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November/December 2008 Issue

Dialectical Behavior Therapy — Treating Borderline Personality Disorder
By Christina Olenchek
Social Work Today
Vol. 8 No. 6 P. 22

Discover why DBT has shown promise in treating borderline personality disorder and read what supporters and critics of this therapy are saying about it.

Treating someone with borderline personality disorder can be one of the toughest challenges a social worker encounters. Life for such a client is like trying to drive a car that is constantly careening out of control. Emotional vulnerability, fear of abandonment, and a seemingly invalid environment push the car from one side of the road to the other. The tiniest stressors can force the car into a ditch.

Problems often ensue when a therapist tries to get the car on a straight and steady path. A client’s seemingly constant crises, demands, and mood fluctuations can frustrate and wear out the therapist. This frustration can convince the client that the therapist doesn’t care, a belief that leads the client to let problem behaviors escalate or leave therapy. In the end, both the client and the therapist are left to wonder whether there really is anything that can be done to help the client.

But exasperation is waning as more social workers learn of a different approach to treating borderline personality disorder. The approach, called dialectical behavior therapy (DBT), provides a clear framework for treating borderline personality disorder that takes into account clients’ need for validation and self-coping skills and therapists’ need for boundaries in relationships with clients. Research and anecdotal reports show that DBT can be effective for many clients, although some observers are not yet convinced it is the best approach.

“(DBT) is not magic, it’s not a cure all,” says Cathy Nelson, MSW, LISW, owner of Compassionate Counseling & Skills Training in Ames, IA. “But I like it because it gives you a road map. I like having a treatment that I can use for something that is often considered untreatable.”

DBT: A Snapshot
Marsha Linehan, PhD, a clinical psychologist at the University of Washington, began developing DBT more than 20 years ago in an attempt to better treat suicidal patients. Today, the therapy is best known for its use among people with borderline personality disorder. It has also been used to treat several other disorders, including eating disorders, substance abuse, posttraumatic stress disorder, anxiety, and obsessive-compulsive disorder. DBT can be administered in various inpatient and outpatient settings.

DBT is built around the concept of dialectics, which involves trying to create synthesis or balance between opposing ideas. Using a dialectical approach recognizes the all-or-nothing, black-or-white attitude that drives the thoughts and behaviors of patients with borderline personality disorder. Linehan (1993) contends that many of the relationship-decimating behaviors such clients exhibit are the result of dialectical dilemmas. One of these dilemmas is emotional vulnerability vs. self-invalidation. A client who as a child was encouraged to suppress negative emotions may decide that the only way to get the outside environment to validate those emotions is to express them in an extreme form, such as threatening suicide.

Another dilemma is active passivity vs. apparent competence. In this situation, clients can sometimes be extremely dependent on others for help with personal problems, while at other times the shame of being too dependent convinces them to feign competence when they really need help.

The third dilemma is unrelenting crises vs. inhibited grieving. A client experiencing this conflict jumps from being extremely emotionally vulnerable during moments of crisis to inhibiting all affective responses to a crisis.

To bring balance to the client’s chaotic emotional and behavioral state, a therapist must straddle the line between several seemingly opposing attitudes, according to Linehan. A therapist’s attitude toward a client must be one of acceptance while promoting change. The therapist must also strike a balance between nurturing and benevolent demanding and between compassionate understanding and unwavering centeredness. Linehan believes that such an approach is necessary to help clients truly take charge to change the behaviors that have made them so miserable.

DBT brings together the following four treatment modalities. Each modality plays an important role in the overall success of the program:

• Individual psychotherapy: These sessions, which are generally held once a week, are designed to help the client find ways to reduce or eliminate borderline behaviors.

• Group skills training: These sessions, which also usually meet weekly, concentrate on four skills sets: core mindfulness skills, interpersonal effectiveness, emotional regulation, and distress tolerance skills.

• Telephone consultation: Making therapists available by phone gives clients a healthy way to reach out for assistance during times of crisis and helps them learn how to generalize skills they have learned in therapy.

