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1. What Is Borderline Personality Disorder ?
Definition
By Mayo Clinic staff
Borderline personality disorder can be a distressing medical
condition, both for the people who have it and for those
around them. When you have borderline personality disorder
(BPD), you have difficulty controlling your emotions and are
often in a state of upheaval — perhaps as a result of harmful
childhood experiences or brain dysfunction.
With borderline personality disorder your image of yourself is
distorted, making you feel worthless and fundamentally
flawed. Your anger, impulsivity and frequent mood swings
may push others away, even though you yearn for loving
relationships.
Increasing awareness and research are helping improve the
treatment and understanding of borderline personality
disorder. Emerging evidence indicates that people with
borderline personality disorder often get better over time and
that they can live happy, peaceful lives.
Borderline personality disorder affects how you feel about
yourself, how you relate to others and how you behave.
When you have BPD, you often have an insecure sense of
who you are. That is, your self-image or sense of self often
rapidly changes. You may view yourself as evil or bad, and
sometimes may feel as if you don't exist at all. An unstable
self-image often leads to frequent changes in jobs,
friendships, goals, values and gender identity.
Your relationships are usually in turmoil. You often
experience a love-hate relationship with others. You may
idealize someone one moment and then abruptly and
dramatically shift to fury and hate over perceived slights or
even minor misunderstandings. This is because people with
the disorder have difficulty accepting gray areas — things are
either black or white. For instance, in the eyes of a person
with BPD, someone is either good or evil. And that same
person may seem good one day and evil the next.
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2. Other signs and symptoms of borderline personality disorder
may include:
Impulsive and risky behavior, such as risky driving, unsafe
sex, gambling sprees or taking illicit drugs
Strong emotions that wax and wane frequently
Intense but short episodes of anxiety or depression
Inappropriate anger, sometimes escalating into physical
confrontations
Difficulty controlling emotions or impulses
Suicidal behavior
Fear of being alone
Causes
By Mayo Clinic staff
Although definitive data are lacking, it's estimated that 1
percent to 3 percent of American adults have borderline
personality disorder. As with other mental disorders, the
causes of borderline personality disorder are complex. The
name arose because of theories in the 1940s and 1950s that
the disorder was on the border between neurosis and
psychosis. But that view doesn't reflect current thinking. In
fact, some advocacy groups have pressed for changing the
name, such as calling it emotional regulation disorder.
Meanwhile, the cause of borderline personality disorder
remains under investigation, and there's no known way to
prevent it. Possible causes include:
Genetics. Some studies of twins and families suggest that
personality disorders may be inherited.
Environmental factors. Many people with borderline
personality disorder have a history of childhood abuse,
neglect and separation from caregivers or loved ones.
Brain abnormalities. Some research has shown changes
in certain areas of the brain involved in emotion regulation,
impulsivity and aggression. In addition, certain brain
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3. chemicals that help regulate mood, such as serotonin, may
not function properly.
Most likely, a combination of these issues results in
borderline personality disorder.
Self-Injury:
Types, Causes and Treatment
Approximately 1% of the population has, at one time or
another, used self-inflicted physical injury as a means of
coping with an overwhelming situation or feeling. ASHIC - the
American Self-Harm Information Clearinghouse - strives to
increase public awareness of the phenomenon of self-inflicted
violence and the unique challenges faced by self-injurers and
the people who care about them.
Self-harm scares people. The behavior can be disturbing and
difficult to understand, and it is often treated in a simplistic or
sensational manner by the press. As a result, friends and
loved ones of people who self-injure often feel frightened,
isolated, and helpless. Sometimes they resort to demands or
ultimatums as a way of trying to regain some control over the
situation, only to see things deteriorate further.
The first step toward coping with self-injurious behavior is
education: bringing reliable information about who self-injures,
why they do it, and how they can learn to stop to people who
self-injure and to their friends, loved ones, and medical
caregivers. ASHIC was founded to meet this need for honest,
accurate information.
About Self-harm
Self-harm, also known as self-injury, self-inflicted violence,
self-injurious behavior, or self-mutilation, can be defined as
the deliberate, direct injury of one's own body that causes
tissue damage or leave marks for more than a few minutes
and that is done in order to deal with an overwhelming or
distressing situation.
