Marc Macian

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 star 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 there’s a behavioural deregulation (linked to suicide intentions
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 don’t mind about them.
Marc Macian

- ​perfect families​don’t tolerate negative emotional reactions by their sons/daughters

- ​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 self-image (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 m​eetings 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 effectivity 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, m​eetings 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 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,
Marc Macian

interpersonal and positive relation between the therapist and the client. Treatment stages are
headed by the cutback of behaviours which interfere in the patient’s life, this one’s 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 devil’s 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
patient’s 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 patient’s problem.
Lastly we find the central strategies, are compounded by validation and resolution. In the one
hand there’s 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
what’s dysfunctional, DBT uses techniques that come from the cognitive-conductual therapy,
like self-monitoring, 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.

Bibliographic references
Marc Macian

- Marsha M., L. (1993). ​Manual de tratamiento de los trastornos de personalidad límite.​ New
York: The Guilford Press

- Aaron t., B., Freeman, A., & , O. (1992). ​Terapia cognitiva de los tratamientos de personalidad​.
New York: The Guilford Press.

- Elices, M., & , S.C. (2011). ​Terapia dialéctico conductual para el tratamiento del trastorno
límite de la personalidad. R
​ etrieved April 2013,from
http://revista.psico.edu.uy/index.php/revpsicologia/article/view/67/26

- Aramburú Fernandez, B. (1996).​La terapia dialéctica conductual para el trastorno límite de la

personalidad. R
​ etrieved April 2013, from
http://www.behavioralpsycho.com/PDFespanol/1996/art08.1.04.pdf

Audiovisual material

The next link explains the DBT therapy and the borderline disorder, as well as it’s relation, while
the second gives a more cynical explanation of what the borderline disorder is about.

http://www.youtube.com/watch?v=n9Qmjcd7Wm4
http://www.youtube.com/watch?v=iraGmA7-9FA