Dialectical Behavior Therapy

Patients showing the features of Borderline Personality Disorder as defined in DSM-IV are notoriously difficult to treat (Linehan 1993a). They are difficult to keep in therapy, frequently fail to respond to our therapeutic efforts and make considerable demands on the emotional resources of the therapist, particular when suicidal and parasuicidal behaviours are prominent.

Dialectical Behaviour Therapy is an innovative method of treatment that has been developed specifically to treat this difficult group of patients in a way which is optimistic and which preserves the morale of the therapist.

The technique has been devised by Marsha Linehan at the University of Washington in Seattle and its effectiveness has been demonstrated in a controlled study, the results of which will be summarised later in this paper.

BORDERLINE PERSONALITY DISORDER

Dialectical Behaviour Therapy is based on a bio-social theory of borderline personality disorder. Linehan hypothesises that the disorder is a consequence of an emotionally vulnerable individual growing up within a particular set of environmental circumstances which she refers to as the 'Invalidating Environment'.

An 'emotionally vulnerable' person in this sense is someone whose autonomic nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to baseline once the stress is removed. It is proposed that this is the consequence of a biological diathesis.

The term 'Invalidating Environment' refers essentially to a situation in which the personal experiences and responses of the growing child are disqualified or "invalidated" by the significant others in her life. The child's personal communications are not accepted as an accurate indication of her true feelings and it is implied that, if they were accurate, then such feelings would not be a valid response to circumstances. Furthermore, an Invalidating Environment is characterised by a tendency to place a high value on self-control and self-reliance. Possible difficulties in these areas are not acknowledged and it is implied that problem solving should be easy given proper motivation. Any failure on the part of the child to perform to the expected standard is therefore ascribed to lack of motivation or some other negative characteristic of her character. (The feminine pronoun will be used throughout this paper when referring to the patient since the majority of BPD patients are female and Linehan's work has focused on this subgroup).

Linehan suggests that an emotionally vulnerable child can be expected to experience particular problems in such an environment. She will neither have the opportunity accurately to label and understand her feelings nor will she learn to trust her own responses to events. Neither is she helped to cope with situations that she may find difficult or stressful, since such problems are not acknowledged. It may be expected then that she will look to other people for indications of how she should be feeling and to solve her problems for her. However, it is in the nature of such an
environment that the demands that she is allowed to make on others will tend to be severely restricted. The child's behaviour may then oscillate between opposite poles of emotional inhibition in an attempt to gain acceptance and extreme displays of emotion in order to have her feelings acknowledged. Erratic response to this pattern of behaviour by those in the environment may then create a situation of intermittent reinforcement resulting in the behaviour pattern becoming persistent.

Linehan suggests that a particular consequence of this state of affairs will be a failure to understand and control emotions; a failure to learn the skills required for 'emotion modulation'. Given the emotional vulnerability of these individuals this is postulated to result in a state of 'emotional dysregulation' which combines in a transactional manner with the Invalidating Environment to produce the typical symptoms of Borderline Personality Disorder.

Patients with BPD frequently describe a history of childhood sexual abuse and this is regarded within the model as representing a particularly extreme form of invalidation.

Linehan emphasises that this theory is not yet supported by empirical evidence but the value of the technique does not depend on the theory being correct since the clinical effectiveness of DBT does have empirical support.

MODES OF TREATMENT

There are four primary modes of treatment in DBT :

1.Individual therapy
2.Group skills training
3.Telephone contact
4.Therapist consultation

Whilst keeping within the overall model, group therapy and other modes of treatment may be added at the discretion of the therapist, providing the targets for that mode are clear and prioritised.

The individual therapist is the primary therapist. The main work of therapy is carried out in the INDIVIDUAL THERAPY sessions. The structure of individual therapy and some of the strategies used will be described shortly. The characteristics of the therapeutic alliance have already been described.

Between sessions the patient should be offered TELEPHONE CONTACT with the therapist, including out of hours telephone contact. This tends to be an aspect of DBT balked at by many prospective therapists. However, each therapist has the right to set clear limits on such contact and the purpose of telephone contact is also quite clearly defined. In particular, telephone contact is not for the purpose of psychotherapy. Rather it is to give the patient help and support in applying the skills that she is learning to her real life situation between sessions and to help her find ways of avoiding self-injury. Calls are also accepted for the purpose of relationship repair where the patient feels that she has damaged her relationship with her therapist and wants to put this right before the next session. Calls after the patient has injured herself are not acceptable and, after ensuring her immediate safety, no further calls are allowed for the next twenty four hours. This is to avoid reinforcing self-injury.