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4. It's important to remember that, even though it may not be
apparent to an outside observer, self-injury is serving a
function for the person who does it. Figuring out what
functions it serves and helping someone learn other ways to
get those needs met is essential to helping people who self-
harm. Some of the reasons self-injurers have given for their
acts include:
Affect modulation (distraction from emotional pain, ending
feelings of numbness, lessening a desire to suicide, calming
overwhelming/intense feelings)
Maintaining control and distracting the self from painful
thoughts or memories
Self-punishment (either because they believe they deserve
punishment for either having good feelings or being an "evil"
person or because they hope that self-punishment will avert
worse punishment from some outside source
Expression of things that can't be put into words (displaying
anger, showing the depth of emotional pain, shocking others,
seeking support and help)
Expression of feelings for which they have no label -- this
phenomenon, called alexithymia (literally no words feeling), is
common in people who self-harm
See Osuch, Noll, & Putnam, Psychiatry 62 (Winter 99), pp:
334-345
Zlotnick et al, Comprehensive Psychiatry 37(1) pp:12-16.
People who self-injure often never developed healthy ways to
feel and express emotion or to tolerate distress. Studies have
shown that self-harm can put a person at a high level of
physiological arousal back to a baseline state.
It's natural to want to help people who self-injure develop
healthier ways of coping when they feel overwhelmed, but it's
important not to let your discomfort with the concept of self-
harm cause you to issue ultimatums, punish self-harming
behavior, or threaten to leave if the person self-harms again.
Ideally, you should set boundaries to keep yourself feeling
safe while respecting the person's right to make his or her
own decisions about how to deal with stress.
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5. Common Myths about Self-Injury
Self-harm is usually a failed suicide attempt.
This myth persists despite a wealth of studies showing that,
although people who self-injure may be at a higher risk of
suicide than others, they distinguish between acts of self-
harm and attempted suicide. Many, if not most, self-injuring
people who make a suicide attempt use means that are
completely different to their preferred methods of self-inflicted
violence.
People who self-injure are crazy and should be locked up.
Tracy Alderman, Ph.D., author of The Scarred Soul,
addressed this:
"Fear can lead to dangerous overreactions. In dealing with
clients who hurt themselves, you will probably feel fear. . . .
Hospitalizing clients for self-inflicted violence is one such form
of overreaction. Many therapists, because they do not
possess an adequate understanding of SIV, will use extreme
measures to assure (they think) their clients' best interests.
However, few people who self-injure need to be hospitalized
or institutionalized. The vast majority of self-inflicted wounds
are neither life threatening nor require medical treatment.
Hospitalizing a client involuntarily for these issues can be
damaging in several ways. Because SIV is closely related to
feelings of lack of control and overwhelming emotional states,
placing someone in a setting that by its nature evokes these
feelings is very likely to make matters worse, and may lead to
an incident of SIV. In addition, involuntary hospitalization often
affects the therapeutic relationship in negative ways, eroding
trust, communication, rapport, and honesty. Caution should
be used when assessing a client's level of threat to self or
others. In most cases, SIV is not life threatening. . . . Because
SIV is so misunderstood, clinicians often overreact and
provide treatment that is contraindicated.
People who self-harm are just trying to get attention.
A wise friend once emailed me a list of attention-seeking
behaviors: wearing nice clothing, smiling at people, saying
"hi", going to the check-out counter at a store, and so on. We
all seek attention all the time; wanting attention is not bad or
sick. If someone is in so much distress and feel so ignored
that the only way he can think of to express his pain is by
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6. hurting his body, something is definitely wrong in his life and
this isn't the time to be making moral judgments about his
behavior.
That said, most people who self-injure go to great lengths to
hide their wounds and scars. Many consider there self-harm
to be a deeply shameful secret and dread the consequences
of discovery.
Self-inflicted violence is just an attempt to manipulate
others.
Some people use self-inflicted injuries as an attempt to cause
others to behave in certain ways, it's true. Most don't, though.
If you feel as though someone is trying to manipulate you with
SI, it may be more important to focus on what it is they want
and how you can communicate about it while maintaining
appropriate boundaries. Look for the deeper issues and work
on those.
Only people with Borderline Personality Disorder self-
harm.
Self-harm is a criterion for diagnosing BPD, but there are 8
other equally-important criteria. Not everyone with BPD self-
harms, and not all people who self-harm have BPD
(regardless of practitioners who automatically diagnose
anyone who self-injures with BPD).
