Q: While we’re bumping up awareness for borderline personality disorder (BPD), perhaps you could help us understand dialectical behavior therapy (DBT). I’ve heard that it’s the only effective therapy for BPD, but I don’t know much about it. I’m often skeptical of magic bullets, and I’m wondering what your take is on this. Thanks! -Ariel P.
P.S. I always enjoy your posts. Thanks for talking about these difficult issues with clarity and honesty.
Lordy, how healthy skepticism warms my heart. Too often in this world, emotion passes as evidence. If you feel that the polar bear population is declining, or that The Beatles are better then Elvis, then it must be true. (Fact: The Beatles are not better than Elvis.)
That kind of irrational obedience to emotion happens to be characteristic (though not indicative) of borderline personality disorder. Dialectical behavior therapy is certainly no magic bullet – it is not that easy. It can involve years of hard work but dedicated patients have reported improved lives, and DBT has demonstrated measurable reductions in problems such as anger, self-mutilation, and psychiatric inpatient visits.
I dislike the term “personality disorder” because it conveys hopelessness to an unyielding, irreparably damaged state. People with borderline personality disorder (BPD) often suffer that stigma, even among some of my colleagues. I prefer the term “personality style.” As labels go, it holds much more hope for change. The fact is, the symptoms of BPD can be replaced with new skills, and lives can be improved. Dialectical behavior therapy (DBT) seems to be the best hope at hand for borderline sufferers.
I can see where DBT might develop the reputation of an untested “miracle cure.” My profession has sold its share of snake oil in the past. Treatments like Critical Incident Stress Debriefing come to mind. It was unempirical, embarrassing to my industry, and it arguably did more harm than good. On the surface, DBT might bear some resemlance: one reason for the success of DBT is simply that clinicians like it – hardly a justification for promoting a treatment, and one that frequently accompanies fraudulent or unsupported “magic bullets.”
But in this case, popularity does not portend impotence. DBT, having been a mainstream treatment for more than a decade, has data to back it up. From a theoretical standpoint, DBT is simple, rational, and almost poetic in its design. (Sorry if I seem misty-eyed. Not everyone shares my romantic attachment to sound treatment models.)
The ABCs of DBT
People suffering from BPD are plagued by fears of abandonment, unstable relationships in which they alternately idealize and devalue people, impulsive and reckless behavior, and chronic feelings of emptiness. Living with a borderline sufferer can be an emotional rollercoaster with periods of adoration punctuated by high drama and undiluted fury.
DBT tackles the symptoms of BPD through a combination of group and individual therapy. The individual component provides a place to discuss progress and cope with the crises that inevitably pop up in the life of someone with a borderline personality style. But the real meat of DBT happens in the structured group meetings where participants study up on four skill sets (Linehan, 1993):
Mindfulness: Participants learn to notice their thoughts and emotions without necessarily acting on them or trying to change them. If you’ve ever had a “heat of the moment” moment in which you were swept up in emotion and later regretted your actions, then you have had a small taste of one of BPD’s most pronounced symptoms. Thoughts and emotions can simply overpower the borderline sufferer. DBT mindfulness training helps participants develop a detached, accepting view of emotions so that they can avoid emotional reactivity.
Interpersonal effectiveness: Participants study skills similar to those offered in assertiveness and interpersonal communication classes. They learn how to pursue their needs and interact with others more effectively than they have in the past.
Emotion regulation: A primary experience of the borderline sufferer is intense, rapidly shifting emotion. DBT participants learn to respond thoughtfully to their emotional experience rather than being tossed about helplessly like a boat on a stormy ocean. Trainers discuss the possibility of changing emotional states, but the primary focus is on responding to emotions constructively rather than engaging in a futile battle to eliminate painful emotions.
Distress tolerance: Sometimes, life’s problems matter less than how we respond to them. Participants learn how to tolerate and rise above crises rather than reacting blindly or frantically attempting to eliminate bad experiences through destructive coping mechanisms like substance abuse or suicide.
Unfortunately, DBT groups are frequently limited by real-world limitations such as funding and so they are often presented in blocks of several weeks. Ideally, DBT takes place weekly for as long as a few years. Frequently, medication is added to the mix to help manage emotions while the participant is brushing up on new skills. If all of that seems like a large investment, consider the alternative: a lifetime of misery, danger, chaos, and destructive relationships – not to mention a high risk of suicide.
Hard Work and Change
DBT has its skeptics; as any good theory should. Some have pointed out that while DBT is “promising,” we don’t know how it works, exactly, and it therefore cannot be considered an evidence-based practice (Martens, 2005).
Still, DBT accomplishes something beyond the effects one would expect from standard good therapy. Compared to patients receiving other forms of treatment, DBT participants are half as likely to attempt suicide, require fewer hospitalizations, are less likely to intentionally harm themselves, and are less likely to drop out of treatment. The data have been consistent through many studies.
As to why DBT works, I’m sure the debate will continue. In the meantime, I stand by my preference for the more optimistic term “personality style” rather than “personality disorder.” Bottom line: people can improve destructive ways of relating… if they are willing to work hard. DBT appears to genuinely provide the framework for doing so.
Feigenbaum, J. (2007). Dialectic behavior therapy: An increasing evidence base. Journal of Mental Health, 16(1), 51-68.
Linehan, M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press.
Linehan, M., Comtois, K.A., Murray, A.M., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766.
Martens, W.H.J. (2005). Therapy on the borderline: effectiveness of dialectical behavior therapy for patients with borderline personality disorder. Annals of the American Psychotherapy Assn, 8(4), 5-12.