- Using Dialectical
Behavior Therapy to Treat Borderline Personality Disorder:
A Broad Overview
- by Mikako Osada ©
The therapist and client must constantly ask themselves -
"what is being left out of their understanding" - to
help them clarify the ethical dilemmas that exist within the
client (Linehan & Kehrer, 1993, p. 401).
- As social workers entering the millennium, we need to continuously
be updated on newer clinical approaches that can provide valuable
treatment outcomes with the mentally ill population. One such
approach is dialectical behavior therapy, which was developed
by Marcia Linehan (1993a). Dialectical behavior therapy (DBT)
is a relatively new intervention that combines both cognitive
and behavioral techniques in treating borderline personality
disorder (BPD). In this author's opinion, DBT is an innovative
approach that is useful for treating individuals with BPD. Although
the concepts underlying DBT may not be new, its highly structured
treatment protocol and the support it lends to therapists (through
therapist consultation) not only makes this a unique approach,
but also an effective form of intervention.
Linehan defines the pathology of BPD using the criteria currently
defined in the DSM IV (Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition) and the Diagnostic Interview for Borderlines
(Linehan & Kehrer, 1993). Individuals with BPD generally
present with emotion dysregulation and instability- emotional
responses are reactive, and individuals usually experience problems
with episodic depression, anxiety, irritability, and anger. Individuals
with BPD also exhibit behavioral dysregulation with extreme and
problematic impulsive behavior. Frequent attempts to injure,
self-mutilate, or commit suicide also occur in this population
(Linehan & Kehrer, 1993).
Individuals meeting the criteria for borderline personality disorder
(BPD) have been found to be difficult to treat successfully.
These individuals frequently fail to respond to therapeutic efforts,
make considerable demands on the therapist, and are difficult
to keep in therapy (Kiehn & Swales, 1995). BPD is a serious
mental illness, and individuals with BPD are flooding mental
health and clinical practitioners' offices (Linehan, 1993b).
Encounters with borderline individuals can be very stressful,
however, and therapists are often hesitant to treat them.
Most practitioners must treat at least one borderline client
because they are so numerous (Linehan, 1993a). The increased
amount of initial dysfunction in these individuals and the slow
rate of significant clinical improvement can leave a therapist
feeling overwhelmed and inadequate (Linehan, 1993a). Individuals
with BPD exhibit behavioral patterns that are particularly problematic-perhaps
the greatest concern being the high incidence of parasuicidal
(self-injurious) and suicidal acts (Linehan & Kehrer, 1993).
Surprisingly, patterns of intentional self-injurious acts and
suicide attempts have been comparatively ignored as targets for
treatment efforts (Linehan, 1993a). Marcia Linehan (1993a) perceived
the available treatment modalities to be inadequate; thus, dialectical
behavior therapy was initially developed specifically to treat
borderline personality disorder. DBT is a combination of individual
psychotherapy and psychosocial skills training that has been
shown via controlled clinical trials to be effective in treating
individuals with BPD (Linehan, 1993b).
Psychosocial treatment in some form is necessary for individuals
with BPD (Linehan, Armstrong, Suarez, Allmon, and Heard, 1991).
Although many psychosocial treatments for BPD exist, few have
been empirically validated to be effective (Linehan et al., 1999).
Some treatments (for example, pharmacotherapy) may be sufficient
for certain criterion problems (e.g., depression) of BPD, but
when the disorder is present as a whole, these methods may not
prove to be as effective. Dialectical behavior therapy, however,
is one psychosocial treatment that has been shown in some controlled
clinical trials to be effective in treating BPD, specifically
with individuals who are chronically parasuicidal (Linehan, Heard,
and Armstrong, 1993).
The empirical studies that initially showed the effectiveness
of the treatment program for DBT were limited to women with BPD
who had a chronic history of parasuicidal behavior (intentional
self-harm, including suicide attempts) (Linehan, 1993a). According
to Linehan (1993a), this group constitutes a major portion of
the borderline population, and is probably the most disturbed.