If the wounds aren't "bad enough," self-harm isn't
serious.
The severity of the self-inflicted wounds has very little to do
with the level of emotional distress present. Different people
have different methods of SI and different pain tolerances.
The only way to figure out how much distress someone is in is
to ask. Never assume; check it out with the person.
Only teen-aged girls self-injure.
In five years of existence, the bodies-under-siege email list
has had members of both genders, from six continents, and
ranging in age from 14-60+. It's a person-who-has-no-other-
way-to-cope thing, not a teenage (or female or American or
whatever) thing.
ASHIC's goals
The American Self-Harm Information Clearinghouse strives to
educate the general public and medical and psychological
professionals about the phenomenon of self-harm. We hope
that by disseminating clear, concise, and accurate information
about self-harm, we can improve the treatment that those who
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7. cope with distress by injuring themselves receive from
hospitals, physicians, therapists, and their own families and
friends.
The more people know about the realities of self-inflicted
violence, the less fearful and stigmatizing they will be when
confronted with it. ASHIC's main project to date has been
National Self-Injury Awareness Day (March 1, 2002). Other
services we offer now are:
Sending out fact sheets, brochures, copies of the Bill of
Rights for those who self-harm, and other materials on
request
Acting as a media liaison -- putting writers and reporters in
contact with self-injury experts and self-injuring people
Helping with research in special situations (recently, we
helped someone put together a package explaining why
involuntary commitment to a state hospital might be harmful to
a person who self-injures
Operating a limited Speakers' Bureau
Producing press kits
We are working on an informational booklet to be released in
summer 2002, as well.
Contact information
Materials can be requested by sending a stamped, self-
addressed envelope to:
ASHIC
521 Temple Pl
Seattle, WA 98122
E-mail inquires should be sent to ashic@selfinjury.org and
telephone inquiries should be directed to Deb Martinson at
206-604-8963.
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8. The number of young people who participate in acts of self-mutilation
is growing. Although self-harm is rarely a suicidal act, it must be taken
seriously because accidental deaths do occur. It’s difficult to see the
light at the end of the tunnel but breaking the cycle of self-abuse is
possible if you reach out to someone you trust. Finding new ways of
coping with your feelings can help to tone down the intense urges you
feel which results in you hurting yourself. Recovery is a continuous
process and learning how to stop this addictive behavior is within your
reach if you work at it.
Who engages in self-injury?
The numbers are staggering…about two million people in the U.S. are
self-injurers and approximately 1% of the population has inflicted
physical injury upon themselves at some time in their life as a way to
cope with an overwhelming situation or feeling. Those numbers are
most likely an underestimation because the majority of acts of self-
injury go unreported. In other parts of the world the numbers are
considerably higher. Self-injury does not discriminate against race,
culture, or socio-economic strata, but there is conflicting data
regarding demographics. Some reference sites indicate that the
majority of people who engage in this type of addictive behavior are
predominately female teenagers and young adults, while other sites
indicate that both genders, ranging in age from 14 to 60 self-injure.
However, there is consistent agreement that self-harm has more to do
with having poor coping mechanisms than anything else.
Types of self-injury
Definition of self-injury
Self-injury, self-inflicted violence, self-injurious behavior or self-
mutilation is defined as a deliberate, intentional injury to one’s own
body that causes tissue damage or leaves marks for more than a few
minutes which is done to cope with an overwhelming or distressing
situation.
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9. The most common self-injurious behaviors are:
Cutting - involves making cuts or scratches on your body with any
sharp object, including knives, needles, razor blades or even
fingernails. The arms, legs and front of the torso are most commonly
cut because they are easily reached and easily hidden under clothing
Branding – burning self with a hot object, Friction burn – rubbing a
pencil eraser on your skin
Picking at skin or re-opening wounds (dermatillomania) - is an
impulse control disorder characterized by the repeated urge to pick at
one's own skin, often to the extent that damage is caused which
relieves stress or is gratifying
Hair-pulling (trichotillomania) – is an impulse control disorder, which
at times seems to resemble a habit, an addiction, or an obsessive-
compulsive disorder. The person has an irresistible urge to pull out
hair from any part of their body. Hair pulling from the scalp often
leaves patchy bald spots on their head, which they hide by wearing
hats, scarves and wigs. Abnormal levels of serotonin or dopamine
may play a role in this disorder. The combined treatment of using an
anti-depressant such as Anafranil and cognitive behavioral therapy
(CBT) has been effective in treating this disorder. CBT teaches you to
become more aware of when you’re pulling, helps you identify your
pulling habits, and teaches you about what emotions and triggers are
involved in hair pulling. When you gain awareness of pulling, you can
learn to substitute healthier behaviors instead.
