Skills Training Manual for Treating Borderline Personality Disorder
Marsha M. Linehan
Dialectal Behavior Therapy
This is a broad-based Cognitive behavioral treatment
First form of treatment for borderline personality disorder shown to be effective in controlled trials (Linehan 1991, 1993).
Understanding philosophy and theory are important because they determine therapist attitude toward the patient suffering from borderline personality disorder. This therapy is a combination of individual therapy and group skills trading. DBT is based on a dialectical world view, which has two meanings: that of the fundamental nature of reality and of the effective dialogue within relationships. Dialectics forms the basis of DBT.
Dialectics stresses the fundamental relatedness or wholeness of reality. This means that analyses of individual parts is of limited value unless it relates the part to the whole. Thus dialectics focuses on the larger context of behavior as well as the interrelatedness of individual behavior patterns. A therapist must take into account first the interrelatedness of skills deficits. However, learning social skills is impossible unless one also learns other skills simultaneously, a task that is even more difficult.
The dialectical view is also compatible with the feminist and contextual views of psychopathology. Learning psychosocial skills is particularly hard when one’s immediate surroundings and larger culture do not support such learning. Therefore, the patient suffering from borderline personality disorder must also learn self-regulation skills as well as skills at better influencing her environment.
[Note that the author uses the pronoun she and her because most patients diagnosed with borderline personality disorder are women and all of the patients enrolled in the DBT trials were only women.]
Second, external reality is not seen as static, but as composed of dynamic, opposing forces, thesis and antithesis, out of whose synthesis evolves a set of new, opposing forces. All propositions contain within them their own oppositions. I assume that truth is paradoxical, that besides each truth stands a contradiction.
Dichotomous, extreme thinking, characteristic of borderline personality disorder, is viewed as a failure of dialectics. The borderline is stuck in polarities, unable to move to synthesis. Three of these polarities cause particular difficulty in treatment:
DBT not only focuses the clients on these polarities, but offers solutions out of them.
The third fundamental of dialectics is the assumption that the fundamental nature of reality is change and process rather than content and structure. The important implication here is that both the individual and the environment are undergoing constant change. The objective of DBT is not to help the client maintain a stable environment, but to become comfortable with change. Therapists must be aware not only of how their clients are changing, but also how they and their therapy are changing over time.
One of the core tenets of the biopsychosocial theory of borderline personality disorder is that the heart of the disorder is emotional dysregulation. This is viewed as joint outcome of biological disposition and environmental interaction.
Borderline personality disorder clients have difficulty with emotional vulnerability and with the ability to modulate emotions. This emotional vulnerability is characterized by:
Emotional modulation is the ability to:
The bottom line is that borderline personality disorder is the combination of an overly sensitive and overreactive emotional system with an inability to inhibit the resulting strong emotional response. The disposition to emotional vulnerability is biologically based, although not necessarily genetically. Any deficit in the complex system of emotional regulation can lead to the difficulties of the borderline personality disorder patient.
It is unlikely that any one biological abnormality will be found that is responsible for all borderline personality disorder.
The Invalidating Environment
The crucial developmental circumstance is the invalidating environment. This is particularly true in a child whose temperament already predisposes them to extreme emotional sensitivity. In this case, the child elicits invalidation from an environment that might otherwise have been supportive. An invalidating environment responds erratically and inappropriately to private experience, such as thoughts, feelings, and sensations, and is particularly insensitive to private experiences with no public accompaniment. In addition, the invalidating environment tends to overreact or underreact to private experience that does have a public manifestation.
The easiest way to illustrate this is by contrasting an invalidating environment with one that fosters more adaptive and effective emotional regulation skills. In a healthier family, when a child says, for example, that she is thirsty, her parents respond by giving her a drink rather than saying, "No, you’re not." When a child cries, the parents soothe or attempt to find out what is wrong rather than saying, "Stop being a crybaby." Frustration is taken seriously rather than dismissed as unimportant. When a child says, "I did my best," the parent agrees rather than saying, "No, you didn't."
In an optimal family, the child’s preferences, e.g., for clothes, color of room, etc., are taken into account. The child’s emotions are viewed as important communications. The response to a child’s expression of emotions will lead to behaviors on the part of the environment and the child that will increase the probability that the child’s needs will be met.
