From The Journal, March 1, 1997, Vol. 8/Iss. 1
THOMAS R. LYNCH, Ph.D. is a Clinical Associate at Duke University Medical Center where he conducts research, maintains a clinical practice and participates nationally as a trainer for Dialectical Behavior Therapy.
CLIVE J. ROBINS, Ph.D. is an Associate Professor in Psychology and Medical Psychology at Duke University, a diplomat in Behavioral Psychology and is both a researcher and therapist, as well as a national trainer for Dialectical Behavior Therapy.
In the middle of this road we call our life
I found myself in a dark wood
With no clear path through
Divine Comedy, "Inferno"
The road is an arduous one, often with no clear path through, for individuals diagnosed with Borderline Personality Disorder (BPD). Features of this disorder include a pervasive pattern of instability and dysregulation across emotional, behavioral, cognitive, and interpersonal domains. Individuals with this disorder typically have a multitude of chaotic relationships which consist of frequent alternations between an idealization or devaluation of the other person and / or frantic attempts to avoid real or imagined abandonment. They often describe chronic feelings of emptiness, experience an unstable self-image, and often have highly reactive, intense emotional experiences. In addition, they frequently engage in impulsive behaviors (e.g.., spending, sex, substance abuse, reckless driving, binge eating) and / or self-destructive behaviors (e.g., overdose, self-mutilation).
Treatment of these behavioral patterns usually is very difficult. Medications typically have quite limited effects and, until recently, there was no psychosocial treatment approach with empirically demonstrated efficacy. Dialectical Behavior Therapy (DBT), as developed and researched by Marsha Linehan, Ph.D. at the University of Washington in Seattle has been found to provide some hope for individuals suffering from this disorder, leading to reductions in self-injury, hospitalizations, anger, and to other improvements. The purpose of this article is to describe some of the treatment aspects of DBT and how they have been implemented at Duke University, and to discuss some of the features of this treatment that we find particularly interesting.
Dialectical Behavior Therapy, first and foremost, is based on a biosocial theory which states that BPD develops out of, and is maintained by, an ongoing transaction between an emotional vulnerability and dysregulation within the individual and an experience of invalidation from the environment. Emotional dysregulation encompasses a low threshold for emotional stimulation, extreme emotional reactions with high arousal, and emotional experiences that last a long time. The environment may be invalidating in a number of ways: A person's needs, wants, and desires may be seen as inappropriate; thoughts and feelings may be characterized as socially unacceptable, over reactive and / or manipulative; ease of controlling emotional expressiveness may be oversimplified and / or negative emotional expression may be punished. In this theory, BPD could develop even with originally low levels of invalidation or emotional dysregulation, given high enough levels of the other, because each tends to reciprocally produce the other over time.
As a therapy, DBT has evolved out of standard cognitive-behavioral treatments based on principles of learning, and blends behavioral change oriented strategies with concepts and techniques associated with acceptance and tolerance derived from Western contemplative and Eastern meditation practice. These two very different traditions are synthesized and balanced dialectically. Dialectics emphasizes wholeness, interrelatedness and change as fundamental characteristics of reality. A dialectical view asserts that within any component of reality lies its polarity, and that change occurs upon synthesis of these opposing forces. Thus, treatment always entails a balance of acceptance versus change and searching for what is left out.
At Duke University, Dialectical Behavior Therapy has been ongoing in some form since 1992. Treatment has included the standard DBT modes of outpatient treatment: individual therapy, group skills training, telephone consultation, and consultation team meetings. We have also developed an inpatient DBT program.
Individual therapy involves weekly (or daily if inpatient) sessions in which problem behaviors (e.g., self-mutilation, therapy interfering behaviors, bingeing / purging, abuse of alcohol / drugs, etc.) are analyzed in great depth for both precipitants and consequences which elicit, lead to, maintain, or reinforce the behavior. Solutions are developed that address what gets in the way of skillful behavior by changing reinforcement patterns, overcoming inhibitions through exposure, cognitive modification, and directly teaching skills.
Individual therapy works on the premise that eliminating self destructive behavior is of primary importance and must be managed prior to working on quality of life interfering behavior or the sources of the disorder (e.g., post traumatic stress). A major task of the individual therapist is to help motivate the individual to use his or her most skillful behavior. To that end, the individual therapist agrees to provide phone consultation to patients as needed outside of scheduled sessions. The idea is similar to a basketball coach providing skill consultation and strategy for players during a time out called when playing a game. Phone consultation increases the likelihood that skill generalization will occur by allowing coaching to occur while the game is going on. Of course, therapists vary as to how available they can be, depending on their own personal limits. It is important for therapists to observe their own limits so as to remain willing to work with difficult and demanding patients and not burn out.
Group Skills Training
Individuals with BPD lack many of the fundamental skills required to regulate emotional experience , engage in successful interpersonal relationships, tolerate painful experience, and manage cognitive dysregulation. Therefore, in DBT, individual treatment is augmented by group skills training which includes four modules: mindfulness skills, interpersonal skills, emotional regulation skills, and distress tolerance skills. Groups have a didactic orientation and the entire sequence of weekly skills training takes approximately six months to complete. Patients typically go through the skills training at least twice. This is not only because of the amount of material which must be learned, but Linehan and colleagues have found that the intense aversive emotions which these patients suffer from often limit the amount of learning which can occur on any given day. Thus, by going through the material twice we have found patients are better able to make use of skills.
Because working with borderline individuals can be very difficult and distressing, effective DBT treatment requires the formation of a consultation team. At Duke University our teams have consisted of psychologists, psychiatrists, nurses, social workers, psychology interns, psychiatry residents, and other trainees who lead skill training groups and / or have individual DBT patients. The goal of the consultation team is to provide feedback to therapists so that they keep the treatment balanced, to strategies treatment approaches which may be helpful to the patient, to look for what may be missing in any analysis or hypothesis, to help the therapists observe their own limits and values, to strive for phenomenological empathy, and to cheerlead when a therapist becomes demoralized.
