Dialectical Behavior Therapy for Borderline Personality Disorder

Dialectical Behavior Therapy for Borderline Personality Disorder

Steve Weber

University of Oklahoma

Dialectical Behavior Therapy for Borderline Personality Disorder

         Dialectical Behavior Therapy (DBT) was developed in the late 1980’s by Dr. Marsha M. Linehan. The psychosocial therapy was designed by Linehan to specifically treat individuals with borderline personality disorder (BPD) whose behaviors were not only ineffective, but quite often harmful and life-threatening. Specifically, Linehan’s initial focus when developing the intervention was on those with the most dangerous behaviors including extreme self-mutilation and suicidal ideations and actions (Westen, 2000). Linehan, a practicing psychologist, modified cognitive behavioral therapy (CBT) to specifically address the characteristics and needs of her clients who suffered from BPD (Westen). The cornerstone of DBT theory is the application of acceptance and change. DBT therapists convey their unconditional acceptance for the client and the client’s thoughts and behaviors. The therapist encourages the client to accept themselves in a similar fashion. With that acceptance, the therapist and client explore the debilitating and dangerous consequences of certain thoughts and behaviors and what skills can be used to modify them into more acceptable and less threatening behaviors. Originally, DBT was designed for an outpatient setting. However, it has also successfully been used in psychiatric inpatient and forensic settings (McCann, Ball, Ivanoff, 2000). According to the American Psychiatric Association (2006), no less than a dozen randomized controlled trials have shown DBT to be affective at reducing the severity and rate of self-injurious behaviors, the numbers and lengths of inpatient hospitalizations, the numbers of clients dropping out of treatment, and the rate of suicidal ideation. The randomized studies also indicated that DBT, compared to standard individual therapy, significantly reduced substance abuse and depression in individuals with BPD (American Psychiatric Association).

DBT’s Foundational Theories

Linehan based the development of DBT upon three broad theories. These theories are the biosocial theory of development, dialectical philosophy, and behavioral theory (Rizvi, Steffel, & Carson-Wong, 2013).

Biosocial Theory

            Linehan proposed that a biological dysfunction must be present which enables extreme emotional dysregulation seen in clients with BPD (Rizvi, Steffel, & Carson-Wong, 2013). This described biological irregularity in the brain is thought to allow greater emotional sensitivity and reactivity while also allowing slower returns to baseline emotional levels. In summary of the biological theory, BPD can develop when the above-mentioned biological irregularities are exposed over time to an invalidating environment where emotions are routinely discounted by caregivers (Rizvi, Steffel, & Carson-Wong). Additionally, recent studies indicate that an early childhood development of impulsivity is also a biological factor associated with the formation of BPD (Koerner, 2013).

Behavioral Theory

DBT therapists use behavioral theory as the foundational theory to guide them in almost every aspect of how DBT is administered. Behavioral theory has a significant impact on the assessment of behaviors, conceptualization of problems, the methods used to apply interventions, and the overall assessment of each individual’s case. With DBT, behavior theory dictates that interventions should decrease unhealthy behaviors while maximizing adaptive behaviors. For example, in the case of self-mutilation, behavioral descriptions would define in very precise terms the magnitude and frequency of the self-mutilation and the circumstances leading to the behaviors. The intervention would then specify well defined objectives for lessening the magnitude and frequency of the self-injury. Within DBT, behavior is defined as not only a person’s actions, but also his or her thoughts and feelings. DBT is designed to decrease unhealthy behaviors and increase adaptive behaviors. Treatment plans focus on identifying maladaptive behaviors and decreasing their frequency or intensity, what antecedents may trigger the behavior, and how to improve on past outcomes of those behaviors. DBT therapists follow behavioral theory philosophy with the beliefs that ongoing problem behaviors are the result of poor skills, unrecognized antecedents, and ineffective emotional and cognitive processing. Thus, treatment focuses on enhancing all those areas where deficiencies exist (Rizvi, Steffel, & Carson-Wong, 2013).