• Case consultation meetings for therapists: Because working with clients with borderline personality disorder can be so taxing for therapists, Linehan believes that therapists must work as a team and hold meetings to offer each other guidance and support.

A hierarchy guides how a client’s unhealthy behaviors are addressed. Suicidal and life-threatening behaviors are addressed first, followed by behaviors that interfere with therapy and behaviors that harm quality of life. The DBT process typically lasts between one and two years.

Effectiveness of DBT
Linehan and other DBT proponents promote the treatment as having been empirically proven to be effective in many cases. In fact, several studies demonstrate that DBT shows promise for clients with borderline personality disorder and other disorders.

One study (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) compared a group of women with borderline personality disorder who received DBT for one year with a group of women with borderline personality disorder who received treatment as usual. Members of the DBT group were less likely to commit parasuicidal acts (self-harm with little or no intention to cause death), more likely to stay in therapy, and required fewer days of inpatient psychiatric hospitalization.

A study by Safer, Telch, and Agras (2001) found that women with bulimia nervosa reported significantly lowered levels of binging and purging after being treated with DBT compared with women in wait-list status.

Linehan, Schmidt, Dimeff, Craft, Kanter, and Comtois (1999) compared DBT with treatment as usual for a group of drug-dependent suicidal women displaying borderline personality disorder. The DBT group had a much lower dropout rate (36%) than the treatment as usual group (73%). The DBT group also showed a significant decline in substance abuse.

DBT also has been shown to be an effective treatment for female veterans with borderline personality disorder, depressed older adults, and other populations (Koons, Robins, Tweed, Lynch, Gonzalez, Morse, Bishop, Butterfield, & Bastian, 2001; Lynch, Morse, Mendelson, & Robins, 2003).

The fact that DBT’s claims of effectiveness have been validated by research is an important reason why it should be seen as a frontline treatment for borderline personality disorder, according to Linehan. She believes that treatments for mental health problems should be held to the same standards as those used to treat problems affecting physical health.

There is also anecdotal evidence among practitioners that DBT works for many clients. Among these practitioners is Gulin Guneri, PsyD, of The Awakening Center in Chicago. She runs the center’s group skills training program for adults who are receiving the individual psychotherapy portion of DBT elsewhere. Her clients include people dealing with borderline personality disorder, obsessive-compulsive disorder, and depression. Guneri believes that DBT relieves clients’ suffering because it gives them concrete, practical ways to address and change their behaviors.

“If [the clients] really apply the skills, it works wonders. You can see the symptoms reducing significantly within a few weeks,” Guneri says. “It is a lifestyle change.”

The combination of individual therapy and group skills training is another reason why DBT works, says Neil Bockian, PhD, a Chicago-based therapist who provides individual therapy in conjunction with Guneri’s sessions. Bockian is a member of the faculty at the Adler School of Professional Psychology in Chicago and the author of New Hope for People With Borderline Personality Disorder, which outlines various therapies, including DBT. The group sessions give clients the skills they need to better cope with anxiety, feelings of hostility, and other emotions that often come up in individual therapy, Bockian says.

DBT also is effective because it has a pretreatment stage that orients clients to the disorder they’re experiencing and lays out what is expected of them and their therapists, says Reed Stewart, MSW, LMSW, co-owner of the DBT Center of Michigan. “We found that by spending time on creating a solid framework for the treatment, we’re having much higher retention rates,” he adds.

Concerns About DBT
Not everyone is enthusiastic about DBT. As some practitioners rush to embrace the treatment, others wonder if DBT is simply the latest bandwagon to hit the mental health profession.

“The mental health field is really into fads and fashions,” says Barry L. Duncan, PsyD, codirector of the Institute for the Study of Therapeutic Change. “Therapists are enamored with different techniques.”

