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Borderline Personality Disorder
  and Dialectical Behavioral
        Therapy (DBT)




              Sharon Fischman, LCSW-C
  St. Luke’s House and Threshold Services United
Borderline Personality Disorder
• Instability in interpersonal behavior, marked
  by intense and unstable relationships
• Impulsive and unpredictable behavior
• Profound, inappropriate shifts in mood and
  affect
• There is a high rate of self-injury without
  suicide intent, as well as a significant rate of
  suicide attempts and completed suicide
• Patients often need extensive mental health
  services, and account for 20% of psychiatric
  hospitalizations
• While a person with depression or bipolar
  disorder typically endures the same mood for
  weeks, a person with BPD may experience intense
  bouts of anger, depression, and anxiety that may
  last only hours. These may be associated with
  episodes of impulsive aggression, self-injury, and
  drug or alcohol abuse. Distortions in cognition and
  sense of self can lead to frequent changes in long-
  term goals, career plans, jobs, friendships, gender
  identity, and values. Sometimes people with BPD
  view themselves as fundamentally bad, or
  unworthy. They may feel unfairly misunderstood
  or mistreated, bored, empty, and have little idea
  who they are. Such symptoms are most acute
  when people with BPD feel isolated and lacking in
  social support, and may result in frantic efforts to
  avoid being alone.
• People with BPD often have highly unstable patterns of
  social relationships. While they can develop intense
  but stormy attachments, their attitudes towards
  family, friends, and loved ones may suddenly shift from
  idealization (great admiration and love) to devaluation
  (intense anger and dislike). They may form an
  immediate attachment and idealize the other
  person, but when a slight separation or conflict
  occurs, they switch unexpectedly to the other extreme
  and angrily accuse the other person of not caring for
  them at all. Even with family members, individuals with
  BPD are highly sensitive to rejection, reacting with
  anger and distress to any separations.
Dialectical Behavioral Therapy
• Dialectical Behavioral Therapy (DBT) is a form of
  therapy that has been found to be effective in treating
  Borderline Personality Disorder.
• The most important of the overall goals in DBT is
  helping clients create “lives worth living.” What makes
  a life worth living varies from client to client.
• The balance between acceptance and change
  strategies in therapy form the fundamental “dialectic.”
  “Dialectic” means “weighing and integrating
  contradictory facts or ideas with a view to resolving
  apparent contradictions.” In DBT, therapists and clients
  work hard to balance change with acceptance, two
  seemingly contradictory forces or strategies.
• The central dialectic is that everyone is doing
  the best he or she can AND that everyone has
  to try harder, do better, and want to change
  more.
• A key assumption in DBT is that self-
  destructive behaviors are learned coping
  techniques for unbearably intense and
  negative emotions. Negative emotions like
  shame, guilt, sadness, fear, and anger are a
  normal part of life. However, it seems that
  some people are particularly inclined to have
  very intense and frequent negative emotions.
• An invalidating environment is also a major
  contributing factor. “Invalidating” refers to a failure to
  treat a person in a manner that conveys
  attention, respect, and understanding..

• A vicious cycle can get started: The person is really sad
  and scared, she has no one who listens to her, she is
  afraid to ask for help or knows no help is available, and
  so she tries to kill herself. Then, when her pain is
  treated seriously at the hospital, she learns (without
  being conscious of it) that when she’s suicidal, other
  people understand how badly she feels. Repeated self-
  injury can result if it is seen as the only means for
  getting better or achieving understanding from other
  people.
Stages of treatment


