Diagnosis & Treatment of Borderline Personality

Disorder usingDialectical Behavioral

Therapy

Amy Copeland, M.S., LPC

From Psychoanalysisto…DBT?!

What happened??

Recognize and diagnose the characteristics of Borderline Personality Disorder (BPD) and the psychosocial influences.

Utilize Dialectical Behavior Therapy (DBT) skills in working with clients diagnosed with Borderline Personality Disorder.

Applying the treatment and working with the challenges of treating the client with the disorder.

What We Will Cover Today:

What is Dialectical Behavioral Therapy (DBT)

A set of skills that is taught to people in services who decide they want to commit to the DBT treatment program.

People who commit to DBT learn skills to deal with relationships, emotions, chaos, trauma, pain, suffering, loss of identity and acceptance.

DBT focuses on problem solving, acceptance and building a life worth living.

The History of DBT

DBT is a clinical treatment program created by Marsha Linehan (PH.D) for people who struggle with relationships, balancing emotions, coping with chaos, and being in the present.

DBT was originally started out as a treatment for people diagnosed with Borderline Personality Disorder (BPD).

Marsha Linehan felt a treatment was needed for this disorder because of the high suicide rate associated with this diagnosis and the many struggles clinicians faced working with people diagnosed with BPD.

The History of DBT (con’t)

DBT grew out of failed attempts to apply Cognitive Behavioral Therapy (CBT) and behavioral therapy (BT) to people who were constantly suicidal and suffering from trauma.

Marsha noticed people she was working with experienced invalidation from therapy, withdrawal from therapy, clients would feel the need to “attack” the therapists who applied CBT and BT treatment techniques in therapy. CBT and BT were too rigid and invalidating at times to the pain and suffering people were trying to cope with.

The History of DBT (con’t)

Marsha and her colleagues discovered they were unable to teach people how to deal with conflicts and chaos because the treatment team was constantly addressing a crisis.

People who were in CBT and/or BT treatment often expressed dissatisfaction with therapist because therapists disagreed with hospitalization when a person felt suicidal. (Most people used hospitalization as a coping skill instead of trying to exist with suffering.)

Also the person in therapy was pleasant with the therapist when the therapist and the person focused on topics that the person wanted to discuss in therapy. Therefore, that made it hard for therapist to tackle issues that interfered with the person gaining control of their lives.

Myths of Borderline Personality Disorder (BPD) People can’t find happiness in their life if

diagnosed with BPD.People diagnosed with BPD are attention

seekers and manipulative.People diagnosed with BPD rarely commit

suicide.People diagnosed with BPD don’t make

progress and will always be hospitalizedPeople diagnosed with BPD caused all their

problems.

Facts of Borderline Personality Disorder (BPD)

People diagnosed with BPD can find happiness and purpose in their life. DBT is about “building a life worth living!”

People who are labeled as attention seekers or as manipulative are only trying to get their needs met and have learned doing certain behaviors have “rewarded” them with what they were needing from others.

10% of people diagnosed with BPD commit suicide every year. This is higher those not in services and/or lack of services

People diagnosed with BPD have the same ability to recover from their illness just like any other illness.

People can’t be entirely blamed for the problems in their life, but we do have to deal with them regardless of whose fault it is. Being unhappy with life is the motivation to change what we can.

Psychosocial Influences

Commonly in women who have history of abuse.(discussion)

Exhibited commonly in self destructive behaviors. This is commonly due to the validating and invalidating environments. (discussion of invalidating environments: ‘no

wonder you behave this way as … how could you not … that’s all you’ve known your whole life’)

According to the Diagnostic and Statistical Manual of Mental Disorders, Borderline Personality Disorder is…

…A pervasive pattern of instability of interpersonal relationships, self-

image, and affects, and marked impulsivity beginning by early

adulthood and present in a variety of contexts, as indicated by five (or

more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. Note: does not include suicidal or self mutilating behaviors.

Intense fear of abandonment. “I will be alone forever”

What does it look like: Girl calling boyfriend 150 times a day and waiting on the door step for him to come home.

Husband showing up at wife’s work demanding to talk to wife right away because the wife did not answer the phone and he tried to call five times in a row.

2. A pattern of unstable, intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

What does it look like: Experiences intense up and down emotions and beliefs regarding people in their life based off experiences between them and the other person(s). Reacts to people intensely based off feelings, beliefs and assumptions. “I hate you, don’t leave me!” May go to extremes to keep relationships or push away relationships in fear of being hurt.