The theory, however, is designed flexibly, and Linehan (1993a)
speculates it may be effective for men, as well as individuals
who are less severely disturbed (e.g., nonsuicidal borderline
DBT was first evaluated with a one-year clinical trial involving
44 female subjects who met criteria for BPD (Linehan et al.,
1991). To be admitted to the study, subjects met BPD criteria
on DSM-III, had at least 2 incidents of parasuicide in the last
5 years (with one during the last 8 weeks) and were between the
ages of 18 and 45. Those individuals that met DSM-III criteria
for schizophrenia, bipolar disorder, substance dependence or
mental retardation were excluded from the study.
Subjects were randomly assigned to either DBT or treatment-as-usual
(TAU) (Linehan et al., 1991). TAU was a naturalistic condition
where subjects were given alternative therapy referrals and were
allowed to participate in any type of treatment available in
the community. There was no reference psychotherapy demonstrating
efficacy that could be used as a comparison treatment to DBT,
and preventing therapy for a chronically parasuicidal person
was unethical; thus, TAU served as the control condition (Linehan
et al., 1991).
This study was the first controlled trial of the efficacy of
a psychosocial treatment intervention with randomization to treatment
and control groups (Linehan et al., 1991). The aim of the study
was to determine whether DBT was effective in addressing the
primary targets of treatment when offered as a total treatment
program (Shearin & Linehan, 1994). The primary treatment
targets were: 1) reduction of parasuicide and life-threatening
behaviors, 2) reduction of behaviors that interfere with the
process of therapy (e.g., missed sessions), and 3) reduction
of behaviors that interfere with the quality of life (Linehan
et al., 1991).
The study yielded three main results. First, subjects receiving
DBT had a significant reduction in the frequency and medical
risk for parasuicidal behavior compared with that for control
subjects. DBT subjects had a median of 1.5 parasuicide acts per
year compared to 9 acts per year for control subjects (Linehan
et al., 1991). Second, the attrition rate for staying in therapy
was better for subjects in the DBT condition. The 1-year attrition
rate was 16.7% for DBT subjects, while the rate was 50% for those
in the control condition. And third, those subjects receiving
DBT had fewer days of inpatient psychiatric hospitalization.
Subjects receiving DBT had an average stay of 8.46 inpatient
days per year, compared to 38.86 days for control subjects (Linehan
et al., 1991).
Although DBT seemed to have better treatment effects than the
TAU condition, there were no between group differences on measures
of depression, hopelessness, reasons for living and suicidal
ideation (Linehan et al., 1991). DBT appeared to improve life
in a number of areas of functioning, but it was not enough to
normalize functioning (Shearin & Linehan, 1994). However,
these gains are consistent with the DBT emphasis that behavioral
improvements are necessary before significant relief from emotional
pain can be expected (Shearin & Linehan, 1994). Thus, subjects
appeared to become more proficient in tolerating difficult situations
and in functioning while they still felt emotional distress.
From the results of this study, DBT seemed to be effective for
addressing its primary targets of treatment (i.e., reducing life
threatening, therapy interfering, and quality of life interfering
behaviors). It is unclear exactly what specifically in the treatment
condition produced these effects. Linehan et al. (1991) suggest
that it could have been due to differences in the conduct of
the individual therapy, the group behavioral skills training
in DBT, or a combination of the individual therapy with the skills
There were a number of limitations to this initial study. The
study had relatively few subjects and the sample was a relatively
homogeneous group of severely dysfunctional, chronically parasuicidal
female individuals with BPD (Linehan et al., 1991). It is unclear
if the results are generalizable to less severely dysfunctional
borderline individuals. It is also unclear whether DBT would
be effective for non-suicidal individuals, or for males.
Yet, the follow-up data conducted for this study shows treatment
gains in DBT being maintained after the 1-year therapy (Linehan
et al., 1993). In general, the superiority of DBT over treatment-as-usual
that was found in the initial study was retained during a 1-year
follow-up. In the follow-up comparison of DBT with the TAU condition,
DBT superiority was stronger during the first 6 months following
the experimental treatment year for measures of parasuicidal
behavior, anger, and self-reported social adjustment. In contrast,
superiority emerged for psychiatric inpatient days and interviewer-rated
social adjustment in the last 6 months of follow-up. There were
no significant between-group differences on parasuicidal behavior
during the 18-24 month period after the experimental treatment
year. The authors explain that although DBT was an effective
treatment in producing improvement, it was not a long-term "cure"
for the borderline individual (Linehan et al., 1993). In addition,
some chronically parasuicidal individuals might decrease their
parasuicidal behavior either on their own or with the assistance
of available mental health resources (Linehan et al., 1993).