SKILLS TRAINING is usually carried out in a group context, ideally by someone other that the individual therapist. In the skills training groups patients are taught skills considered relevant to the particular problems experienced by people with borderline personality disorder. There are four modules focusing in turn on four groups of skills:

1.Core mindfulness skills.
2.Interpersonal effectiveness skills.
3.Emotion modulation skills.
4.Distress tolerance skills.

The 'core mindfulness skills' are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment.

The 'interpersonal effectiveness skills' which are taught focus on effective ways of achieving one's objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people.

'Emotion modulation skills' are ways of changing distressing emotional states and 'distress tolerance skills' include techniques for putting up with these emotional states if they can not be changed for the time being.

The skills are too many and varied to be described here in detail. They are fully described in a teaching format in the DBT skills training manual (Linehan, 1993b).

The therapists receive DBT from each other at the regular THERAPIST CONSULTATION GROUPS and, as already mentioned, this is regarded as an essential aspect of therapy. The members of the group are required to keep each other in the DBT mode and (among other things) are required to give a formal undertaking to remain dialectical in their interaction with each other, to avoid any pejorative descriptions of patient or therapist behaviour, to respect therapists' individual limits and generally are expected to treat each other at least as well as they treat their patients. Part of the session may be used for ongoing training purposes.

STAGES OF THERAPY AND TREATMENT TARGETS

Patients with BPD present multiple problems and this can pose problems for the therapist in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organised into a number of stages and structured in terms of hierarchies of targets at each stage.

The PRE-TREATMENT STAGE focuses on assessment, commitment and orientation to therapy.

STAGE 1 focuses on suicidal behaviours, therapy interfering behaviours and behaviours that interfere with the quality of life, together with developing the necessary skills to resolve these problems.

STAGE 2 deals with post-traumatic stress related problems (PTSD)

STAGE 3 focuses on self-esteem and individual treatment goals.

The targeted behaviours of each stage are brought under control before moving on to the next phase. In particular post-traumatic stress related problems such as those related to childhood sexual abuse are not dealt with directly until stage 1 has been successfully completed. To do so would risk an increase in serious self injury. Problems of this type (flashbacks for instance) emerging whilst the patient is still in stages 1 or 2 are dealt with using 'distress tolerance' techniques. The treatment of PTSD in stage 2 involves exposure to memories of the past trauma.

Therapy at each stage is focused on the specific targets for that stage which are arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy but it is essential for therapists working in each mode to be clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking.

The hierarchy of targets in individual therapy for example is as follows:

1.Decreasing suicidal behaviours.
2.Decreasing therapy interfering behaviours.
3.Decreasing behaviours that interfere with the quality of life.
4.Increasing behavioural skills.
5.Decreasing behaviours related to post-traumatic stress.
6.Improving self esteem.
7.Individual targets negotiated with the patient.

In any individual session these targets must be dealt with in that order. In particular, any incident of self harm that may have occurred since the last session must be dealt with first and the therapist must not allow him or herself to be distracted from this goal.

The importance given to 'therapy interfering behaviours' is a particular characteristic of DBT and reflects the difficulty of working with these patients. It is second only to suicidal behaviours in importance. These are any behaviours by the patient or therapist that interfere in any way with the proper conduct of therapy and risk preventing the patient from getting the help she needs. They include, for example, failure to attend sessions reliably, failure to keep to contracted agreements, or behaviours that overstep therapist limits.

Behaviours that interfere with the quality of life are such things as drug or alcohol abuse, sexual promiscuity, high risk behaviour and the like. What is or is not a quality of life interfering behaviour may be a matter for negotiation between patient and therapist.

The patient is required to record instances of targeted behaviours on the weekly diary cards. Failure to do so is regarded as therapy interfering behaviour.

TREATMENT STRATEGIES

Within this framework of stages, target hierarchies and modes of therapy a wide variety of therapeutic strategies and specific techniques is applied.

The core strategies in DBT are 'validation' and 'problem solving'. Attempts to facilitate change are surrounded by interventions that validate the patient's behaviour and responses as understandable in relation to her current life situation, and that show an understanding of her difficulties and suffering.

Problem solving focuses on the establishment of necessary skills. If the patient is not dealing with her problems effectively then it is to be anticipated either that she does not have the necessary skills to do so, or does have the skills but is prevented from using them. If she does not have the skills then she will need to learn them. This is the purpose of the skills training.

Having the skills, she may be prevented from using them in particular situations either because of environmental factors or because of emotional or cognitive problems getting in the way. To deal with these difficulties the following techniques may be applied in the course of therapy:

1.Contingency management
2.Cognitive therapy
3.Exposure based therapies
4.Pharmacotherapy

The principles of using these techniques are precisely those applying to their use in other contexts and will not be described in any detail. In DBT however they are used in a relatively informal way and interwoven into therapy. Linehan recommends that medication be prescribed by someone other than the primary therapist although this may not be practical.

