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Psychotherapy

Psychotherapy

This is the main treatment option in helping clients with borderline personality disorder.  Although medications may help to relieve some of the symptoms related to this disorder, they cannot assist clients in learning new coping mechanisms or emotion regulation.  In psychotherapy, assessment should be regularly conducted in regards to the risk of suicide.  If the client’s feelings of suicide are severe, hospitalisation and the prescribing of medication should be considered.

Dialectical behaviour therapy (DBT)

DBT was designed by Marsha Linehan is regarded as the most effective treatment for client’s with borderline personality disorder as it was created specifically to treat those with the disorder.  The aim of DBT is to teach the client to take control of their emotions and their lives.  It is frequently used through a group therapy setting, although it may not be an ideal treatment for those clients who struggle to learn new concepts.

Dialectical Behaviour Therapy (DBT) has been defined as:

  • “A novel method of therapy specifically designed to meet the needs of patients with Borderline Personality Disorder and their therapists. It directly addresses the problem of keeping these patients in therapy and the difficulty of maintaining therapist motivation and professional well-being. It is based on a clear and potentially testable theory of BPD and encourages a positive and validating attitude to these patients in the light of this theory.

    The approach incorporates what is valuable from other forms of therapy, and is based on a clear acknowledgement of the value of a strong relationship between therapist and patient. Therapy is clearly structured in stages and at each stage a clear hierarchy of targets is defined. The method offers a particularly helpful approach to the management of parasuicide with a clearly defined response to such behaviours.

    The techniques used in DBT are extensive and varied, addressing essentially every aspect of therapy and they are underpinned by a dialectical philosophy that recommends a balanced, flexible and systemic approach to the work of therapy. Techniques for achieving change are balanced by techniques of acceptance, problem solving is surrounded by validation, confrontation is balanced by understanding.

    The patient is helped to understand her problem behaviours and then deal with situations more effectively. She is taught the necessary skills to enable her to do so and helped to deal with any problems that she may have in applying them in her natural environment. Generalisation outside therapy is not assumed but encouraged directly. Advice and support available between sessions and the patient is encouraged and helped to take responsibility for dealing with life's challenges herself. The method is supported by empirical evidence which suggests that it is successful in reducing self-injury and time spent in psychiatric in-patient treatment”.

Stages of DBT

Patients with BPD present multiple problems and this can pose problems for the therapist in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organised into a number of stages and structured in terms of hierarchies of targets at each stage:

  • Pre-treatment stage

This focuses on assessment, commitment and orientation to therapy.

  • Stage 1

Focuses on suicidal behaviours, therapy interfering behaviours and behaviours that interfere with the quality of life, together with developing the necessary skills to resolve these problems.

  • Stage 2

Deals with post-traumatic stress related problems (PTSD)

  • Stage 3

Focuses on self-esteem and individual treatment goals.

The targeted behaviours of each stage are brought under control before moving on to the next phase.

DBT Targets

DBT consists of a hierarchy of targets in which the main goal of each is to increase “dialectical thinking”. An example of such a hierarchy would be:

  1. Decreasing suicidal behaviours.
  2. Decreasing therapy interfering behaviours.
  3. Decreasing behaviours that interfere with the quality of life.
  4. Increasing behavioural skills.
  5. Decreasing behaviours related to post-traumatic stress.
  6. Improving self esteem.
  7. Individual targets negotiated with the patient.

In an individual DBT session, the targets outlined above should be dealt with in that order.  If in between therapy sessions, self harm or any other incidents have occurred these must be dealt with first before the therapist moves on to anything else.

How are DBT sessions structured?

Dialectical Behaviour Therapy is separated into four parts, three of which the client will experience.

1) Individual Therapy
In one to one therapy with a DBT therapist you will work on your self-damaging behaviours and work to continually ensure you are following the skills taught by the DBT course.

2) Group Work
Group work will help you to work on your social skills but also teach you new skills from the DBT modules and ways of implementing these.

3) Telephone support
Should you be feeling suicidal or as if you may be at risk of self-harm then you may contact your therapist or a member of the DBT team to discuss these and work through your thoughts. You will be urged to apply your DBT skills and techniques. You may only call between times agreed between your therapist and yourself.

4) This is for the therapist only
This is the consult group. You could also call it group supervision. This group would meet frequently and is made up by all those who have trained to become DBT Therapists. It’s a place to let off some steam and to make sure you are working effectively and efficiently but also keeping to the model of DBT. The group will encourage you to remain non judgemental and validating of the persons thoughts and feelings.

So now you have a feel for the way the therapy works let’s go into the four separate modules, working on increasing the quality of life of the sufferer.

DBT Skills

Mindfulness

Mindfulness is considered the most important part of Linehan’s DBT skill module. The mindfulness skills focus on "what" and "how" skills; "what" the individual needs to do in order to be mindful and "how" to do this. For example, a typical approach to developing the "what" skill would include an intent and attempt to observe, describe and participate in open dialogue. The "how" skill may require non-judgement, one-mindfulness, and collaboratively determining what is effective.

Interpersonal Effectiveness

Interpersonal effectiveness skills that are used in DBT sessions focus on assertiveness in saying no, making a request, and coping with problems. The purpose of the Interpersonal effectiveness skills are to allow the individual to increase the likelihood of goals being met, while maintaining self respect and keeping the relationship.

Distress Tolerance

Distress Tolerance is the skill set for accepting, finding meaning for, and tolerating distress. This area of DBT focuses on learning to bear the emotional pain resulting from distressing circumstances and events in the individual's life. An important focus in Distress Tolerance is the idea of radical acceptance. Linehan describes radical acceptance as a means by which to free oneself from suffering, and requires a choice to let go of fighting with reality. These skills in "letting go" promote acceptance without judgment or evaluation of the self, others or the situation in general. In theory, focusing on the acceptance of reality rather than the approval of reality will foster a clearer understanding of controllable vs. uncontrollable factors and help facilitate manageability of emotional pain.

Emotional Regulation

Emotional regulation assists individuals with reducing their vulnerability to an emotional state of mind. This is accomplished by providing methods to identify and label emotions, finding barriers in changing emotions and applying distress tolerance skills. The other key component of this skill set is to find ways to increase positive emotional events through healthy living and participation in activities that increase self-confidence.

Downfalls of DBT

DBT is an effective treatment for borderline patients but does have its downsides. These include:

the course being very difficult and requires a lot of commitment,

It excludes those with alcohol, substance misuse and those with eating disorders, even though these groups account for a high number of those with a diagnosis of personality disorder.

 

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