Dialectical Behavioural Therapy
Dialectical Behavioural Therapy
Authored by: Christiana Louisa Ticoalu, M.A., Psychology & Management
Language Editor: Alda Belinda, S. Psi.
Clinical Editor: Dr. phil. Edo S. Jaya, M.Psi., Psikolog
A Quick Refresher
What is Borderline Personality Disorder?
Borderline personality disorder (BPD) is a condition that describes individuals who endure personality disturbances that manifest as instability of personal relationships, affect, and impulsivity. Those with the condition often struggle with their identity and self-image (for instance, they may define and present themselves differently depending upon whom they are with). During periods of heightened negative affect, the tendency for impulsivity may lead to engagement in rash behaviours. In some instances, individuals engage in self-destructive behaviours including self-harm. Furthermore, periods of heightened arousal are sometimes accompanied by the experience of transient dissociative or psychotic-like features.
The condition is also characterized by feelings of chronic emptiness. Generally, those with borderline personality disorder experience an intense fear of abandonment and have difficulty tolerating instability or uncertainty. Despite craving closeness and interpersonal intimacy, many may think and behave in ways that undermine, and challenge the formation of, healthy relationships.
With symptoms lasting at least one year, borderline personality disorder is often detrimental to one’s day-to-day life and is accompanied by considerable distress and impairment across important life domains, interfering with functioning (social, occupational or otherwise). Importantly, disruptions are not attributable to other mental health conditions, substances, medication, or withdrawal.
Symptoms of Borderline Personality Disorder:
For a comprehensive list of the condition’s symptomatology, we recommend you visit the ICD-11 webpage. Please note that on this page, it is referred to as the “Borderline Pattern” under the umbrella of “Personality Disorders”.
Hallmarks of Borderline Personality Disorder
Emotional Dysregulation
Individuals with borderline personality disorder demonstrate heightened emotional sensitivity and instability, mood reactivity, and negative affect. Consequently, many experiences a deficit in the ability to regulate emotions or the use of maladaptive techniques to do so.
Impulse Control
Many individuals with borderline personality disorder struggle to control their actions. This may cause them to engage in self-destructive behaviours including but not limited to:
- Gambling
- Drinking
- Excessive spending
- Substance use
- Promiscuous behaviours
- Suicide attempts
- Suicide
Interpersonal Difficulties
A hallmark of borderline personality disorder is a pattern of unstable relationships. Individuals with the condition often experience an intense, at times irrational, fear of being alone or being abandoned. Those with this condition frequently shift from idealization to devaluation. Generally speaking, many view the world as, ultimately, black-and-white: believing that all people are “all good” or “all bad”. Unfortunately, their very impulsive and volatile emotions and behaviours sometimes lead to the very abandonment and alienation that they fear.
Furthermore, interpersonal difficulties may be further exacerbated by identity disturbance, volatility or incoherence. For instance, those with the condition may demonstrate the frequent change of goals, beliefs, perspectives, and vocational aspirations.
Moreover, their sense of self may shift depending upon whom they are with.
Cognitive difficulties
Cognitive difficulties often appear alongside borderline personality disorder and are closely associated with its psychopathology. These are spread across multiple domains, but commonly involve disruptions to executive functions. In addition to brief, psychotic symptoms, commonly endured cognitive symptoms include:
- Derealization (perceiving the external world to be strange, bizarre, or not quite real)
- Depersonalization (the sensation that one’s body is not one’s own, unreal, or has been altered in some strange way).
- In some instances, individuals may also experience illusions, the misinterpretation or misperception of existing stimuli.
What is Dialectical Behavioural Therapy?
Dialectical Behavioural Therapy (DBT) is an evidence-based outpatient treatment that Dr Marsha Linehan originally developed in an endeavour to treat multi-problematic, parasuicidal patients with borderline personality disorder. The treatment is based on cognitive behavioural therapy but is specifically adapted for individuals who experience intense emotional dysregulation.
The term in itself, “dialectical” is used to convey two conflicting ideas. Used as a behavioural therapy, it encourages patient acceptance of their life situations whilst simultaneously promoting positive change. Considered the “golden standard” for the treatment of borderline personality disorder, in essence, dialectical behavioural therapy addresses the symptoms of borderline personality disorder through providing those who are experiencing the condition with healthier coping mechanisms and skills.