Dialectical Theory

            Broadly speaking, dialectical theorystatesthat opposing and dynamic forces form the basis for reality. In other words, opposite thoughts and views can exist simultaneously and harmoniously within a person’s thoughts. For instance, “I want to be sober” and “I want to drink alcohol” or “I hate you” and “please don’t leave me” can be co-occurring thoughts within an individual. These contradicting views are very disturbing for people with BPD who often perceive people and circumstances as being very “black or white” with no room for margins of error in either direction. Dialectic philosophy allows for the argument that two truths, although possibly very contradicting, can be present and allowed at the same time. For example, a person with BPD may believe that being abandoned by a mate would most likely be the end of their world as they know it. The person is unable to process any thoughts other than abandonment is unacceptable and dire consequences would result. On the other hand, he or she realizes that abandonment is always a possibility in relationships; it happens to others and it could happen in their case to. This is the conflict the therapist must address. In such a case, dialectical philosophy allows for the existence and acceptance of each circumstance. Allowing, accepting, and being at peace with conflicting viewpoints and possible circumstances is a key component of DBT’s desired outcomes for the client. With DBT, the dialectic focuses primarily on allowing both change and acceptance (Rizvi, Steffel, & Carson-Wong, 2013).

Treatment Method

DBT consists of four treatment modes (Rizvi, Steffel, & Carson-Wong, 2013).These treatment modes are individual psychotherapy, available telephone consultations with the therapist (outside of normal sessions), skills training, and regular treatment team meetings with the involved therapists. The individual psychotherapy sessions are usually scheduled weekly for one hour. The skill training is performed in group therapy settings and usually consists of a weekly group session lasting for at least two hours. Optimum outcomes from DBT are usually achieved with treatment regimens of 12 months. DBT’s four treatment modalities are designed to address five functions of the client. These functions (1) increase a client’s motivation for change, (2) elevate and improve the capabilities of the client, (3) generalize the newly acquired and modified capabilities to the client’s relative environment and life circumstances, (4) enhance the therapists’ motivation and abilities, and (5) structure or modify the client’s environment to reinforce the client’s positive changes and gains (Linehan, 1993).

Stages of Treatment

Although DBT consists of five stages of treatment, the stages do not provide or imply that there is a session-by-session guide for treatment; in other words, the stages are not necessarily addressed in a linear fashion. While many other types of interventions are protocol-based, DBT is principle-based. Protocol-based interventions tend to adhere to guidelines that dictate session-by-session treatments. On the other hand, DBT’s principle-based philosophy is flexible and does not map out the content or objectives of interventions in a step-by-step manner. The therapist can adjust each session to match the current needs of the client. Oftentimes, as milestones are reached in one area, another area may suffer and need to be re-addressed. For homework, the client is assigned Diary Cards which are completed in the days between each session. With the Diary Cards, the client details his or her daily achievements or problems. In the beginning of each individual therapy session, the therapist and client review the cards and the therapist adjusts the session accordingly. For example, a client may be well into therapy and working at Stage IV. However, a significant event may have recently occurred that caused the client to engage in severe self-mutilation or suicidal ideations. In such cases the therapist would return the focus to Stage I in order to address the immediate needs of the client.

The therapy begins with a pretreatment stage where goals, expectations, and the client’s commitment to therapy are established. This stage also includes the initial foundation for a strong therapeutic alliance between the client and therapist.

Following pretreatment, the therapy moves to Stage I. The purpose of this stage is to address and reduce unhealthy behaviors. Clients are considered in Stage I when their behaviors are a threat to their survival or greatly reduce their quality of life. In this stage the client should acknowledge the triggers associated with the behaviors and learn new and effective behavioral skills to cope with those triggers. Stage I is also where behaviors that interfere with therapy are addressed. For example, the causes of missed appointments or tardiness and incomplete homework would be addressed while in Stage I.

