Dialectical Behavior Therapy (DTB) for Treatment of Borderline Personality Disorder

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Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a mental condition that is characterized with series of varying moods, self-image, and behavior. Therefore, these symptoms might result in impulsive actions that may cause problematic relationships. Patients with BPD have intense episodes of anger, depression, and anxiety that might last for a specific duration of time. This paper will present a practical case of a patient with Borderline Personality Disorder. The patient will be named Jane (not her real name, to safeguard her confidentiality), and was aged 15 years. Consequently, the paper will present Dialectical Behavior Therapy as the main form of intervention that was as a form of treatment to this patient. Therefore, the main aim of this paper is to critically investigate a Dialectical Behavior Therapy as one of the most effective method of treating BPD.

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Intervention strategy

Using Dialectical Behavior Therapy (DTB), the paper will aim at identifying problematic behavioral patterns that are prominent in Jane Doe’s difficulties in functioning, and then systematically target these patterns in accordance to a hierarchy by assessing and prioritizing thee behavior that are prone to threaten Jane’s life, treatment, and quality of life. Therefore, DTB will be used as the main framework to conceptualize the case of Jane Doe. The structure of DTB will be used to inform the treatment strategies in regards to DTB treatment plan. The motivation of the intervention strategy is mainly motivated Scherb (2014).

DTB was first developed by Marsha Linehan to treat women with suicidal behaviors and BPD. The method has gained numerous support from various scholars and practitioners, and this is because it has been found to have a strong empirical support from randomized clinical trials (Lynch et al., 2007). One of the major effectiveness of this intervention strategy is that it has been found to significantly reduce suicidal and self-injurious behavior, minimize depression, and decrease the rate of psychiatric hospitalization (Lynch et al., 2007). DBT has recently been included in ensuring that there is effectiveness in diagnoses like drug addiction and eating disorders, and other treatment settings (Lynch et al., 2007). Therefore, it was prudent to use DBT to Jane’s BPD treatment.

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This study chose to explore the intervention of a young female student who is 15 years old. The rationale for the selection of this case it to ensure the concept of social justice, since the female are the most vulnerable population at the risk of developing borderline personality disorder (Lawson, 2004). Since Jane is a female and she has suffered from a lack of attachment from her parents, it is important to address her problem so that she does not continue to cycle of borderline personality disorder when she grows up and has her own family.

Methods of engagement

The first method of engagement that was performed was to assess Jane Doe’s psychological history and the presenting problems. This was vital since it helped in formulation of a case in determining the client’s present level of the disorder so as to ascertain the level of treatment.  The fact that DBT was used on Jane Doe, relational engagement to DBT such as validations, consultation teams, holistic approach, behavioral strategies, ad cognitive restricting were used. In regards to validations, radical genuineness was instigated, and this was meant to instill confidence. This prompted the patient to disclose that she was not close her parents, and that she had no attachment to her parents since they were very busy in their respective day-to-day activities. This was very important since it helped in ascertaining the uniqueness of the patient, and this ensured that labeling of the patient was dismissed.

The method of engagement also ensured that therapist was accountable by adhering to the same set of principles of the patient. This was achieved through consultation teams. The therapists met with other healthcare providers to examine if the prescribed DBT principles were met including validating and engaging the client. The fact that it was BPD been treated, it was vital for the engagement to assess the rationale behind emotional reactions. Therefore, this form engagement helped in ensuring that through consultation, both the therapist and the patient’s points of vulnerability were identified.

There method of engagement also comprised of perceiving the BPD holistically. Nonetheless, client was made to accept anything unconditional. This method of engagement was supposed to acknowledge that despite the fact the client had a traumatic and challenging life it is only the client that has the opportunity to change the behavior. There is difficulty and unique tension that exist when the therapist tries to make the client to acknowledge the challenges that are associated with BPD. This is in line with Linehan (1993) recommendation that a person living with BPD are doing their best to make sure that they live a life that is filled with intolerable suffering and anguish, but they are supposed to do better and improve. These assumption are dialectical in nature as well as contradictory, but they are very important to consider when engaging the client.

