Borderline Personality Disorder and Dialectical Behavioral Therapy (DBT) Sharon Fischman, LCSW-C St. Luke’s House and Threshold Services United
Borderline Personality Disorder• Instability in interpersonal behavior, marked by intense and unstable relationships• Impulsive and unpredictable behavior• Profound, inappropriate shifts in mood and affect• There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide• Patients often need extensive mental health services, and account for 20% of psychiatric hospitalizations
• While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long- term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
• People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). They may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to any separations.
Dialectical Behavioral Therapy• Dialectical Behavioral Therapy (DBT) is a form of therapy that has been found to be effective in treating Borderline Personality Disorder.• The most important of the overall goals in DBT is helping clients create “lives worth living.” What makes a life worth living varies from client to client.• The balance between acceptance and change strategies in therapy form the fundamental “dialectic.” “Dialectic” means “weighing and integrating contradictory facts or ideas with a view to resolving apparent contradictions.” In DBT, therapists and clients work hard to balance change with acceptance, two seemingly contradictory forces or strategies.
• The central dialectic is that everyone is doing the best he or she can AND that everyone has to try harder, do better, and want to change more.• A key assumption in DBT is that self- destructive behaviors are learned coping techniques for unbearably intense and negative emotions. Negative emotions like shame, guilt, sadness, fear, and anger are a normal part of life. However, it seems that some people are particularly inclined to have very intense and frequent negative emotions.
• An invalidating environment is also a major contributing factor. “Invalidating” refers to a failure to treat a person in a manner that conveys attention, respect, and understanding..• A vicious cycle can get started: The person is really sad and scared, she has no one who listens to her, she is afraid to ask for help or knows no help is available, and so she tries to kill herself. Then, when her pain is treated seriously at the hospital, she learns (without being conscious of it) that when she’s suicidal, other people understand how badly she feels. Repeated self- injury can result if it is seen as the only means for getting better or achieving understanding from other people.
Stages of treatment• Eliminate life-threatening behaviors• Eliminate therapy-interfering behaviors• Focus on quality of life behaviors
Open-Minded Thinking• Seeing things in a new way
Open-Minded Skills• Two ideas can both be true at the same time• Two things that seem like (or are) opposites can both be true (you are doing the best that you can AND you need to try harder, do better, and want to change more)• A life worth living has both comfortable and uncomfortable parts• Being open-minded means letting go of being “right” and “all or nothing” thinking• It means listening to yourself and others, seeing things in a new way, getting unstuck, taking responsibility for your own behavior• No one owns the truth• We might not have caused all our problems, but we have to solve them• Avoid words like always, never, you make me.• Look at all sides of an issue
Validation• What we think and feel is real, important, and makes sense
Validation Skills• Emotions, thoughts and sensations are all experiences that we sometimes doubt in ourselves. Telling ourselves and others that what we (they) feel is real, important, and makes sense.• Validation does not mean that you agree or approve of a behavior. Validation is not worried about right or wrong.• Look at the person, not the behavior.• Describe the facts of the situation, name your feelings, tell yourself (or someone else) that it’s OK to feel this way.
Balanced Thinking• Focus on what is happening right now. Reasoning mind and feeling mind are in balance.
Balanced Thinking Skills• Balanced thinking is the ability to think and feel at the same time.• Thinking mind + feeling mind = balanced thinking mind.• Notice what is happening. Notice that how you feel. Notice that thoughts and feelings come and go like waves. Notice what comes through your senses. Have a teflon coating.• Be part of what is happening right now – be mindful in the moment.• Be non-judgmental (separate your own thoughts and feelings and focus on the facts).• Be effective – focus on your goals.
Calming Skills• Balancing my thoughts and feelings
Calming Skills• Feelings are not good or bad. They just are. And they don’t last forever.• DBT is not about stopping feelings.• Feelings are the reason you have urges.• Feelings help us to communicate, help us do things (act now, stay focused), and give us information.• Feelings aren’t facts.• Thinking or wanting to do something is part of having a feeling. Your response may be different than someone else’s response.• People tend to avoid painful or uncomfortable feelings. DBT asks you to experience these feelings, sometimes without doing anything to change them.
Calming Skills• Events lead to thoughts that lead to feelings that lead to choices.• We can’t control what we feel, but we can control our behaviors.• Make a list of positive experiences, calming skills, and a plan for staying strong.
Distress Tolerance• Getting through painful situations without making them worse
Distress Tolerance Skills• Self-soothe• Think of pros and cons (of using skills and not using skills)• Urge management• Radical acceptance – this is how life truly is• Be willing rather than willful
Getting Along Well With Others• Playing nice in the sandbox of life
Getting Along Well With Others Skills• Try to get the thing you want effectively• Remember your goals• Keeping and improving your self-respect and liking yourself• Getting what you want (or accepting that you won’t) using Dear Man statements• Maintaining relationships – GIVE (be gentle, act interested, validate, use an easy manner)• Keeping respect for yourself – FAST (be fair to yourself and the other person, apologize for what you’re responsible for but not for having an opinion, stick to values, be truthful)
Questions?• So how do we apply this in the moment and outside therapy?• Any questions?• Any concerns?• If you would like more training on DBT or have any questions, call Sharon Fischman at St. Luke’s House and Threshold Services United at 301-896-4221.