• Eliminate life-threatening behaviors
• Eliminate therapy-interfering behaviors
• Focus on quality of life behaviors
Open-Minded Thinking
• Seeing things in a new way
Open-Minded Skills
• Two ideas can both be true at the same time
• Two things that seem like (or are) opposites can both be true
  (you are doing the best that you can AND you need to try
  harder, do better, and want to change more)
• A life worth living has both comfortable and uncomfortable
  parts
• Being open-minded means letting go of being “right” and “all
  or nothing” thinking
• It means listening to yourself and others, seeing things in a
  new way, getting unstuck, taking responsibility for your own
  behavior
• No one owns the truth
• We might not have caused all our problems, but we have to
  solve them
• Avoid words like always, never, you make me.
• Look at all sides of an issue
Validation
• What we think and feel is
  real, important, and makes
  sense
Validation Skills
• Emotions, thoughts and sensations are all experiences
  that we sometimes doubt in ourselves. Telling
  ourselves and others that what we (they) feel is
  real, important, and makes sense.
• Validation does not mean that you agree or approve of
  a behavior. Validation is not worried about right or
  wrong.
• Look at the person, not the behavior.
• Describe the facts of the situation, name your
  feelings, tell yourself (or someone else) that it’s OK to
  feel this way.
Balanced Thinking
• Focus on what is happening right now.
  Reasoning mind and feeling mind are in
  balance.
Balanced Thinking Skills
• Balanced thinking is the ability to think and feel at the
  same time.
• Thinking mind + feeling mind = balanced thinking mind.
• Notice what is happening. Notice that how you feel.
  Notice that thoughts and feelings come and go like
  waves. Notice what comes through your senses. Have a
  teflon coating.
• Be part of what is happening right now – be mindful in
  the moment.
• Be non-judgmental (separate your own thoughts and
  feelings and focus on the facts).
• Be effective – focus on your goals.
Calming Skills
• Balancing my thoughts and feelings
Calming Skills
• Feelings are not good or bad. They just are. And they don’t
  last forever.
• DBT is not about stopping feelings.
• Feelings are the reason you have urges.
• Feelings help us to communicate, help us do things (act
  now, stay focused), and give us information.
• Feelings aren’t facts.
• Thinking or wanting to do something is part of having a
  feeling. Your response may be different than someone
  else’s response.
• People tend to avoid painful or uncomfortable feelings. DBT
  asks you to experience these feelings, sometimes without
  doing anything to change them.
Calming Skills
• Events lead to thoughts that lead to feelings
  that lead to choices.
• We can’t control what we feel, but we can
  control our behaviors.
• Make a list of positive experiences, calming
  skills, and a plan for staying strong.
Distress Tolerance
• Getting through painful
  situations without making
  them worse
Distress Tolerance Skills
• Self-soothe
• Think of pros and cons (of using skills and not
  using skills)
• Urge management
• Radical acceptance – this is how life truly is
• Be willing rather than willful
Getting Along Well With Others
• Playing nice in the sandbox of life
Getting Along Well With Others Skills
• Try to get the thing you want effectively
• Remember your goals
• Keeping and improving your self-respect and
  liking yourself
• Getting what you want (or accepting that you
  won’t) using Dear Man statements
• Maintaining relationships – GIVE (be gentle, act
  interested, validate, use an easy manner)
• Keeping respect for yourself – FAST (be fair to
  yourself and the other person, apologize for what
  you’re responsible for but not for having an
  opinion, stick to values, be truthful)
Questions?
• So how do we apply this in the
  moment and outside therapy?
• Any questions?
• Any concerns?
• If you would like more training on
  DBT or have any questions, call
  Sharon Fischman at St. Luke’s House and
  Threshold Services United at 301-896-4221.

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Borderline personality disorder