The method of engagement also comprised of behavioral strategies especially since the client was diagnosed with BPD (Swales, Heard, & Williams, 2000). Therefore, when engaging the client ensured that positive reinforcing technique of validating, listening carefully to the client’s experience, and been present all through were applied. However, there was need to avoid that facial expression and language as a form of punishing unwanted actions by disapproving looks might be perceived as encouraging more BPD.

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The final form of engagement included cognitive restricting technique that were used extensively because it was DBT been used as the main method of intervention. The main aim of these method of cognitive restructuring a form of engagement was to encourage the client to act in an opposite way to their feeling, or to assess whether a particular thought pattern is based on reality or based on an emotional reaction. Therefore, this technique compelled the therapist to be present so as ascertain what was really happening to the client (Bateman, 2005).

Assessment framework using the Dialectical Behavior Therapy (DTB)

Biopsychosocial assessment

Biopsychosocial assessment of Jane was centered at DBT by conceptualizing the biosocial theory. This was aimed to make sure that the manner that the client’s biology and environment contributed to her current maladaptive behavioral pattern. Therefore, this was mapped to the client’s personal developmental history so as to conceptualize Jane’s current difficulties. The information was gotten by discussing with the client in the first sessions of the therapy, as well as communicating in a non-pejorative fashion so as to explicitly understand the manner that the client developed maladaptive behavioral patterns over a period of time.

The biological factors that contributed to the Jane’s current behavior is that she had very unsupportive parents that did not care about her growth and development. The parents only cared about the client’s grades in school. Jane grew with very minimal attachment to her parents, she even confessed that she believed that those were not her parents. The parents especially her father was very cold towards her, he showed very minimal affection towards the girl as he always kept dumb-he could not even wish the girl a good night.

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The environment also informed contribute to the client’s behavior. The environment that the client was brought up was very violent. She grew up knowing that if anyone does any wrong to you should fight, yell, or insult the person. This is was mainly influenced by the fact that her mother was not scared of her father, she would sometime yell at her father without a lot of zeal. Therefore, it can be asserted that the client’s decision to yell and shout to some the classmate is as a result of this behavior. There is also the perception that men are equal, and this why she was disgusted and frustrated by the men that assaulted her fellow female classmate.

Treatment plan and goals

The treatment goals DBT are either described form a behaviorally perspective, which implies that either the behavior can either increase or decrease. The overarching goal for client as described by Linehan (1993) is to increase dialectical behavior pattern and   decrease the extreme behavior and cognitions so that they can respond to each moment with more balanced and integrated responses. In Jane’s case, some of the dialectical tensions that were assessed were self-efficacy versus help-seeking, and independence v independence. The following is the manner that Jane’s targeted behavior were addressed in accordance to DBT hierarchy.

Dysfunctional behaviors

The first stage of DBT treatment targeted behaviors that were life threatening such as suicide and self-injury. The second treatment was based on therapy-interfering behaviors, and quality-of-life. Jane only been hospitalized in hospital for only three times prior to her treatment, and it found that it is necessary to ascertain if her behavior were related to these three form of hospitalization. Some of the factors that were considered included presence of suicidal thoughts, and her intent to injure herself or other during a violent outburst. The other behavior that was assessed was either the client had any intent or possessed a behavior harm herself. The only thing that was ascertained is that she could really scratch her scalp when she was extremely anxious.

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The client also indicated that she hated boys, and this is because she perceived them to be arrogant and mean. Her perception was informed by the fact that one of her classmate was physically assaulted by her boyfriend. She also claimed that his father did not treat her mother in a special because there are instances that he shouted at her mother. This form of behavior in the framework of DBT can be classified as a quality-of-life interfering behavior. Her negative attitudes towards men was very intense, and this because she indicated that there is a time she contemplated harming on of the boys in the school that bothered her. Thought, she did not explicitly define what she meant by harming the boy, this is a very dangerous trend that can make her to cause harm other boys in the school. Therefore, the goal to ascertain whether the client has any form of life-threatening behavior was very vital in relation to treatment of BPD.

