CCM: Treating borderline personality disorder from a Dialectical Behavioural Therapy (DBT) A small glimpse to the borderline disorder

and Dialectical Behavioural Therapy

I will dedicate the following lines to explain how border lines are treated with DBT, but first I should explain what DBT is. Dialectical behavioural therapy (DBT) is focused, overall, in gaining a strong therapeutic link, using dialog as main weapon. Marsha Linehan (1993) shows us three basic characteristics:

1. Understanding thoroughly reality, in other words, patients may learn not only self-management, but also the ability to interfere in his environment.

2. Reality is not something static, the patient is trapped in (three) polarities (reckoning the first one as the need of accepting himself the way he is, the second refers to the tension between having what he wants or what he needs, moreover, the last has to do with the maintenance of the clients personal integrity and the acceptance of his/hers points of view on his or hers troubles facing the new abilities which lead to a non suffering way of life).

3. Real nature of reality is change, not its structure nor content, to put it in another way, therapy is not centered in keeping an stabilized atmosphere but make the patient comfortable with the change.

The author opts for providing self-confidence to the patient as well as a chance for a change, instead of only basing the therapy in acknowledging the change within the patient, in which case it would be noxious for him because we would be supporting his fear of being mentally insane, besides, if the intervention was centered on gaining a profitable bond between the therapist and the patient, the last one could feel undervalued due to the feeling of not considering what the patient is experiencing as important. Marsha Linehan defined a Biosocial approach for making the borderline disorder more understanding. The leading dysfunction in this disorder, in terms of this Biosocial point of view, is a lack of regulation in different aspects. To start with, we find the emotional deregulation based on an affective instability, which is followed by an interpersonal deregulation (defined by the fear of being abandoned), secondly theres a behavioural deregulation (linked to suicide intent ions and impulsivity), a cognitive deregulation (dissociative symptoms) and a self deregulation (based on emptiness). Therefore, there are incapacitating environments, that teach the patient that their emotional reactions are inappropriate as in trivializing his or her thoughts and emotions, but without receiving any solutions nor any type of counselling (Elices, M and Cordero, S. 2011). Moreover, Linehan defines three types of invalidating families:

- Chaotic families: where their members suffer from alcoholism or any other kind of abuse and spend no time with their sons/daughters or they simply dont mind about them.

- Perfect families sons/daughters

dont

tolerate

negative

emotional

reactions

by

their

- Typical families over control emotions and cognitions.

In fact, borderline disorder is defined by a long-lasting pattern of perception, relation and thoughts leaded to the environment and oneself in which appears several problems related to the interpersonal behaviour, the mood and the selfimage (Beck, Aaron T., Freeman, A., 1992). As a result the most impressive features are the heaviness of the emotional reactions, mood instability; normal borderline patients present erratical problems, such as self-damage, as well as, illogical and unpredictable problems. Another remarkable fact of being a person who suffers from borderline personality disorder is to swing from neurotic to psychotic behaviours (Linehan, 1993). As a conclusion, treating borderline disorder implies great skills from the therapist due to he or she needs extra patience, tact, self-confidence and hope for change.

What treatment relates DBT and borderline disorder

DBT is structured the following way: first of all we find individual psychotherapy, followed by skill training group, telephone consulting, finally there is the meetings of the therapeutic team consulting (Elices, M and Cordero, S. 2011). From now on I will explain one by one each step, individual therapy is based on planning the treatment, helping integrate what learnt in the other steps. Whereas the second phase, is made up of four units: mindfulness, tolerance to physical discomfort skills, interpersonal effectiveness and emotional regulation skills. The principal aim of these is to teach abilities which will help to reduce some dysfunctional behaviours (as self-injuries) and replace them for behaviours which consequences are less aversive. First of all mindfulness abilities must be taught, these will last a year and come from oriental practitioners and is based on focusing in emotions and thoughts trying to describe without any kind of judgement. Emotional regulation abilities help patients to reduce impulsive behaviours. Furthermore, interpersonal effectiveness skills may teach assertiveness and reaching their goals keeping self-respect and others, all units might be completed in six months but it is recommended that patients rotate twice through all units. Talking about the third part of the process, telephone consultancy has the duty to generalize the learnt abilities in the group therapy. This type of consultancy follows a protocol: the patient has to make contact with his individual therapist before executing the harmful action, these are brief calls in which the therapist evaluates the kind of risk in which the patient is. Finally, meetings of the therapeutic team consulting is designed for counselling individual therapists and training group aptitudes referring to possible difficulties that might appear.

From now on I will explain the treatment program and whatever I consider worth mentioning related to it, the bright side of DBT is that it offers a wide range of cognitive and behavioural therapeutic strategies for borderline treatment, including patients with suicidal tendencies, besides DBT treats also, through fearful stimulus exposition, all avoidance tendencies of the subject. It is continually trying to promote the construction and sustenance of a collaborative, interpersonal and positive relation between the therapist and the client. Treatment stages are headed by the cutback of behaviours which interfere in the patients life, this ones followed by the reduction of actions which interfere in therapy (arriving late or not arriving), the same way are treated the comportment that interferes with the lifestyle (isolation, working problems...). At last the therapy reinforces the conductive abilities which are taught in the skill training group. After all this conductive redirection, comes the stage of working with the post-traumatic stress, various authors find a relation in traumas during childhood and BLD, confirming that there are high rates of trauma in borderline patients, in summary, Golier et al. (2003) found that a huge number of patients suffered from physical abuses during their childhood and adolescence, on the same wavelength, Wilkins and Warner (2001) reported a combination of emotional and sexual abuses and parental neglect in patients diagnosed with BLD.

Henceforth I will talk about the variety of strategies that bear in mind DBT, first of all we find the dialectical strategies, the central strategies, there are also case management strategies and the stylistic ones, I will only talk about the first to, since they are the essentials for DBT. Linehan (1993) defines eight dialectical strategies: entering paradox shows the patient which situations, thoughts or emotions may seem contradictory but they might not be after all; the use of metaphors is an alternative way of showing dialectical behaviours, and for instance, easier to remind; the devil's advocate is used for making the patient comfortable in terms of change; extending is in, terms of emotions, equal to the devils advocate; activating the wise mind, in DBT there is three states of mind: the rational one (which activates when we think intellectually), the emotional one (when behaviours are leaded by emotions), the wise mind is the integration of those two, due to it unifies observation, logical reasoning, sensitive experience, intuition and apprenticeship (Linehan, 1993); making lemonade from lemons which means using the patients resistance against them; permitting the natural change means that reality is a process, it develops and changes; finally dialectical evaluation consists in keeping an objective point of view towards the patients problem. Lastly we find the central strategies, are compounded by validation and resolution. In the one hand theres the validation, this involves reflecting the acceptance of the actions, the thoughts and emotions of the patient; while in the other, problems resolution is focused in change, this two strategies must be used in every interaction with the patient with the intention of changing whats dysfunctional, DBT uses techniques that come from the cognitive-conductual therapy, like selfmonitoring, behaviour analysis, cognitive restructuring and self-exposure. Therefore, as a conclusion I would say, DBT might be the most effective technique to treat the borderline disorder due to its centered-in-the-interaction strategies, its integrative and non-excluding position.