Particular note should be made of the pervading application of contingency management throughout therapy, using the relationship with the therapist as the main reinforcer. In the session by session course of therapy care is taken to systematically reinforce targeted adaptive behaviours and to avoid reinforcing targeted maladaptive behaviours. This process is made quite overt to the patient, explaining that behaviour which reinforced can be expected to increase. A clear distinction is made between the observed effect of reinforcement and the motivation of the behaviour, pointing out that such a relationship between cause and effect does not imply that the behaviour is being carried out deliberately in order to obtain the reinforcement. Didactic teaching and insight strategies may also be used to help the patient achieve an understanding of the factors that may be controlling her behaviour.

The same contingency management approach is taken in dealing with behaviours that overstep the therapist's personal limits in which case they are referred to as 'observing limits procedures'.

Problem solving and change strategies are again balanced dialectically by the use of validation strategies. It is important at every stage to convey to the patient that her behaviour, including thoughts feelings and actions are understandable, even though they may be maladaptive or unhelpful.

Significant instances of targeted maladaptive behaviour occurring since the last session (which should have been recorded on the diary card) are initially dealt with by carrying out a detailed 'behavioural analysis'. In particular every single instance of suicidal or parasuicidal behaviour is dealt with in this way. Such behavioural analysis is an important aspect of DBT and may take up a large proportion of therapy time.

In the course of a typical behavioural analysis a particular instance of behaviour is first clearly defined in specific terms and then a 'chain analysis' is conducted, looking in detail at the sequence of events and attempting to link these events one to another. In the course of this process hypotheses are generated about the factors that may be controlling the behaviour. This is followed by, or interwoven with, a 'solution analysis' in which alternative ways of dealing with the situation at each stage are considered and evaluated. Finally one solution should be chosen for future implementation. Difficulties that may be experienced in carrying out this solution are considered and strategies of dealing with these can be worked out.

It is frequently the case that patients will attempt to avoid this behavioural analysis since they may experience the process of looking in such detail at their behaviour as aversive. However it is essential that the therapist should not be side tracked until the process is completed. In addition to achieving an understanding of the factors controlling behaviour, behavioural analysis can be seen as part of contingency management strategy, applying a somewhat aversive consequence to an episode of targeted maladaptive behaviour. The process can also be seen as an exposure technique helping to desensitise the patient to painful feelings and behaviours. Having completed the behavioural analysis the patient can then be rewarded with a 'heart to heart' conversation about the things she likes to discuss.

Behavioural analysis can be seen as a way of responding to maladaptive behaviour, and in particular to parasuicide, in a way that shows interest and concern but which avoids reinforcing the behaviour.

In DBT a particular approach is taken in dealing with the network of people with whom the patient is involved personally and professionally. These are referred to as 'case management strategies'. The basic idea is that the patient should be encouraged, with appropriate help and support, to deal with her own problems in the environment in which they occur. Therefore, as far as possible, the therapist does not do things for the patient but encourages the patient to do things for herself. This includes dealing with other professionals who may be involved with the patient. The therapist does not try to tell these other professionals how to deal with the patient but helps the patient learn how to deal with the other professionals. Inconsistencies between professionals are seen as inevitable and not necessarily something to be avoided. Such inconsistencies are rather seen as opportunities for the patient to practice her interpersonal effectiveness skills. If she grumbles about the help she is receiving from another professional she is helped to sort this out herself with the person involved. This is referred to as the 'consultation-to-the-patient strategy' which, among other things, serves to minimise the so-called "staff splitting" which tends to occur between professionals dealing with these patients.

Environmental intervention is acceptable but only in very specific situations where a particular outcome seems essential and the patient does not have the power or capability to produce this outcome. Such intervention should be the exception rather than the rule.

REFERENCES

Linehan, M.M. (1993a) Cognitive Behavioural Treatment of Borderline Personality Disorder. The Guilford Press, New York and London.

Linehan, M.M. (1993b) Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press, New York and London.

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. & Heard, H.L. (1991) Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

Linehan, M.M., Heard, H.L. & Armstrong, H.E. (in press) Dialectical behaviour therapy, with and without behavioural skills training, for chronically parasuicidal borderline patients.

Stone, M.H. (1987) The course of borderline personality disorder. In Tasman, A., Hales, R.E. & Frances, A.J. (eds) American Psychiatric Press Review of Psychiatry. Washington DC; American Psychiatric Press
inc. 8, 103-122.

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