Dialectical Behavior Therapy (DBT) is a modality developed in the late 1970s by Dr. Marsha M. Linehan, a psychology researcher at the University of Washington. DBT became the gold star treatment for borderline personality disorder, which had always been resistant to treatment.
“Borderline personality disorder has been stigmatised although more is understood about it now,” said Binta Cross, LCSW, a therapist at Maria Droste Counseling Center. “The truth is that people with BPD are often deeply wounded and misunderstood and those who are diagnosed with it fall on a spectrum.The word ‘borderline’ indicates that the person is sometimes brushing up against psychotic symptoms. Those with more severe symptoms often feel like they don’t know who they are; they have no solid sense of self and they sometimes experience paranoia.”
Binta explained that borderline personality disorder is born out of trauma. People develop it when they have been treated horrifically in childhood. Physical, sexual and emotional abuse leaves them feeling invalidated in their family environment. They are often given messages that equate to, “You and your feelings are wrong.” As a result, they develop confusion over what they are feeling and thinking. This manifests in a number of ways:
Trouble regulating emotions like anger.
Fear of being abandoned (tumultuous relationships, difficulty with interpersonal connections)
Chronic suicidality (Even if they are not acting on it, the feeling is often there.)
Standard therapies were not typically effective for patients with a significant history of trauma because they tend to have difficulty regulating their emotions. “Sometimes people come to therapy on and off, talking and talking, gaining lots of good insight, making some progress, but patterns keep repeating and behaviors don’t change,” Binta said. As a result, clinicians would end up feeling like they were hitting a wall and, in some cases, would take out their frustrations on their clients when treatments weren’t working. The clients were then labeled impossible to treat.
DBT is a form of cognitive behavioral therapy blended with mindfulness and meditation to help people who are dealing with issues that don’t have easy solutions. “DBT opened doors for clinicians and patients. As a therapist, I found it worked wonderfully. Rather than coming up against a wall, I started being able to work effectively with people who were struggling with tough issues,” Binta said. “DBT is effective for many difficult disorders.”
In its pure form, DBT is practiced in a very structured group format. It is run like a class that lasts approximately a year long. Each class addresses emotional regulation skills, interpersonal relationship skills, distress tolerance skills and mindfulness skills. It is paper heavy and clients are expected to complete homework.
One significant difference with DBT compared to other therapies is that there is less processing. “The focus is on changing behaviors that don’t work for you anymore, with an emphasis on mindfulness, communicating with people who are important to you, managing suicidality, and practicing these skills regardless of what is going on. How can you act effectively to change what you can and also to accept what you can’t change?” said Binta. In one-on-one sessions she limits venting or sharing time. “The rest of the time is spent applying DBT skills and examining, for example, how could you have felt safer or acted less impulsively?” Clients don’t always see how they may be inadvertently contributing to the problem. They just know they want things to change.
In a DBT group there is a handout that explains the skill training assumptions the group is based on. One key assumption is that people may not have caused their own problems, but they have to solve them anyway. “It’s not your fault that someone beat the crap out of you as a kid and you have PTSD, but only you can help you recover and take responsibility for your mental health. Not fair, but it’s the truth,” Binta said. “We go over this a lot. It sounds harsh but it is a way to empower people who feel victimized without invalidating their very real trauma. Stop waiting for someone to make things fair so you can feel better. The longer you wait, the more you waste your life. People who aren’t ready to hear it will drop out.”
Dialectical thinking is an important aspect of DBT. The “both and” instead of “either or” helps address the fact that clients may not have caused their problems, but are left to deal with them anyway. It is a way to hold empathy and compassion for people and to validate their very real pain and suffering, while encouraging them to act in the service of reaching their goals.
Once people complete the class, they can keep their skills sharp with self-guided therapeutic support. “I often send clients to Insight Timer, a free meditation app. Mindfulness meditation is useful for recognizing patterns and problematic thoughts,” said Binta.
As a therapist, Binta said she feels empowered with this tool that can change people’s lives. “I’m always rooting for the underdog,” she said. “Clients with BPD often feel that life is meaningless. They come out of DBT feeling that life has value. It is quite powerful for people who respond well. This is a way for them to create a life that’s worth living.”
***Thank you to Maria Droste therapist, Binta Cross LCSW, for contributions to this blog.***