Development of Skills
Dialectical Behavioural Therapy functions to address the symptoms of borderline personality disorder and replace any maladaptive behaviours with adaptive coping skills encompassing:
Acceptance skills
Mindfulness skills
Mindfulness is a core skill that is covered during dialectical behavioural therapy. In general, mindfulness skills may be further subdivided into “what” and “how” skills.
Individuals with borderline personality disorder demonstrate the tendency to react to environmental stimuli with impulsive and emotionally-driven responses. The implementation of “what” skills encourages individuals to observe, describe, and participate in the current moment.
Those with borderline personality disorder demonstrate the tendency, at times, to both idealize and devalue themselves and others. Furthermore, many tend to overthink the past or worry extensively about the future. Additionally “how” skills seek to equip patients with the ability to ground themselves in the present moment. These skills aim to assist a patient face one thing at a time, whilst approaching their surroundings effectively. Further, this skill is implemented to increase the probability that a patient will make measured decisions, no longer acting upon snap judgments.
Distress tolerance skills
Distress intolerance is one of the hallmarks of borderline personality disorder. The need for certainty typically leads effected individuals to engage in problematic behaviours that inadvertently further perpetuate their struggles.
Distress tolerance skills seek to increase patients’ understanding that pain and distress are inescapable, inevitable parts of human life. It is paramount that those with borderline personality disorder learn to accept this.
Typically, distress tolerance skills involve both “crisis survival skills” and “acceptance strategies”. The former involves increasing the patients’ understanding and ability to use distracting and self-soothing techniques. Additionally, acceptance skills aim to facilitate reframing. Specifically, acceptance skills seek to shift the patients’ perception of intolerable suffering and distress to tolerable, yet inevitable, discomfort.
Change skills
Interpersonal effectiveness
Individuals with borderline personality disorder typically have a history of intensely volatile and unstable relationships. In part, these relationships are often fractured due to the patients’ inability to assert themselves, and, consequently, their struggle to react adaptively to the difficulties they inevitably face. In addition to these factors, patients may be unable to realize longevity within relationships due to their aforementioned struggle to tolerate distress.
Dialectical behavioural therapy seeks to address patients’ fear of abandonment and equip them with the ability to maintain meaningful and respectful relationships with others, and themselves.
Emotional regulation skills
Many individuals with borderline personality disorder elicit intense, extreme, and highly unpredictable emotional responses. In reality, this materializes as dysfunctional behaviours wherein the sufferer will demonstrate inappropriate behaviours in an effort to either placate or avoid these emotions.
Emotional regulation skills involve the identification of emotions. This learned skill can assist patients to understand how emotions may influence their behavioural responses. Dialectical behavioural therapy aims to equip patients with the ability to learn to identify obstacles that may prevent them from regulating their emotions (such as the intense need for validation and parasuicidal behaviours). Generally, the treatment seeks to prepare patients with strategies to address their emotions in adaptive ways.
Functions of Treatment
Capability enhancement
Many patients with borderline personality disorder either lack or have underdeveloped, life skills. These typically include the aforementioned:
- Emotional regulation skills (e.g.appropriately responding to environmental stimuli)
- Mindfulness skills (e.g. paying attention to the present moment and being mentally present)
- Interpersonal effectiveness skills (e.g. effectively navigating different interpersonal situations)
- Distress tolerance skills (e.g. tolerating distress, uncertainty and crisis without maintaining their dependence upon maladaptive coping skills)
In general, this therapy provides individuals with the ability to build upon, and strengthen, their existing abilities.
Generalization
Generally, one of the central goals of Dialectical Behavioural Therapy is equipping patients with skills that have the potential to impact their daily lives. Where successful, Dialectical Behavioural Therapy may facilitate the transfer of various acquired skills across relevant settings. Individuals may apply what they have learned throughout their psychotherapeutic journey in the arenas of social, occupational, academic or other settings. For instance, patients who have learned emotional regulation may use this strategy outside of the therapist’s office when they are faced with an uncooperative family member or friend who angers them.
Motivational enhancement
Therapists typically tailor behavioural treatments to individual patients. This functions to target maladaptive behaviours, set goals, aid implementation, and improve the patient’s overall quality of life. It is, therefore, critical that patients maintain the motivation to change, holding fast to their goals of diminishing the maladaptive behaviours that will inarguably hinder their progress. Depending upon severity, therapists may employ different strategies to enhance a patient’s commitment to both acceptance and change.