The dialectical emphasis (e.g., acceptance and change) in DBT
may be an important factor in the reduction of suicidal behavior
(Shearin & Linehan, 1994). A small process study was conducted
by Shearin and Linehan in 1992 to test the relationship of therapeutic
strategies prescribed by DBT to week-by-week changes in patient
behavior (Shearin & Linehan, 1994). Subject and therapist
ratings were taken to study the effect of dialectical strategies
on subject's parasuicidal urges and amount of suicidal ideations
(Shearin & Linehan, 1994). The combined use of acceptance
and change techniques seemed to produce a better effect in reducing
suicidal behavior than either change or acceptance techniques
alone. The authors suggest the use of acceptance techniques may
help borderline individuals feel accepted and validated, while
the change techniques simultaneously move the individuals toward
long-term solutions to their pain and distress (Shearin &
Another important component of DBT seems to be the group skills
training. Linehan et al. (1999) reviewed two studies that suggest
DBT group skills training is not enough for a positive outcome-that
it must be combined with individual therapy. One study conducted
by Barley and colleagues used a controlled, non-randomized design
to compare components of DBT with standard treatment (TAU) on
a psychiatric inpatient unit. There were no differences in rates
of parasuicidal behavior between the DBT group skills training
only to TAU. However, a combination of coaching techniques and
other aspects of individual therapy combined with DBT group skills
training resulted in significantly lower rates of parasuicidal
behavior for patients receiving DBT (Linehan et al., 1999). In
another study conducted by Linehan et al. (1993), the DBT group
skills training only condition was compared with a no-skills
training control condition group - no significant differences
were found between groups (Linehan et al., 1999).
Although DBT seems effective in improving the functioning of
chronically parasuicidal female individuals, 1 year of treatment
with DBT is clearly not enough to relieve the suffering of this
population. It should also be noted that most of the studies
I reviewed here were conducted by Linehan and her colleagues;
this may have placed some limitations on gaining an unbiased
perspective. More research is necessary to replicate these outcomes
with rigorous control groups. Yet, despite these limitations,
these studies have shown promising results for the DBT treatment
Dialectical Behavior Therapy- A Dialectical World View
As a treatment for borderline personality disorder, DBT evolved
from standard cognitive-behavioral therapy. The actual procedures
and strategies of the therapy also overlap with other orientations
such as psychodynamic, client-centered, and cognitive therapies
(Linehan & Kehrer, 1993). Like standard cognitive-behavioral
techniques, DBT emphasizes ongoing assessment and data collection
on current behaviors, clear and precise definition of treatment
targets, and a collaborative working relationship between therapist
and client. Many components of DBT, such as problem solving,
skills training, and cognitive modification, have been prominent
in cognitive-behavior therapies for years (Linehan, 1993b).
The main assumption in cognitive-behavioral theories is that
borderline individuals have early maladaptive schemas or patterns
of thinking that develop during childhood and result in maladaptive
behavior. Although DBT also incorporates this assumption, it
is based on a bio-social theory of BPD (Kiehn & Swales, 1995).
Linehan hypothesizes that the disorder is a consequence of an
emotionally vulnerable individual growing up within an 'invalidating
environment', where the growing child's personal experiences
and responses are invalidated by significant others in her life
(Kiehn & Swales, 1995). The biological susceptibility to
emotional sensitivity and the invalidating environment both contribute
to the development of symptoms.
Another difference between standard cognitive-behavioral techniques
and DBT is the dialectical world view that DBT assumes. "A
dialectical world view emphasizes wholeness, inter-relatedness
and process (change) as fundamental characteristics of reality"
(Linehan & Kehrer, 1993, p.400). The fundamental value of
the dialectical view is never to accept an absolute truth or
an indisputable fact (Linehan & Kehrer,1993). For example,
an individual with BPD may only be able to see things in black
or white, or from one extreme to another. The dialectical view
does not search for either extreme, but takes the middle road
of balance. Thus, there is no search in absolute truth, for there
are many truths and different perspectives. The therapist and
client must constantly ask themselves "what is being left
out of [their] understanding" to help them clarify the dialectical
dilemmas that exist within the client (Linehan & Kehrer,
1993, p. 401).
