Tag Archives: CBT

DBT Treatment for Borderline Personality Disorder – Dialectic Behavioral Therapy

Posted on by
11

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

DBT therapy – mindfulness.
Photo courtesy of pixabay.

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

Seven David Joel Miller Books are available now!

My newest book is now available. It was my opportunity to try on a new genre. I’ve been working on this book for several years, but now seem like the right time to publish it.

Story Bureau.

Story Bureau is a thrilling Dystopian Post-Apocalyptic adventure in the Surviving the Apocalypse series.

Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.

As society collapses and his family gets plunged into poverty, Baldwin takes a job in the capital city, working for a government agency called the Story Bureau. He discovers the Story Bureau is not a benign news outlet but a sinister government plot to manipulate society.

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Dark Family Secrets: Doris wants to get her life back, but small-town prejudice could shatter her dreams.

Casino Robbery Arthur Mitchell escapes the trauma of watching his girlfriend die. But the killers know he’s a witness and want him dead.

Planned Accidents  The second Arthur Mitchell and Plutus mystery.

Letters from the Dead: The third in the Arthur Mitchell mystery series.

What would you do if you found a letter to a detective describing a crime and you knew the writer and detective were dead, and you could be next?

Sasquatch. Three things about us, you should know. One, we have seen the past. Two, we’re trapped there. Three, I don’t know if we’ll ever get back to our own time.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

For videos, see: Counselorssoapbox YouTube Video Channel

Getting some recovery – preventing relapse

Posted on by
4

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Urge Surfing Prevents Relapses.

Urge Surfing Prevents Relapses.
Photo courtesy of Pixabay.com

How do you get this recovery thing?

Moving from being “in the problem” to being “recovered” is a process. Many of the things that will take you from the pain to the solution are simple. That does not mean they are easy. Sometimes healing from the past can be painful also.

In past posts, we have talked about Defining Recovery and how recovery is possible for anyone, and that recovery means having the best life possible not necessarily a cure for your condition.

In another post we looked at Why giving up the drugs and alcohol might not make you any happier. Just trying to not do the negative or dysfunctional behaviors will not be enough. Recovery literature talks a lot about using “recovery tools” (see: Getting your tools dirty) and things like internal and external triggers.

What may be missing are the blueprints for creating recovery.

Reader Sue made the following comment.

How exactly should one get their recovery tools dirty? Giving up something that is bad for one, you do expect to feel better but when you don’t you feel disheartened. What’s left is yourself and your problems. So you read all the self-help books and try and work on yourself but how do you connect the practice to the theory? All those learned responses and ways of coping are very hard to unlearn – is it about keeping a record, making new goals, or just trying to get through without going backward?

There are a lot of recovery processes in use today, 12 step models, CBT & REBT therapy, counseling, and so on. They all have their place and they all have some common elements. Here are some basic steps for transforming your life from being hopeless and suffering to having a healthy recovery.

1. What is the problem?

You don’t get chemotherapy for depression or a drinking problem. Drug and alcohol treatment is not very effective for cancer. Make sure you are treating the real problem.

For most people who come to treatment for an addiction problem, the drugs, and the alcohol is not the problem! The drugs and alcohol are their solutions. The real problem is that their coping method, drinking or drugging to ease the pain, is not working. The problem has become that they don’t know how to live without the drugs and alcohol.

Part of defining problems is to admit that your efforts to control the problem have not been working. This is sometimes referred to as “Powerlessness” which is not the same thing as being helpless. Applying this concept of powerlessness to ways to cope with family members who have the problem was the subject of another blog post.

Mental illnesses can play the same role. Depression, anxiety, and dissociation can all function to avoid a painful life experience. The current problem, the one you need to solve first is how to live life without drugs, alcohol, depression, anxiety, or any other negative coping mechanisms.

Most of the time we think the solution to drugs and alcohol is to just stop doing them. This rarely works. Once deprived of your coping mechanism people just suffer. The most effective treatment is to replace the substances with something positive. With clients that I work with we start by creating a Happy Emotional Life Plan (HELP). As a counselor, I believe I am in the happy life business.

With emotional issues, as with eating disorders, it is a little more difficult. You can’t just give up sadness or anxiety and you have to eat and stay healthy. You need to learn to feel feelings without having them control you.

2. Are you ready to change? What help will you need?

Self-help groups talk about recovery being a “we” program not an “I” program. You need to be willing to accept help and support from any source that is healthy. Counselors, Therapists, 12 step groups all can assist in your recovery.

3. Change requires moving through a process

Twelve-step programs refer to “working” the steps or “taking” the steps. Counseling involves some self-examination. To really change requires a lot of action steps. For a detailed description of the process see the series of posts on “Stages of Change”

Pre-contemplation
Contemplation
Preparation or determination
Early Action
Late Action
Maintenance

4. Even after you have changed there is more work to do.

For change to be lasting you will need to do some sort of maintenance. Our old behavior patterns are deeply grooved into the structure of our life. It takes work to avoid falling back into the same old groove.

5. Progress, not perfection.

People in early recovery try to do everything now. They want to do recovery, get a job, find a new relationship, and generally create the perfect life all in one week. Learn to take things “one day at a time.”

Relapse, in my view, may not be a required “part of recovery, ” but it happens often enough that it is nothing to beat yourself up about. If you relapse on substance or depression, just get back into recovery as quickly as possible and move on.

The goal, as the old saying goes is “progress not perfection.” Keep your eyes on the gains you are making, give yourself credit for anything well done, and try to build on small successes until you create the bigger ones.

Life in recovery is a sort of experiment. We try things and learn from our efforts. Try to avoid experiments that result in a lot of pain or require time behind bars, but you will have to make choices and some of those choices will not work out the way you would have hoped.

This is a real-life, sometimes I like it sometimes I don’t. Learning to sit and feel bad and know this will pass, but I can tolerate this feeling without using my negative coping mechanism.

So, yes Sue, recovery is about trudging forward, trying on new behaviors and sometimes it is hard or painful and sometimes we fall back but always keep track of what works and what doesn’t and keep moving forward.

Staying connected with David Joel Miller

Seven David Joel Miller Books are available now!

My newest book is now available. It was my opportunity to try on a new genre. I’ve been working on this book for several years, but now seem like the right time to publish it.

Story Bureau.

Story Bureau is a thrilling Dystopian Post-Apocalyptic adventure in the Surviving the Apocalypse series.

Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.

As society collapses and his family gets plunged into poverty, Baldwin takes a job in the capital city, working for a government agency called the Story Bureau. He discovers the Story Bureau is not a benign news outlet but a sinister government plot to manipulate society.

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Dark Family Secrets: Doris wants to get her life back, but small-town prejudice could shatter her dreams.

Casino Robbery Arthur Mitchell escapes the trauma of watching his girlfriend die. But the killers know he’s a witness and want him dead.

Planned Accidents  The second Arthur Mitchell and Plutus mystery.

Letters from the Dead: The third in the Arthur Mitchell mystery series.

What would you do if you found a letter to a detective describing a crime and you knew the writer and detective were dead, and you could be next?

Sasquatch. Three things about us, you should know. One, we have seen the past. Two, we’re trapped there. Three, I don’t know if we’ll ever get back to our own time.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

For videos, see: Counselorssoapbox YouTube Video Channel