Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder
Key Features of People with Borderline Personality Disorder
Linehan groups the features of BPD in a particular way, describing the patients as showing dysregulation in the sphere of emotions, relationships, behavior, cognition and the sense of self. She suggests that, as a consequence of the situation that has been described, they show six typical patterns of behavior, the term ‘behavior’ referring to emotional, cognitive and autonomic activity as well as external behavior in the narrow sense.
First, they show evidence of emotional vulnerability as already described. They are aware of their difficulty coping with stress and may blame others for having unrealistic expectations and making unreasonable demands.
Second, they have internalized the characteristics of the Invalidating Environment and tend to show “self-invalidation;” that is, they invalidate their own responses and have unrealistic goals and expectations, feeling ashamed and angry with themselves when they experience difficulty or fail to achieve their goals.
These two features constitute the first pair of so-called dialectical dilemmas, the patient’s position tending to swing between the opposing poles since each extreme is experienced as being distressing.
Next, they tend to experience frequent traumatic environmental events, in part related to their own dysfunctional lifestyle and exacerbated by their extreme emotional reactions with delayed return to baseline. This results in what Linehan refers to as a pattern of ‘unrelenting crisis’, one crisis following another before the previous one has been resolved. On the other hand, because of their difficulties with emotion modulation, they are unable to face, and therefore tend to inhibit, negative affect and particularly feelings associated with loss or grief. This ‘inhibited grieving’ combined with the ‘unrelenting crisis’ constitutes the second dialectical dilemma.
The opposite poles of the final dilemma are referred to as ‘active passivity’ and ‘apparent competence’. Patients with BPD are active in finding other people who will solve their problems for them but are passive in relation to solving their own problems. On the other hand, they have learned to give the impression of being competent in response to the Invalidating Environment. In some situations they may indeed be competent but their skills do not generalize across different situations and are dependent on the mood state of the moment. This extreme mood dependency is seen as being a typical feature of patients with BPD.
A pattern of self-mutilation tends to develop as a means of coping with the intense and painful feelings experienced by these patients and suicide attempts may be seen as an expression of the fact that life is at times simply does not seem worth living. These behaviors in particular tend to result in frequent episodes of admission to psychiatric hospitals. Dialectical Behavior Therapy, which will now be described, focuses specifically on this pattern of problem behaviors and in particular, the suicidal behavior.
Background on Dialectical Behavior Therapy
The term dialectical is derived from classical philosophy. It refers to a form of argument in which an assertion is first made about a particular issue (the ‘thesis’), the opposing position is then formulated (the ‘antithesis’ ) and finally a ‘synthesis’ is sought between the two extremes, embodying the valuable features of each position and resolving any contradictions between the two. This synthesis then acts as the thesis for the next cycle. In this way truth is seen as a process which develops over time in transactions between people. From this perspective there can be no statement representing absolute truth. Truth is approached as the middle way between extremes.
The dialectical approach to understanding and treatment of human problems is therefore non-dogmatic, open and has a systemic and transactional orientation. The dialectical viewpoint underlies the entire structure of therapy, the key dialectic being ‘acceptance’ on the one hand and ‘change’ on the other. Thus DBT includes specific techniques of acceptance and validation designed to counter the self-invalidation of the patient. These are balanced by techniques of problem solving to help her learn more adaptive ways of dealing with her difficulties and acquire the skills to do so. Dialectical strategies underlie all aspects of treatment to counter the extreme and rigid thinking encountered in these patients. The dialectical world view is apparent in the three pairs of ‘dialectical dilemmas’ already described, in the goals of therapy and in the attitudes and communication styles of the therapist which are to be described. The therapy is behavioral in that, without ignoring the past, it focuses on present behavior and the current factors which are controlling that behavior.
The Importance of the Experienced DBT Therapist
The success of treatment is dependent on the quality of the relationship between the patient and therapist. The emphasis is on this being a real human relationship in which both members matter and in which the needs of both have to be considered. Linehan is particularly alert to the risks of burnout to therapists treating these patients and therapist support and consultation is an integral and essential part of the treatment. In DBT support is not regarded as an optional extra. The basic idea is that the therapist gives DBT to the patient and receives DBT from his or her colleagues. The approach is a team approach.
The therapist is asked to accept a number of working assumptions about the patient that will establish the required attitude for therapy:
- The patient wants to change and, in spite of appearances, is trying her best at any particular time.
- Her behavior pattern is understandable given her background and present circumstances. Her life may currently not be worth living (however, the therapist will never agree that suicide is the appropriate solution but always stays on the side of life. The solution is rather to try and make life more worth living).
- In spite of this she needs to try harder if things are ever to improve. She may not be entirely to blame for the way things are but it is her personal responsibility to make them different.
- Patients can not fail in DBT. If things are not improving it is the treatment that is failing.
In particular the therapist must avoid at all times viewing the patient, or talking about her, in pejorative terms since such an attitude will be antagonistic to successful therapeutic intervention and likely to feed into the problems that have led to the development of BPD in the first place.
Linehan has a particular dislike for the word “manipulative” as commonly applied to these patients. She points out that this implies that they are skilled at managing other people when it is precisely the opposite that is true. Also the fact that the therapist may feel manipulated does not necessarily imply that this was the intention of the patient. It is more probable that the patient did not have the skills to deal with the situation more effectively.
The therapist relates to the patient in two dialectically opposed styles. The primary style of relationship and communication is referred to as ‘reciprocal communication’, a style involving responsiveness, warmth and genuineness on the part of the therapist. Appropriate self-disclosure is encouraged but always with the interests of the patient in mind. The alternative style is referred to as ‘irreverent communication’. This is a more confrontational and challenging style aimed at bringing the patient up with a jolt in order to deal with situations where therapy seems to be stuck or moving in an unhelpful direction. It will be observed that these two communication styles form the opposite ends of another dialectic and should be used in a balanced way as therapy proceeds.
The therapist should try to interact with the patient in a way that is:
- Accepting of the patient as she is but which encourages change.
- Centered and firm yet flexible when the circumstances require it.
- Nurturing but benevolently demanding.
Psych Central. (2020). Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder. Psych Central. Retrieved on August 5, 2020, from https://psychcentral.com/lib/dialectical-behavior-therapy-in-the-treatment-of-borderline-personality-disorder/