Duncan acknowledges that DBT works for many clients, but he is dubious of claims that it is evidence-based therapy. One of his arguments is that many DBT studies use small numbers of participants and focus only on women. He also believes insufficient research has been done to directly compare DBT with other treatments.

DBT’s structured approach may be beneficial for therapists, but that structure could be too demanding for all but the highest functioning patients with borderline personality disorder, says Joel Kanter, MSW, LCSW, who is in private practice in Silver Spring, Md. Attending multiple therapeutic sessions each week might be difficult, if not impossible, for many clients with borderline symptoms such as mood swings and unstable personal relationships.

“You’d love to be able to do it and enroll people in (DBT), but you can’t sometimes,” Kanter says. “What we wish for and what is the reality are not always the same.”

Private practice clinicians may report good results with DBT because their clients, by asking for help, are showing the motivation necessary to handle the demands of the therapy, Kanter adds. The results may not be as promising among patients who are court referred to therapy or who want a quick fix from medications, he says.

Even some DBT proponents express concerns about the approach. DBT’s popularity has grown so much that it’s getting harder to keep the purity of the approach intact, says Josh Smith, MSW, LMSW, also of the DBT Center of Michigan. Some clinicians are using only parts of it, or are using it without proper training, he says.

Linehan agrees, acknowledging that a piecemeal approach does not have the same research-based evidence as standard DBT. “The evidence is not for a little bit of this, a little bit of that,” she says.

The Future of DBT
Just as there is a debate over the effectiveness of DBT, so too is there disagreement over the future of the therapy. Guneri believes the therapy’s popularity will continue to grow as more mental health professionals, including social workers, become more aware of it. “My hunch is that DBT is going to be really big in a few years, and more people will be catching up on it,” she says.

Duncan offers a different view. “There’s a mythology around (DBT) now, but I think the next new wave will kind of bowl it over,” he says. “It won’t be thought of as a best practice in the future.”

That scenario wouldn’t necessarily surprise—or bother—Linehan. She continues to look at ways to improve the approach, acknowledging that another approach may eventually come along that is more effective than DBT. That’s good if it means more people overcome borderline personality disorder and other mental health problems, she says.

— Christina Olenchek is a freelance writer based in Harrisburg, PA, and an MSW candidate at Temple University.

Mindfulness Matters
One aspect of dialectical behavior therapy (DBT) that is attracting a lot of attention is its focus on teaching mindfulness. Mindfulness is being more aware of one’s thoughts, emotions, and motivations, as well as understanding the outside reality. The concept is rooted in Eastern thought, particularly Zen Buddhism.

One problem that clients with borderline personality disorder face is that their behaviors are often ruled by emotions. This frequently leads to destructive behaviors such as drug use, risky sexual encounters, and self-injury. The goal of mindfulness as used in DBT is to get patients to recognize these patterns so they can act more thoughtfully. Part of this involves activating what Marsha Linehan, PhD, who developed DBT, calls “wise mind.” Activating wise mind helps patients establish a balance between logic-driven behavior and emotion-driven behavior.

Another aspect of mindfulness is helping patients become better observers and describers of reality. “Once they’re aware, they can adapt their reactions to reality,” says Josh Smith, MSW, LMSW, of the DBT Center of Michigan. “It’s about letting go of anger, feelings of vengeance, feelings that life is unfair.”

There are many ways in which therapists can help build mindfulness among their DBT clients. Patients at Smith’s center, for example, participate in activities such as counting their breaths and describing their thoughts and emotions as they take a walk or eat chocolate.

— CO

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., et al. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371-390.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12), 1060-1064.

Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J. & Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug dependence. The American Journal on Addictions, 8(4), 279-292.

Lynch, T. R., Morse, J. Q., Mendelson, T. & Robins, C. J. (2003). A randomized trial of dialectical behavior therapy for depressed older adults: Post-treatment and six month follow-up. American Journal of Geriatric Psychiatry, 11(1), 33-45.

Safer, D. L., Telch, C. F. & Agras, W. S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158(4), 632-634.