Therapy-interfering behavior

These are the behaviors that are associated when the patient interfere with the therapy process. Scherb’s treatment plan does not comprehensively address treatment interfering behavior as a specific target.  However, there is one incident that Jane refused to cooperate, she kept quit and claimed that the therapist is wasting her time. She extremely rude and she interfered with the therapy process. DBT suggest that such incident should be addressed as a target in the following session. The circumstances that led to the incident were carefully analyzed and it found out that the therapist was questing her actions and wanting to know the type of harm she was contemplated to do to the boy that was bothering her. The importance of addressing the issue was to make sure that Jane did not hold on to her agenda. If the behavior was not addressed in the subsequent session the main goal of the therapy would not have been reached. The therapist was able to know the intensity of the client’s behavior that included shouting and rudeness.

Quality-of-life interfering behavior

Majority of the problems that the client cited can be asserted to fall under this category. One of the problem was that Jane’s parent never gave her any attention, all they did was to concentrate with their life and career. The fact that Jane was a teenager, she wanted vast attention from her parents, she felt that she could share a lot of her personal experience with her parent. However, she felt alone and neglected. She also wanted self-dependence from men, as according to her the men were very violent and insensitive. In this regard, one of the main goal of the patient was to make Jane changed her attitude. The goal of identifying the quality-of-life threatening behavior was also prominent especially since this was the main behavior that needed to be altered.

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Issue in the worker client relationship

From the perspective of Scherb’s description of the intervention of Jane’s case, she enters the therapeutic process in stage 1 of treatment since she has a positive attitude towards therapy, and commits to undertaking the therapeutic process by collaborating with the therapist. At first, she was hesitant to commence treatment, but later, through the insistence of the therapist, she agreed to be involved and commit to the process to help improve her quality of life, which has been deteriorating consistently.

The first point in developing a favorable intervention relationship involves development of the understanding that Jane would move towards achievement of the goals of the therapy, and that she will be a central part in her process of recovery (Kellong & Young, 2006). To develop this relationship, Jane needs to work in conjunction with the therapists to acquire some basic capacities that will help her gain some confidence to pursue her realistic goals. This is an important part of the therapeutic relationship since Jane has a history of attachment issues, which means she could form some unrealistic attachment expectations from the therapist or withdraw and refrain from sharing issues that may help her overcome her trauma. Given the understanding that DBT is primarily a talking type of therapy, it can be very tricky when dealing with clients with attachment issues as they suffer from serious security problems (Gunderson, 1996).

Contracting issues

The contracting issues that need to be marked before the establishment of the patient-therapist relationship is the issue of boundaries. While it is important for Jane to be close to her therapist, she is very vulnerable at this moment and she has the tendency to expect an attachment from a person who shows concern. It is important to notes that, having been alone most of her life, Jane has low self-esteem and therefore, she may find herself attached to the therapist due to her caring, empathic and compassionate attitude towards her. The therapeutic relationship should cultivate warmth, compassion, empathy and concern, but it should be clear from the onset of therapy that there is a permanent boundary between her and her therapist, and that showing concern is part of the therapist’s role in helping her overcome the disorder.

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Methods of intervention

The intervention process in Jane’s case will be based on the framework provided in DBT treatment. The first stage in the treatment involved eliciting her commitment to the treatment process. Jane was not interested in joining therapy, especially since she did not have the support of her family like most of the patients she interacted with. However, during the orientation process, she was introduced to the therapy sessions and she learned why it was important for her to manage her condition while she was still young, and how reaching her treatment goals would help her achieve her dream career of becoming a doctor. In the achievement of this level of commitment, Scherb recognizes some strategies that are aimed at linking the goals of the patient with the commitment to the treatment process; and demonstrating the incompatibility of the future goals of the client and the current dysfunctional behaviors.

The strategy of the “Devil’s Advocate” involves eliciting the interest of the client to take part in the intervention process, by making them the change agent so that they may stop their dysfunctional behaviors. In the case of Jane, since she has a tendency of shouting at people and being aggressive when provoked, Scherb recommends the therapist to tell her something like: “Why would you allow people to stop you from shouting at your friends during class times or the therapist during therapy when everyone is blaming you and treatment you like you are an outcast?” Using this strategy would help Jane argue against the therapist upon the realization that she needs to change her behavior. She may even point to the idea that changing her impulsive and aggressive behavior would be an important step to helping her achieve her goals.