High expectations of others … and when the person’s needs are not met, the emotional reactions are extreme. “I’m mad at you because you did not cook me dinner.”

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

Feeling like “I don’t know who I am ?”and/or feeling constantly misunderstood.

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

The person may do impulsive things without thought of consequences and/or feel they could care less about the consequences.

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

Repeated attempts of suicide and/or self-harm behaviors; constantly has thoughts and feelings of wanting to commit suicide. Fantasizes about death. “Keeping the door open to suicide”.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Has extreme reactions or many intense feelings/moods within a day or two and struggles returning to balanced emotions.

7. Chronic Feelings of emptiness.

Is feeling or have felt for long periods of time feelings of emptiness and loneliness.

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

The person maybe unable to control highly intense fierce anger and/or been in a lot of physical fights.

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Feels loss of time or becomes disconnected from reality. Person may have beliefs that other people are working against them and/or feel they themselves are “evil”.

DBT Skills – Goals of Skills Training

To learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems in living, that is, those causing misery and distress.

Behaviors to Increase:1. Interpersonal effectiveness skills2. Emotion regulation skills3. Distress tolerance skills4. Core mindfulness skills

Why DBT Skills Are Important

DBT helps people cope with crisis, have meaningful relationships, and regulates emotions all in the process of building a life worth living and finding happiness. (People commit suicide because they are not happy and are overwhelmed by sadness and feel like they are suffering.)

The skills give clients more control of their lives. Puts their life back in the client’s hands along with skills, commitment and support of a treatment team.

DBT Skills Training Modules • Stronger sense of self, increasing

attention to the moment, gain control over thinking, increasing awareness of self and environment.

Mindfulness

• Healthier relationships, gain skills to improve relationships and self respect/self-worth, learn how to get along with others despite our/their flaws and strengths.

Interpersonal Effectiveness

• Balance intense array of emotions, control reactions and express emotions in a effective way, building more positive experiences and learning how to be skillful holistically.

Emotion Regulation

• Learn how to make healthy choices in stressful situations/ crises and skills to tolerate pain. Learn to exist with trauma & move beyond suffering. Finding the “middle path” in order build a life worth living.

Distress Tolerance

MINDFULNESS – 3 States of Mind

RESONABLE MIND – “COOL” attitude most of the time, Logic, planning, work/volunteer, problem solving and reasoning.

EMOTIONAL MIND - “HOT” Intense feeling, experience many emotions, yell, love, hate, fight, creativity and often react with the moment.

WISE MIND – “Warm” integration of both minds, gut feeling, deep truth and understanding the bigger picture without judgment.

INTERPERSONAL EFFECTIVENESSGoals of Interpersonal Effectiveness

Getting your objectives or goals in a situation met Getting or keeping a good relationship Keeping or improving self-respect and liking yourself

Situations for Interpersonal Effectiveness Attending to relationships Balancing priorities vs. demands Balancing the wants-to-shoulds Building master and self-respect

Factors Reducing Interpersonal Effectiveness Lack of skill Worry thoughts Emotions Indecision Environment

EMOTION REGULATION

Understand Emotions You Experience

• Identify (observe & describe) emotion.• Understand what emotions do for you.

Reduce Emotional Vulnerability

• Decrease negative vulnerability (vulnerability to emotion mind).

• Increase positive emotions.

Decrease Emotional Suffering

• Let go of painful emotions through mindfulness.• Change painful emotions through opposite action.

Interaction of Behavior with Thoughts & Emotions

EMOTIONS

THOUGHTS

ACTION

BODILY

SENSATIONS

EVENT

How to Reduce Your Vulnerability to being Emotional

Accumulate Positive Experiences•In the short term – do pleasant things that are possible right now!•In the long term – make changes in life so positive events will occur more often – build a life worth living!

Build Mastery•Schedule one or more activities each day to build a sense of accomplishment.

Cope Ahead of Time With Emotional Situations•Create a plan ahead of time so that you are prepared to cope skillfully with emotional situations. Imagine yourself coping effectively.

