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DBT Treatment for Borderline Personality Disorder – Dialectic Behavioral Therapy

Posted Aug 15 2012 12:05am

Does treatment for Borderline Personality Disorder work?

Lots of treatments for Borderline Personality Disorder have been tried over the years. One treatment, Dialectic Behavioral Therapy (DBT) has lots of evidence that it works and is effective.

The problem

Lots of clinicians (Counselors and Therapists) do not use DBT and don’t want to learn it. In fact plenty of clinicians I know don’t even like seeing BPD clients. Some clients don’t like going for DBT either, despite the glowing testimonials we hear from clients who say DBT changed their life.

If DBT is so effective for treating BPD, why do so few clinicians want to use it and why aren’t their lines of clients waiting for treatment?

BPD is a painful disorder. Treating BPD is like treating a burn victim. They are in terrible pain. Just touching them (emotionally) may cause them to feel the pain. Helpers don’t like to hear their clients scream in pain. Clients in pain tend to lash out. Clients with BPD are more likely than other people to lash out at the therapist, walk out of session and even go out and try to hurt themselves.

Their pattern of unstable relationships is so pervasive that they have difficulty forming a health relationship with the clinician. Just when we think we are helping them they may quit treatment and blame the clinician for their increased pain. They are also more likely to file complaints with the licensing board or even a law suit because they feel therapy did not help them and now their pain is even worse.

Despite all these issues DBT does work and does help clients with BPD.

About DBT

DBT was developed by Marsha Linehan (PhD) at the University of Washington. Her book Cognitive Behavioral Treatment of Borderline Personality Disorder is a classic in the field and her workbook has lots of useful exercises for clients to use. I have had the pleasure of hearing Marsha Linehan speak a number of times but can’t say I am fully trained on DBT. What follows is my horrifically oversimplified understanding of what DBT is and how it works.

DBT is a blend of Cognitive Behavioral Therapy, that change your thinking, to change your feelings, to change your behavior stuff that I like to use, and “stuff” Marsha Linehan calls mindfulness. The pain from BPD is so intense that the normal reaction would be to run away.

Mindfulness involves stress reduction, mediation and ways to be able to reduce and tolerate that pain. By reducing the need to run from pain the pain can be shrunk to a manageable size. This skill is called “distress tolerance.”

Since many clients with BPD (maybe all) came from non-affirming environments they struggle with issues of self-worth and self-acceptance. Clients with the full blown disorder not just some small level of BPD traits have lots of self-harming and self-destructive behaviors which they use to get away from the negative feelings.

Treating DBT has been described as “like driving a car with one foot on the gas and one on the brake.”  It makes for a bumpy ride for both the clinician and the client.

The client needs to learn to accept and like themselves just the way they are. The clinician continually tells the client that they are a worthwhile human just the way they are.   

The client needs to change. They need to stop doing those self-destructive, self-sabotaging behaviors, which are keeping them stuck in an unhappy life. Now comes the tricky part.

When the clinician says “I want you to change” the client hears “I am no good and need to change to be accepted.” The clinician then says “You are accepted just the way you are, but I still want you to change.”

The struggle here is to have clients accept that the goal is not for them to be a certain way to be acceptable, but that what we are looking for is “progress not perfection.”  Any good coach or teacher wants to see their student’s progress and do better, that does not mean there is anything wrong with them if they do not become the best at their discipline.

There is a second challenge for those with BPD and those who treat them which DBT seeks to address.

People who have BPD do not live in the meadow full of flowers in the spring time, they live in the hurricane. If they are ever in a calm place, they know this is the eye of the hurricane and the next blast of storm is a moment away. 

Because the volume on their emotions is turned up so loud, there is always the crisis of the day, hour or minute. When you are living in an emotional hurricane it is hard to think about disaster preparedness.  

The clinician who does DBT has to limit the time they spend on today’s crisis so they can work on developing skills to prevent or cope with future crisis. This “let’s not talk about your urges to cut on yourself or use drugs right now, let’s work on you skills” attitude is hard for clinicians and client who are used to that warm fuzzy empathetic listening stuff.

Clients can leave a skills based session thinking that the counselor didn’t listen to them and doesn’t care. The counselor may worry “what if they do cut or self-harm? Will it be my fault because I wanted to work on stress reduction skills?” Sticking to the skills building curriculum can be difficult for both.

One ethical principle that clinicians have learned is that it is not helpful to keep the client dependent on their counselor to cope with life. Our goal should be to get the client to the place where they can function without the clinician. Sometimes that is uncomfortable for both client and counselor.

So DBT is very useful in treating BPD because it increases the client’s self-confidence and self-esteem while teaching them the skills to believe they can cope with life’s problems without having other people do it for them.

Other posts on Borderline Personality Disorder include:

What is Borderline Personality Disorder?

What causes Borderline Personality Disorder?

Levels or types of Borderline Personality Disorder

Treatment for Borderline Personality Disorder

If any of you have been to someone for Dialectic Behavioral Therapy or have had another treatment for Borderline Personality Disorder, would you be willing to leave a comment and tell us how it worked or didn’t work for you?

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