The next step in the intervention process was walking through the goals that she formulated in order to encourage her to talk about the current issues she is facing. The goals identified in the identification of the goals can be reduced to acquisition of the basic skills that could help her improve her quality of life and life expectancy. The other goals identified was reduction in the impulsive behavior and self-esteem so that she may have a greater level of confidence when interacting with other people. The implementation of Scherb’s inspired DBT approach followed the same steps.

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The next step involved addressing the attachment problems she faced especially due to the poor relationship with her parents. Gaining Jane’s capacity to improve her communication with her parents and develop faith in them was aimed at giving her back some of the control she had lost due to the neglect she felt growing up. This helped her reduce some of her impulse behavior, especially those involving being aggressive in terms of talking and yelling at others. This step was consistent with the first treatment step recommended by Scherb (2014) which aims to cultivating self-esteem. According to Markowitz et al. (2006), it is important to address the body, mind and soul by not only focusing on changing the observable behavior, but also targeting the issues related to the mood and its relation to life events. The development of a higher self-esteem is consistent with the goal of caring for the soul and the mind as it is aligned with behavioral approach which is aimed at helping Jane develop desired behaviors by rewarding her for exhibiting behaviors aligned to the goals of the therapy such as reduced yelling or reduced aggressiveness and violence.

After development of self-esteem and building her basic capacities such as concentrating on her education and improving her relationship with her parents through the effective control of her emotions, the next step in the therapeutic process involved reduction in Jane’s perception of the behavior of others as abandonment and rejection. During the assessment, it was evident that the poor attachment between Jane and her parents was due to the fact that they both worked very late at night and they got very little time to spend together due to the nature of her parent’s jobs. Since they are both doctors, they are sometimes forced to work very late, in most cases, Jane had to be left alone in the house and she felt very neglected, rejected and abandoned. The feeling of rejection was especially intense when she compared herself with some of her friends who ate dinner with their parents every day and still got time to drive them to school every day. For Jane, she ate mostly alone and had to go to school by bus.

Reducing the interpretation of others’ behavior helped Jane learn to distance herself from the negative feelings of rejection by challenging the negative perceptions she had about her parents and her friends.  It allowed her to appreciate the little gestures of love and concern they showed her. During this stage, Jane was able to accomplish an important goals that had previously curtailed the quality of the life; learning how to appreciate others especially her family and performing better in her education due to a reduction in the great level of baggage she had carried for a long time.

From the perspective of DBT intervention, the intervention was complete as the client had achieved the goals identified at the beginning of the therapeutic process. As such, upon review, Jane was considered for termination.

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Termination

The termination of Jane from the therapeutic process was based on her successful completion of the process and her achievement of the goals of therapy. She was able to build her self-esteem and replace her dysfunctional behavior with functional behaviors that appreciated her parents and the people who loved her. Moreover, she was able to successfully improve her grades in school as she was no longer bitter, violent and impulsive, but a friendly person who was able to compose herself to listen to others before reacting. Moreover, Jane had been very actively committed to her therapeutic process, which demonstrated that she was intrinsically motivated to achieve the goals she has set out to achieve at the beginning of therapy. During the last stage of therapy, DBT has clear guidelines that explicitly lays down grounds for vacation from treatment when the goals of therapy has been achieved.

Termination will be performed by assessing the current performance of the patients in relation to the initial performance of the patient to determine whether there are consistent and robust changes in the patient’s behavior. Moreover, the therapist will have Jane planned for follow-up sessions where she would be evaluated for any progress made or if she has encountered problems that could negate the progress she had made in therapy, promoting her to relapse back into her dysfunctional behavior.

Evaluation strategies

The evaluation strategies adopted was aimed at ensuring that it was possible to determine if the DBT intervention had worked on Jane in terms of eliminating all the behavioral tendencies associated with borderline personality disorder include impulsiveness, aggression, violence, depressive undertones and the likelihood of self-harm.