Hitting (with hammer or other object), Bone breaking, Punching,
Head-banging (more often seen with autism or severe mental
retardation)
Multiple piercing or tattooing - may also be a type of self-injury,
especially if pain or stress relief is a factor
Drinking harmful chemicals
Reasons for self-injury
Why do they do it?
Even though it is possible that a self-inflicted injury may result in
death, self-injury is usually not suicidal behavior. The person who self-
injures may not recognize the connection, but this act usually occurs
after an overwhelming or distressing experience and is a result of not
having learned how to identify or express difficult feelings in a
healthy way. Sometimes the person who deliberately harms
themselves thinks that if they feel the pain on the outside instead of
feeling it on the inside, the injuries will be seen, which then perhaps
gives them a fighting chance to heal. They may also believe that the
wounds, which are now physical evidence, proves their emotional pain
9

10. is real. Although the physical pain they experience may be the catalyst
that releases the emotional pain, the relief they feel is temporary.
These coping mechanisms in essence are faulty because the pain
eventually returns without any permanent healing taking place.
Self-harm serves a function for the person who does it. If you can
figure out what function the self-injury is serving then you can learn
other ways to get those needs met which will reduce your desire to
hurt yourself.
It is difficult to understand the motivations behind self-injurious
behavior, but a clearer picture develops when you hear the common
explanations self-injurers give for doing it:
“It expresses emotional pain or feelings that I’m unable to put into
words. It puts a punctuation mark on what I’m feeling on the inside!”
“It’s a way to have control over my body because I can’t control
anything else in my life”
“I usually feel like I have a black hole in the pit of my stomach, at
least if I feel pain it’s better than feeling nothing”
I feel relieved and less anxious after I cut. The emotional pain slowly
slips away into the physical pain”
Self-injury can regulate strong emotions. It can put a person who is
at a high level of physiological arousal back to a baseline state.
Deliberate self-harm can distract from emotional pain and stop
feelings of numbness.
Self-inflicted violence is a way to express things that cannot be put
into words such as displaying anger, shocking others or seeking
support and help.
Self-injurious behavior can exert a sense of control over your body
if you feel powerless in other areas of your life. Sometimes magical
thinking is involved and you may imagine that hurting yourself will
prevent something worse from happening. Also, when you hurt
yourself it influences the behavior of others and can manipulate
people into feeling guilty, make them care, or make them go away.
Self punishment or self-hate may be involved. Some people who self-
injure have a childhood history of physical, sexual and emotional
abuse. They may erroneously blame themselves for having been
abused, they may feel that they deserved it and are now punishing
themselves because of self-hatred and low self-esteem.
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11. Self-abuse can also be a self-soothing behavior for someone who
does not have other means to calm intense emotions. Self-injury
followed by tending to one’s own wounds is a way to express self-care
and be self-nurturing for someone who never learned how to do that in
a more direct way.
People who self-injure have some common traits:
o Expressions of anger were discouraged while growing up
o They have co-existing problems with obsessive-compulsive disorder,
substance abuse or eating disorders
o They lack the necessary skills to express strong emotions in a
healthy way
o Often times there is a limited social support network
Self-injury as an addiction
BECOMING A HABITUAL SELF INJURER IS A PROGRESSIVE
PROCESS
The first incident of self- The next time a similar
injury may occur by strong feeling arises, the
accident, or after finding person has been
out about others who “conditioned” to seek relief
engage in this behavior in the same way
The person has strong The person feels compelled
feelings such as anger, fear to repeat self-harm, which is
or anxiety before an injuring likely to increase in frequency
event and degree
These feelings build, and The person hides the tools
the person has no way to used to injure, and covers up
express or address them the evidence, often by
directly wearing long sleeves
Cutting or other self-injury Endorphins, specifically
provides a sense of relief; enkephalins, contribute to
a release of the mounting the 'addictive’ nature of
tension self-injury
A feeling of guilt and shame When a person injures
usually follows the event themselves endorphins are
The feelings of shame released in the body and
paradoxically lead to function as natural pain killers
continued self-injurious The behavior may become
behavior addictive because the person
learns to associate the act of
self-injury with the positive
feelings they get when
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12. BECOMING A HABITUAL SELF INJURER IS A PROGRESSIVE
PROCESS
endorphins are released in
their system
The use of SSRI
medications (selective
serotonin reuptake inhibitors)
such as Prozac and Zoloft,
may be helpful in increasing
brain serotonin levels and
reducing self-injury in cases
of moderate to severe
depression
FDA Suicide Warning
In May 2007, the U.S. Food and Drug Administration (FDA)
recommended a new warning label for all antidepressant medications.