Parental responses that is attuned and nonaversive produce children who are better able to discriminate between their own and other’s emotional states. In contrast, in an invalidating environment, the parental response to expressions of a child’s emotions are not in tune with those underlying emotions, either through nonresponsiveness or through negative responses. Persistent discrepancies between her inner experience and the response elicited in her environment (her external reality) lay the groundwork for many of the behavioral deficits encountered in borderline personality disorder.
An invalidating environment is most concerned with controlling emotional experience, especially the expression of negative affect. Painful emotional experiences are trivialized and attributed to personal deficits, such as a failure to adopt a more positive attitude, lack of discipline, or laziness. Strong positive emotions maybe associated with negative traits such as lack of judgment or impulsivity. Other characteristics of the invalidating environment include restricting the demands the child may make on the environment, discrimination against the child because of arbitrary characteristics such as gender, and using punishment – from criticism to physical and sexual abuse – to control behavior.
The invalidating environment teaches dysfunctional emotional response by failing to teach the child to recognize, label, and modulate emotions, to tolerate distress, or to trust her own emotional responses as valid interpretations of reality. It also tends to invalidate the child’s own feelings, forcing her to scan the environment for cues as to how to think and feel. By oversimplifying the ease of solving life’s problems, it fails to teach the child how to set realistic goals. By punishing the expression of negative emotion and erratically reinforcing emotional expression only after escalation by the child, the family shapes an emotional expression style that vacillates between extreme inhibition and extreme dysinhibition. This arbitrary and extreme response to emotions cuts off the communicative function of ordinary emotions. Emotional invalidation, especially of negative emotions, is characteristic of societies that place a premium on individual self-control and achievement, so is quite common in Western society in general.
A certain amount of emotional invalidation is of course necessary to discipline a child and teach self-control. Not all expressions of emotions or beliefs can be (or should be) responded to in a positive fashion. A highly emotional child with difficulty modulating emotion may elicit from the environment invalidation, which can be effective at temporarily inhibiting expressions of negative emotion. Note also that an invalidating environment may have dramatically different effects on different children; one physiologically able to regulate emotions may emerge relatively unscathed. It is only when the combination of emotional vulnerability and invalidating environment meet that the effect can be devastating.
This transactional view should not be used to diminish the importance of abusive environments in the etiology of borderline personality disorder. Research indicates up to 75% of those suffering from borderline personality disorder experienced some sexual abuse in childhood. It is unclear if the abuse is causative or if both the abuse and the disorder are both signs of the same dysfunctional, invalidating family pathology.
Pathogenesis of Borderline Personality Disorder
The development of self-regulatory repertoires, especially the inhibition or modulation of affect, is one of the most important tasks of childhood. Its absence leads to disruption of goal-oriented and social behavior. Having a repertoire of self-soothing skills allows the child to compete with those whose behaviors is not driven by strong emotions. Impulsive behavior, such as parasuicidal behavior, can be thought of as maladaptive, but highly effective emotional regulation strategies. Although the mechanism is unclear, self-mutilation commonly leads to tremendous relief and reduction of anxiety, and is also very effective at eliciting helping behavior from the environment.
Lacking emotional regulation skills also impairs the development of a sense of self. Generally, one’s sense of self is formed by observations of oneself and people’s reactions to one’s actions. Predictability and consistency over time are prerequisites to one’s development of a stable sense of self. Behavioral inconsistency and cognitive dissonance can interfere with identity development. The numbness associated with inhibited affect is often expressed as inner emptiness, or an inadequate or at times completely absence sense of self. Similarly, if an individual’s perception of reality is never "correct" or not predictably "correct" then an individual may develop an overdependence on others for validation. Success in a relationship depends on both a stable sense of self and a capacity for spontaneity of emotional expression, as well as a tolerance of emotionally painful stimuli and the ability to regulate emotional expression. Without these skills, it is no surprise that borderline personality disorder patients develop chaotic relationships. In particular, difficulty with anger and anger expression preclude the maintenance of stable relationships.
The Treatment Program
DBT applies a broad array of cognitive behavioral therapy strategies to borderline personality disorder. Like standard cognitive behavioral therapy, DBT emphasizes:
Many components (Problem Solving, Exposure Skills Training, Contingency Management, and Cognitive Modification) have been common in cognitive behavioral therapy for years. DBT adds a matter-of-fact, sometimes irreverent, sometimes outrageous attitude toward certain behaviors and circumstances.
