Marsha M.

Linehan
r
American psychologist
5 May 1943 - present

T
DBT
Also
for BPD →
mentaligation -
based treatment
(MBD
 Psychotherapy for Borderline
Personality Disorder

Presenter: Ms. Shereena E.A.

Chairperson: Dr. Manjula
Date: 22-03-2010
 Overview

● Introduction
● History
● Characteristics
● Etiology
● Psychotherapy for BPD
Psychodynamic Psychotherapy
Supportive Psychotherapy
Dialectic Behaviour Therapy
● Conclusion
 Introduction

● BPD is a life threatening disorder

● Widely studied and one of the most prevalent neurotic
personalities

Prevalence
● Estimated to be about 2-3% of the general population
● 30-60% among clinical populations
● 5times more likely in first degree relatives
● Women to men (3:1)
● 70-75% have a history of at least one self-injurious act
● Suicide rates for BPD are 9%
 History

● Hoch and Polatin (1949) – “pseudo neurotic

schizophrenia”
● Kernberg (1967) borderline personality organization
● Guderson and singer (1975)- identified criteria clearly
distinguishing BDL from other conditions
● DSM III- BPD first appeared as a category
 Borderline Personality Disorder
DSM IV-TR

● Frantic efforts to avoid real or imagined abandonment

● Pattern of unstable and intense interpersonal relationships
(valuing and devaluing)
● Identity disturbance, unstable self image
● Impulsivity that is self damaging
● Recurrent suicidal behavior, gestures or threats, or self
mutilating behavior
● Affective instability due to a marked reactivity of mood
● Feelings of emptiness
● Inappropriate, intense anger
● Transient, stress-related paranoid ideation or severe
dissociative symptoms
 Characteristics- I RAISED A PAIN
● Identity disturbance
● Relationships are unstable
● Abandonment is frantically avoided
● Impulsive
● Suicidal gestures are made
● Emptiness is a description of inner self
● Dissociative SX
● Affective instability
● Paranoid ideation
● Anger is poorly controlled
● Idealization of others
● Negativistic- undermine their efforts and those of others
 Etiology
● Genetic influence
● Biological
➢ Reduced serotonogenic activity (Siever & Trestman 1993)
➢ Amygdala hyperactivity (Herpetz,2001)
➢ Structural & functional disturbances of PFC, Frontal and
OF lode volume reduction (Tebartz, 2003)
● Psychodynamic
Kernberg (1975)- Disturbance in the mothers emotional
availability during separation- individuation phase- lack
object consistency and thus cannot integrate good and bad
aspects of themselves or their mothers
Environmental factors-
Millon, 1981: Difficult temperament + inconsistent parenting
Biosocial theory- Linehan (1993): Biological vulnerability to
high emotionality + an invalidation environment =
Pervasive dysfunction of the emotional regulation system
Cognitive – Behavioural Formulation (Beck, 1990)
3 basic assumptions
I am powerless & vulnerable
I am inherently unacceptable
The world is dangerous

Dichotomous thinking
 Psychotherapy for BPD
● Most difficult & frustrating, results are uneven
● Assessment – Over all level of functioning & Rx readiness
in making decisions about Rx approaches, modalities &
strategies
● General Principles (Waldinger, 1986)
➢ Therapist must be active in identifying, confronting, &
directing
➢ Stable Rx environment- setting, limits, boundaries,
scheduling, payment of fees, & role expectation of patient &
clinician
➢ Connection btw patient’s actions & feelings need to be
established
➢ Self destructive bhvr must be made ungratifying
➢ Counter transference issues
 Psychodynamic Psychotherapy

Psychoanalytic Psychotherapy
Indications:
● Psychological mindedness-able to see connection btw one’s
difficulties &inner world
● Tolerance to frustration
Sessions- 3 or more / week, minimum of 4 yrs
Challenges- Impulsivity & therapeutic alliance
Goal- Help the client for separation individuation
Indicated only for patients with exceptional strengths
 Supportive Psychotherapy
Goal
● To reduce anger, anxiety and depression that interfere
with the capacity to function adaptively
● To improve their adaptation to daily life &
● To reduce their self-destructive responses to
interpersonal stressors
Techniques: reality testing, encouragement, direction,
problem solving and medication
Klein (1989) – 2 types
1.Confrontative psychotherapy: confronting
resistances that maintain maladaptive behaviour
until they become ego dystonic
2. Counseling : low functioning patients, history of
repeated abuse, neglect or separation trauma,
severe psychiatric regressive episodes, suicidal or
homicidal actions
 DBTR attempts

self
Muy
BID
w_omen
meet criteria
,
of who
of
+ hlo chronic & .

