Dialectical Behaviour Therapy:

Treating the dramatic symptoms of borderline personality disorder


IN THE FIRST MONTH THAT SHE BEGAN treatment, Michelle* overdosed and slashed her arms repeatedly, landing her in hospital a dozen times. But she didn't die. In fact, she never wanted to die.

While some people with borderline personality disorder such as Michelle are suicidal, suicide was not Michelle's intent, explains Dr. Shelly McMain, supervisor of the Centre for Addiction and Mental Health program where Michelle is treated. These types of self-harming acts, carried out without the person actually wanting to commit suicide, are what are termed "parasuicidal tendencies," and they're not unusual for people with the disorder. They were Michelle's way of communicating painful emotions, McMain says.

For years, there was no one established treatment for people with borderline personality disorder. Then in the early 1990s, Dr. Marsha Linehan, a professor of psychiatry and psychology at the University of Washington, introduced a new treatment regime called Dialectical Behaviour Therapy (DBT). In 1991 the groundbreaking results of a study headed by Linehan were published -- in which researchers found that the condition of 47 severely dysfunctional, chronically parasuicidal women with borderline personality disorder improved significantly when undergoing DBT.

"DBT is the first approach that has really given people a sense of hope or optimism," says McMain. "Compared to treatment as usual, DBT has been shown to help reduce parasuicidal behaviour and substance abuse, and to decrease these individuals' reliance on the health care system."

Without understanding the impact of the disorder on people's lives, it's difficult to realize the significance of such a discovery. Those afflicted with the disorder -- 75 per cent of whom are women -- are impulsive, highly sensitive emotionally and prone to sudden and dramatic shifts in their mood. Therapists can expect to be worshipped one minute and vilified the next. They can expect frightening and dangerous behaviours that are extremely difficult to change -- and for the disorder to be accompanied by other conditions such as eating disorders, addictions or mood disorders. They can also expect clients to miss appointments, or drop out, thereby compromising their treatment.

But with DBT, both clients and therapists have reason for optimism. DBT combines cognitive and behavioural therapy strategies by blending Western psychology and Eastern Zen practice in what Dr. Linehan terms "the reconciliation of opposites." "The most fundamental dialectic is the necessity of accepting patients just as they are within a context of trying to teach them to change," Dr. Linehan writes in Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993). "DBT blends a matter-of-fact, somewhat irreverent and at times outrageous attitude about current and previous parasuicidal and other dysfunctional behaviours with therapist warmth, flexibility, responsiveness to the patient and strategic self-disclosure."

It sounds like an oxymoron. But the key is to validate and also to challenge the client, says Isabelle Niquette, a psychologist at the Community Mental Health Centre in Moncton, N.B. If a client says she's quitting therapy, instead of trying to convince her to stay, for example, the therapist might ask if she'd like a referral.

Clients participating in DBT programs make use of a combination of therapies. They attend skills training meetings with about six or eight other clients for two hours a week. They keep a diary card, receive individual therapy -- usually once a week for 60- to 90-minute sessions -- and have access to telephone consultations with the therapist.

Niquette describes the behavioural analysis component of DBT. "It assesses minute by minute, second by second, the [problematic] event. We don't necessarily focus on what they did so much as what led up to that, so we have to look at what went on, and we go into excruciating detail. Usually it's really painful for clients... at first, but after a while they get used to the type of questions we ask them, and they get to the answers -- the thoughts, emotions, body memories, reactions of others -- looking at what is reinforcing the parasuicidal behaviour."

DBT is particularly innovative in that it also incorporates support for therapists, skills trainers and group facilitators as an integral component of treatment. (In fact, in Washington, DBT is covered by third party insurance only as long as the clinician support component is included, says McMain.)

DBT is a slow, difficult process -- often taking more than a year before clients abandon their dangerous high-risk behaviour.

"Many of the clients I work with don't feel justified in asking for help unless their arms are dripping with blood," says McMain. But it does help. Michelle hasn't overdosed or cut herself in more than four months. And she recently went back to work.

*not her real name

DBT makes its way to Canada...

While DBT spread like wildfire through the States, it's only recently been introduced in Canada, where there are still only a handful of programs.

The first was established in 1995 at the Community Mental Health Centre in Moncton, N.B., with three therapists, two psychologists and a nurse for 12 clients.

Another was developed at the CAMH, where McMain works. Her program -- as far as she knows -- is the only one to specifically target clients with both a diagnosis of borderline personality disorder and a substance abuse problem. Like the Moncton program, the ratio of staff to clients is high.

The reason for the paucity of Canadian programs is that therapists learning to practice DBT often have to go to the United States for training. However Corrections Canada is carrying out some DBT training, and the CAMH will be launching its own introductory and advanced DBT training courses in the early new year.

From the September/October 1999 issue of "CrossCurrents" The Journal of Addiction & Mental Health

DBT Skills Discussion List Work Linehan's DBT skills to cope with BPD. This list can be very helpful but is not designed as a replacement for (not is it) therapy. It is a moderated peer-support list that facilitates the dicussion and working of Linehan's DBT Skills.

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The Borderpd List is one for anyone who has Borderline Personality. It is a list that offers support, it is those with BPD supporting each other. From time to time we do have people in relationships with Borderlines (non-borderlines) who join the list and from time to time, professionals who join as well. So, while the list is open to all with an interest in Borderline Personality Disorder, it is first and foremostly for those with BPD.

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Last up-dated January 14, 2006