Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder
There is a clear and open emphasis on the limits of behavior acceptable to the therapist and these are dealt with in a very direct way. The therapist should be clear about his or her personal limits in relations to a particular patient and should as far as possible make these clear to her from the start. It is openly acknowledged that an unconditional relationship between therapist and patient is not humanly possible and it is always possible for the patient to cause the therapist to reject her if she tries hard enough. It is in the patient’s interests therefore to learn to treat her therapist in a way that encourages the therapist to want to continue helping her. It is not in her interests to burn him or her out. This issue is confronted directly and openly in therapy. The therapist helps therapy to survive by consistently bringing it to the patient’s attention when limits have been overstepped and then teaching her the skills to deal with the situation more effectively and acceptably.
It is made quite clear that the issue is immediately concerned with the legitimate needs of the therapist and only indirectly with the needs of the patient who clearly stands to lose if she manages to burn out the therapist.
The therapist is asked to adopt a non-defensive posture towards the patient, to accept that therapists are fallible and that mistakes will at times inevitably be made. Perfect therapy is simply not possible. It needs to be accepted as a working hypothesis that (to use Linehan’s words) “all therapists are jerks”.
The Commitment to Therapy
This form of therapy must be entirely voluntary and depends for its success on having the co-operation of the patient. From the start, therefore, attention is given to orienting the patient to the nature of DBT and obtaining a commitment to undertake the work. A variety of specific strategies are described in the Linehan’s book (Linehan, 1993a) to facilitate this process.
Before a patient will be taken on for DBT she will be required to give a number of undertakings:
- To work in therapy for a specified period of time (Linehan initially contracts for one year) and, within reason, to attend all scheduled therapy sessions.
- If suicidal behaviors or gestures are present, she must agree to work on reducing these.
- To work on any behaviors that interfere with the course of therapy (‘therapy interfering behaviors’).
- To attend skills training.
The strength of these agreements may be variable and a “take what you can get approach” is advocated. Nevertheless a definite commitment at some level is required since reminding the patient about her commitment and re-establishing such commitment throughout the course of therapy are important strategies in DBT.
The therapist agrees to make every reasonable effort to help the patient and to treat her with respect, as well as to keep to the usual expectations of reliability and professional ethics. The therapist does not however give any undertaking to stop the patient from harming herself. On the contrary, it should be make quite clear that the 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.
Dialectical Behavior Therapy in Practice
There are four primary modes of treatment in DBT:
- Individual therapy
- Group skills training
- Telephone contact
- 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.
1. Individual Therapy
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.
2. Telephone Contact
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.
3. Skills Training
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:
- Core mindfulness skills.
- Interpersonal effectiveness skills.
- Emotion modulation skills.
- 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 one’s 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).
4. Therapist Consultation Groups
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.
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/