Borderline personality disorder · Therapy · Uncategorized

DBT: improving the lives of people with borderline personality disorder

Man standing next to a sign reading “Having BPD is difficult, but not hopeless.  I’ve learned to use what makes me different to grow a beautiful person, a better person.” –Anonymous

Dialectical behavioral therapy (DBT) was created by Marsha Linehan, PhD, to help people with borderline personality disorder (BPD) improve the quality of their lives.

Basically this therapy is an intensive 6-month program that targets difficult-to-treat symptoms like suicidal thoughts and behaviors, poor sense of self, mood regulation difficulties, problems relating to others, and poor stress tolerance.  The program was created specifically for people with BPD.  Here’s a quick overview of the illness.

Borderline Personality Disorder

What’s BPD about?

BPD is a mental health condition characterized by patterns of dysfunction in mood, sense of self, behavior, and functioning.  Symptoms include:

(1) Mood swings and rejection sensitivity.  People with this disorder tend to have extreme mood swings, going from happy to suicidal to angry and back to happy in a matter of hours. They’re very sensitive to perceived rejection; no matter how hard the person tries to keep things under wraps, a small slight can open a flood of emotions.  On the other hand, a tiny flourish of positivity in the environment can send feelings afloat, high and happy.  This love for life lasts minutes to hours before something (like a thought or event) triggers a downfall.

“I feel everything all the time. It’s exhausting.  But it also makes me passionate, which is beautiful.” –Alicia Sarah Raimundo.

(2) Vacant ego and troubled friendships.  Individuals struggle with an unstable self-image and have difficulty being alone.  Their identity is dependent entirely on their relationship with others.  They’ll go to great lengths to avoid abandonment.  Unfortunately, as much as they need connection with others, their relationships are usually intense and problematic.  Many BPD individuals report needing immediate attention to their needs and find themselves blaming others when these needs aren’t met, making friendship even more difficult.

(3) Black and white thinking, “playing games,” and splitting.  BPD sufferers often describe life in terms of all good or all bad, with nothing in between.  Some “play games” to get their needs met, even if they don’t do so consciously. For example, they might inadvertently project their extremes onto those around them, causing people to “split” against one another, in a way that benefits the person with BPD.  Providers and families tend to respond by setting harsh “limits” on the ill person.

(4) Hurting self and others.  The most alarming aspects of BPD is the person’s tendencies to have self-injurious behaviors, harming themselves to deal with stress or communicate that they’re hurting, or threatening to commit suicide to get others to do something they desire.  It’s common to have problems with rage, and occasionally people with BPD become assaultive if they feel their distress isn’t acknowledged or needs aren’t being met.

“With BPD my emotions are 10x’s amplified than an average person.  When I’m mad, sad, hurt, happy, my emotional regulation is 10x’s more amplified.  Both a blessing and a curse to feel so deeply.” –Chanelle, FB user.

How is the illness diagnosed?

BPD is identified when the symptoms are chronic, widespread, and destructive.   The disorder can’t be diagnosed in people under 18 years of age.  Remember, don’t diagnose yourself with any mental illness based on an article or internet post!  It takes careful evaluation and time to establish what’s really going on, and the doctor needs to rule out many conditions that can mimic BPD.

What causes BPD?

The disorder seems to be related to a chaotic, invalidating environment during early childhood.  This is the home where a kid’s mother praises him for something on day one, then slaps him for doing the same thing on day two, and where a child’s life is filled with inconsistent messages about his worth, often connected to sexual abuse.  A lot of people with BPD are victims of severe, repetitive childhood trauma.

The theory of an invalidating childhood makes sense.  If as a child you didn’t get fed unless you acted out, then you kicked and screamed often and emphatically!  Anything less would have meant starving to death.  In that situation, “kicking and screaming” worked as an effective coping skill.

Like everyone, however, the person with BPD recycles “successful” coping skills, carrying them over into adulthood.  Indeed, as kids they were taught few other skills.  Now they use that coping skill to deal with most issues, despite catastrophic outcomes, because no one has shown them there are better ways to do things.

What are the treatments?

