Dialectical Behavior Therapy Borderline Personality Disorder
General Overview • Marsha Linehan (1993). • Recommended readings. • Orientation combines systemic/transactional approach, CBT, Buddhism, and principles of Dialectics. • Developed for use with persons with BPD, but has also been applied to suicidal behavior in adolescents and bulimia.
“Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.” --Marsha Linehan
Linehan’s Theory of the Development of BPD • Based on a bio-social theory of BPD.
The Dialectical Dilemma of Person’s with BPD • Inappropriate blame of other vs. In appropriate blame of self. • Inhibited grieving vs. Unrelenting crisis. • Active passivity vs. Apparent competence.
Therapists’ Working Assumptions about the Client • The client wants to change, and despite appearances, is trying his/her best as a particular time. • His/Her behavior pattern is understandable given his/her background and present circumstances. • In spite of this, he/she needs to try harder if things are to improve. • Clients can not fail at DBT.
Therapists’ Dialectical Style • Reciprocal communication vs. Irreverent communication. • Accepting of the client as he/she is, but encouraging change. • Centered and firm, yet flexible when the circumstances require it. • Nurturing, but benevolently demanding.
Clients’ and Therapists’ Agreements • To work in therapy for a specified period of time, and to attend the majority of therapy session. • If suicidal or para-suicidal behaviors are present, he/she must agree to work on reducing these. • To work on therapy interfering behaviors. • To attend skills training.
Modes of Treatment • Individual therapy. • Group skills training. • Telephone contact. • Therapist consultation.
Skills Training • Core mindfulness skills. • Interpersonal effectiveness. • Emotion modulation skills. • Distress tolerance skills. http://www.dbtselfhelp.com/html/dbt_skills__defined_.html http://www.behavioraltech.com/index.cfm
Individual Therapy • Stages of therapy. • Hierarchy of therapy targets. • Treatment strategies.
Stages of Therapy • Pre-treatment. • Stage 1: focus on suicidal behaviors and therapy interfering behaviors. • Stage 2: focus on PTSD related problems. • Stage 3: focus on self-esteem and individual treatment goals.
Hierarchy of Therapy Targets • Decreasing suicidal behaviors. • Decreasing therapy interfering behaviors. • Decreasing behaviors that interfere with quality of life. • Increasing behavioral skills. • Decreasing behaviors related to post-traumatic stress. • Improving self-esteem. • Individual targets negotiated with the client.
Treatment Strategies • Contingency management. • Cognitive therapy. • Exposure based therapies. • Pharmacotherapy.
Recommended Readings • Dimeff et al. (2007). Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings. • Linehan (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. • McKay et al. (2007). Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance . • Moonshine (2008). Dialectical Behavior Therapy Volume 2 - Companion Worksheets.