Introduction
In 1987, psychologist Marsha M. Linehan published her method for treating patients with
borderline personality disorder (BPD), which she called dialectical behavioral therapy. Borderline personality disorder is one of more serious and treatment-resistant personality disorders, characterized by dysregulation of emotions (an inability to regulate and control emotional responses), as well as of thoughts, behaviors, and interpersonal relations, including how a person relates to the self. People with this personality configuration experience affective instability, difficulty managing their anger, random impulsivity, proclivity for self-harm, paranoia, extreme fear of abandonment, uncertainty about who they are, and chronic emotional emptiness.
Traditional treatments assumed that therapists could not avoid rejecting patients’ self-destructive behaviors and attitudes. These approaches were change-oriented and, though well intentioned, frequently put the therapist at odds with the patient. In developing dialectical behavioral therapy, Linehan enumerated strategies that allowed therapists to accept patients where they were, promoting acceptance-oriented skills in addition to traditional change-oriented skills. An accepting attitude toward patients affirms the worldview inherent in their feelings, attitudes, thoughts, and behavior. It promotes the rectitude of patients’ experiences and all aspects of their personal worlds. It also maintains that, however patients are being in the moment, it is the best that they are able to be at that time.
Underlying dialectical behavioral therapy is a constellation of worldviews that highlights the importance of dialectic and the acceptance of life as it is. Acceptance draws heavily from Zen principles; dialectic has its philosophical roots in the work of Immanuel Kant, Frederick Shelling, and, most of all, Georg Hegel. Dialectic is the synthesizing of point and counterpoint. For every stance or particular behavioral occurrence, there is an equally valid, but opposite, stance or occurrence. The therapist supports the patient’s moving toward a healthier integration of these ostensibly irreconcilable positions. In practice, dialectical behavioral therapy strategies draw heavily from traditional cognitive and behavioral therapy techniques and process approaches well known in person-centered and emotion-focused therapies.
Before dialectical behavioral therapy, patients with borderline personality disorder were considered almost impossible to treat effectively beyond varying levels of therapeutic stabilization. People with borderline personality disorder are emotionally flammable and fragile, unable to reliably regulate their inner states, have conflict-ridden relationships, frequently consider suicide, and often engage in self-harming behaviors such as cutting. They were raised in and typically perpetuate an invalidating environment, a social environment that actively opposes acceptance of patients’ perceptions, feelings, judgments, attitudes, and behaviors. This toxic climate perpetuates pervasive criticism, denigration, trivializing, and random social reinforcement. People in this environment are denied genuine attention, respect, understanding from others, and positive regard for who they are and what they are experiencing. Stress and perceived abandonment or rejection overwhelm the ability of people with borderline personality disorder to self-regulate, and they remain chronically, recurrently, emotionally vulnerable. Therapists were often frustrated (and sometimes intimidated) by these patients’ volatility and high degree of risk. Dialectical behavioral therapy became a road map for therapists who trained in it.
How the Therapy Works
Patients who undertake dialectical behavioral therapy begin with “pretreatment,” a series of psychotherapy sessions in which the therapist and patient establish a shared understanding of dialectical behavioral therapy’s rationale, agreements about what each expects of the other, the levels of dialectical behavioral therapy interventions and treatment targets, and perhaps most important, the commitment to be in treatment. In pretreatment, patients agree to stay in therapy for a specified period, most commonly a year, to come to all therapy sessions, to come on time, to work toward ending all self-harming behaviors, to undertake interpersonal skills training, and to pay fees in a timely manner. Therapy is usually discontinued if four consecutive sessions are missed. Therapists promise to maintain their own ongoing and professionally supportive training, to be available for weekly sessions and phone consultations, to demonstrate positive regard and nonjudgmental attitudes, maintain confidentiality, and obtain additional consultation as would benefit the therapy.
Levels of Treatment
Level I of treatment establishes a target hierarchy that includes reduction of self-harming behaviors such as cutting or burning oneself, of behaviors and barriers that interfere with treatment, and of behaviors that interfere with establishing a healthier quality of life. Patients at the early stages of dialectical behavioral therapy treatment are usually highly distressed, bordering on hopelessness, and at the mercy of the enigmatic flow of their own emotional surges. Self-injury, drug abuse, depression, and suicidal thinking are the norm at this state.
Level II begins when the skills developed in Level I are sufficient to contain self-harming patterns. The therapist begins to presumptively treat patients with post-traumatic stress interventions, as these enhance their ability to experience aversive emotions without being undone by them. As progress is made, other emotionally difficult, even overwhelming targets are identified. The emotional and psychological commitments to remaining in treatment at these early stages can result in patients’ working against their goals, as in missing therapy appointments, showing up late, and not completing agreed-on homework; it can also result in psychological regression, wherein patients at Level II treatment exhibit Level I functioning (for example, burning or cutting themselves or engaging in other dangerous behaviors). Patients at these levels of care must be closely monitored. Once the functional goals of Level II are reliably sustained, the majority of patients leave treatment. They have expended a great effort at much personal cost to have gotten this far.
For patients proceeding to Level III, the targets of treatment are similar to those of typical psychotherapy in that they aim at reducing or eliminating behaviors that are not debilitating but interfere with experiencing ordinary pleasure, happiness, fulfillment, and personal meaning.
Level IV targets higher-order psychological values: a functional application of one’s philosophy of person, integration, and the blending of spiritual elements with those of psychological self-actualization.
Modalities of Treatment
Dialectical behavioral therapy uses four modes of treatment that are not commonly found together in other therapeutic approaches: group-skills training for patients, individual therapy for patients, telephone consultations between patients and therapists, and therapists’ participation in an ongoing consultation team. Many of the ways borderline personality disorder patients regress are through perceived, and thus experienced, negative social interactions. These are most effectively worked through and improved by training in a group setting. Individual therapy is typically weekly and involves working toward the established and mutually agreed-on targets during pretreatment. Because the inner life of patients with borderline personality disorder can be so tumultuous, telephone consultations are routinely used to bolster patients and review how to apply the concepts and skills discussed in individual and group training. Because this is such a challenging patient population, the standard practice of dialectical behavioral therapy requires its practitioners to meet regularly with other dialectical behavior therapists for case presentation, honing of dialectical behavioral therapy therapeutic skills, and peer consultation.
Future
Though Linehan focused her earlier work on patients with borderline personality disorder, and dialectical behavioral therapy is the therapy of first choice in their treatment, the principles and techniques have been applied to other often hard-to-treat patient groups such as those with eating disorders, bipolar disorder (in conjunction with targeted psychopharmacology), histrionic personality disorder, a history of sexual and violent assault, and a variety of diagnoses among the elderly. Though it requires a high degree of patient commitment and specific training that implies lifelong learning, it is the most powerful and effective intervention available to a patient group that had often been considered nearly impossible to treat effectively.
Bibliography
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