Dialectical Behaviour Therapy:
Treating the dramatic symptoms of borderline personality disorder
BY TAMSEN TILLSON
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
"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
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