Therapists must be warm, flexible, limit-setting, and use strategic self-disclosure to help clients reframe and adopt new coping and interpersonal strategies. The emphasis is on validating the client’s emotional and cognitive responses in the moment just as they are. All therapy-interfering behaviors must be addressed in and out of sessions in a systematic way, including conducting a collaborative analysis of the behaviors, formulating hypotheses about variables influencing the behavior, generating possible solutions, and trying out the implementation of these solutions.
The therapist must pay attention to the cyclical nature of the therapy, and may use natural as well as artificial contingencies, especially when the behavior is lethal. The tendency of borderlines to avoid intense anxiety-provoking situations is a continuing theme in DBT. The therapist should search for the grain of truth inherent in each client response, believe in her ultimate desire to change and grow, and frequently acknowledge the desperate emotional state of the client (validation).
The primary role of the therapist is to be a consultant to the client, not to others; the therapist is consistently on the side of the client. Standard cognitive behavioral therapy was originally developed for patients without serious personality disorders. Some areas of cognitive behavioral therapy have been expanded to deal with borderline personality disorder.
In DBT, four areas are emphasized, while not new, have not received as much attention in pure cognitive behavioral therapy:
DBT began from a view of borderline personality disorder as a combination of motivation problems and capability defecits. They are incapable of inhibiting strong emotional reactions, or of initiating behaviors independent of mood. Second, the invalidating environment inhibits whatever skills the patient may have and reinforces maladaptive borderline behaviors.
DBT separates therapy into two broad areas: psychosocial skills training and motivational issues. The objective is to learn more adaptive self-soothing and interpersonal skills, then to create a life worth living.
4 Specific skills training areas:
Emotion Regulation Skills, especially of anger, mood lability.
Interpersonal Effectiveness Skills: Borderlines tend to do well when in stable relationships, and poorly when not. They tend to frantically cling to relationships even when abusive.
Distress Tolerance: behavioral dysregulation: impulsive, suicidal, parasuicidal behaviors are viewed as maladaptive coping behaviors stemming from an individual’s inability to tolerate negative emotions. One DBT module attempts to teach distress tolerance skills.
Mindfulness Skills to avoid depersonalization, derealization, and other manifestations of a borderline’s absence of self-awareness; this module trains the patient to focus mindfully on herself and her immediate environment.
Each module lasts 8 weeks; average client remains in skills training for 1 year, meaning they cycle through each module twice.
Group members must have borderline personality disorder and have engaged in recent parasuicidal acts, e.g., self mutilation. The fear is that a group of only borderlines will provide no appropriate modeling; in general, this turns out not to be the case. Contagion of suicidal behavior can be a problem, however. It is helpful for borderlines to be around others who can understand the difficulties peculiar to the borderline personality disordered client.
Most skills training occurs in groups, in a didactive format. Older group members are used to help train newer ones.
The term skills is used synonymously with abilities. Effectiveness is gauged by both direct and indirect consequences of behavior. Often a borderline personality disorder patient will have the skills but not be able to put them all together at the right time. Coping actively and effectively with problems is encouraged and trained. The objective of DBT is to replace ineffective, maladaptive solutions to problems with skillful, effective behaviors.
Note that the agenda is not set by the current problems of the client, which can be distracting in a borderline personality disorder patient who may often be distracted by crisis. The therapist must take a very direct, active role; most therapists are not trained to do this. Even those who are have great difficulty staying on task. It is therefore difficult to stick to anything except the crisis du jour. It is particularly difficult to stay on track if a client threatens suicide. It is easy to get difficult with the client and just give up. It can also be boring, like doing the same operation over and over. Therapy drift is much more likely in individual than in group therapy, so group therapy is critical.
Skills training for a borderline is never immediately reinforcing for therapist or client, so is very difficult. It should be done in almost all cases in group therapy, then reinforced individual therapy. Teaching skills therapy to a borderline is like "trying to teach a person to put up a tent in the middle of a hurricane."
How does the therapist teach the client the ability to cope when her current skills set does not allow her to develop new skills?
Groups can be therapeutic if for nothing else than teaching patients to be in a group therapy. Linehan will virtually require group as well as individual therapy. Open group – number of members is variable; new ones come and go – have some advantages over closed group. Borderlines may implore therapist to keep group constant, but this is a good practice of distress tolerance and flexibility.
