Borderline Personality Disorder

and Dialectical Behavioral

Therapy (DBT)

Sharon Fischman, LCSW-C

St. Luke’s House and Threshold Services United
 Borderline Personality Disorder
• Instability in interpersonal behavior, marked
by intense and unstable relationships
• Impulsive and unpredictable behavior
• Profound, inappropriate shifts in mood and
affect
• There is a high rate of self-injury without
suicide intent, as well as a significant rate of
suicide attempts and completed suicide
• Patients often need extensive mental health
services, and account for 20% of psychiatric
hospitalizations
• While a person with depression or bipolar
disorder typically endures the same mood for
weeks, a person with BPD may experience intense
bouts of anger, depression, and anxiety that may
last only hours. These may be associated with
episodes of impulsive aggression, self-injury, and
drug or alcohol abuse. Distortions in cognition and
sense of self can lead to frequent changes in long-
term goals, career plans, jobs, friendships, gender
identity, and values. Sometimes people with BPD
view themselves as fundamentally bad, or
unworthy. They may feel unfairly misunderstood
or mistreated, bored, empty, and have little idea
who they are. Such symptoms are most acute
when people with BPD feel isolated and lacking in
social support, and may result in frantic efforts to
avoid being alone.
• People with BPD often have highly unstable patterns of
social relationships. While they can develop intense
but stormy attachments, their attitudes towards
family, friends, and loved ones may suddenly shift from
idealization (great admiration and love) to devaluation
(intense anger and dislike). They may form an
immediate attachment and idealize the other
person, but when a slight separation or conflict
occurs, they switch unexpectedly to the other extreme
and angrily accuse the other person of not caring for
them at all. Even with family members, individuals with
BPD are highly sensitive to rejection, reacting with
anger and distress to any separations.
 Dialectical Behavioral Therapy
• Dialectical Behavioral Therapy (DBT) is a form of
therapy that has been found to be effective in treating
Borderline Personality Disorder.
• The most important of the overall goals in DBT is
helping clients create “lives worth living.” What makes
a life worth living varies from client to client.
• The balance between acceptance and change
strategies in therapy form the fundamental “dialectic.”
“Dialectic” means “weighing and integrating
contradictory facts or ideas with a view to resolving
apparent contradictions.” In DBT, therapists and clients
work hard to balance change with acceptance, two
seemingly contradictory forces or strategies.
• The central dialectic is that everyone is doing
the best he or she can AND that everyone has
to try harder, do better, and want to change
more.
• A key assumption in DBT is that self-
destructive behaviors are learned coping
techniques for unbearably intense and
negative emotions. Negative emotions like
shame, guilt, sadness, fear, and anger are a
normal part of life. However, it seems that
some people are particularly inclined to have
very intense and frequent negative emotions.
• An invalidating environment is also a major
contributing factor. “Invalidating” refers to a failure to
treat a person in a manner that conveys
attention, respect, and understanding..

• A vicious cycle can get started: The person is really sad

and scared, she has no one who listens to her, she is
afraid to ask for help or knows no help is available, and
so she tries to kill herself. Then, when her pain is
treated seriously at the hospital, she learns (without
being conscious of it) that when she’s suicidal, other
people understand how badly she feels. Repeated self-
injury can result if it is seen as the only means for
getting better or achieving understanding from other
people.
 Stages of treatment

• Eliminate life-threatening behaviors

• Eliminate therapy-interfering behaviors
• Focus on quality of life behaviors
 Open-Minded Thinking
• Seeing things in a new way
 Open-Minded Skills
• Two ideas can both be true at the same time
• Two things that seem like (or are) opposites can both be true
(you are doing the best that you can AND you need to try
harder, do better, and want to change more)
• A life worth living has both comfortable and uncomfortable
parts
• Being open-minded means letting go of being “right” and “all
or nothing” thinking
• It means listening to yourself and others, seeing things in a
new way, getting unstuck, taking responsibility for your own
behavior
• No one owns the truth
• We might not have caused all our problems, but we have to
solve them
• Avoid words like always, never, you make me.
• Look at all sides of an issue
 Validation
• What we think and feel is
real, important, and makes
sense
 Validation Skills
• Emotions, thoughts and sensations are all experiences
that we sometimes doubt in ourselves. Telling
ourselves and others that what we (they) feel is
real, important, and makes sense.
• Validation does not mean that you agree or approve of
a behavior. Validation is not worried about right or
wrong.
• Look at the person, not the behavior.
• Describe the facts of the situation, name your
feelings, tell yourself (or someone else) that it’s OK to
feel this way.
 Balanced Thinking
• Focus on what is happening right now.
Reasoning mind and feeling mind are in
balance.
 Balanced Thinking Skills
• Balanced thinking is the ability to think and feel at the
same time.
• Thinking mind + feeling mind = balanced thinking mind.
• Notice what is happening. Notice that how you feel.
Notice that thoughts and feelings come and go like
waves. Notice what comes through your senses. Have a
teflon coating.
• Be part of what is happening right now – be mindful in
the moment.
• Be non-judgmental (separate your own thoughts and
feelings and focus on the facts).
• Be effective – focus on your goals.
 Calming Skills
• Balancing my thoughts and feelings
 Calming Skills
• Feelings are not good or bad. They just are. And they don’t
last forever.
• DBT is not about stopping feelings.
• Feelings are the reason you have urges.
• Feelings help us to communicate, help us do things (act
now, stay focused), and give us information.
• Feelings aren’t facts.
• Thinking or wanting to do something is part of having a
feeling. Your response may be different than someone
else’s response.
• People tend to avoid painful or uncomfortable feelings. DBT
asks you to experience these feelings, sometimes without
doing anything to change them.
 Calming Skills
• Events lead to thoughts that lead to feelings
that lead to choices.
• We can’t control what we feel, but we can
control our behaviors.
• Make a list of positive experiences, calming
skills, and a plan for staying strong.
Distress Tolerance
• Getting through painful
situations without making
them worse
 Distress Tolerance Skills
• Self-soothe
• Think of pros and cons (of using skills and not
using skills)
• Urge management
• Radical acceptance – this is how life truly is
• Be willing rather than willful
 Getting Along Well With Others
• Playing nice in the sandbox of life
 Getting Along Well With Others Skills
• Try to get the thing you want effectively
• Remember your goals
• Keeping and improving your self-respect and
liking yourself
• Getting what you want (or accepting that you
won’t) using Dear Man statements
• Maintaining relationships – GIVE (be gentle, act
interested, validate, use an easy manner)
• Keeping respect for yourself – FAST (be fair to
yourself and the other person, apologize for what
you’re responsible for but not for having an
opinion, stick to values, be truthful)
 Questions?
• So how do we apply this in the
moment and outside therapy?
• Any questions?
• Any concerns?
• If you would like more training on
DBT or have any questions, call
Sharon Fischman at St. Luke’s House and
Threshold Services United at 301-896-4221.