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Dialectical Behavioral Therapy
in the Treatment of Borderline
Personality Disorder
Four aspects of treatment give patients tools to
achieve self-acceptance
By Regina Walker, LCSW, BCD, CASAC
Borderline
personality disorder (BPD) is a
psychiatric illness
characterized by patterns of violent
mood swings, unstable relationships,
poor self-image and a tendency to act
impulsively. The majority of people
with BPD harm themselves and also
make repeated suicide attempts.
One of the more promising therapies for BPD is dialectical behavioral
therapy, or DBT. Dr. Marsha Linehan
developed DBT to treat compulsive
patterns of self-harm with simple,
practical, effective techniques. For
Linehan, DBT is anything but an
exercise in abstraction. As she recently revealed, its methods come from
insights gained at a huge personal
cost from her own struggles with
mental illness.
Linehan was first diagnosed with
schizophrenia at age 17. According to
an in-depth look at her struggles with
mental illness published in The New
York Times in 2011, as a teenager she
was precocious but also dangerously
violent towards herself. In the article,
Benedict Carey wrote, “The girl
attacked herself habitually, burning
her wrists with cigarettes, slashing her
arms, her legs, her midsection, using
any sharp object she could get her
hands on.”
“I felt totally empty, like the Tin
Man,” Linehan said. “I had no way to
communicate what was going on, no
way to understand it.” She was dosed
with Thorazine, Librium and other
powerful drugs and endured hours
of Freudian analysis as well. She was
also subjected to electroshock treatments, but nothing changed. She
often found herself back in seclusion
on the locked ward.
In 1967, Linehan had what can
only be described as an epiphany.
She had been regularly praying at the
Cenacle Retreat Center in Chicago
and suddenly felt transformed. “It was
this shimmering experience, and I
just ran back to my room and said, ‘I
love myself,’” she said.
The high lasted for about a year.
The feelings of devastation returned
in the wake of a romance that ended.
But something was different. Linehan
could now weather her emotional
storms without cutting or harming
herself. Quite simply, she accepted
herself as she was. She referred to this
as “radical acceptance” – acceptance
of life as it is, not as it is supposed to
be, and acknowledging the need to
change – both despite that reality and
because of it. On the one hand, she
learned, you have to take life as it is;
on the other hand, change is essential
for survival. But for real change to
happen, both self-acceptance and
acceptance of the need for change
have to come together. This blending
of two seemingly opposite views is
called a dialectic, and it’s the vision
behind DBT.
Linehan was trapped in a downward spiral of shame, self-loathing,
psychic pain and self-harm from
which there seemed to be no escape.
During her first psychiatric hospitalization, Linehan said, “I was in hell.
And I made a vow: When I get out,
I’m going to come back and get others out of here.”
Linehan originally developed DBT
as a treatment for highly suicidal
patients. Linehan believed if these
individuals could be taught skills to
better deal with emotional and life
issues and lessen their psychic pain,
the desire to die or harm themselves
would be greatly diminished. Simply,
the goal of DBT is for the patient to
acquire skills to deal with his or her
mental anguish and create a life worth
living.
Over time and study (she earned
a Ph.D. at Loyola in 1971), Linehan
acknowledged acceptance and change
alone were not enough. Patient
needed tools to handle the feelings
and circumstances in their lives that
led to self-harming behavior. DBT is
a way to achieve self-acceptance while
simultaneously accepting the need for
change. There are four basic aspects
to DBT: mindfulness, interpersonal
relations, emotion regulation and distress tolerance.
Mindfulness is an idea originally
borrowed from Zen Buddhism. It
is about focusing on the present
moment, as opposed to the past or
future, and being aware and accepting
of what is happening both within and
without, without making judgments
about the experience. This can also
be described as acceptance of the self
and the circumstances.
The next skill set in DBT focuses
on interpersonal relations. This
“module” teaches patients how to set
limits and safeguard themselves and
their relationships.
The emotion regulation aspect of
DBT teaches patients how to identify,
regulate and experience emotions
without becoming overwhelmed and
acting on impulse. The skills aim to
reduce vulnerability and increase
positive experiences.
The fourth area of DBT is distress
tolerance. This module focuses on
developing skills to cope with crises
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when emotions become overwhelming and the individual is unable to
immediately solve the problem (a
death, sickness, loss of job, etc.). The
patient needs to persevere and live
through the crisis without making it
worse by impulsive actions (for example, cutting or substance abuse).
DBT pushes for immediate and
permanent cessation of self-harmin