In a closed group, it becomes much easier to drift since the members become more familiar and comfortable with each other.
DBT individual therapy plus skills training group therapy is superior to either alone.
One difference between DBT and other therapy is that no long-term conflicts can be explored until therapy-interfering behaviors are ameliorated. In skills training, discussion of parasuicidal behavior is generally not discussed out of interests of time; such discussion is usually reserved for individual therapy.
Application of Skills Training
DBT therapy strategies are divided into 5 major areas:
Case Management Strategies
Interaction of client, therapist, and enmeshed social support
Problem-solving of problems as they arise, e.g., suicidal behaviors.
Structuring of DBT skills training: the agenda is set before the client shows up, whereas in individual therapy, the agenda is open until the client shows up.
It is not possible to do well without understanding cognitive modifications, contingency strategies, and limit setting.
Learning a new skill doesn’t necessarily mean having to use it. An overall rational should be given for any skill illustrating why it should be useful. Learning new skills requires practice, practice, practice, especially in situations in which they are actually needed.
DBT does NOT assume that most of a borderline personality disordered patient’s problems are motivational in nature. Instead, skills are taught and changes are monitored. Borderlines may for example confuse being anxious about doing something with being unable to do something.
Some therapists are biased to believe that coaching, giving advice, taking a more direct role, fosters dependency. Others believe that clients can hardly do anything, that they are unable to learn new behaviors. A dialectical solution is to look for synthesis.
Remember that most borderlines are used to punishment, either from their environment or from within, as the primary strategies used in the past to shape their behavior. Over the long run, skill reinforcement by the therapist can modify the client’s self image in a positive way, and enhance their sense that they can control positive outcomes in their life.
Willingness Versus Willfulness
The tension between these is important in treating borderline clients. Willingness is responding to a situation in terms of what the situation requires; willfulness, on the other hand, is responding based on one’s individual needs. Thus, willfulness encompasses both trying to fix a situation and sitting passively on one’s hands, refusing to respond at all. Using these terms can be very helpful with borderline clients.
If you find yourself arguing with patients over whether they or you are being willful or willing, refocus on the situation and ask what is required of the situation.
It is easy to get into a power struggle between group leaders and group members. It is important to balance the need for progress against the needs of the group members.
Content generally takes precedence in group skills training over process except for emergencies. Even if members are hostile, passive, don't want to deal with each other, leaders should try to continue with the content. Sometimes, however, it may be useful to stop and process.
Core Mindfulness Skills
These are the first skills taught and are present on the diary cards clients must complete each week. They are highlighted at the beginning of each module. They are psychological principles distilled from Eastern medication training.
Three states of mind are present:
Reasonable Mind: rational, logical, planning, focused in attention, cool in approach to problems.
Emotion Mind: cognitions are "hot" and swayed by emotion; facts are distorted to be congruent with the emotional state; reason and logic may not be present. Note that most borderlines have very active emotion minds and this is not entirely a bad thing; this makes them passionate about causes and beliefs, and can make them very dramatic and energized. When emotion mind should be examined closely is when it is pleasurable in the short term but drives behavior that is painful in the long-term or when it creates a state that is painful in itself, such as anxiety or depression.
Wise Mind: integration of Reasonable Mind and Emotion Mind. You can’t create emotions with reason or reasons with emotion; you must go in and integrate the two. Wise mind adds intuitive knowing to cognitive knowledge and emotional awareness. Wise mind is that part of a person that can know and experience truth; it is that part of a person’s mind that knows something to be true or valid in a centered way. It has a certain peace.
The Mindfulness Skills attempt to encourage using one’s Wise Mind. There are Three "What Skills": "the goal is to create a lifestyle of participating with awareness"
Observing: client sees without judging. Requires an ability to step back and see oneself. This simply is, without reason, judgment, or labeling. Especially necessary when learning a new skill, e.g., a beginning piano player must observe finger placement. Does not involve words. Very Zen-like; senses alone. Clients should be told to resist the impulse to label.
