By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.
Does treatment for Borderline Personality Disorder work?
Lots of treatments for Borderline Personality Disorder have been tried over the years. One treatment, Dialectic Behavioral Therapy (DBT) has lots of evidence that it works and is effective.
The problem in treating Borderline Personality Disorder.
Lots of clinicians (Counselors and Therapists) do not use DBT and don’t want to learn it. In fact, plenty of clinicians I know don’t even like seeing BPD clients. Some clients don’t like going for DBT either, despite the glowing testimonials we hear from clients who say DBT changed their life.
If DBT is so effective for treating BPD, why do so few clinicians want to use it and why aren’t their lines of clients waiting for treatment?
BPD is a painful disorder. Treating BPD is like treating a burn victim. They are in terrible pain. Just touching them (emotionally) may cause them to feel the pain. Helpers don’t like to hear their clients scream in pain. Clients in pain tend to lash out. Clients with BPD are more likely than other people to lash out at the therapist, walk out of session, and even go out and try to hurt themselves.
Their pattern of unstable relationships is so pervasive that they have difficulty forming a healthy relationship with the clinician. Just when we think we are helping them they may quit treatment and blame the clinician for their increased pain. They are also more likely to file complaints with the licensing board or even a lawsuit because they feel therapy did not help them and now their pain is even worse.
Despite all these issues DBT does work and does help clients with BPD.
About Dialectic Behavioral Therapy (DBT.)
DBT was developed by Marsha Linehan (Ph.D.) at the University of Washington. Her book Cognitive-Behavioral Treatment of Borderline Personality Disorder is a classic in the field and her workbook has lots of useful exercises for clients to use. I have had the pleasure of hearing Marsha Linehan speak a number of times but can’t say I am fully trained on DBT. What follows is my horrifically oversimplified understanding of what DBT is and how it works.
DBT is a blend of Cognitive Behavioral Therapy, that change your thinking, to change your feelings, to change your behavior stuff that I like to use, and “stuff” Marsha Linehan calls mindfulness. The pain from BPD is so intense that the normal reaction would be to run away.
Mindfulness involves stress reduction, meditation, and ways to be able to reduce and tolerate that pain. By reducing the need to run from pain the pain can be shrunk to a manageable size. This skill is called “distress tolerance.”
Since many clients with BPD (maybe all) came from non-affirming environments they struggle with issues of self-worth and self-acceptance. Clients with the full-blown disorder not just some small level of BPD traits have lots of self-harming and self-destructive behaviors which they use to get away from the negative feelings.
Treating DBT has been described as “like driving a car with one foot on the gas and one on the brake.” It makes for a bumpy ride for both the clinician and the client.
The client needs to learn to accept and like themselves just the way they are. The clinician continually tells the client that they are a worthwhile human just the way they are.
The client needs to change. They need to stop doing those self-destructive, self-sabotaging behaviors, which are keeping them stuck in an unhappy life. Now comes the tricky part.
When the clinician says “I want you to change” the client hears “I am no good and need to change to be accepted.” The clinician then says “You are accepted just the way you are, but I still want you to change.”
The struggle here is to have clients accept that the goal is not for them to be a certain way to be acceptable, but that what we are looking for is “progress not perfection.” Any good coach or teacher wants to see their student’s progress and do better, that does not mean there is anything wrong with them if they do not become the best at their discipline.
There is a second challenge for those with BPD and those who treat them which DBT seeks to address.
People who have BPD do not live in the meadow full of flowers in the springtime, they live in the hurricane. If they are ever in a calm place, they know this is the eye of the hurricane and the next blast of the storm is a moment away.
Because the volume on their emotions is turned up so loud, there is always the crisis of the day, hour, or minute. When you are living in an emotional hurricane it is hard to think about disaster preparedness.
The clinician who does DBT has to limit the time they spend on today’s crisis so they can work on developing skills to prevent or cope with future crises. This “let’s not talk about your urges to cut on yourself or use drugs right now, let’s work on your skills” attitude is hard for clinicians and clients who are used to that warm fuzzy empathetic listening stuff.
Clients can leave a skills-based session thinking that the counselor didn’t listen to them and doesn’t care. The counselor may worry “what if they do cut or self-harm? Will it be my fault because I wanted to work on stress reduction skills?” Sticking to the skills-building curriculum can be difficult for both.
One ethical principle that clinicians have learned is that it is not helpful to keep the client dependent on their counselor to cope with life. Our goal should be to get the client to the place where they can function without the clinician. Sometimes that is uncomfortable for both client and counselor.
So DBT is very useful in treating BPD because it increases the client’s self-confidence and self-esteem while teaching them the skills to believe they can cope with life’s problems without having other people do it for them.
Other posts on Borderline Personality Disorder include:
What is Borderline Personality Disorder?
What causes Borderline Personality Disorder?
Levels or types of Borderline Personality Disorder
Treatment for Borderline Personality Disorder
If any of you have been to someone for Dialectic Behavioral Therapy or have had another treatment for Borderline Personality Disorder, would you be willing to leave a comment and tell us how it worked or didn’t work for you?
Staying connected with David Joel Miller
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Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.