Stage II addresses the client’s feelings of internal misery and desperation. According to Linehan (1993), these internal feelings are more easily addressed once harmful and interfering behaviors are under control (Stage I objectives). Also during this stage, clients begin working on other co-occurring problems such as anxiety, moderate depression, and moderate substance abuse.

Stage III allows the client to focus on more common issues such as gaining self-respect and refining everyday social skills. Also included in this stage is the building of trust in one’s self and improving personal happiness.

Stage IV is the last stage of DBT. It focuses on self-awareness and spiritual fulfillment. Addressing discontentment and examining one’s purpose for life is also part of Stage IV.

Phone Coaching

When clients encounter issues in between sessions that result in confusion for how to use or choose particular skills for a given situation, they are encouraged to call their therapist. Included with comprehensive DBT therapy is a 24-hour hotline that clients have access to for calling their therapist. The calls are typically short and last less than 10 minutes. The use of the hotline is prohibited in the 24 hours following an instance of self-injury. The reasoning for this rule is that the issue was already solved by the client in an unhealthy way. The episode will be discussed during the next individual therapy session. Additionally, the 24-hour rule exists so as not to reinforce the maladaptive behaviors by providing attention from the therapist (Rizvi, Steffel, & Carson-Wong, 2013).

Treatment Team Consultations

            Treatment team meetings are held throughout the treatment process. These consultations between the individual therapists, the group therapists, and their supervisors are usually held on a weekly basis. These meetings are necessary for enhancing the therapist’s motivation and skills as well as ensuring that treatment fidelity is maintained. Team therapists may seek advice for specific cases for how best to apply DBT. Additionally, they may seek personal help from the team when feelings of burnout or frustration are experienced (Rizvi, Steffel, & Carson-Wong, 2013).

Comprehensive DBT

As mentioned earlier in this paper, there is substantial evidence, with randomized studies that DBT can significantly reduce maladaptive behaviors in individuals with BPD. Taken as a whole, clients receiving DBT significantly reduce their frequency and intensity of self-mutilation, they have fewer instances of suicidal ideations and attempts, and they experience fewer future in-patient hospitalizations with shorter stays . Additionally, these studies have shown that DBT significantly improves the overall quality of life outcomes for individuals with BPD (Rizvi, Steffel, & Carson-Wong, 2013). However, every randomized study analyzed comprehensive DBT only. Comprehensive DBT includes individual psychotherapy once per week, 2 ½ hours of group skills training per week, 24-hour hotline access to therapists, and the weekly treatment team meetings between all involved therapists and supervisors. To date, there have been no studies that have looked at partial applications of DBT. Therefore, even though aspects of DBT might be successfully integrated into small, private practice clinics, it is important that practicing therapists make the distinction between applying only select components of DBT versus applying comprehensive DBT. It would be unfair and unethical to suggest to clients they are receiving evidenced based therapy in the form of DBT when in fact they are only receiving components of the comprehensive version. Because many aspects of DBT’s individual therapy approach are quite similar to methods used in CBT, it is likely more appropriate that therapists using only aspects of DBT philosophy maintain the labeling of their therapeutic methods under the umbrella of CBT methodologies.

DBT for Substance Abuse Disorder

Numerous studies indicated a strong association between substance use disorder (SUD) and BPD. The studies find that between 26 percent and 84 percent of individuals diagnosed with SUD also are diagnosed with BPD (Dimeff, & Linehan, 2008). When DBT is applied to individuals with BPD, substance use is often one of the harmful behaviors addressed. Randomized trials have shown that individuals with SUD are more than twice as likely to remain in treatment when DBT is used for the intervention. Additionally, DBT recipients experienced significantly reduced rates of substance use compared to Twelve-Step program results during 16-month follow-up evaluations (Dimeff & Linehan). Few studies have been done with respect to the efficacy of using DBT with individuals without BPD. The literature only describes studies involving the use of DBT to treat individuals with eating disorders and without BPD. To date, no studies have examined the use of DBT with individuals with SUD without BPD. However, Dimeff and Linehan, with evidence from numerous randomized studies, described the significant success rates for treating SUD in clients with BPD. Although Dimeff and Linehan believe the length and intensity of DBT may be problematic and ill-advised for most individuals with SUD (and without BPD), there are many aspects of dialectical theory that are appropriate for incorporating into the treatment of substance use in a wide range of cases. Dimeff and Linehan of course caution that all evidence based interventions for treating SUD should be given priority for the type of intervention selected.