Describing: applying verbal labels to emotions and thoughts; they should not be taken literally. For example, feeling afraid does not mean that one is actually in danger. Many borderlines (and others) confuse emotions and precipitating events. As a more elaborate exam, rather than say, "I feel my stomach muscles tightening and my throat constricting," they might say to themselves, "I am nervous because I am taking this exam" which may lead to a dysfunctional thought such as, "I am going to fail this test." Also, separating feelings from reality is important, e.g., "I feel unloved" instead of "I am unloved." An exercise is to have the borderline see her feelings as packages coming down a conveyer belt and describe them as they go by. Note that describing ("just the facts") differs from judging, which is labeling something in an evaluative way.
Participating: the ability to engage in an activity without self-consciousness. This involves entering completely into the activities of the moment. Can be mindless, e.g., driving home while thinking of something else, but can also be mindful, meaning participating with attention to the task, such as an athlete focused on an event or game. It is becoming one with something, throwing yourself into something.
Three "How Skills":
Note that judging is often shorthand for something; e.g., "This meat is bad" is actually a chain of thoughts describing outcome: "This meat maybe filled with bacteria. If I eat the meat, I may get sick." We often forget, however, that we are engaging in shorthand and begin to take it literally as a statement of fact.
Don’t judge judging. A teacher giving grades or a butcher throwing out bad meat are both necessary; the problem is that the borderline judges excessively and inappropriately.
Example: tailgating someone who is driving too slowly in the left lane on a highway. This is focusing on what is "right" ("It isn’t right that someone should drive slowly in the fast lane!") versus what is effective ("I should wait for an opportunity to pass but drive safely in the meantime."). It involves taking people where they are, rather than where they should be. Cultural analogy: trying to focus on what is right rather than what works is like trying to impose your culture’s values on a country you are visiting.
Attending to relationships: unattended relationships often blow up; the longer they are unattended to, the harder they are to repair.
Balance priorities (what you want) versus demands (what others want of you). Balance "want’s" versus "should’s."
Build mastery: self respect, self confidence, standing up for what you believe to be right in such a way that you are taken seriously. Getting up after falling down is mastery; falling down is irrelevant.
If you were raised in a punishing family, one that invalidated difficulties, then it is difficult to achieve mastery.
Initiating a discussion and saying No (refusing unwanted or unreasonable requests) are two situations used in skills training as exercises.
Objectives Effectiveness = attaining your goals or objectives in a given situation. Note that patients should be told that even the most skilled individuals have no guarantee of getting their needs met; sometimes environments make this impossible.
Note that many borderlines believe that if they make no demands on others and never complain that their relationships will go smoothly, but this is not an effective strategy. Assertiveness in such a way that the relationship is preserved, that the other person wants to give you what you request (or feels good about saying no), is more likely to lead to preservation of the relationship, and less likely to lead to passive-aggressive behaviors, such as parasuicidal gestures, angry outbursts, or suddenly leaving or sabotaging a relationship.
Self Respect Effectiveness
Attempting to maintain your self respect and feel good about yourself while attempting to attain your objectives, acting in ways that respect your morality and values. Giving in for the sake of approval, lying to please others, diminish self respect and mastery. Acting helpless to force someone to act may work in the short-term buy over the long-run diminishes mastery and increases dependence.
Example: landlord unfairly keeps your deposit. Objective: getting the deposit back while preserving self-respect (by not getting too emotional, fighting dirty, or giving in) and your relationship with the landlord (or at least a good reference). It is important to avoid distracting "worry thoughts" such as, "I’m so stupid, I’ll probably fall apart" or "She’ll probably hate me for asking."
ABSTRACT of summary article:
M. Linehan developed "dialectical behavioral therapy" specifically to treat chronically suicidal borderline patients. It rests on a biosocial model that assumes a disorder in the regulation of emotions and in tolerance of stress. The numerous dysfunctional patterns of behavior such as self-destructive behavior, inability to govern impulses or severe dissociative phenomena are regarded as attempts at problem-solving. This concept of therapy focuses on the continuing balance between the necessity of accepting maladaptive behavior patterns in both an intrapsychic and an interactional context while still working to change them. A comprehensive manual outlines the clearly structured therapy and integrates a wide choice of therapeutic strategies.
Parallel to development of the therapy itself, a method also was developed for testing therapist adherence to the manual's guidelines, thus providing a basis for empirical evaluation. An initial controlled, randomized study demonstrated the significant superiority of this method to methods of unspecific psychotherapy at various levels. In the current endeavor to develop disorder-specific approaches to the treatment of personality disorders, "dialectical behavioral therapy" is a noteworthy model.