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Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder

Stages of Dialectical Behavior Therapy

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 organised into a number of stages and structured in terms of hierarchies of targets at each stage.

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 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 patient’s 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:

  • Contingency management
  • Cognitive therapy
  • Exposure based therapies
  • Medications

The principles of using these techniques are precisely those applying to their use in other contexts and will not be described in any detail. In DBT however they are used in a relatively informal way and interwoven into therapy. Linehan recommends that medication be prescribed by someone other than the primary therapist, although this may not always be practical.

Particular note should be made of the pervading application of contingency management throughout therapy, using the relationship with the therapist as the main reinforcer. In the session by session course of therapy care is taken to systematically reinforce targeted adaptive behaviors and to avoid reinforcing targeted maladaptive behaviors. This process is made quite overt to the patient, explaining that behavior which reinforced can be expected to increase. A clear distinction is made between the observed effect of reinforcement and the motivation of the behavior, pointing out that such a relationship between cause and effect does not imply that the behavior is being carried out deliberately in order to obtain the reinforcement. Didactic teaching and insight strategies may also be used to help the patient achieve an understanding of the factors that may be controlling her behavior.

The same contingency management approach is taken in dealing with behaviors that overstep the therapist’s personal limits in which case they are referred to as ‘observing limits procedures’.
Problem solving and change strategies are again balanced dialectically by the use of validation strategies. It is important at every stage to convey to the patient that her behavior, including thoughts feelings and actions are understandable, even though they may be maladaptive or unhelpful.

Significant instances of targeted maladaptive behavior occurring since the 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 behavior is dealt with in this way. Such behavioral analysis is an important aspect of DBT and may take up a large proportion of therapy time.

In the course of a typical behavioral analysis a particular instance of behavior is first clearly defined in specific terms and then a ‘chain analysis’ is conducted, looking in detail at the sequence of events and attempting to link these events one to another. In the course of this process hypotheses are generated about the factors that may be controlling the behavior. This is followed by, or interwoven with, a ‘solution analysis’ in which alternative ways of dealing with the situation at each stage are considered and evaluated. Finally one solution should be chosen for future implementation. Difficulties that may be experienced in carrying out this solution are considered and strategies of dealing with these can be worked out.

It is frequently the case that patients will attempt to avoid this behavioral analysis since they may experience the process of looking in such detail at their behavior as aversive. However it is essential that the therapist should not be side tracked until the process is completed. In addition to achieving an understanding of the factors controlling behavior, behavioral analysis can be seen as part of contingency management strategy, applying a somewhat aversive consequence to an episode of targeted maladaptive behavior. The process can also be seen as an exposure technique helping to desensitize the patient to painful feelings and behaviors. Having completed the behavioral analysis the patient can then be rewarded with a ‘heart to heart’ conversation about the things she likes to discuss.

Behavioral analysis can be seen as a way of responding to maladaptive behavior, and in particular to suicidal gestures or attempts, in a way that shows interest and concern but which avoids reinforcing the behavior.

In DBT a particular approach is taken in dealing with the network of people with whom the patient is involved personally and professionally. These are referred to as ‘case management strategies’. The basic idea is that the patient should be encouraged, with appropriate help and support, to deal with her own problems in the environment in which they occur. Therefore, as far as possible, the therapist does not do things for the patient but encourages the patient to do things for herself. This includes dealing with other professionals who may be involved with the patient. The therapist does not try to tell these other professionals how to deal with the patient but helps the patient learn how to deal with the other professionals. Inconsistencies between professionals are seen as inevitable and not necessarily something to be avoided. Such inconsistencies are rather seen as opportunities for the patient to practice her interpersonal effectiveness skills. If she grumbles about the help she is receiving from another professional she is helped to sort this out herself with the person involved. This is referred to as the ‘consultation-to-the-patient strategy’ which, among other things, serves to minimize the so-called “staff splitting” which tends to occur between professionals dealing with these patients.
Environmental intervention is acceptable but only in very specific situations where a particular outcome seems essential and the patient does not have the power or capability to produce this outcome. Such intervention should be the exception rather than the rule.

Reprinted here with the authors’ permission.

Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder


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APA Reference
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/
Scientifically Reviewed
Last updated: 17 May 2020 (Originally: 17 May 2016)
Last reviewed: By a member of our scientific advisory board on 17 May 2020
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