Dialectical Behaviour Therapy (DBT) for the treatment of Borderline Personality Disorder
Dialectical behaviour therapy (DBT) was developed in the early 1990s in response to the need for effective treatment to help distressed people making repeated attempts at suicide and repeatedly engaging in serious self harm, risky or self-injurious behaviour.
It has since become established as a widely researched and clinically effective long-term intervention and has also been demonstrated as effective in treating patients with mood disorders, bipolar disorder, addiction and recovery from sexual abuse. The DBT programme itself teaches patients skills to decrease suicidal and self-injurious behaviour, manage their emotions and improve their quality of life.
Who benefits from DBT?
Patients who benefit from DBT are often individuals who appear to be living chaotically and are seemingly in a constant state of ‘crisis.’ Doctors, other health professionals and family members often despair at continued self-destructive behaviour in spite of numerous attempts to help them. Typically, such patients:
- Are highly susceptible to sudden and abnormal changes in emotions and have difficulty returning to a normal emotional state. For example, they might feel devastating grief where sadness would be expected, humiliation in place of disappointment and destructive rage instead of anger. They are likely to experience extreme feelings of rejection, failure, isolation and a sense of victimisation
- Attempt to cope with emotional dysregulation in ways which are frequently harmful. Impulsive behaviours are common, including substance or alcohol abuse, indiscriminate sexual behaviour, reckless spending, risk-taking, self-harm and suicidal behaviour. Impulsive behaviours frequently lead to ending of friendships and relationships and loss of employment. Individuals with borderline personality disorder (BPD) may enter a harmful cycle of engaging in the above behaviours leading to intense shame and guilt which leads to further unhelpful attempts to soothe their emotional pain
Untreated BPD leads to escalation in the behaviours described above, frequently resulting in serious self-harm, overdose and suicide. The rate of suicide in individuals with BPD is 8-10% which is 400 times higher than the general population.
How does it work?
DBT comprises a mixture of group based skills training and individual therapy. Groups are always facilitated by two experienced therapists.
The skills have four elements:
- Emotion regulation
- Distress tolerance
- Interpersonal effectiveness skills
Emotion regulation skills enable patients to moderate distressed emotional states and to understand moods and emotions more effectively. Distress tolerance skills enable patients to make sense of and manage crisis situations rather than ‘act out’ their emotions in old, destructive ways. Interpersonal effectiveness (a little like assertion skills) provides skills to help maintain positive relationships and limit interpersonal conflict, which is often the cause of intense emotions. Mindfulness, the skill of observing oneself and environment in the moment and non-judgementally, is fundamental to DBT as it underpins all the other skills.
The skills are introduced in the group, practised during the week, recorded on diary cards and discussed in one-to-one therapy.
What makes DBT different?
The skills of DBT are drawn mainly from cognitive behavioural therapy (CBT) but they are applied differently. In DBT, the focus is on the individual and how they can learn to understand and accept themselves. There is a strong emphasis on developing a personal spiritual programme. It is not expected that patients simply learn the skills and make instant improvements. Instead, through personal commitment, the support of their peers in the group and the relentless encouragement of their therapist, patients come to see their DBT programme not just as therapy but as a way of life. In DBT, the therapist is ‘active’ alongside the patients and, unlike most therapists, is more likely to disclose examples from their own life to support the therapeutic teaching, and may be contacted by the patient on the phone between sessions.
In summary, DBT is not just a form of psychological therapy but a life programme which patients use, initially to prevent serious self-harm or suicide and ultimately to build fruitful, satisfying lives. DBT is a powerful programme which is often an unforgettable experience for patients and practitioners alike and one which undoubtedly has saved many lives.