The current “black box” label includes a warning about the increased
risk of suicidal thinking and behavior in children and adolescents. The
FDA wants to expand this warning to include young adults from ages
18 to 24. Children and young adults should also be monitored for the
emergence of agitation, irritability, and unusual changes in behavior,
as these symptoms can indicate that the depression is getting worse.
The risk of suicide is particularly great during the first one to two
months of treatment.
Self-injury and suicide
Self-injury is usually not suicidal behavior but rather a way to reduce
tensions. Inflicting physical harm on oneself is a poorly learned coping
mechanism which is used to communicate feelings and self-soothe.
Self-injury is strongly linked to a poor sense of self-worth, and over
time, that depressed feeling can spiral into a suicidal attempt.
Sometimes self-harm may accidentally go farther than intended, and a
life-threatening injury may result which is why intervention and
profession help is required sooner rather than later.
Helping a friend or family member who is a self-injurer
No matter how you look at it, self-harm scares people. It is very hard
coming to terms with the fact that someone you care about is
physically harming themselves. From the depths of your own fear and
helplessness you may feel frustrated if you are unable to get the
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13. person to stop hurting themselves which can further drive the person
away.
Some helpful tips in dealing with someone who self-injures
Understand that self-harming behavior is an attempt to maintain a
certain amount of control which in and of itself is a way of self-
soothing
Let the person know that you care about them and are available to
listen
Encourage expressions of emotions including anger
Spend time doing enjoyable activities together
Offer to help them find a therapist or support group
Don’t make judgmental comments or tell the person to stop the self-
harming behavior – people who feel worthless and powerless are
even more likely to self-injure
If your child is self-injuring, prepare yourself to address the difficulties
in your family. Start with expressing feelings which is a common factor
in self-injury – this is not about blame, but rather about learning new
ways of dealing with family interactions and communications which
can help the entire family
How can a self-injuring person stop this behavior?
Self-injury is a behavior that over time becomes compulsive and
addictive. Like any other addiction, even though other people think the
person should stop, most addicts have a hard time just saying no to
their behavior – even when they realize it is unhealthy.
What you can do to help yourself
Acknowledge You are probably hurting on the inside
this is a and need professional help to stop this
problem addictive behavior
Realize this is This is about recognizing that a behavior
not about being that helped you handle your feelings has
a bad person become a big problem
Find one Maybe a friend, teacher, rabbi, minister,
person you counselor, or relative. Tell them you need
trust and get to talk about something serious that is
professional bothering you
help
Get help in Ask for help in developing ways to either
identifying what avoid or address those triggers
“triggers” your
self-harming
behaviors
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14. What you can do to help yourself
Recognize that Learn how to develop better ways to calm
self-injury is an and soothe yourself
attempt to self-
soothe
Figure out what Replace the act of self-harm with learning
function the how to express anger, sadness, and fear
self-injury is in healthy ways
serving
Treatments for self-injury
One danger connected with self-injury is that it tends to become an
addictive behavior, a habit that is difficult to break even when the
individual wants to stop. As with other addictions, qualified
professional help is almost always necessary. It is important to find a
therapist who understands this behavior and is not upset or repulsed
by it. Call your doctor or insurance company for a referral to a mental
health professional who specializes in self-injury.
Cognitive-behavioral therapy may be used to help the person learn
to recognize and address triggering feelings in healthier ways
Because a history of abuse or incest may be at the core of an
individual’s self-injuring behavior, therapies that address post-
traumatic stress disorder such as EMDR may be helpful (see
Helpguide’s article on Eye Movement Desensitization and
Reprocessing)
Hypnosis or other self-relaxation techniques are helpful in reducing
the stress and tension that often precede injuring incidents (see
Helpguide’s article on Yoga, meditation and other relaxation
techniques)
Group therapy may be helpful in decreasing the shame associated
with self-harm, and help to support healthy expressions of emotions
Family therapy may be useful, both in addressing any history of
family stress related to the behavior, and also in helping other family
members learn how to communicate more directly and non-
judgmentally with each other
In cases of moderate to severe depression or anxiety an
antidepressant or anti-anxiety medication may be used to reduce the
impulsive urges to self-harm in response to stress, while other coping
strategies are developed.
