BORDERLINE PERSONALITY DISORDER - FROM THE INSIDE OUT

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).
Literature Review 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 clients). 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 training.
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 & Linehan, 1994).
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 protocol.
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, 1993).
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 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, 1995).
Conclusion 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 the client.

References Comtois, K., Levensky, E., and Linehan, M. (1999). Behavior therapy. In M. Hersen, and A. Bellack (Eds.), Handbook of comparative interventions for adult disorders (pp.555-583). New York: John Wiley and Sons, Inc. Kiehn, B., & Swales, M. (1995). An overview of dialectical behavior therapy in the treatment of borderline personality disorder. Psychiatry On-line [Online]. Available: http://www.cmhc.com/articles/dbt1.htr Linehan, M.M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press. Linehan, M.M. (1993b). Skills training manual for treating borderline personality disorder. New York, NY: The Guilford Press. Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D., and Heard, H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064. Linehan, M.M., Heard, H.L., Armstrong, H.E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50 (12), 971-974. Linehan, M.M., Kanter, J.W., and Comtois, K.A. (1999). Dialectical behavior therapy for borderline personality disorder. In D. Janowsky (Ed.), Psychotherapy indications and outcomes (pp. 93-118). Washington DC: American Psychiatric Press, Inc. Linehan, M.M. & Kehrer, C.A. (1993). Borderline personality disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological 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 for chronically suicidal borderline patients. American Journal of Psychiatry, 151, (12), 1771-1776. Shearin, E.N., and Linehan, M.M. (1994). Dialectical behavior therapy for borderline personality disorder: theoretical and empirical foundations. Acta Psychiatrica Scandinavica, 89, (suppl 379), 61-68.

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