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Hi I was diagnosed with BPD early in 2011 and was lucky to be accepted into a DBT group in July the same year At the time I found the group and participants (24 male and female) very confronting and over whelming
The group rules of respect and understanding patience and tolerance To leave judgements at the door and have an open mind (to the group as a whole, individuals and to ourselves) were explained and agreed with and a no violence policy was gone through and agreed to (again as a group individuals self and the trainers and related staff)
I also noticed many differences and variations of BPD with in the group
I was the only person with in the group who worked full time (night shift) and realised that despite having the same label, few were the same
I had a psychologist I was also seeing who said was familiar with BPD and DBT would help guide and assist the group sessions as the group met once a month, couldn’t always answer my questions or was un familiar with what I was showing her This became distressing for me
There were times I would feel I shouldn’t be there as I was judged for working and not having a partner (relationship break down and differences with in my family structure etc) some of my group made my participation an intrusion as if by my employment status was proof I was falsely diagnosed and I didnt belong (no one but the psychiatrist and psychologist leading the group knew my back ground due to confidentiality, I was so grateful for them and policies)
I had my psychologist and my workplace as my supports
I felt so shunned for working and some got confrontational and were quick to anger
It was very uncomfortable for myself and others within the group
I talked to the psychologist n the group leaders and voiced my concerns and we mutually found a solution, After 3 group sessions, I left the group sessions an increased my private sessions to incorporate the DBT
My psychologist and I basically learned the course together and at the time could see improvements and the benefits to myself my environment I did struggle with a few concepts n found myself getting argumentative but this delighted my psychologist because I was challenging my thinking and making sense of what I was learning and the world and getting stronger
It took me longer to understand that and then my psychologist became very unwell and left her practice, she did refer me on to another psychologist but unfortunately I didn’t gel with her
I needed the support n therapy but I felt myself drop out n slowly drift away
I still have and re read my work but recent events have happened, my health was severely bad and I fell back into that hole cycling moods, self harm, doubt, rejection and I do not want to be here
I have tried to re do the course on my own but get triggered by some things Or misunderstand as I read because I’m also trying to recall the explanations or examples and I get frustrated with myself and give up and the feel bad about getting frustrated and punish myself for not trying harder then think to myself “what a waste n this is how I deserve to be….. It’s an awful roundabout with high cage sides I can’t escape till all that noise in my head quiets enough for me to fall asleep, that could be 36-48-56 hours awake of my mind chattering at me I definately do hate doing that but I can’t help myself when it’s happening
So, I am trying to find support and new psychologist and to re do the DBT course again
DBT is beneficial and I did improve and maybe not with such a large group, I will succeed and complete the whole course
I look forward to starting but for now mindfulness helps and I have finally worked out how to meditate successfully and practice 3-4 time a week
I will let you know when I start DBT and keep you updated I can not continue as I am and as much as I can do myself I am but I’m looking forward to having to do it alone
Thank you for letting me share/vent my little ramble to you
Vickie (47 y/o female)
Hi Vickie, thanks for sharing your experience. That group sounds very large. It sounds like you would benefit from getting back into therapy. You need to find a counselor you will “jell” with. Best wishes.
Hi, I’ve been told that DBT is no good for someone like me, if I had to drop myself onto the BPD scale I would probably be low with some medium traits, I have a long term relationship (26 years) and hold 2 professional jobs, nurse and lecturer, but.. there’s always a but isn’t there? My psychologist and psychiatrist have both said DBT wouldn’t work because I’m too rational and research focused. The problem I have is I can see the answer, if someone came and asked me what to do in XYZ I could tell them. I just don’t have an emotional attachment to the answer myself.
I had a couple of years CBT before diagnosis and was the same there, I now know it’s because I don’t really know what emotions actually are, I can guess from a theoretical view point that in this situation the most recognised emotion would be happy/sad/upset/angry but I don’t know what they actually feel like. I talked to my MH nurse about this and we’ve spent nearly a year just looking at emotions, names and physical sensations, I’ve done lots of research into naming feelings because I just don’t know if what I’m feeling id the right emotion.
Following these discussions my Psych team feel that Cognitive analytical therapy followed by EMDR is the best way to go, (I’m UK based) if that makes a difference.
What is your view on CAT for BPD as I’ve only found 1 real piece of research on the efficacy and use of CAT for BPD?
Hi Caral, thanks for the comment. Some great questions. Short answer here and more to come. Most therapy’s focus on either thinking or feelings. DBT is one of the few that works on both. One goal of therapy should be to have a life that is in balance. Consider working with a patient and only listening to what they say but never looking at their body to see the blood coming out. You need to know where are they bleeding from and why. We use pain scales to give us insight into the inner feelings of patients. An athlete needs to work on more than one muscle group and we humans need to pay attention to the inputs from all our channels. Feelings like thoughts are not infallible but for optimal functioning we need to pay attention to both. My suggestion is look for the areas of your person that need developing and work on them. I added this topic ot my list to write about. We will see when I get to that part of the list. Best wishes.
Hi, I’ve been in DBT treatment for a year. I have a wonderful psychologist. I’ve gone through a 16 week group DBT workshop. And I have learned a lot about myself and ways to address my BPD. You are right about it being a bumpy road. In my blog, I have an ongoing allegory documenting my battles and victories as I journey toward peace from despair. I’ve only been blogging since November, but in just this short time, seeing the frequent mood swings from day to day (or hour to hour), has helped me stay in counseling. I otherwise would have quit long ago, feeling there is no hope. But the victories in my allegory remind me that progress, however slow, can be made. I think your description of BPD and DBT are right on. Already, your site has been very helpful to me. I look forward to following it closely. Hope.
Thanks for sharing your experience and for the comment. Best wishes. David
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