  • 1. Borderline Personality Disorder and Dialectical Behavioral Therapy (DBT) Sharon Fischman, LCSW-C St. Luke’s House and Threshold Services United
  • 2. Borderline Personality Disorder • Instability in interpersonal behavior, marked by intense and unstable relationships • Impulsive and unpredictable behavior • Profound, inappropriate shifts in mood and affect • There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide • Patients often need extensive mental health services, and account for 20% of psychiatric hospitalizations
  • 3. • While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long- term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
  • 4. • People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). They may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to any separations.
  • 5. Dialectical Behavioral Therapy • Dialectical Behavioral Therapy (DBT) is a form of therapy that has been found to be effective in treating Borderline Personality Disorder. • The most important of the overall goals in DBT is helping clients create “lives worth living.” What makes a life worth living varies from client to client. • The balance between acceptance and change strategies in therapy form the fundamental “dialectic.” “Dialectic” means “weighing and integrating contradictory facts or ideas with a view to resolving apparent contradictions.” In DBT, therapists and clients work hard to balance change with acceptance, two seemingly contradictory forces or strategies.
  • 6. • The central dialectic is that everyone is doing the best he or she can AND that everyone has to try harder, do better, and want to change more. • A key assumption in DBT is that self- destructive behaviors are learned coping techniques for unbearably intense and negative emotions. Negative emotions like shame, guilt, sadness, fear, and anger are a normal part of life. However, it seems that some people are particularly inclined to have very intense and frequent negative emotions.
  • 7. • An invalidating environment is also a major contributing factor. “Invalidating” refers to a failure to treat a person in a manner that conveys attention, respect, and understanding.. • A vicious cycle can get started: The person is really sad and scared, she has no one who listens to her, she is afraid to ask for help or knows no help is available, and so she tries to kill herself. Then, when her pain is treated seriously at the hospital, she learns (without being conscious of it) that when she’s suicidal, other people understand how badly she feels. Repeated self- injury can result if it is seen as the only means for getting better or achieving understanding from other people.
  • 8. Stages of treatment • Eliminate life-threatening behaviors • Eliminate therapy-interfering behaviors • Focus on quality of life behaviors
  • 9. Open-Minded Thinking • Seeing things in a new way
  • 10. Open-Minded Skills • Two ideas can both be true at the same time • Two things that seem like (or are) opposites can both be true (you are doing the best that you can AND you need to try harder, do better, and want to change more) • A life worth living has both comfortable and uncomfortable parts • Being open-minded means letting go of being “right” and “all or nothing” thinking • It means listening to yourself and others, seeing things in a new way, getting unstuck, taking responsibility for your own behavior • No one owns the truth • We might not have caused all our problems, but we have to solve them • Avoid words like always, never, you make me. • Look at all sides of an issue
  • 11. Validation • What we think and feel is real, important, and makes sense
  • 12. Validation Skills • Emotions, thoughts and sensations are all experiences that we sometimes doubt in ourselves. Telling ourselves and others that what we (they) feel is real, important, and makes sense. • Validation does not mean that you agree or approve of a behavior. Validation is not worried about right or wrong. • Look at the person, not the behavior. • Describe the facts of the situation, name your feelings, tell yourself (or someone else) that it’s OK to feel this way.
  • 13. Balanced Thinking • Focus on what is happening right now. Reasoning mind and feeling mind are in balance.
  • 14. Balanced Thinking Skills • Balanced thinking is the ability to think and feel at the same time. • Thinking mind + feeling mind = balanced thinking mind. • Notice what is happening. Notice that how you feel. Notice that thoughts and feelings come and go like waves. Notice what comes through your senses. Have a teflon coating. • Be part of what is happening right now – be mindful in the moment. • Be non-judgmental (separate your own thoughts and feelings and focus on the facts). • Be effective – focus on your goals.
  • 15. Calming Skills • Balancing my thoughts and feelings
  • 16. Calming Skills • Feelings are not good or bad. They just are. And they don’t last forever. • DBT is not about stopping feelings. • Feelings are the reason you have urges. • Feelings help us to communicate, help us do things (act now, stay focused), and give us information. • Feelings aren’t facts. • Thinking or wanting to do something is part of having a feeling. Your response may be different than someone else’s response. • People tend to avoid painful or uncomfortable feelings. DBT asks you to experience these feelings, sometimes without doing anything to change them.
  • 17. Calming Skills • Events lead to thoughts that lead to feelings that lead to choices. • We can’t control what we feel, but we can control our behaviors. • Make a list of positive experiences, calming skills, and a plan for staying strong.
  • 18. Distress Tolerance • Getting through painful situations without making them worse
  • 19. Distress Tolerance Skills • Self-soothe • Think of pros and cons (of using skills and not using skills) • Urge management • Radical acceptance – this is how life truly is • Be willing rather than willful
  • 20. Getting Along Well With Others • Playing nice in the sandbox of life
  • 21. Getting Along Well With Others Skills • Try to get the thing you want effectively • Remember your goals • Keeping and improving your self-respect and liking yourself • Getting what you want (or accepting that you won’t) using Dear Man statements • Maintaining relationships – GIVE (be gentle, act interested, validate, use an easy manner) • Keeping respect for yourself – FAST (be fair to yourself and the other person, apologize for what you’re responsible for but not for having an opinion, stick to values, be truthful)
  • 22. Questions? • So how do we apply this in the moment and outside therapy? • Any questions? • Any concerns? • If you would like more training on DBT or have any questions, call Sharon Fischman at St. Luke’s House and Threshold Services United at 301-896-4221.