Capability and motivational enhancement of therapists
Whilst stimulating and rewarding, treating patients with borderline personality disorder is inarguably a difficult task. Accordingly, therapists are often supervised and have a support network. This network serves as an avenue through which they may receive inspiration, clinical guidance, training or emotional support.
Structuring of the external environment
Therapy seeks to develop positive, adaptive behaviours that individuals may employ within a vast range of circumstances and arenas. As such, it is paramount that the patients’ external surroundings are structured in such a way that does not reinforce maladaptive or problematic behaviours. The aim is the modification of these behaviours to the extent where positive progress will be attainable. Depending upon severity, and where possible, patients may be tasked with slowly and gradually re-structuring their environment. For instance, patients who engage in self-harm may be tasked to reduce the amount of time spent with others who engage in similar, maladaptive coping behaviours.
General Stages of Treatment
Dear Reader,
Thank you for making it this far. Before you continue your reading, we would like to provide you with a quick disclaimer. The stages we outline below are general and theoretical stages that are traditionally involved in Dialectical Behavioural Therapy. We have outlined them below to increase your understanding of the general structure of this intervention. Your treatment at IndoPsyCare may not always follow this sequence or include these components.
Stage 1
Patients who are suicidal or pose an imminent threat to themselves typically begin therapy with stage 1. This stage is focused on reducing and where possible, eliminating, the most dangerous and disabling behaviours. In essence, it focuses on stabilizing the patient and helping them develop control over their behaviour. Stage 1 is further broken down into the following targets:
- Reduce (and where possible, eliminate) extreme behaviours that eminently affect their day-to-day activities (for instance, suicide attempts and engagement in self-harm)
- Reduce behaviours that interfere with therapy (for instance, missing treatments, behaviours that lead to therapist burn-out, refusal to participate or collaborate in therapy, refusing to take the steps required for positive change)
- Reduce behaviours that threaten the quality of life (for instance, substance use/abuse, unemployment, and financial crises)
- Promote skill acquisition (Increase skilful behaviours to combat and replace dysfunctional behaviours through a component called Dialectical Behavioural Therapy skills training)
Stage 2
Patients who have developed some control over their behavioural dysfunction typically undergo the second stage of treatment. From a theoretical standpoint, patients in this stage no longer pose imminent threats to themselves. Nevertheless, they are typically experiencing tormenting thoughts due to the past invalidation and trauma they have experienced.
In general, patients entering this stage exhibit emotional avoidance, numbness, and posttraumatic stress symptoms. As such, this stage is often regarded as a stage of “quiet desperation”; as such, individuals experience emotional inhibition that further exacerbates their already compromised quality of life.
This stage aims to shift the patient toward emotional experience after prolonged periods of avoidance. During this stage, therapists aim to guide patients toward the use of a “here and now” approach, which will enable them to live life, a life within which they possess the capability of experiencing the full range of emotions.
Stage 3
Patients in this stage have typically reduced, or significantly gained a hold over, their behavioural dyscontrol, and passed the stage of quiet desperation. They have consequently entered into a stage that addresses the “ordinary problems of living”. In theory, those in this stage typically endure conflict within their interpersonal relationships, such as their marriage, struggle to care for themselves and suffer protracted occupational or financial challenges.
Stage 4
Patients who enter into this stage of treatment endure lingering problems surrounding meaning. Many feel lonely, purposeless, empty, and struggle to experience happiness, contentment and joy. From a theoretical standpoint, the goal of this stage is to achieve transcendence through increasing the patients’ ability to engage in behaviours that instil a sense of completeness within them.
Tailored Treatment Plans
At IndoPsyCare, we formulate treatment plans on a case-by-case basis, based upon your condition and situation. At the current time, IndoPsyCare offers a Dialectical Behavioural Therapy-inspired version of Cognitive Behavioural Therapy.
Assessments
Your therapist may administer assessments at various points throughout your therapeutic journey. This is done as a way of assessing your improvements and thus the effectiveness of the treatment plan. When treating borderline personality disorder, therapists may administer the Borderline Personality Questionnaire (BPQ), the Borderline Symptom List (BSL-23), and assessments to gauge emotional regulation skills. Nevertheless, we ask that you please keep in mind that assessments may vary depending upon your specific condition.