In severe cases an in-patient hospitalization program with a multi-
disciplinary team approach may be required
Alternatives to avoid self-harm
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15. If you self-injure to…Deal with anger that you cannot express openly,
try working through those feelings by doing something different –
running, dancing fast, screaming, punching a pillow, throwing
something, ripping something apart
If you hurt yourself in order to…Feel something when you feel numb
inside, hold ice cubes in one hand and try to crush them, hold a
package of frozen food, take a very cold shower, chew something with
a very strong taste (like chili peppers, raw ginger root, or a grapefruit
peel), wear an elastic rubber band around your wrist and snap it (in
moderation to avoid bruising) when you feel like hurting yourself
If you inflict physical pain to…Calm yourself, try taking a bubble bath,
doing deep breathing, writing in a journal, drawing, or doing some
yoga
If you self-mutilate to…See blood, try drawing a red ink line where
you would usually cut yourself, in combination with the other
suggestions above
To Learn More: Related Helpguide Articles
Understanding Anxiety Obsessive-Compulsive
- Symptoms, Types and Disorder (OCD) –
Treatment Symptoms, treatment
Medications for Anxiety options, and support for
- Drug Benefits, Risks OCD
and Side Effects Post-traumatic Stress
Stress Management: Disorder (PTSD):
Skills to Reduce, Symptoms, Help, and
Prevent, and Cope with Treatment
Stress
References and resources for self-injury
General Self-injury Resources
S.A.F.E. alternatives (Self-Abuse Finally Ends) – Blog and news for
individuals who cause self-injuries. Information Line: 1-800-DONT
CUT (Self-injury.com)
Education about self injury – Provides simple and clear definitions of
what self-injury is, myths and information about why people injure
themselves. (American Self-Harm Information Clearinghouse)
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16. Self-injury coping skills – Describes many things you can do to help
cope with the self-injuring tendencies and provides helpful resources
for recovery, information, and support. (Self-injury support)
Adolescent self-harm – Provides a brief overview and also includes
suggestions for parents on addressing self-injury with their child.
There is also a list of books available on the subject. {American
Association of Marriage and Family Therapists (AAMFT)}
Help for family and friends – Lets self-injurers know that they are NOT
alone and provides information to help their friends and family (Self-
injury.net)
Deborah Cutter, Psy.D., Jaelline Jaffe, Ph.D., and Jeanne Segal,
Ph.D., contributed to this article. Last modified: February 08.
Self Injury Coping Skills
A person who has developed self-injury as a coping method obviously
needs to learn to develop new healthy coping methods. Not all
healthy coping skills work for everyone. Below is a list of many
alternatives to self-injury. The key to being able to utilize many of
these methods is to identify when you are escalating to a crisis
situation. The ability to do this is a learned skill in itself but once
achieved your alternatives to self-injury become abundant.
If you are able to identify that you are escalating in anxiety, becoming
overwhelmed with emotion or detaching from your feelings and are
entertaining the idea of self-injury, here are some good alternatives:
Get rid of any sharp objects around that you have access
to
Go to a public place
Read a book/magazine
Journal (identify the trigger)
Take a shower
Listen to music
Take a walk
Draw/Color
Watch TV.
Get grounded
Visualize your safe scene
Talk to a parent, pastor or friend
Pray
Play sports
Make crafts
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17. Get on the computer (stay away from triggering web
sites)
Talk into a tape recorder
Shred paper
Hold ice cubes in your hands until they melt and then use
warm water
Call your therapist
Make a no-harm contract with yourself or someone you
trust
Clean the house
Take a bubble bath
Do relaxation exercises
Do deep breathing exercises
Go shopping
Wear a rubber band around a wrist and snap it tightly
when the urge arises
Make marks (washable red marker) where you want to
hurt yourself (sometimes self-injurers like the sight of
blood)
If you are unable to utilize the above methods and self-injury
ideation becomes imminent then “deal making” is used by many self-
injurers as a last resort and can be very affective. “Deal making” is
the process where you basically make a no harm contract with
yourself or with someone you trust that you will not harm yourself for a
designated amount of time. Once the time elapses you positively
acknowledge the fact that you did not act out on your urge, re-assess
your feeling state and make another contract or “deal” if necessary.