The dialectical view assumes that clients' problems are caused
by these dialectical failures. In dialectics, reality is seen
as comprised of internal opposing forces (thesis and antithesis)
out of whose synthesis evolves change. Dichotomous and extreme
thinking, behavior, and emotions, which are characteristic symptoms
of BPD, are considered to be dialectical failures (Linehan, 1993b).
The borderline individual becomes stuck in polarities (opposite
extremes) and is unable to move to synthesis. For instance, the
individual with BPD may not be able to see a solution to a problem,
such as feeling isolated, and therefore may react with impulsive
behavior such as binge drinking. The individual needs to find
a balance between accepting her feeling of isolation and finding
a more adaptive way to cope with it. The therapist must help
the client move towards a workable synthesis by balancing the
need for the client to accept herself as she is in the moment
and the need for her to change. The change process is conceptualized
by the borderline individual being able to "radically accept"
her present situation in the moment, and being willing to change
it to better her life (Linehan, 1993b). The therapist supports
the client by validating her views and difficulties, and uses
dialectics to focus the client's attention on the opposing polarities
and help her find ways out of them. Through the therapeutic opposition
of contradictory positions, the client and therapist can both
"arrive at new meanings within old meanings and move closer
to the essence of the subject under consideration" (Linehan
& Kehrer, p.401).
Modes of Treatment
There are four primary modes of treatment: individual therapy,
group skills training, telephone contact, and therapist consultation
(Linehan, 1993a). DBT must be entirely voluntary, and its success
depends on having the cooperation of the client. In the beginning
of therapy, sessions are focused on orienting the borderline
individual on the nature of dialectical behavior therapy, and
the client must commit to undertake the work for a specified
period of time and attend all scheduled therapy sessions. If
suicidal or parasuicidal behaviors exist, the client must agree
to reduce these and any other behaviors that might interfere
with the course of therapy.
Another commitment that the client must make is to attend skills
training (Linehan, 1993b). Skills training is usually conducted
in a group context, where clients are taught groups of skills
that are considered relevant to particular problems experienced
by individuals with borderline personality disorder (Kiehn &
Swales, 1995). There are four groups of psychosocial skills this
training focuses on: core mindfulness skills, emotion regulation,
distress tolerance and interpersonal effectiveness (Linehan,
1993b). Linehan (1993b) states that active practice and use of
behavioral skills is difficult for borderline individuals since
it would require them to move out of their passivity patterns.
Skills training is different from individual therapy in that
time is only spent on acquisition, strengthening and generalization
of the psychosocial skills.
- Individuals in skills training are given homework assignments
every week to practice the skills they learn, and are required
to fill out diary cards to record their use of skills. Diary
cards also help the therapist monitor the client's behavioral
progress during the week between sessions (Linehan, 1993b).
Telephone contact is another mode of treatment that is offered
to the client between sessions (Kiehn & Sales, 1995). Although
this may sound overwhelming, the therapist has a right to set
clear limits on this type of contact. The main purpose of telephone
contact is to give the clients support and help in applying the
skills they are learning to real life situations, and to help
them avoid self-injury when they are out of sessions. Calls can
also be used when the client feels there needs to be repair in
the relationship with the therapist before the next session.
In order to avoid reinforcing self- injury, if a client has injured
herself, after ensuring her immediate safety, calls are not allowed
for the next twenty-four hours (Kiehn & Sales, 1995).
DBT is a team approach, where the success of treatment is dependent
upon the quality of the relationship between patient and therapist
(Kiehn & Swales, 1995). Linehan (1993b) emphasizes the need
for support in DBT since therapists are at a high risk for burnout
in treating individuals with BPD. The last, and probably most
important mode in treatment is therapist support and consultation.
Therapists give DBT to the borderline individual, and simultaneously
receive DBT from their colleagues (Kiehn & Swales, 1995).
This will allow therapists to be aware of their own behaviors
that might interfere with therapy, address problems that arise
in the course of treatment delivery, and it helps the therapist
stay within the DBT therapeutic framework (Linehan & Kehrer,
Stages of Therapy and Treatment Goals
Progress toward treatment targets can be grouped into four stages
(Linehan & Kehrer, 1993). Since individuals with borderline
personality disorder can present multiple problems, the structure
and organization within these stages provide therapists with
a focus to help them decide which problems to concentrate on
and when. The pretreatment stage focuses on commitment from the
client, an orientation to DBT, and agreement on treatment goals.