Treatment Duration
How many sessions will I need?
Our psychologists base your treatment plan upon scientific literature and recommendations from bodies such as the Cochrane Library, the UK’s National Institute of Health and Care Excellence (NICE) and IPK Indonesia’s National Clinical Practice Guidelines.
Typically, the number of sessions you require is typically influenced by:
- The severity of your symptoms
- Existing comorbidities (co-existing conditions)
- The length of time you have been experiencing your condition
- Your personal motivation and progress
- Your social support network
Making the Most of Therapy
Asking for help is commendable
Asking for help is understandably difficult, thus reaching out is a testament to the strength of each individual who does so. A call for help should never be seen as a sign of weakness, as it is the first step in your journey to recovery. Although sometimes uncomfortable, sharing your vulnerabilities with the right people may provide an appropriate, timely, and forthright avenue through which your problems can be assessed and addressed.
Be open and honest
Think of therapy as a journey in which you are steering the ship; your therapist is your guide, navigating the journey based on your account of what you see and experience. Reaching your desired destination and goals will be acquired with more proficiency when you share your feelings and fears. As your therapist acquires a clearer understanding of the intricacies of your situation, he or she will be in a better position to guide you in the right direction.
Be consistent
You will not see change overnight. True, lasting, cognitive and behavioural change takes time. Therapy is not a “quick fix”, rather it requires patience, consistency and tenacity on your part. Allow yourself time, communicate with your therapist, and share your feelings if you feel you are losing sight of your destination.
Trust the process
More often than not, improving your condition requires you to go beyond your comfort zone, letting go of your maladaptive coping strategies. Trust that, whilst this process may inevitably become uncomfortable or difficult at times, temporary discomfort may bring long-term and lasting benefits.
A Gentle Reminder
Dear Reader,
We sincerely appreciate your dedication; you have made it through this page of our library. We trust that you have gleaned valuable information from this page. Before we part ways we would like to reiterate that each treatment plan will be uniquely tailored to you, your situation and your requirements. Your personal treatment plan may or may not include the elements on this page.
If you feel as though you require professional assistance, please refrain from self-diagnosis. IndoPsyCare has professionals who are here to help.
Sources and Recommended Readings
Disclaimer
We would like to emphasize that the information presented herein was derived from external sources. IndoPsyCare does not claim ownership of any information or research within these pages. For your convenience, our team has constructed a list of the sources utilized and included further research and reading.
National Institute of Health and Care Excellence. (2022). Borderline personality disorder: recognition and management. Retrieved 3 July 2022, from https://www.nice.org.uk/guidance/cg78
World Health Organization. (2019). ICD-11: International Classification of Diseases (11th revision). Retrieved from https://icd.who.int/
Code for Borderline Pattern: 6D11.5
Bozzatello, P., Bellino, S., Bosia, M., & Rocca, P. (2019). Early Detection and Outcome in Borderline Personality Disorder. Frontiers in psychiatry, 10, 710. https://doi.org/10.3389/fpsyt.2019.00710
Koerner, K., & Linehan, M. M. (2000). Research on dialectical behavior therapy for patients with borderline personality disorder. The Psychiatric clinics of North America, 23(1), 151–167. https://doi.org/10.1016/s0193-953x(05)70149-0
Kulacaoglu, F., & Kose, S. (2018). Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe. Brain Sciences, 8(11), 201. https://doi.org/10.3390/brainsci8110201
Linehan M (1993). Cognitive–behavioral treatment of borderline personality disorder. New York: Guilford Press.
Linehan, M. M., Schmidt, H., 3rd, 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. https://doi.org/10.1080/105504999305686
Shearin, E. N., & Linehan, M. M. (1994). Dialectical behavior therapy for borderline personality disorder: theoretical and empirical foundations. Acta psychiatrica Scandinavica. Supplementum, 379, 61–68. https://doi.org/10.1111/j.1600-0447.1994.tb05820.x
Silberschmidt, A., Lee, S., Zanarini, M., & Schulz, S. C. (2015). Gender Differences in Borderline Personality Disorder: Results From a Multinational, Clinical Trial Sample. Journal of Personality Disorders, 29(6), 828–838. https://doi.org/10.1521/pedi_2014_28_175