Dialectical Behavior Therapy and Twelve-Step Programs

            There are several note-worthy differences and similarities between DBT and traditional Twelve-Step programs. The Serenity Prayer incorporated into the Twelve-Step program remarkably mirrors DBT’s philosophy of change and acceptance – “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” Additionally, Twelve-Step programs promote spirituality and inner peace which is in line with DBT’s eastern philosophy of mindfulness and self-awareness.

However, the two approaches for treating substance use differ in how success is defined and obtained. Specifically, DBT and Twelve-Step programs utilize very different approaches for achieving a state of abstinence in individuals with SUD. In Twelve-Step interventions, only total abstinence is acceptable; without abstinence, the program offers no definitions for success. This all-or-nothing approach is one of the main aspects critics of the Twelve-Step programs point to (Dimeff, & Linehan, 2008). Dimeff and Linehan describe how this all-or-nothing approach within treatment all but guarantees “failure” in the beginning of treatment. Additionally, the black and white view of success can increase the severity of use in single episodes as individuals may take the position of, “I’ve already failed with this one drink, I might as well go ahead and enjoy myself.”

According to the literature, DBT takes an entirely and apparently more successful approach to abstinence. Of course abstinence may in fact be a long-term goal, but a DBT intervention allows for the acceptance that simply decreasing the number of episodes or the amount of use during those episodes (or both) can lead to significant improvements in an individual’s wellbeing. DBT incorporates a failing well approach when clients temporarily revert back to heavier or more frequent use of substances. The instances of relapse are used to further understand and learn about behaviors instead of being examples of failure. When relapse occurs, the DBT therapist gently guides the client back to Stage I in order to address behavior, antecedents and what skills to use in future and similar circumstances. During relapse, DBT encourages acceptance of self and focuses on adapting skills and adjusting behaviors in order to minimize future relapse. DBT, in contrast with Twelve-Step programs, embraces the concept of “three steps forward, two steps back” while addressing relapse and achieving healthy levels of substance use or outright abstinence when possible (Dimeff, & Linehan, 2008).

Offering DBT in Private Practice

            Many clinicians in private practice believe that DBT’s multi-modal structure prohibits its use in such small settings. However, with creative thinking, comprehensive DBT is being successfully offered in small practices. In such cases like-minded therapists have connected and established working teams to administer DBT. Additionally, some teams have joined together to form larger and more informative treatment teams which communicate during consultations via internet technology (White, 2007). This larger team approach can assure quality services to the client, for example, by having ample back-up therapists on-call for the 24-hour hotline. Clients should of course be informed of the arrangement and that their cases will be discussed among treatment team members who may or may not be employed in the same practice.


Personality disorders are well known for being difficult to treat. However, with the ever-increasing amounts of empirical evidence that DBT is a reliable intervention for treating BPD, the intervention is increasing in popularity in the United States and around the world. Perhaps one of the most exciting aspects of DBT is how effective the intervention is for treating co-occurring disorders often associated with BPD. Studies have shown that eating disorders, substance use, and severe depression can be successfully treated during DBT interventions. Lastly, clinicians considering DBT in their practice are reminded that evidence only supports the comprehensive application of DBT’s four modalities. Significant training and resources are required before individual therapists and agencies can successfully implement DBT.



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