Dialectical therapy for borderline personality disorder

Treating Borderline Personality Disorder | NAMI: National Alliance on Mental Illness

JUN. 07, 2017

By Luna Greenstein

Imagine having difficulty controlling your thoughts and actions. Imagine that your sense-of-self is almost entirely dependent on your relationships with others. Imagine struggling to manage stress, rejection or conflict. This is what it’s like to live with Borderline Personality Disorder (BPD): a mental health condition characterized by a pattern of ongoing instability in moods, behavior, self-image and functioning.

BPD is a highly-misunderstood condition—even within the mental health field. So, to better understand this complex condition, I talked with a NAMI HelpLine volunteer who bravely told me his story.

Randy* was diagnosed with BPD at 17 after a suicide attempt landed him in the hospital. “The concept of being able to like yourself and want to live just went over my head,” he explained. “I also couldn’t handle being rejected. If I sent a text message and they didn’t get back to me for five minutes, I’d already be thinking about killing myself.”

After several years of talk therapy and one month of cognitive behavioral therapy, Randy's therapist suggested dialectical behavior therapy last January. Dialectical behavior therapy (DBT) is a cognitive behavioral treatment developed to help people manage symptoms that are considered “difficult to treat,” such as: impulsivity, interpersonal problems, emotional dysregulation, self-harm and suicidal behaviors. DBT works for a range of conditions (substance abuse, depression, PTSD, among others), but it was originally developed to treat chronically suicidal individuals with BPD.

Skill-Building Through DBT

DBT is a combination of group therapy and individual treatment designed to help therapists offer the best treatment possible. What makes DBT unique and effective is its focus on teaching participants a set of behavioral skills that help them cope with their difficult symptoms. “The skills are what people talk about when they talk about DBT; they are the active ingredient in DBT,” explains the creator of DBT, Dr. Marsha Linehan. These skills include:

Mindfulness: Being fully aware and present
Distress Tolerance: Tolerating difficult or uncomfortable situations
Interpersonal Effectiveness: Asking for what you want and saying no when you need to (while still maintaining self-respect and healthy relationships)
Emotion Regulation: Changing emotions that you want to change

Each skill is a separate module of DBT and it takes a full year to go through all four modules in group therapy. Some may choose to repeat a module to help make those specific skills stick—like Randy, who repeated all the modules twice and the distress tolerance module three times because that’s the skill he struggles with the most. It takes a lot of time and energy to learn these coping mechanisms and implement them when symptoms flare.

Everything in DBT is connected and works together to help people manage their symptoms. Skills are introduced in group therapy lessons and are learned through practice and homework. “We have a handbook,” Randy says. “It ranges from things like how to talk to someone you don’t agree with without getting emotional to ‘I’m freaking out, what do I do?’” This is followed with individual therapy that includes lessons tailored to each person so they can apply what they’ve learned to everyday life.

The Gold Standard

While it takes time and effort, the components of DBT work together effectively. Even though DBT has only been around for a couple decades, it has already improved and saved the lives of many. Research shows it’s incredibly effective—one study from 2014 showed that 77% of participants no longer met criteria for BPD diagnosis after undergoing treatment.

DBT is recognized as the “gold standard” for people with BPD. “It’s weird how much better I’ve gotten from it. Looking back, I was so different; I didn’t know how to handle life. Sometimes I still don’t, but I’m getting there. I’m getting better.”

*Name has been changed to protect our volunteer's privacy

Laura Greenstein is communications coordinator at NAMI.

If you or someone you know is interested in entering a DBT program, you can search for a certified clinician here.
In addition, you can contact the NAMI HelpLine at 800-950-6264 or [email protected], and we will help direct you on how to find the closest DBT program.

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Dialectical Behavior Therapy for Borderline Personality Disorder

Dialectical behavioral therapy (DBT) may improve symptoms of borderline personality disorder (BPD) by teaching skills that include mindfulness and emotion regulation.

Marked by difficulties with emotional regulation, interpersonal relationships, self-image, thoughts of suicide, and other symptoms, living with borderline personality disorder (BPD) isn’t always easy. However, it’s possible to live a happy, fulfilling life with the right kind of treatment and support.