Incorporates :

CBT

Behavioral approaches
¥ systems
emotional
functioning theories

Eastern mindfulness
Western contemplative spiritual practises .

mods of modes

specialists
Primary treatment : IMPLEMENT 4
A¥
1 group skills
training
2 individual
Therapy
3 telephone skills consult at

@ consultation DBT
team
of

:
Therapists had 99 burnout
 to uatealifewoNhlimngT
linehan multifaceted approach
-
THEORETICAL ISSUES

Dietetics . ACCEPTANCE us . CHAN 66

2
types of thinking
would view
of change to
+
process
-

① Formalist universalism
" "

there is absolute teudh

② Relativistic
"
thinking
"
there truths
are
many
I

Dialectics

✓ thinking of
µ ACCEPTANCE t CHANGE +
wind
way
-

SYNTHESIS Of POLARITIES .

Dialectics = would view

ontological perspective of interrelated a wholeness applied to

uyndenstanding
human perspective .

Behavior conceptualized . content

wally
+
systematically
•
across
pouuate a
public observable onpeeiienee
whole
Treating pt as a

The dialectical process of change promotes the resolution of apparently contradictory stances by
yielding an integrated alternative, or a synthesis, that takes into account the fluidity of a constantly
dynamic context.
 1310 SOCIAL THEORY Of BPD .

>
]

[ 1
EMOTIONAL
,
VULNERABILITY
EEE.mg?wdgmo:mignEhmotIgMntenpemin
It
.

verbal communicate
indiscriminately rejected
Biologically pnedispositn pt
chronically pathological having socially as
mediated .

undesirable traits
1 HEIGHTENED SENSITIVITY
b
2 HEIGHTENED REACTIVITY

3 SLOW RETURN TO BASELINE

lack of trust in
self
b
9 reliance on social environment for cues on how to

think feel behave

, ,

DYSREGULATWN t

hypersensitivity to IP cues +
impairment in
interpretation
+ of cues
appropriate behavior punished pervasively
entaeme emotional displays intermittently reinforced
b

escalated
emotnally behavior .

Processes of dysregulation thought to mediate

borderline symptoms include problems with up- or
down-regulation of physiological arousal, inhibition of
mood-dependent behavior, reliance on avoidance
strategies, attentional dyscontrol, processing of
emotional information, self-soothing, and self-validation.
 4 primary modes

: skills
training
group format skills class
-

skills
acquire new
coping
-

↳
sp .
behavioral ,
emotional , cognitive ,
IP skills not learnt earlier in
life .

basis 2h
weekly
-

.
session .

,
4 -10ps .

it honu = HW review : successes ) challenges in

Implementing skills

[ brief mindfulness practise

from previous week

"& hour
c Dff
2 '
new skills
taught
modules

CORE skhl : INTERPERSONAL

vienpress
DISTRESS TOLERANCE EMOTIONAL REGULATN
Mindfulness intended to interrupt and
EFFECTIVENESS
I change habitual and most
inrp
=

problematic responses to acute " " chaotic IPR :

paying attention in emotional distress, allowing the opposite to acting .

Hallmark
opportunity for newer, more
particular Way behavioral ammon
trigger for DSH
-

effective behaviors to emerge. urges alw

t
emotions
skills
crisis
mngmt identify problems E P
.

on purpose .
. .

distract 1 challenge distontns

in present moment temporary Is cmotn
justified ?
-
.
.

. without
judgment
.

eliciting opp . emotns .

2 know action .

urge
•
determine appropriate
central skill ) I anger attack
.

( intensity of
self soothing guilt repair response
-

yy
.