The evaluation process measured the instances of impulsive behavior, aggression, violence, depressive undertones, the likelihood of self-harm and change in behavior at every follow-up appointment scheduled. Generally, the measurement targeted the evaluation of the patient’s impulsiveness as it is a very common trait among BPD patients, and was highly prevalent in Jane’s life. DBT in Jane’s case was extended to include the other aspects of the intervention including aggression, violence, depressive undertones and the likelihood of self-harm as they are also manifested in patients exhibiting symptoms of impulsiveness. For instance, while Jane was mainly impulsive as demonstrated by her unending yelling and arguments when she sought treatment, impulsive behaviors may also be linked aggression, violence and self-harm, especially committing suicide (Linehan et al., 2006).

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According to Rizvi and Harned (2013), continued assessment of the progress of the patient is key to determining the efficiency of the therapy. While the DBT is a long term process of therapy, it is important to ensure that the achieved progress is persistent over time, which ensures that the treatment is cost-effective and time-limited, through the avoidance of instances of a relapse. To achieve the effectiveness of the treatment, the therapist needs to schedule Jane for follow-up session where the assessment takes place. The main strategy used in the evaluation process is to determine the level of behavior change in relation to impulsiveness, aggressive and violence.

Follow up

The follow-up process is the last stage in the DBT therapeutic process that is used to assess whether the patients has achieved the therapeutic goals, and remained consistent even after the termination of the intervention. The follow-up process in Jane’s case was scheduled after every one month during the initial months after completion of the treatment. The goals of scheduling the follow-up close to the terminated date is to ensure that any change in behavior may be detected before the escalation of the problem. After the assessment revealed that she has achieved long term change in desirable behavior, the assessment interval was extended to 3 months and then to six months.

Currently, Jane is highly functional without any trace of impulsiveness or aggressive behavior that initially threatened her quality of life as well as that of her family and people around her. It would be prudent, therefore, to conclude that DBT had helped Jane overcome her BPD by replacing her dysfunctional behavior and improving her social life, relationship with her parents, and her attitude towards her dream of pursuing medicine. The results of Jane’s case are consistent with the resulted reported in Najavits and Gunderson (1995) which indicated positive outcomes in the symptoms of BPD over time as a result of treatment and therapeutic intervention.

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  1. Bateman, A. W. (2005). Psychological treatment of borderline personality disorder. Psychiatry, 4(3), 15-18.
  2. Gunderson, J. G. (1996). The borderline patient’s intolerance of aloneness: insecure attachments and therapist availability. american Journal of psychiatry, 153(6), 752-758.
  3. Kellogg, S. H., & Young, J. E. (2006). Schema therapy for borderline personality disorder. Journal of clinical psychology, 62(4), 445-458.
  4. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., … & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of general psychiatry, 63(7), 757-766.
  5. Linehan, Marsha. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guildford Press.
  6. Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. (2007). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459-480
  7. Markowitz, J. C., Skodol, A. E., & Bleiberg, K. (2006). Interpersonal psychotherapy for borderline personality disorder: Possible mechanisms of change. Journal of Clinical Psychology, 62(4), 431-444.
  8. Markowitz, J.C. (1998). Interpersonal psychotherapy for dysthymic disorder. Washington, DC: American Psychiatric Press.
  9. Najavits, L. M., & Gunderson, J. G. (1995). Better than expected: improvements in borderline personality disorder in a 3-year prospective outcome study. Comprehensive Psychiatry, 36(4), 296-302.
  10. Rizvi, S. L, & Harned, M. S. (2013). Increasing treatment efficiency and effectiveness: Rethinking approaches to assessing and treating comorbid disorders. Clinical Psychology: Science and Practice, 20. 285-290.
  11. Scherb, E. (2014). The case of “Sonia”: Psychotherapy with a complex, difficult patient grounded in the integrated psychot herapy model of Héctor Fernández – Álvarez. Pragmatic Case Studies in Psychotherapy, 10 (1 ) , Article 1 , 1 – 29.
  12. Swales, M., Heard, H. L., & Williams, M. G. (2000). Linehan’s dialectical behavior therapy (DBT) for borderline personality disorder: Overview and adaptation. Journal of Mental Health, 9(1), 7-23.
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