A

B

C

Changing Emotions You Want to Change

Sadness

1. Retrieve what you have lost2. Accumulate positives3. Increase contact with rewarding people4. Avoid thinking about what you have lost5. Radically Accept

Anger1. Overcome the obstacle2. Stop further attacks3. Avoid threatening people

Anxiety / Fear1. Remove the threat2. Avoid the threat

Emotion Problem Solving

Changing Emotions You Want to Change (con’t)

Jealousy1. Protect what you have OR2. Leave the relationship

Shame

1. Find a new group that fits your values or that likes your personal characteristics OR

2. Change your behavior to fit in OR3. Avoid groups who disapprove of you

Guilt

1. Repair the transgression/wrongdoing2. Make things better, repair the harm3. Commit to avoiding that mistake in the

future4. Accept the consequences gracefully

Envy1. Improve yourself and your life2. Get others to be fair3. Avoid people who have more than you

Emotion Problem Solving

Changing Emotions byActing Opposite to the Current Emotion

If an emotion we want to change is NOT JUSTIFIED,then use OPPOSITE ACTION by following these steps:

1. Figure out what emotion you are feeling

2. What is the action that goes with that

3. Ask yourself: Do I want to change the emotion?

4. Figure out the opposite action

5. Do the opposite action ALL THE WAY!

EmotionAction Urge

Example

Opposite Action

Anxiety / Fear Avoid Approach

Sadness Withdraw Get Active

Anger Attack Gently Avoid/ Be Decent

Envy Sabotaging, Criticizing

Count Your Blessings

Jealousy Accusing, Spying

Let go of controlling

others / Share

Shame / Guilt Hide Be Open

DISTRESS TOLERANCE

Distress Tolerance is about Crisis Survival Strategies. One of the important set of strategies is Accepting Reality. There are three basic principles of accepting reality:

1. Radical Acceptance2. Turning the Mind3. Willingness over Willfulness

Radical Acceptance Freedom from suffering requires ACCEPTANCE

from deep within of what is. Let yourself go completely with what is. Let go of fighting reality.

ACCEPTANCE is the only way out of hell.

Pain creates suffering only when you refuse to ACCEPT the pain.

Deciding to tolerate the moment is ACCEPTANCE.

ACCCEPTANCE is acknowledging what is.

To ACCEPT something is not the same as judging it good.

Turning The Mind

Acceptance of reality as it is requires an act of CHOICE. It is like coming to a fork in the road. You have to turn your mind towards the acceptance road and away from the “rejecting reality” road.

You have to make an inner COMMITMENT to accept.

The COMMITMENT to accept does not itself equal acceptance. It just turns you toward the path. But it is the first step.

You have to turn your mind and commit to acceptance OVER AND OVER AND OVER again. Sometimes, you have to make the commitment many times in the space of a few minutes.

Willingness Willingness is DOING JUST WHAT IS

NEEDED in each situation, in an unpretentious way. It is focusing on effectiveness.

Willingness is listening very carefully to your WISE MIND, acting from your inner self.

Willingness is ALLOWING into awareness your connection to the universe – to the earth, to the floor you are standing on, to the chair you are sitting on, to the person you are talking to.

Willingness is throwing yourself into life and participating as best you can.

Willfulness Willfulness is SITTING ON YOUR HANDS

when action is needed, refusing to make changes that are needed.

Willfulness is GIVING UP.

Willfulness is the OPPOSITE OF “DOING WHAT WORKS,” being effective.

Willfulness is trying to FIX every situation.

Willfulness is REFUSING TO TOLERATE the moment.

Move from Willfulness to Willingness

Notice you are being willful – observe your willfulness, identify it, and describe it.

Radically accept that you are being willful. Turn your mind toward acceptance, and make a commitment to be willing and to participate in reality as it is.

Ask yourself “what is the threat”? What do you fear you might lose by being willing.

Application of DBT

1. Need a committed DBT team to work with clients.

2. Need to adhere to the practice of DBT (keep DBT pure).

3. Must be able to work as hard as the client.

4. Must practice DBT in your own life.5. Create a DBT program that has

consultation meetings, skills group, individual therapy, access to coaching calls and skill coaches.

Challenges of DBT

1. Keeping empathy for clients (keeping hope for the client even if they don’t have it).

2. Getting clients committed to DBT program.

3. DBT homework, showing up to therapy and skills group (don’t work harder than the client).

4. Starting a new program – Tweak, tweak, and more tweak.

5. Team members may struggle with each other’s style. Keep the balance of differences and still honor each other.

References

Websites:www.dbtselfhelp.comwww.behavioraltech.orgBooks1. “I hate you, don’t leave me” authors: Jerold

Kriesman and Hal Straus. 2. “Don’t shoot the dog” author: Karen Pryor3. “Cognitive Behavioral Treatment of

Borderline Personality disorder” author: Marsha Linehan

4. “Skills training Manuel for Borderline Personality Disorder” author: Marsha Linehan

Thank you!

Questions?