Medications can help with mood swings, depression, impulsivity, anger, and behavioral problems, but DBT is the treatment of choice.

Okay, so tell me a little about DBT

As mentioned beforehand, DBT is an intensive life skills program aimed at treating BPD.  The main goal of therapy is to diminish self-injurious behaviors, but there’s also an emphasis on teaching people to live in the moment, cope better with stress, come to terms with and regulate emotions, and improve social skills.

A basic run-through

The major premise of DBT is that patients are trying the best they can and that they can do even better with the right support and direction.  That’s a contradiction between acceptance and change: the mental health provider accepts the patient as they are but challenges them to do better.

The “dialectical” part of DBT kicks in here: it’s about balancing contradiction.  Balancing acceptance and requesting change is a tremendous part of treatment.

DBT uses this contradiction in a therapeutic way.  People in general, including non-BPD people, are more likely to cooperate and change their behaviors if they feel understood and acknowledged.  In DBT, the therapist first joins with the patient and acknowledges that their current behaviors make sense in context of past experiences, that they are doing the best they can.  Once they have the patient’s permission and trust, they then offer alternative approaches to the problem.

“You are so good.  So good.  You’re always feeling so much.  And sometimes it feels like you’re gonna bust wide open from all the feeling, doesn’t it?  People like you are the best in the world, but you sure do suffer for it.” — Silas House.

What’s DBT like?

DBT involves both group and individual therapy.

Group therapy follows a very specific outline made up of four modules.  In general, the class involves loads of homework, i.e. working on specific coping skills, which are practiced and reported back to the class. The four modules include:

  • Mindfulness. Strengthening the “self” by embracing the moment.
  • Interpersonal skills. Highlights social skills and assertiveness training
  • Emotional regulation. Aims to better understand and deal with negative emotions, while increasing positive emotion
  • Stress tolerance. Presents specific coping skills to increase resilience.

Individual therapy is centered around diminishing self-injurious behaviors, dealing with crises, and balancing acceptance with change.  The DBT therapist is typically available 24/7 to help patients use their coping skills in a crisis.

How about an example?

Here’s a quick example. The Stress Tolerance Module starts with a page devoted to “Crisis Survival.”  There are four general recommendations for dealing with a crisis.

(1) Distraction methods using the mnemonic “Wise Mind ACCEPTS”

(2) Self-soothing exercises

(3) Improving the moment using the mnemonic “IMPROVE”

(4) Weighing the pro’s and con’s of what you’re doing

Let’s hone in on #3, improving the moment: IMPROVE.  IMPROVE stands for:

  • Imagery (different examples of imagery are offered)
  • Meaning (the patient is encouraged to find purpose in their situation)
  • Prayer (or spiritual/philsophical reflection)
  • Relaxation (examples include muscle relaxation, a hot bath, or getting a massage)
  • One thing in the moment (focusing all energy on the now)
  • Vacation (multiple possible escapes are described, including getting in bed and pulling the sheets over one’s head, checking into a hotel and turning off the phone for a day, or going to a park and lying on a blanket)
  • Encouragement (encouragement to cheerlead for oneself and repeat a soothing phrase over and over, like “It won’t last forever.”)

People with BPD tend to have dramatic, painful lives filled with crises and meltdowns — and limited resources to deal with them — so these seven stress-busting methods can be a godsend. Typically the facilitator reviews the skills in great detail, giving personal examples, and the skills are play-acted in class.  Afterwards, students practice these methods at home and report back next time they meet.  They have homework sheets and coping skill diary cards to help organize their efforts.

Where can I learn more about DBT?

If you’re interested in learning more, talk to your provider or check out DBT programs in your area.  Alternatively, look into self-help DBT books or dbt self help websites.

In conclusion:

DBT focuses on helping people with BPD learn how to live and love life.  This includes a medley of skills ranging from Eastern mindfulness and a deeper sense of self to assertiveness, resilience, and regulation of emotions.  In the end, these are skills we all use (or could use) in our day-to-day struggle to enjoy life.

“It was really hard for many, many years.  But I’ve learned to grow with the way I was born with BPD.  I love myself now and because I have been through so much…. I can help [others] so much.” — Anonymous, FB user.

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