Life can be wrenching for people who suffer emotional extremes.
They know the anguish of abandonment, real or imagined, and are far more fragile than most. Their self-esteem can plummet if a friend arrives five minutes late. They may cling to someone for fear of being deserted, then lash out in anger at an innocent remark. Stormy relationships and constant crises trigger a profound sense of emptiness and feeling unloved or worse, evil. Unable to silence their emotional pain, they practice sudden, self-destructive acts – from reckless driving and binge eating to drug abuse, cutting or suicide attempts.
These are the hallmarks of Borderline Personality Disorder (BPD), which affects up to 14 million Americans (nearly 6 percent of all adults), according to the National Education Alliance for Borderline Personality Disorder.
But while reality is daunting for people with BPD – and those who love them – there is effective, research-proven treatment. A growing body of evidence recognizes Dialectical Behavior Therapy (DBT) as the intervention of choice for BPD and its highly reactive, self-harming traits.
DBT is a form of psychotherapy that has been shown to ease the symptoms of borderline personality disorder and other complex, life-threatening conditions – including traumatic brain injury, major depression, eating disorders and drug addiction that co-occurs with mental illness.
“DBT treats people who have high impulsive behavior, who cannot regulate their emotions. We do that by teaching people a set of skills that have to do with how to observe impulsive urges, and how to regulate their reactions,” says Dr. Marsha M. Linehan, the creator of DBT.
Linehan, a professor of psychology and psychiatry at the University of Washington, originally developed DBT for chronically suicidal individuals. She has expanded the treatment over the past 25 years to help those with BPD and multiple, severe diagnoses.
When compared with other treatments for suicidal behaviors, DBT is the only intervention shown to be effective in multiple, independent clinical trials. More than 18 scientific studies demonstrate DBT’s success in reducing suicide attempts, hospitalizations and substance use for those with BPD (newer research shows a biological predisposition to be ultra-sensitive or misperceive others’ actions).
How DBT Works
People with emotional disorders often lack the skills to solve the problems of their lives, Linehan notes, so DBT introduces a new repertoire of healthy behaviors. The therapy enhances clients’ ability to change themselves by teaching them how to manage disturbing emotions, remain calm and mindful, and adopt effective interpersonal skills.
In a nutshell, DBT helps people improve their lives by combining the basic tenets of behavior therapy with mindfulness practices (inspired by Eastern Zen philosophy and Western Christian spirituality).
The art of DBT balances two opposing principles: the need to radically accept yourself as you are – mindful that your feelings may be intense, pervasive and quick to escalate – and the need to
change, by learning more functional behaviors.
DBT “brings a synthesis between acceptance and change,” Linehan says. Acceptance or validation is critical, because clients’ first need to acknowledge their distress and extreme reactions before transformation can occur. In other words, they recognize that they are doing the best they can, but must do better to change their personal trajectory.
“Fighting and screaming and yelling and battling is not useful. You have to radically accept the present in order to change the future,” Linehan says.
In a climate of compassion and acceptance, the DBT therapist acts as ally and coach – helping clients navigate difficult situations. “Many of the skills that we teach are focused on how to inhibit acting on impulsive urges,” Linehan says.
While DBT shares elements with cognitive behavior therapy, there are principal differences. DBT integrates the concepts of acceptance and mindfulness, and puts greater emphasis on changing what you do, not just what you think. And DBT typically requires a longer commitment – at least one year in treatment – to internalize the skills and deflate suicide risk.
Clients attend weekly individual counseling sessions as they progress through four DBT skills training courses. Each includes a core competence that requires 4-6 weeks of practice in structured group therapy sessions (homework, phone coaching and family therapy are also part of standard DBT interventions). The goal is to reduce suicide risk and respond to personal trials with more functional, adaptive behaviors.
As clients acquire new skills and move toward a life worth living, they define long-term goals for their happiness, and continue building self-respect. Some clients explore a further goal of spiritual fulfillment to increase their capacity for joy.
The DBT Skills:
A Balance of Acceptance & Change
Mindfulness – This skill teaches clients to be fully aware of the present moment and calmly observe their personal struggle as it unfolds, without self-criticism. Clients become mindful of their thoughts, emotions and body sensations, positive or negative. Deep breathing and relaxation exercises are often used to help clients “detach” and stay focused on the present – where they won’t suffer the trauma of the past or anxiety about the future.
Distress Tolerance – Clients learn to tolerate painful feelings and powerful urges – without changing them or acting upon them. Instruction in self-soothing techniques is provided to help clients cope with strong emotions, instead of resorting to self-harm or damaging behaviors. This skill is then generalized to real-life situations that may provoke distress.
Emotional Regulation – What triggers an emotional storm? Clients identify and label their feelings – anger, jealousy, sadness, etc. – and learn to change the emotions they want to change. They acquire skills for problem-solving and self-control, and learn how to nourish the body to maintain positive emotional health.