+
.

imaginal anelanatn
ehercisls
justified not justified .
guidelines to
being taken
EFFECTIVENESS µ #

4
behaving consist to repeat repair seriously preserving
,

self
'

ones values +
long
.
term
goals
.

behavior behavior .

respect
) (apologize)

b
but not
coping
]
decisions are eftatiuet
remain within personal values
the of
all emotion .
INTERPERSONAL EFFECTIVENESS
 cards
Diary
-

%
-
chain analysis
2) INDIVIDUAL THERAPY -
skills enhancement

lhr
/ week
validate
,
dialect strategies
-

improve + maintain pt motivatn

environment created
validating

DIARY CARDS
1
monitor
.
to
targets .

2 Behavioral Analysis / CHAIN ANALYSIS

the goal of behavioral analysis is prediction and control of functional classes of problem
behavior rather than traditional diagnostic assessment of disease entities

BPD = viewed as problem beh=auwn - antennal

he internal
←

topography ,
intensity duratn
,
frequency
,

discussed
of target problem
amdned
,
classically
and"ed
is
operantly
t
SOLUTION ANALYSIS .
3 skills enhancement

reinforcement + rehearsal

contingency mngmt
-

Behavioral enposune &

response prevent

4 validatn

5 Dialectical strategies

[ change behavioral acceptance

either .
or - both and
.
 3) Telephone consultatn

pts may enpeuience unrelenting crisis

'

DBT
'

- '

< 10 mins

when pt unable to implement skills

,
but before crisis occurs

rule assistance until 2h after behavior

any self injurious
24 hour : no .

D consultatn team

can help DBT therapists with a more balanced approach toward their patients. A
consultation team also provides opportunities for fresh perspectives and new solutions,
helping therapists to get unstuck and become hopeful.
ASSUMPTIONS t AGREEMENTS IN DBT
LEVEY
OF TREATMENTS

4stagg of DBT DBT House

of Talatment

calling in oiisis

'phip
DSH
①
fanged towards provider
Iintonicatedlate
I
shutting down
② coming
.

hot HW (Idkj
doing +
③ actin
b passivity
( I cant stand it

titnittn.me)
PTSD , ¢DBT
term
))
depression , gelatin peeoblems .
- -

=
-
-

-
PeninatalDBT-pDBT-Biopsychosou.at model

↳ to add thyroid I hormonal depfundm

; social
dysregulation

DBT
strategies for all perinatal paouidus
 active passivity I erapist -

reactivity to pt travesty

£
*
therapy destroying behavior -

repeated crisis
I
behavior -

overt I covert avoidance

leading to therapist burnout .

Ds"

hair-raising communicate
I
I
strategies
distracted in session
-

hostility towards provider I

b
behavior
what to do about
therapy interfering

}
① radical d- in authentic
genuineness an
way
-

anne .

open communication .

pDBTskategg
① Contextualize
-

pt 's behavior
"
all behavior is undeniable in content =

may not be desirably acceptable

done for us t for them
-

② Validate = 6 levels

1) be
present
+
interested

2) accurate reflection
3) the
feeling based behavior
guess on

a) understand behavior from history

5) normalize emotional reactors →
of course
you were

6) radical
+
genuineness amnions
,
anyone
emotionally both ptt therapist would be .

reduce
are
equal to
try to
distress .

encourage pt
to
bring baby to therapy .
diary card PDBT
emotional attachment to
baby
-

chain analysis for postnatal woman

MOI PDBT
I

less intensive
Hw
manageable app
-

emphasis on
family involvement
 Dialectical Behaviour Therapy

● Developed by Marsha M. Linehan (1987) while

working with suicidal individuals
● Now used to treat patients with poor impulse control,
maladaptive behaviors & dysregulated emotions
● Combines standard CBT techniques for emotion
regulation and reality-testing with concepts of mindful
awareness, distress tolerance, and acceptance largely
derived from Buddhist meditative practice
 Origin of DBT
-

● Grew out of series of failed attempt to apply the standard CBT

to chronically suicide clients

● Focusing on change procedures was experienced as

invalidating & often precipitated withdrawal from therapy,
attacks on the therapists, or vacillation between these two pole