A Way of Life
DBT has its roots in Zen philosophy as well as behavioral theory. As a philosophy, Zen considers all reality and individuals as one, and boundaries are seen as delusion. Everything in the world is as it should be and attachment is seen as the root of suffering. In addition, reality as a whole, including one's own actions and reactions, are considered impermanent, yet all individuals have an inherent capacity for enlightenment and truth. DBT utilizes Zen concepts as a basis to encourage patients to be mindful in the current moment, see reality without delusion, and accept reality and themselves without judgment. This skill, which has its roots in Western contemplative and Eastern meditative practices, is called mindfulness.
Mindfulness is a skill which all humans possess naturally, to some degree, yet at the same time is also one that can be developed. In essence, it is the ability to turn one's attention to a chosen focus and to observe, acknowledge, and let go of other thoughts not associated with the chosen focus. Mindfulness exercises in DBT often include observing one's breath, mindfully walking, mindfully doing dishes, mindfully driving, etc.
The goal of mindfulness practice is to fully participate in the present moment with complete awareness yet without judgment. A metaphor we use with patients involves asking them to imagine sitting beside a river while watching leaves float by. Each leaf is a thought or feeling. The idea is not to do anything with the leaves, such as try to make them bigger, try to make them go away, try to change them or even try to not experience them at all. Instead, the idea is to simply watch them float by, label them for what they are (e.g., thought, feeling) and let them go. Mindfulness, as a skill, is taught to patients because it helps them learn to give up on judging themselves and others and thus begin to develop a benign sense of self, provide some degree of distance from emotional experience, and learn to live fully in the here and now. From our perspective, learning to live with more awareness in the present moment is not only a part of developing mental health but is fundamental in learning to lead a more satisfying life.
For our patients, learning to develop a life worth living requires an enormous amount of effort on their part and a willingness to commit to making lifestyle changes which often have little short term benefit. Part of our goal as therapists is to help our patients understand that their self destructive behaviors (e.g., self mutilation, bingeing / purging, drugs / alcohol abuse, etc.) are misguided attempts to "solve" their problems. No human intentionally desires to be miserable. However, for persons struggling with BPD, their frequent attempts to escape emotional pain (e.g., drinking, cutting oneself) on the one hand provide temporary relief (which is why the behavior is repeated), yet produce an increase in shame and less opportunity to practice more effective ways to reduce emotional pain. Thus, to a large degree, the person's chosen solution is the problem, and not the emotion itself. DBT attempts to help individuals understand that emotional avoidance is often the root of their difficulties and teaches people how to distract from emotional pain without increasing shame, learn how to tolerate distress and painful situations, and accept their private experiences in nonjudgmental ways.
Metaphorically, running from emotional experience is like being a bus driver who suddenly realizes she has monsters on her bus. She decides that she must escape from these monsters, and so she drives faster and faster. The problem, of course, is that the monsters are on the bus. No matter how fast she drives she will still have monsters on the bus, and driving fast creates all kinds of other problems in her life and the lives of others (e.g., crashes, tension, speeding tickets, etc.). DBT encourages the patient to slow down the bus - stop, and go back to greet the monsters. The monsters (her feared emotions) look and sound very scary, but in actuality are like holographic pictures. When you reach out to touch them your hand goes right through them. This is because emotional experience is just that, a part of who we are and, by itself, unable to harm us. DBT encourages patients to begin the process of emotional acceptance. By learning to no longer fear emotions the patient begins to experience herself as a whole person, not a compartmentalized self, made up of good and bad parts.
While, one focus of treatment is to help the patient learn ways to modulate intense emotions, change cognitive distortions, and improve interpersonal relationships, too much of a focus on change strategies can mimic the invalidating environment to which the patient was originally exposed. Change strategies to some degree suggest that the patient is the problem and that she cannot trust her own reactions to events. Mistrust of her own reactions to events leads to eventual self invalidation and experiences of shame, fear, and / or anger. This tendency is addressed through acceptance oriented strategies such as mindfulness and the use of validation by the therapist.
Validation in DBT involves five different levels. This first two are similar to other psychotherapies and involve unbiased listening and observing, and eliciting and accurately reflecting the patient's thoughts, feelings, and assumptions. The third step of validation is to articulate for the patient unverbalized emotions, thoughts, or behavior patterns. The idea is to accurately "read their minds" and help them learn to accurately label internal states. The fourth step is for the therapist to validate the person's present behavior based on their past learning history. In other words, from the DBT perspective, any human given the same biological makeup and learning history would end up responding in exactly the same way given the same context. Fifth, the therapist looks for and articulates the part of the patient's response that is valid and / or wise. The idea is that even dysfunctional behavior, to some degree, makes absolute sense at the time the patient engaged in the behavior (e.g., served to reduce pain) and that if the patient could have done anything different (i.e., more adaptive), he or she would have done so. Thus, the therapist validates the grain of truth in any given response, while at the same time he or she works with the patient to change that very same response.
DBT combines Zen philosophy and practice with behavioral analysis and change procedures in the context of Rogerian unconditional regard, empathy, and genuineness. To apply DBT effectively, a therapist has to live DBT (at least from our perspective it works better that way). What this means is that, at its best, DBT is not just a treatment but a way of living. To truly find a way out of the hell associated with BPD, a patient must begin to make a commitment to lifestyle changes, in the face of what at times feels like impossible odds. Our consistent experience has been that DBT provides a map, a compass, and the road.
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