One of the tools practiced in Emotional Regulation is “opposite action” – meaning you act the opposite of how you feel if your emotions don’t fit the facts. For example, a depressed person who doesn’t want to get out of bed must do exactly that, the opposite action, in order to start feeling better. An alcoholic who feels the urge to drink when walking near a bar takes the opposite action – a different route home – to avoid triggers that fuel substance use.
Interpersonal Effectiveness – Healthy relationships are especially challenging for people with BPD. This skills course teaches clients how to cope with interpersonal conflict. They learn how to say no, and how to ask for what they want with confidence and appropriate language. Clients also practice ways to validate the other person and compromise effectively – without hurting the relationship or losing self-respect.
Additional skills training in areas such as drug relapse prevention may be necessary for DBT clients with multiple disorders.
BPD & Substance Use: A Dangerous Duo
BPD often overlaps with other conditions, such as drug or alcohol dependency. An estimated 35 percent of people with BPD also have a substance use disorder, according to the National Institute of Mental Health (one literature review, by Trull et al., 2000, found that nearly 60 percent of people with BPD met the criteria for a substance use disorder).
“People with borderline personality are more likely to have almost any impulsive behavior, so there’s a lot of drug addiction,” Linehan notes. “We have done several (DBT) studies on basic drug abuse, and several studies on heroin addiction, and have had very positive results. To a large extent, the treatment was effective.”
One addiction specialist credits DBT with giving his clients the skills and confidence to rebuild their lives in recovery.
“I have used DBT in private practice, intensive outpatient and partial hospitalization, as well as residential settings. The potential with all clients who suffer from emotional dysregulation is extremely high,” says Bobby Scott, a certified substance abuse counselor, licensed marriage and family therapist and Executive Director/Vice President of Clinical Operations for Addiction Campuses of Mississippi.
“The issue is how clients manage their emotions and their thoughts effectively,” Scott says. “Patients with substance use disorders do not have the skills to do so without alcohol or drugs. DBT gives them the skills, abilities and validation” they need to recover, he says.
While treatment length can vary by individual, Scott encourages clients to commit to a yearlong intervention. “The self-destructive behaviors can cease fairly quickly but to maintain those gains, it is imperative that they stay engaged for some time,” he says.
Those who care for people with BPD can support the treatment process, Scott says, by attending multi-family group and individual family therapy sessions. They participate to learn the DBT skills “but mostly so they can validate their family members and break the dysfunctional family cycle,” he says.
Linehan notes the concept of “radical acceptance” is key to helping families heal – especially if a
relative who is difficult to care for refuses to seek professional help.
“We do a lot of work with family members whose loved ones don’t want treatment but need treatment. It’s a little like Al-Anon,” she says. “We do not help them change the family member. We only help them live with the person they’ve got.”
Setting limits and using contingency management may provide incentive for treatment, Linehan says, noting as an example that “if you don’t get treatment, you’re not going to live in our house.”
“Families also need to work on why (a loved one) won’t get treatment,” she says. “If they’re afraid, why are they afraid? They need to help them see that staying a drug addict is not a good choice.” A computer-based Emotion Regulation program is in development, Linehan says, for people with substance use disorders who are also suicidal.
Resources for Healing
These resources on Dialectical Behavior Therapy (DBT) include links to find a therapist, review the research and learn about DBT’s effectiveness for Borderline Personality Disorder and other conditions.
BEHAVIORAL TECH LLC/THE LINEHAN INSTITUTE
The Behavioral Tech website includes DBT client workbooks, videos and a searchable database to locate a DBT therapist. A national certification program, launched in 2014, is in progress; the database currently lists therapists who have completed DBT training at Behavioral Tech (founded by DBT creator Marsha Linehan to train mental health professionals) or through Behavioral Research and Therapy Clinics of the University of Washington. In-depth videos on suicide risk assessment/prevention are in development.
The Linehan Institute is a nonprofit organization that aims to make leading edge, compassionate treatments available to people with complex and severe mental disorders. This website includes information on DBT clinical trials, mindfulness retreats, the national certification program for therapists, and video lectures by DBT clinicians and researchers.
NATIONAL EDUCATION ALLIANCE FOR BORDERLINE PERSONALITY DISORDER (NEA.BPD)
Includes the largest multi-media library on Borderline Personality Disorder (BPD), with a wealth of information for people with BPD, their families and mental health professionals. Founded in 2001, NEA.BPD is a national nonprofit organization working to raise public awareness and enhance the quality of life for those affected by BPD.
Treatment and Research Advancements Association for Personality Disorder (TARA APD)
This nonprofit advocacy group offers a helpline (1-888-4-TARA-APD) for information on Borderline Personality Disorder, family support groups and referrals to clinicians who treat BPD. The organization fosters education and research on BPD and other personality disorders, and works to reduce the stigma of mental illness.
Longstanding website that provides insights on DBT from people who have been through the treatment. They share their experiences with each DBT skill, in hopes of helping others. Free downloads on self-help topics, guided audio meditations and links to mobile apps for DBT skills practice (these are commercial apps, not affiliated with the official Linehan DBT protocol).