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A Breakthrough for Borderline Personalities: Dialectical Behavior Therapy Proves Effective

About thirty years ago a professor at the University of Washington was working with suicidal women, many of whom were borderline personalities. This group is notoriously difficult to treat. They usually have not just one but a large number of problems, such as self-injury behaviors, substance abuse and eating disorders, that “travel” with their personality disorder. A very high percentage drop out of therapy. Often the best a therapist could do in the 1980s was to lower a patient’s number of suicide attempts, and yet that “cured” patient would remain depressed, unemployed, using drugs, involved in troubled relationships, and otherwise leading a chaotic life.

Professor Marsha Linehan looked for answers to help these women within the therapeutic process itself. Those with borderline personality disorder usually have overwhelming problems in relationships because of their deep fears of abandonment and their overly emotional, often angry, reactions. These patients were bringing these same issues into their therapeutic relationships, causing their therapists to dislike them by phoning too often, becoming overly dependent, and taking every small boundary the therapists set as abandonment.

Cognitive behavioral therapy, the gold standard of clinicians, was not working with borderline personalities, and Dr. Linehan wondered why. Cognitive therapy focuses on getting patients to understand, identify and change emotions, thoughts, and behaviors that are making their lives unpleasant, but Dr. Linehan theorized it was not working with borderlines for a simple reason. A borderline usually grows up in a home where their feelings are not validated and her behaviors are criticized, which leads to a child without a sense of self. This child becomes a teenager who cuts herself just to feel pain instead of emptiness, and attempts suicide to feel valued by others. Cognitive behavior therapy actually was providing her with more invalidation and demanding that she, someone who already has no self-acceptance, become someone different. Couples therapy was likewise a disaster with borderline patients and their partners. Complaints by their partners during therapy sessions only increased the patients’ self-loathing and suicidal tendencies.

Dr. Linehan believed that the suicidal women she was studying needed a therapy that helped them accept themselves while at the same time guided them into making necessary changes to improve their lives. Since acceptance and change are opposed to each other, Dr. Linehan called her new therapy “Dialectical Behavior Therapy” because the word “dialectic” is about combining two things that oppose one another.

Dialectical Behavior Therapy has five goals: self-acceptance, building up the patient’s motive to change, providing her with the skills she needs to change, enhancing her current environment to incorporate change, and providing the means to use her new skills in any environment. The main idea was to transfer what is learned in therapy into normal life. The new emphasis would be on developing skills, not understanding and changing thoughts, feelings and behaviors.

The skills taught were self-acceptance, mindfulness, validation of one’s emotions, distress tolerance, and emotional regulation. Mindfulness is about being aware of the present moment, what you and others are thinking and feeling, what is happening around you, even what smells and noises are in the environment. The idea is experience everything without making judgments or criticisms. Dr. Linehan similarly defined self-acceptance, particularly “radical acceptance of oneself,” as being aware of yourself in the moment without judging yourself, your situation, or others. Patients are taught to stop judging, criticizing, or even approving of themselves, but merely to experience themselves the present moment. “Distress tolerance” is about learning to deal with difficult situations that have no real answers, in other words, developing tolerance of those things you cannot change.

Dr. Linehan’s method was not just a talk therapy. Patients had homework. They kept “diary cards” and recorded their daily reactions, feelings, motives, and even their medications. They had to attend “Group Skills Sessions” with others in Dialectical Behavior Therapy. These sessions lasted 1.5 to 2.5 hours every week, and patients learned interpersonal skills, mindfulness, and so forth within interactive classes.

Dialectical Behavior Therapists did not try to talk their patients out of their feelings, but let them freely express themselves about suicide and self-harming behaviors. Once their feelings were validated, the patients’ destructive behaviors would even make sense to them and to their therapists. In Dr. Linehan’s plan, the first goal of treatment was always to stop any life-threatening acts, and the second was to stop the patient and/or the therapist from sabotaging the therapeutic process. After that, treatment goals became about creating an environment to learn the skills needed for change, helping the patient stay motivated, and enhancing her radical acceptance of herself.

Dr. Linehan’s colleagues at the University of Washington watched and recorded her sessions to help her to refine the process of Dialectical Behavior Therapy. Since the early 1990s, there have been about ten randomized, clinical studies that compared her method with other treatments. Dialectical Behavior Therapy proved better at reducing suicides and suicide attempts, reducing hospitalizations, keeping patients from dropping out of therapy, and improving comorbidities, such as anger management, eating disorders, and depression.

Dr. Blaise Aguirre, the leading expert on borderline personality in teenagers, said that today there are finally effective treatments for borderline personality disorder, once considered untreatable. Dr. Linehan’s pioneering work and faith in clients that others had dismissed as lost causes is part of the reason for this progress.

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References

Aguirre, Blaise (M.D.) Borderline Personality Disorder in Adolescents. Beverly, MA: Fair Winds Press, 2007.

Allmon, D., Armstrong, H. E., Heard, H. L., Linehan, M. M., &.Suarez, A. (1991). Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of General Psychiatry, 48, 1060-1064.

Chapman, Alexander (PhD) and Kim Gratz (PhD). The Borderline Personality Disorder Survival Guide. Oakland, CA: New Harbinger Publications, 2007.

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of Dialectical Behavior Therapy in Women Veterans with Borderline Personality Disorder. Behavior Therapy, 32, 371-390.

Kreger, Randi. The Essential Family Guide to Borderline Personality Disorder. Center City, MN: Hazelden, 2008.

Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292.

Mason, Paul (MS) and Randi Kreger. Stop Walking on Eggshells — Taking Your life Back When Someone You Care About Has Borderline Personality Disorder. Oakland, CA: New Harbinger Publications, 2010.

Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , Stijnen, T., & Van Den Brink, W. (2003). Dialectical Behaviour Therapy for Women with Borderline Personality Disorder, 12-month, Randomised Clinical Trial in The Netherlands. British Journal of Psychiatry, 182, 135-140.

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