Treatment for Borderline Personality Disorder
People diagnosed with Borderline Personality Disorder, or BPD for short, often experience very significant psychological pain and distress. They have a great deal of difficulty regulating their emotions, which frequently feel out-of-control and uncomfortably intense. Attempts to manage these emotions are often ill advised, perhaps destructive or impulsive, and can have distressing ripple effects through interpersonal relationships.
Since the early days of so-called “talking therapy”, attempts have been made to develop effective treatments for people with a diagnosis of Borderline Personality Disorder. Until fairly recently treatment approaches have, to a large degree, failed people with this diagnosis. Problems with emotion regulation can make it very difficult to attend sessions regularly and work on ongoing treatment goals that incorporate long term strategies, when there may be a strong desire to focus solely on recent and current upsets. The sheer number of problems that people with Borderline Personality Disorder often experience make it hard to select and maintain a focus for the sessions, and too often in the past these clients have experienced being “put in the too hard basket”.
The development of Dialectical Behaviour Therapy
In the late 1970’s, Cognitive Behaviour Therapy, or CBT, was becoming a recommended treatment approach for a range of serious psychological problems, including Borderline Personality Disorder. However, despite its clear effectiveness for people with many kinds of psychological difficulties, CBT appeared to be failing clients with BPD. During the 80’s a now-well-known clinical psychologist called Marsha Linehan attempted to improve psychological treatment for people with Borderline Personality Disorder. She wanted to address some of the issues in standard CBT that were causing clients with BPD to become frustrated with their treatment or leave therapy altogether. This resulted in the development of the treatment we now know as Dialectical Behaviour Therapy, or DBT.
Validation and acceptance
Marsha studied the application of standard CBT to treating people with Borderline Personality Disorder and realized that one important factor in treatment failure was the focus in standard CBT on change. For people with Borderline Personality Disorder, this focus on change can feel highly invalidating, reinforcing their sense that they, and everything about them, are wrong, need changing, don’t make sense, and so on. Marsha therefore introduced one of her major innovations, which is the emphasis on validation and, more generally, acceptance, as counter-balancing strategies for the change strategies in traditional CBT. Validation and acceptance strategies communicate to people that they are both acceptable as they are, and that their behaviors, including those that are self-harming and destructive, make sense in authentic ways – for example, as attempts to manage emotions or respond to distressing events in their environment. Marsha also noted that in many situations, these individuals’ thoughts, feelings, and behaviors were “perfectly normal”, and that it was very helpful to support them in learning how and when to trust themselves and their responses, rather than teaching them that always or nearly always their emotional and behavioural responses don’t make sense and should be disregarded or altered. This emphasis on acceptance did not mean that treatment stopped emphasizing change – people with BPD also must change if they want to build a life worth living. Rather, Marsha developed the strategies of acceptance and change to balance and support each other during the course of each session and of therapy as a whole.
The second major innovation, linked to the first, was the introduction of the notion of dialectics to the treatment of Borderline Personality Disorder. Dialectics is a “world view” which proposes, among other things, that we let go of thinking or acting in extremes, seeing only black or white, holding rigidly to one point of view. When we are thinking dialectically we can see both the black and the white –they can both be true. This kind of world view can be incredibly helpful in managing our responses to events and experiences, and in interpersonal situations. Please see my blog post “What does the “D” stand for in DBT?" for more information about dialectics.
A third important addition Marsha made to standard CBT in developing DBT is the use of mindfulness. Mindfulness is now part of many treatment approaches, but when DBT was published in 1993 it was the first treatment to incorporate mindfulness. Mindfulness is a core DBT strategy and is used in every group and individual DBT session.
DBT is effective in the treatment of people with Borderline Personality Disorder
Dialectical Behaviour Therapy, or DBT, has a range of other strategies, including the establishment of a consultation group for the therapists to ensure their adherence to DBT principles, the development of a hierarchy of behaviors to address in individual sessions to avoid either the client or the therapist becoming overwhelmed, the importance of both group skills training sessions and individual sessions, and more. Research has shown DBT to be extremely effective in reducing suicidal behavior, non-suicidal self-injury, rates of hospitalisation, treatment dropout, substance abuse, episodes of anger and low mood, and in improving social functioning and overall ability to manage life.
The development of Dialectical Behaviour Therapy as an evidence-based treatment has been a very significant milestone for people with the diagnosis of Borderline Personality Disorder. This is an effective treatment, and if you or someone close to you has features of Borderline Personality Disorder and struggles with regulating emotions, or if you are interested in learning more about treatment for Borderline Personality Disorder, please contact me so that we can discuss the difficulties you are struggling with, and consider whether Dialectical Behaviour Therapy DBT would be a suitable treatment.