And what help is available for it?

Borderline Personality Disorder—it’s about hurting so bad emotionally that you will do anything, sometimes even hurt yourself physically, to escape the pain of your feelings. This disorder causes pain to the person with the diagnosis as well as the family and friends of that person. Living through the experience of your child or spouse or friend who has just hurt him/herself is a wrenching event.

For many years this disorder lacked a name and defining criteria. With the advent of the Diagnostic and Statistical Manual of Mental disorders, (DSM) it has been diagnosed and recognized with increasing frequency. The task at that point was to develop an effective treatment for this set of symptoms and behaviors.

Many were tried with varying degrees of success, but none with better results than that originated by Marsha Linehan, called Dialectical Behavioral therapy. Dr. Linehan pioneered this treatment, based on the idea that psychosocial treatment of individuals with Borderline Personality disorder was as important in controlling the condition as traditional psychotherapy and medications.

A primary focus of Dialectical Behavior Therapy (DBT) is the emphasis on balancing change and acceptance. In DBT the therapist must make some basic assumptions:
1. Clients are doing the best they can.
2. Clients want to improve.
3. Clients need to do better, try harder, and be more motivated to change.
4. Clients may not have caused all of their own problems, but they still have to solve them anyway.
5. The lives of borderlines are unbearable as they are currently being lived.
6. Client must learn new behaviors in relevant contexts.

A hierarchy of treatment goals is an integral part of dialectical Behavior Therapy. First in the hierarchy is the reduction of parasuicidal (self-injuring) behaviors. These are behaviors done not necessarily for the purpose of suicide but for obtaining relief from overwhelming emotions. They could, however, result in unintended death, thus the term “parasuicide.” Parasuicide is defined as any acute, intentionally self-injurious behavior resulting in physical harm, with or without intent to die.

The next goal to be satisfied in DBT is reducing behaviors that interfere with the therapy process. This can include behaviors by therapist and client alike.

The final goal is to reduce behaviors that compromise the client’s quality of life. Dr. Marsha Linehan published the results of a study in 1991 that answers the need for attaining these goals. She hypothesizes that Borderline Personality Disorder is the consequence of two separate conditions:

1. an emotionally vulnerable individual (a person whose emotion regulation system is not so well developed due to biological factors as yet unknown)
2. grows up in an invalidating environment (a situation in which the personal experiences and responses of the growing child are disqualified or “invalidated” by the significant others in her life. What she says isn’t accepted as an accurate indication of her true feelings. Even if it were accurate, she “shouldn’t feel” that way.)

The result is an individual who can’t trust her own responses to emotions or circumstances. She reacts abnormally to relatively low levels of stress and takes longer than normal to return to baseline once the stress is removed.

This may explain why borderlines are known for crisis-strewn lives and extremes of emotions, which can shift rapidly. Because of their past invalidation, they haven’t learned necessary methods for coping with these sudden, intense surges of emotion. DBT is a treatment method that addresses this need for coping skills.

There are four essential parts to DBT:
1. Once-weekly individual psychotherapy sessions
a. a particular problematic behavior or event from the past week is explored in detail
b. a chain of events leading up to it is identified
c. alternative solutions to the problematic behavior that might have been used are identified
d. effort is made to examine what kept the client from using more adaptive solutions to the problem.

“Both between and during sessions, the therapist actively teaches and reinforces adaptive behaviors, especially as they occur within the therapeutic relationship. . . the emphasis is on teaching clients how to manage emotional trauma rather than reducing or taking them out of crises. . . Telephone contact with the individual therapist between sessions is part of DBT procedures.”
(Linehan, 1991)

2. Weekly Group Skills Training, ideally by someone other than the individual therapist. Clients are taught skills considered relevant to the particular problems experienced by people with Borderline Personality Disorder. There are four modules focusing in turn on the four groups of skills:

a. Core Mindfulness skills
These are derived from certain techniques of religious meditation though they are essentially psychological techniques. These help a person understand what she is experiencing and help her “stay with” the experience rather than fight it or push it away
b. Interpersonal effectiveness skills
The focus in this module is on being effective, “”doing what works” with other people. Clients learn to:
i. ask for what they want effectively
ii. say “no” and be taken seriously
iii. maintain relationships, and
iv. maintain their own self-respect in interactions with other people.

c. Emotion modulation (regulation) skills
i. ways to change distressing emotional states

d. Distress tolerance skills
i. if the circumstances can’t be changed
ii. techniques for skillfully enduring unpleasant emotional states

3. Telephone contact between sessions.

a. Clear limits on such contact are set by the individual therapist
b. The purpose of telephone contact is clearly defined.
c. Telephone contact is not for the purpose of psychotherapy.
d. Telephone contact is for the purpose of giving the client help and support in applying the skills that she is learning; using them in her real life situation between sessions.
e. . Telephone contact is for the purpose of finding ways of avoiding self-injury.
f. Calls are also accepted for the purpose of relationship repair where the client feels that she has damaged her relationship with her therapist and wants to put this right before the next session.

4. Therapist Consultation
Therapists receive DBT from each other at the regular THERAPIST CONSULTATION GROUP, which is an essential aspect of therapy.

Stages of Therapy and Treatment Targets

Individuals with Borderline Personality Disorder 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:

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 can deal 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.

Therapy at each stage is focused on the specific targets for that stage, arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy. It is essential that the therapists are clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking. Dialectical thinking addresses the tension between the good/bad, black/white thinking that frequently occurs in Borderline Personality Disorder.

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 client and therapist

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 her-self to be distracted from this goal.

Other uses of DBT
DBT is currently being used for a variety of disorders which have been difficult to treat in the past. Among these is the treatment of eating disorders, largely due to the fact that eating disorders, like BPD, have both a biological and an environmental etiology. (Marces, Levine, and McCabe at ADAA 11-6-98)

A treatment protocol for adolescents called Multi-Family Skills Training Group has recently been developed by Alec Miller, Jill Rathus, Marcia Landsman and Marsha Linehan. This treatment, as the name implies, includes the parents/caregivers of the adolescent in the treatment process.

Gail has worked in ancillary public mental health, hospital psychiatric services, domestic violence services, nursing homes, and in private practice. She has been a member of the National Alliance for the Mentally Ill and EMDRIA. She is currently a member of the Red Cross Disaster Mental Health Services, the Women’s Therapist Association of Grand Rapids, NASW, and the American Council of Social Workers.