Research shows that the prognosis for BPD is good, especially for those who seek treatment through specialized therapy. The most popular and most effective form of therapy for BPD is dialectical behavioral therapy (DBT). This form of therapy was created for people with borderline personality disorder in mind.

If you’ve been diagnosed with BPD, know that you’re not alone. In fact, it’s estimated that about 1.6% of U.S. adults are affected by this condition.

DBT is a multifaceted treatment approach created by Dr. Marsha Linehan in the early 1990s. Linehan created DBT in hopes of providing relief to those living with BPD, a condition she’s experienced, as she later revealed in her book “Building a Life Worth Living: A Memoir. “

DBT, while created for BPD, has also been helpful for those with:

substance use
eating disorders
attention deficit hyperactivity disorder (ADHD)

DBT is a skills-based treatment program broken into four main modules:

Mindfulness. Mindfulness teaches you to focus on the here and now by becoming aware of your thoughts, feelings, and sensations.
Interpersonal effectiveness. In this module, you learn, for example, how to communicate effectively, build and cultivate healthy relationships, and express your needs.
Emotion regulation. DBT teaches you techniques to help you understand and manage your emotions.
Distress tolerance. In this module, you learn techniques to manage overwhelming emotions or difficult situations.

Each module consists of various skills that are specific to that module’s theme. Some skills you may learn include:

self-soothing
wise mind
radical acceptance
building positive experiences

Each module consists of group and individual therapy, as well as homework assignments. Your therapist may also be available for phone coaching in moments where skills may need to be practically applied.

DBT is skills-based, meaning it’s both practical and achievable. Typically, a DBT program lasts 1 year.

Since those with BPD often experience black-and-white thinking, one of the foundations of DBT is literally within its name: dialectics.

Dialectics is defined as holding two seemingly opposite ideas at one time, considering both to be truths. In DBT, “dialectical” refers to the idea of needing both acceptance and change to help improve symptoms. This can bring greater balance and reduce black-and-white patterns of thought.

The other foundation of DBT is mindfulness. Through mindfulness, those living with BPD can learn to make more intentional, conscious decisions and decrease impulsivity and other unhelpful or potentially harmful behaviors over time.

One mindset taught during mindfulness is “wise mind,” which encourages dialectical thinking in crisis and normalcy. It also helps you to attend to your emotions and reason to make wise and balanced decisions.

Ultimately, DBT helps those with BPD both function and flourish in their everyday lives.

What does research say about DBT?

Research has shown DBT to be the most effective form of treatment for those with BPD. In fact, one study found that after the first year of treatment, 77% of participants no longer met the diagnostic criteria of BPD.

DBT is particularly effective for improving:

suicidal thoughts and behaviors
difficulties with anger management
overall daily functioning, including socially

BPD symptoms such as chronic feelings of emptiness, difficulties with personal relationships, and an intense fear of abandonment tend to be more difficult to treat with DBT — but not impossible.

It’s important to remember that BPD doesn’t look the same for everyone. Different people may have different symptoms, and though DBT may help many people with the condition, it may not work for everyone.

If you feel as if DBT isn’t helping you, there are many other options you can discuss with your treatment team, including:

Mentalization-based therapy (MBT). MBT helps people with BPD identify and understand their own and others’ actions, feelings, and thoughts.
Transference-focused therapy (TFP). In TFP, your therapist allows you to “transfer” thoughts or feelings you may have about another person onto them, which may allow them to understand your symptoms better. In collaboration, you can work out ways to change behaviors or negative thinking that your BPD may cause.
Good psychiatric management (GPM). GPM teaches you problem-solving and stress-management strategies to help with life difficulties and to better understand yourself.
Schema-focused therapy (SFT). SFT helps people with BPD change negative patterns of thoughts, behavior, and emotions, which are known as “schemas.”

At times, short-term hospitalizations may be necessary. This is particularly true in times of extreme stress and when you experience suicidal or impulsive behaviors.