● Teaching/ strengthening new skills was extraordinarily difficult

to do within the context of an individual therapy session while
concurrently targeting client’s motivation to die and suicidal
behaviors
 Biosocial Theory of BPD

Biological dysfunction of the emotion

regulation system

Invalidating environment

Pervasive emotion dysregulation

 Dialectics

➢ The process of change whereby an idea or event (THESIS)

generates and is transformed into its opposite (ANTITHESIS)
and is preserved and fulfilled by it, leading to a reconciliation
of opposites (SYNTHESIS)

➢ The most fundamental dialectic is accepting patients just as

they are, while simultaneously encouraging them to change

➢ Supportive acceptance Vs confrontation & change strategies

➢ Integration of eastern Zen practice with western psychological

practice
 Assumptions

● Dialectical philosophy leads to the following

assumptions
1. Patients are doing the best they can. At the
same time, patient wants to improve, but they
need to do better and try harder
2. Patients may not have caused all their
problems, but they have to solve them anyway
3. Patient cannot fail in therapy; rather, if failure
occurs, it is the Rx that fails
A comprehensive, multi component Rx approach
1) Motivational enhancement
2) Skills strengthening Individual
psychotherapy
3) ensure that new capabilities generalize to the
patient’s natural environment - Group skills training
4) enhance therapist capabilities and motivation to treat
patients effectively – a consultation meeting
5) Structuring the environment in a manner that will
promote and reinforce patient and therapist
capabilities
 Two- Pronged approach

Behavioural Target problem Skill deficit

problems

Problem Skill
Mechanism
solving & acquisition &
Behavioural for change strengthening
analysis

Technique Group skills

Individual training
Psychotherapy

Rx
 Individual therapy

● Eliciting commitment
● Diary card and review of target behaviors
● Chain analysis
● Contingency management and behavioral
skills training
● Exposure therapy and cognitive modification
 Diary Cards

● Daily monitor of target symptoms and skills

usage
● Target symptoms include:
- self harm urge and action
- substance use
- suicidal ideation

Allows individual therapist to target most urgent

target symptoms for a session
Chain Analysis

Vulnerability Problem behavior

Prompting event
Links

Consequences
 Chain Analysis

● Analysis is of chain of events moment to moment

over time
● Examine vulnerabilities, antecedents and
consequences of problem behavior
● Examine options for getting on a different path away
from problems behaviors
 Levels of Disorder &Stages of Treatment

● Highly flexible model that can be readily applied to

patients with disorders of varying severity and
complexity
● Linehan conceptualized 4 levels of disorder, each
level having a corresponding stage of treatment
 Levels of Disorder &Stages of Treatment

Level 1: Severe + pervasive Behavioral Dyscontrol

Stage 1: Behavioral Control

Level 2: “Quiet Desperation”

Stage 2: Non-Traumatic Emotional Experiencing
Level 3: Problems in living
Stage 3: Ordinary happiness & Unhappiness
Level 4: Incompleteness
Stage 4: Capacity for joy
 Stage 1 targets

Level 1: Severe Behavioral Dyscontrol

Decrease:
● Life-threatening behaviors
● Therapy-interfering behaviors
● Quality-of-life interfering behaviors
(Joblessness; homelessness; relationship chaos; Axis
I disorders; environmental structuring)
 Goals of Skills Training
● Behaviors to Increase
● Mindfulness Skills
● Interpersonal Skills
● Emotion Regulation
Skills
● Distress Tolerance Skills
● Behaviors to Decrease
● Identity Confusion
Emptiness and Cognitive
Dysregulation
● Interpersonal Chaos
Fears of Abandonment
● Labile Affect
Excessive Anger
● Impulsive Behaviors
Suicide Threats
 Tasks in Core Mindfulness

1. “be in the moment”

2. Allow distance from emotions and situations

3. Dialectical synthesis of emotional mind and reasonable mind

States of Mind

Wise Mind
Reasonable Emotional
Mind Mind
Tasks in Interpersonal Effectiveness

1. Learn to say no and make requests effectively while

maintaining self-respect and important relationships
2. Learn how to balance over-commitment and
involvement with under- commitment and isolation
3. Learn how to balance assertiveness and joining with
others to increase interpersonal relationships and self-
acceptance
Techniques- “DEAR MAN GIVE”