The first stage of therapy concentrates on attaining basic capacities,
stability, and safety by targeting suicidal behaviors, therapy-interfering
behaviors, quality-of-life interfering behaviors, and behavioral
skills. The second stage addresses post-traumatic stress related
problems, and stage three of the therapy targets self-esteem
and individual treatment goals (Linehan & Kehrer, 1993).
Targeted behaviors of each stage are brought under control before
moving on to the next stage (Kiehn & Sales, 1995). The targets
within each stage are arranged in a hierarchy of relative importance.
For example, in the individual therapy mode of treatment, the
hierarchy of targets would include dealing with the following
in numbered order: 1. decreasing suicidal behaviors; 2. decreasing
therapy interfering behaviors; 3. decreasing quality-of-life
interfering behaviors; 4. increasing behavioral skills; 5. decreasing
behaviors related to post-traumatic stress; 6. improving self-esteem;
7. individual targets negotiated with the client (Kiehn &
Sales, 1995). In any individual session, targets must be dealt
with in this order. Whichever mode of treatment the therapist
might be working in, he/she should be aware of the targets within
that mode. An overall goal across modes is to increase dialectical
thinking (Kiehn & Sales, 1995).
Treatment strategies in DBT refer to the role of the therapist
and to the coordinated set of procedures that function to achieve
specific goals of treatment (Linehan & Kehrer, 1993). DBT
includes five treatment strategies to achieve these behavioral
targets; two examples are dialectical strategies and core strategies.
Not all strategies may be appropriate to use within an individual
session with a given client and certain strategies may be used
more than others (Linehan & Kehrer, 1993).
Dialectical strategies involve how the therapist balances dialectical
tensions within the therapeutic relationship, teaching the client
the "Middle Way" or dialectical behavior, and specific
dialectical treatment strategies. Some of the specific dialectical
strategies include using metaphors, playing devil's advocate,
activating the client's "wise mind", and assessing
dialectically by asking the questions "what is being left
out here?" (for more details, refer to Linehan's skills
training manual 1993b) (Linehan & Kehrer, 1993).
Core strategies include validation (acceptance) and problem-solving
(change) strategies. Validating the clients' experiences and
difficulties is very important, especially when they are used
to an invalidating environment (Linehan & Kehrer, 1993).
Validation can help the client feel supported while she is encouraged
to change. Problem solving focuses on the establishment of necessary
skills for the client to deal with problems effectively. Problem
solving occurs through contingency management, skills training,
cognitive therapy and exposure based therapies (Kiehn & Swales,
Dialectical behavior therapy is an integrative approach that
can be effective in treating individuals with borderline personality
disorder. With the maintenance of structure and consistency,
DBT can be effective in reducing symptoms (i.e., emotion dysregulation,
impulsive behaviors) of BPD. DBT also supports and validates
difficulties that individuals with BPD experience, and helps
them radically accept their situations in the moment while they
learn to acquire more adaptive behavioral skills. Finally, DBT
helps the therapist deal with problems that arise in therapy
so that he/she will not be discouraged or burnt out; therefore,
a strong therapeutic relationship is maintained to further support
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behavior therapy in the treatment of borderline personality disorder.
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personality disorder. New York, NY: The Guilford Press.
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disorders (pp. 396-441). New York: The Guilford Press.
Linehan, M.M., Tutek, D.A., Heard, H.L., and Armstrong, H.E.
(1994). Interpersonal outcome of cognitive behavioral treatment
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DBT Skills Discussion List Work Linehan's
DBT skills to cope with BPD. This list can be very
helpful but is not designed as a replacement for
(not is it) therapy. It is a moderated peer-support
list that facilitates the dicussion and working of
Linehan's DBT Skills.
The Borderpd List is one for anyone who has Borderline Personality. It is a list
that offers support, it is those with BPD supporting each other. From time to time we
do have people in relationships with Borderlines (non-borderlines) who join the list
and from time to time, professionals who join as well. So, while the list is open to all
with an interest in Borderline Personality Disorder, it is first and foremostly for those
as of October 30, 2003
Last up-dated January 1, 2009