothe and pleasure your five senses. A few examples:With VISION:Walk in a pretty part of town. Look at the nature around you. Go to a museum withbeautiful art. Buy a flower and put it where you can see it. Sit in a garden. Watch thesnowflakes decorate the trees during a snowfall. Light a candle and watch the flame.Look at a book with beautiful scenery or beautiful art. Watch a travel movie or video.With HEARING:Listen to beautiful or soothing music, or to tapes of the ocean or other sounds of nature.Listen to a baby gurgling or a small animal. Sit by a waterfall. Listen to someonechopping wood. When you are listening, be mindful, letting the sounds come and go.With SMELL:Smell breakfast being cooked at home or in a restaurant. Notice all the different smellsaround you. Walk in a garden or in the woods, maybe just after a rain, and breathe inthe smells of nature. Light a scented candle or incense. Bake some bread or a cake, andtake in all the smells. 40
  41. 41. With TASTE:Have a special treat, and eat it slowly, savoring each bite. Cook a favorite meal. Drink asoothing drink like herbal tea or hot chocolate. Let the taste run over your tongue andslowly down your throat. Go to a potluck, and eat a little bit of each dish, mindfullytasting each new thing.With TOUCH:Take a bubble bath. Pet your dog or cat or cuddle a baby. Put on a silk shirt shirt orblouse, and feel its softness and smoothness. Sink into a really comfortable bed. Float orswim in a pool, and feel the water caress your body.DiscussionMany of us may feel like we dont deserve these comforts, and may find it hard to givepleasure to ourselves in this way. Do you have these feelings?Some of may also expect this soothing to come from other people, or not wantto do it for ourselves. Have you experienced this feeling?You may feel guilty about pleasuring yourself in this way. It may take some practice toallow yourself to experience these pleasures. These are really simple human pleasuresthat everyone has a right to, and that will give us some good tools to use when we arefeeling bad.ExercisesTry at least one of these self-soothing exercises this week. You may want to choose awhole group of things, say all the visual things, or you may want to choose a single thingto try. As you do what you have chosen, do it mindfully. Breathe gently, and try to befully in the experience, whether it is walking in the woods or watching a flower or takinga bubble bath or smelling some fresh-baked bread.As you begin to overcome your feelings that perhaps you do not deserve this, or guilt,and start to enjoy one or more of these activities, you will be learning very useful tools tohelp you deal with negative feelings and difficult situations. 41