Dialectical Behavior Therapy

Borderline Personality Borderline Personality DisorderDisorder

General OverviewGeneral 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 Linehan’s Theory of the Development of BPDDevelopment of BPD• Based on a bio-social theory of BPD.

The Dialectical Dilemma of The Dialectical Dilemma of Person’s with BPDPerson’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 Therapists’ Working Assumptions about the ClientAssumptions about the Client1) The client wants to change, and despite

appearances, is trying his/her best as a particular time.

2) His/Her behavior pattern is understandable given his/her background and present circumstances.

3) In spite of this, he/she needs to try harder if things are to improve.

4) Clients can not fail at DBT.

Therapists’ Dialectical StyleTherapists’ 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’ Clients’ and Therapists’ AgreementsAgreements• 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 TreatmentModes of Treatment1. Individual therapy.

2. Group skills training.

3. Telephone contact.

4. Therapist consultation.

Skills TrainingSkills Training1. Core mindfulness skills.

2. Interpersonal effectiveness.

3. Emotion modulation skills.

4. Distress tolerance skills.

http://www.dbtselfhelp.com/html/dbt_skills__defined_.htmlhttp://www.behavioraltech.com/index.cfm

Individual TherapyIndividual Therapy• Stages of therapy.

• Hierarchy of therapy targets.

• Treatment strategies.

Stages of TherapyStages 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 Hierarchy of Therapy Targets 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 StrategiesTreatment Strategies• Contingency management.

• Cognitive therapy.

• Exposure based therapies.

• Pharmacotherapy.

Recommended ReadingsRecommended 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.