Currently, there is no medication specifically for BPD. Some people with co-occurring conditions such as anxiety or depression may benefit from taking antidepressants. Your doctor can help you figure out whether medication may be beneficial in your case.

Are you in a crisis or considering suicide?

If you’re having thoughts of suicide or self-harm, you can access free support right away with these resources:

The National Suicide Prevention Lifeline. Call the Lifeline at 800-273-8255, 24 hours a day, 7 days a week.
The Crisis Text Line. Text HOME to the Crisis Text Line at 741741.
The Trevor Project. LGBTQIA+ and under 25 years old? Call 866-488-7386, text START to 678678, or chat online 24-7.
Veterans Crisis Line. Call 800-273-8255, text 838255, or chat online 24-7.
Befrienders Worldwide. This international crisis helpline network can help you find a local helpline.

Overall, dialectical behavior therapy (DBT) has been shown to be the most effective form of treatment for people with borderline personality disorder (BPD), especially if you experience thoughts of suicide or self-harm or want to reduce anger. It also helps with social skills and overall quality of life.

If you think DBT may be right for you, finding a qualified and experienced therapist in your area is crucial.

The National Education Alliance for Borderline Personality Disorder offers helpful tips when searching for a suitable therapist.

Plus, the Borderline Personality Disorder Resource Center maintains a database of healthcare professionals in the United States who have experience treating BPD. You can call them at 1-888-694-2273 or send them an email at [email protected].

Though living with BPD can be challenging at times, try to keep in mind that you’re not alone and that you can get better with the right treatment and support.

For family members and friends

If someone you care about has been diagnosed with BPD, and you’re interested in learning more about the condition and how to be a supportive ally, the National Education Alliance for Borderline Personality Disorder offers the Family Connections Program, a free 12-class course in which you learn about:

BPD and its treatment
DBT-based relationship skills
how to take care of yourself
how to communicate effectively

Keep in mind that the current wait time is 5–6 months, and you have to be 18 years or older to participate.

DBT - Mental Health Center

The lives of people with borderline personality disorder are often filled with harrowing emotional swings, relationship problems, self-harmful behavior, and chronic suicidality.

Dialectical behavior therapy (DBT) is a compassionate and proven model of care.

DBT is a comprehensive cognitive behavioral therapy system designed to treat complex, difficult to treat personality and behavioral disorders. Initially developed for patients with chronic suicidal behavior, DBT has gradually evolved into a treatment for patients with multiple behavioral problems and borderline personality disorder (BPD). Since then, DBT adaptations have been developed for difficult-to-treat behavioral disorders associated with emotional dysregulation, including substance dependence, anorexia and bulimia, depression and suicidal behavior in adolescents, depression in the elderly, and bipolar affective disorder. There are versions of the DBT applicable to a variety of care formats, including outpatient and inpatient care, group therapy, and individual therapy.

Dialectical Behavior Therapy is the global benchmark for helping people with borderline personality disorder, suicidal behavior and self-harm.

DBT is based on a combined deficit-motivation model of BPD, suggesting that (1) people with BPD lack important skills in interpersonal communication, self-regulation (including emotion management), and distress coping, and that (2) individual and environmental factors often block or suppress the acquisition and use of behavioral skills by patients and reinforce dysfunctional behavior.

DBT combines basic behavior therapy strategies with mindfulness practices.

DBT starts from a balanced dialectical therapeutic position emphasizing the synthesis of opposites. The dialectical approach assumes the inevitability of the emergence in the therapy of suicidal patients with BPD of many opposites that are difficult to combine (the need for acceptance and change, passivity and activity, the patient's vulnerability and the need to actively contact the environment, etc.). DBT encourages the formation of flexible dialectical patterns of thinking and behavior instead of the rigid "black and white" type of thinking.

The fundamental dialectical balance in DBT is the balance between accepting the patient for who they are and helping them achieve change.