Describe the situation

Express feelings
Assert wishes
Reinforce
(Stay) Mindful- Ignore other persons threat. Just keep making
your point
Appear confident
Negotiate
(be) Gentle
(act) Interested, Validate
(use an ) Easy manner
 Emotion Regulation Skills

● Identifying and labelling emotions

● Identifying obstacles to changing emotion
● Reducing vulnerability to “emotional mind”
● Increasing positive emotional events
● Mindfulness to emotions
● Taking opposite actions
● Applying distress tolerance technique
 Tasks in Distress Tolerance

1.Replace maladaptive coping that works in the

moment with non-destructive in the moment
coping devices
2. Learn to Accept on-going events and discomfort in
order to reduce severe misery
Steps
1. Crisis survival strategies
2. Radical acceptance of reality
 Crisis survival strategies
● Distracting
● Self soothing
● Improving the moment
● Focusing on pros and cons

Accepting reality
● Breathing exercises
● Half- smiling exercises
● Awareness exercises
 Stage II: Decrease Quiet Desparation/ Increase Emotional
Experiencing

The central problem at this level is avoidance of emotions and

any environmental cues associated with them
Goal - to increase the patient’s ability to experience emotions
without trauma

● Orient to exposure treatment

● Exposure to internal and external cues

● Community/Home/In-vivo work

● Develop trust in client wise-mind

 Stage III: Decrease Problems in Living/ Increase Ordinary
Happiness and Unhappiness

Problematic patterns in living that interfere with

goals.
Goal- To achieve ordinary happiness and a stable
sense of self-respect.

● Model, discuss, reinforce “normal” behaviors, life

management skills
● Implement long-term goals
● Decrease individual sessions
● Reduce advice-giving
Stage IV: Decrease Incompleteness/ Increase Capacity for
Joy

● Developing the capacity for sustained joy via

psychological insight, spiritual practices, and an
expanded awareness of oneself
● Linehan et al. (1991) conducted RCT to evaluate the

effectiveness of DBT for the treatment of chronically

parasuicidal women who met the criteria for BPD. Results

revealed that pts who received DBT in comparison to TAU pts

had fewer incidences of parasuicides, were likely to stay in

individual therapy and had fewer inpatient psychiatric days.

Scores on depression, hopelessness and suicidal ideation

decreased throughout the year

● Linehan et al. (2002) did RCT to evaluate whether
DBT would be more effective for haroin-dependent
women with BPD (N=23) than comprehensive
Validation therapy. After 16 month of follow-up
DBT clients were found to have lower levels of
opiate in their urinanalyes and were more accurate
in their self-report of opiate use than those assigned
to CVT.
Rathus et al. (2002) investigated DBT with a group of suicidal
adolescents with borderline personality features. DBT group
(n=29) received 12 weeks of twice weekly therapy consisting
of individual therapy and a multifamily skills training. The
TAU group (n=82) received 12 week of twice supportive-
psychodynamic individual therapy plus weekly family therapy.
Pre-post asessment showed that there was significant reduction
in suicidal ideation, general psychiatric symptoms and
symptoms of borderline personality in DBT group
 Conclusion

● Research evidence to date suggests that across

studies, DBT reduces severe dysfunctional behaviors

that are targeted for intervention enhances Rx

retention, and reduces psychiatric hospitalization

● Combined Rx
 References

● Beck, A.T., Freeman, A. & Davis, D.D.(2004) Cognitive Therapy for

Personality Disorders, 2nd edition. New York: The Guilford Press.
● Linehan, M. M. (1993). Skills Training Manual for Treatment of Borderline
Personality Disorder. New York: Guilford Press.
● Oldham, J.M., Skodol, A.E. & Bender D.S. (2005) Textbook of Personality
Disorders. Washington D.C: American Psychiatric Publishing.
● Sperry, L.(1995).Handbook of Diagnosis and Treatment of The DSM- IV
Personality Disorders. New York: Brunner/ Mazel Publishers.
THANK YOU
PeninatalDBT-pDBT-Biopsychosou.at model

↳ to add thyroid I hormonal depfundm

; social
dysregulation

DBT
strategies for all perinatal paouidus