“People with BPD are like people with third-degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.”
― Marsha Linehan
Borderline personality disorder (BPD) is a common long-standing mental disorder, with an enduring pattern of fluctuating moods, self-image, and behaviour, often resulting in impulsive actions and problems in relationships. What makes this disorder complicated to diagnose and manage is the frequently overlapping picture with other mental disorders like anxiety, substance use, major depression, bipolar disorder, or eating disorders.
The statistics related to borderline personality disorder are alarming and makes it evident that effective techniques need to be employed because the overall wellbeing of an individual and those close to him or her is at stake. A recent study by Goodman et al., (2017) concluded that the overall rate for self-harm in those with BPD ranges between 75- 90%, which is a substantial figure. Even though in most cases self-harm is not intended to attempt suicide, almost 10% of the BPD patients who attempted suicide have completed it. Self-harm is one of the common symptoms because of which the patient is brought for treatment, which is an additional reason that the therapist be appropriately skilled and sensitive to the needs of the patient and the situation. The severity of dysfunction caused by this personality disorder can be estimated by the fact that among patients with BPD seen for treatment, 72% have had at least one psychiatric hospitalization. Research also states that patients with BPD use more services (in-patient and out-patient) than those with major depression and other personality disorders. Despite this high-use pattern, patients with BPD are generally regarded as difficult to treat by the professionals. These findings are ironical because even though a major chunk of regular clients that a psychotherapist may be seeing comprise of those with BPD, they are not sure about the outcome of the therapy. This could be because of lack of skills or expertise on the therapist’s part or not being exposed to evidence-based treatments. However, with evidence-based treatments, many patients with BPD experience fewer and less severe symptoms, improved functioning, and an improved quality of life.
It is important for patients to receive individually tailored treatment from a trained mental health professional, in order to ensure the efficacy of the treatment (NIMH, 2017). Dialectical Behavior Therapy (DBT), developed by Marsha Linehan (1993) is one of the evidence-based treatment for BPD patients, with the aim of “creating a life worth living”. DBT is considered an advanced version of Cognitive Behavioral therapy, with the core comprising of mindfulness and meta-cognition skills.
DBT is a synthesis of three paradigms- Dialectics, Behaviorism and Mindfulness. The aims of this therapy are reducing dysfunctional behaviours, increasing skilful behaviours, and building a life worth living. The client is given a validating environment in which s/he is taught to regulate emotions, deal with interpersonal conflicts, tolerate distress, and find balance.
The four areas focussed in this treatment are:
- Mindfulness: improving an individual’s ability to accept and be present in the current moment
- Distress tolerance: increasing a person’s tolerance of negative emotion, rather than trying to escape from it
- Emotion regulation: using effective strategies to manage and change intense emotions that are causing problems in a person’s life
- Interpersonal effectiveness: using practices that communicate assertiveness, maintain self-respect, and build up relationships with others.
In principle, the skills of mindfulness are intrapsychic, psychological, and behavioural versions of meditation, in particular, those associated with Zen spiritual practices. These include ‘what’ skills (such as observing, describing, participating) and ‘how’ skills which consist of taking a non-judgemental position, focusing on one thing at the moment, and being effective. These skills are used to balance states of mind within the individual of which there are three- ‘emotional mind’, ‘reasonable mind’ and ‘wise mind’. In a reasonable mind state, a person is able to think logically whilst in an emotional mind state, the person’s mind is controlled by the present feeling. The wise mind is a combination of rational and emotional mind, letting the person add insight to emotional understanding and logical thought, bringing about a greater synthesis and stability. Thus, mindfulness as a skill will have an impact on emotion regulation (being aware of emotions, thoughts and behaviors), distress tolerance (surviving a crisis, distracting or soothing oneself) as well as interpersonal effectiveness (balance the “wants” and “shoulds”, attend to relationships, self-respect) (Bateman & Fonagy, 2004).
After Linehan’s pioneering work, there have been various books, workbooks, and manuals that focus on using DBT effectively. The one found particularly useful and effective is “The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance” by McKay, Wood and Brantley (2007). It gives basic and advanced activities with adequate descriptions and handouts that can be used within the session and in the day to day life. The next section of this article is majorly adapted from this book.
Activities to develop skills of DBT
It is usually suggested that the therapy begins with a no harm contract, with validation of the client’s feelings. Basic activities targeting mindfulness is a good way to start DBT, even though the therapists can choose what they want to focus on, depending on the client’s immediate needs. Most of these skills have activities that overlap, targeting the development of different skills with practice.
Mindfulness skills are usually built in DBT with basic activities like focus on a single minute, focus on a single object, recording thoughts, describe an emotion, mindful breathing, mindful awareness of emotions; and advanced activities likewise mind meditation, mindful communication with others, daily mindfulness regimen, etc.
Emotion regulation skills are built initially by basic activities like recognizing your emotions, overcoming the barriers to healthy emotions, reducing your physical and cognitive vulnerability, and increasing your positive emotions. Advanced activities are gradually introduced that includes being mindful of your emotions without judgement, emotion exposure, doing the opposite of your emotional urges and problem solving
Interpersonal effectiveness is targeted by basic activities like mindful attention, understanding passive versus aggressive behaviour, “I want-they want” ratio, “I want- I should” ratio, building on key interpersonal like negotiating conflicting wants, saying no in a way that protects the relationship, and acting according to your values. Advanced activities include making a simple request, making basic assertiveness scripts, using assertive listening skills, saying no, coping with resistance and analyzing problem interactions.
Distress tolerance in DBT includes basic activities like radical acceptance coping statements, distraction from self-destructive behaviours (using pleasurable activities, attention to someone else, distracting thoughts or paying attention to tasks and chores), relaxation and soothing during a crisis.
Advance activities that are gradually introduced are safe place visualization, cue-controlled relaxation, rediscovering values, identifying one’s higher power, taking a timeout, self-affirming statements, etc.
In essence, it is utmost important that the therapist has faith in the treatment that he or she is using, and believe that the patient can improve. Even more important is the need for the patient to seek and stick with a treatment.