Acceptance procedures in DBT include mindfulness techniques (ie, attention to the present, taking a nonjudgmental stance, focusing on performance) as well as a range of validation and acceptance strategies. Change strategies in DBT include behavioral analysis of maladaptive behavior and solution techniques, including interpersonal skills training, emotional self-regulation, learning management (reinforcement and punishment in therapy), cognitive modification, and exposure-based strategies.

As part of a comprehensive treatment, DBT aims to achieve five main goals:

(1) expansion of the behavioral repertoire,
(2) increased motivation for change (through modification of suppression and reinforcement factors),
(3) generalization of new patterns of behavior beyond therapeutic space,
(4) structuring the therapeutic environment necessary for the implementation of the resources of the therapist and the patient,
(5) increasing the ability and motivation of the therapist to effectively help the patient.

In the standard DBT, these functions are distributed among various formats of care, including individual psychotherapy, group skills training, telephone coaching, and the DBT advisory group.

Website of the community of dialectical behavioral therapy in Russia - www.dbtrussia.org

Dialectical behavioral therapy (DBT) for BPD, how it works and how it helps

DBT (dialectical behavioral therapy) is one of the areas of cognitive behavioral psychotherapy « third wave, which was developed to help people with self-harm and proved to be extremely effective in the complex treatment of patients with borderline personality disorder. This method was developed by the American psychologist Marsha Linehan more than 20 years ago and is successfully practiced at the International Institute of Psychosomatic Health Center for the Treatment of Borderline Personality Disorder.

DBT psychotherapy is based on the idea that the main difficulty in borderline personality disorder is the inability to control one's emotions and related impulsive actions. The fact is that the roots of borderline disorder go back to childhood. The child's psyche is mobile, vulnerable, and when in a close environment the child does not find the right emotional support, self-regulation skills, emotional stability is not formed in him. It also happens that the normal reactions of the child are perceived by parents as pathological, a ban on emotions is practiced, a person learns not to feel himself, his needs, but when a stressful situation arises, emotions, like a volcano, break out from under the layers of parental attitudes, burn the person and everything around. . Therefore, one of the most important tasks of psychotherapy for borderline personality disorder is to return the right to emotions to a person, to inform that he can feel what he feels. And then a person has a choice, he ceases to be a hostage to unambiguous cause-and-effect relationships, returns the ability to critical thinking, can take a step back, look at his reactions, at the situation, see that there can be many behavior options and choose the most optimal for himself . Specialists of the Center for the Treatment of Borderline Personality Disorder of the International Institute of Psychosomatic Health practice careful, attentive attitude towards the patient, unconditional acceptance, sincere compassion.

The term “dialectic” here reflects the unity of opposites, the need and development of the ability to combine seemingly mutually exclusive things: acceptance and change, passivity and activity, vulnerability and the need for active contact – therefore, the ability to be flexible in different situations is the path to success .

In order to achieve results, the Center for the treatment of borderline personality disorder of the International Institute of Psychosomatic Health conducts trainings that help to master and develop basic skills. They are combined into 4 modules:

Mindfulness skills - helps to stay in the current moment and soberly assess the situation;
stress resistance skills - allow you to maintain self-control and critical assessment in situations of psycho-emotional overload;
emotional regulation skills - help to be in touch with your emotions, to be aware of them and accept them;
interpersonal effectiveness skills - increase the level of social competence, allow you to communicate more comfortably and productively.

DBT is a flexible, eclectic direction of therapy that uses the methods and techniques of other psychotherapeutic schools, borrowing the most valuable ones. In the course of the work, an analysis of maladaptive behavior is carried out, the development and strengthening of skills in emotional regulation, communication, exposure is used, and much more. As a result, this allows you to achieve the following goals: finding motivation for change, acquiring new ways of behavior, transferring acquired skills to real life, maintaining the structuring of the therapeutic environment necessary to maintain resources.

Dialectical Behavioral Therapy at the International Institute of Psychosomatic Health Center for Borderline Personality Disorder is delivered in a variety of formats and includes individual sessions with a psychologist, group work in a safe environment, and accompaniment by a coach who is always available for support.

See also: Borderline personality disorder, BPD in adolescents, BPD medication, BPD group therapy.

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