Here’s an example:
“The Fifteen Minute Rule”
One of the most effective things that can precede anything else
on this list is the 15-minute rule. Make a contract with yourself that
you will wait 15 minutes before hurting yourself. During this time, use
whatever coping skills work for you (this is best), or just do something
to pass the time. After the 15 minutes are over, recognize the fact that
you were able to successfully complete the contract and immediately
make another, realizing you have the power within to not react
impulsively (you’ve already shown that). If you still want to hurt
yourself, make another 15-minute contract making sure to give
yourself credit for not acting impulsively. If at any time you believe
you are in jeopardy of not continuing the self-contracting skill,
reach out for assistance immediately. When the desire to self-
injure finally passes, maybe you can tell a friend who knows about
your self-injury that you made it through. Even looking forward to
17

18. saying, "I made it!" is an incentive, and can make you feel good about
yourself.
An Overview of Dialectical Behavior Therapy in the Treatment of
Borderline Personality Disorder
by Barry Kiehn and Michaela Swales
Patients showing the features of Borderline Personality Disorder as
defined in DSM-IV are notoriously difficult to treat (Linehan 1993a).
They are difficult to keep in therapy, frequently fail to respond to our
therapeutic efforts and make considerable demands on the emotional
resources of the therapist, particular when suicidal and parasuicidal
behaviors are prominent.
Dialectical Behavior Therapy is an innovative method of treatment that
has been developed specifically to treat this difficult group of patients
in a way which is optimistic and which preserves the morale of the
therapist.
The technique has been devised by Marsha Linehan at the University
of Washington in Seattle and its effectiveness has been demonstrated
in a controlled study, the results of which will be summarized later in
this paper.
BORDERLINE PERSONALITY DISORDER
Dialectical Behavior Therapy is based on a bio-social theory of
borderline personality disorder. Linehan hypothesizes that the disorder
is a consequence of an emotionally vulnerable individual growing up
within a particular set of environmental circumstances, which she
refers to as the 'Invalidating Environment'.
An 'emotionally vulnerable' person in this sense is someone whose
autonomic nervous system reacts excessively to relatively low levels
of stress and takes longer than normal to return to baseline once the
stress is removed. It is proposed that this is the consequence of a
biological diathesis.
The term 'Invalidating Environment' refers essentially to a situation in
which the personal experiences and responses of the growing child
are disqualified or "invalidated" by the significant others in her life. The
child's personal communications are not accepted as an accurate
indication of her true feelings and it is implied that, if they were
18

19. accurate, then such feelings would not be a valid response to
circumstances. Furthermore, an Invalidating Environment is
characterized by a tendency to place a high value on self-control and
self-reliance. Possible difficulties in these areas are not acknowledged
and it is implied that problem solving should be easy given proper
motivation. Any failure on the part of the child to perform to the
expected standard is therefore ascribed to lack of motivation or some
other negative characteristic of her character. (The feminine pronoun
will be used throughout this paper when referring to the patient since
the majority of BPD patients are female and Lineman’s work has
focused on this subgroup).
Linehan suggests that an emotionally vulnerable child can be
expected to experience particular problems in such an environment.
She will neither have the opportunity accurately to label and
understand her feelings nor will she learn to trust her own responses
to events. Neither is she helped to cope with situations that she may
find difficult or stressful, since such problems are not acknowledged. It
may be expected then that she will look to other people for indications
of how she should be feeling and to solve her problems for her.
However, it is in the nature of such an environment that the demands
that she is allowed to make on others will tend to be severely
restricted. The child's behavior may then oscillate between opposite
poles of emotional inhibition in an attempt to gain acceptance and
extreme displays of emotion in order to have her feelings
acknowledged. Erratic response to this pattern of behavior by those in
the environment may then create a situation of intermittent
reinforcement resulting in the behavior pattern becoming persistent.
Linehan suggests that a particular consequence of this state of affairs
will be a failure to understand and control emotions; a failure to learn
the skills required for 'emotion modulation'. Given the emotional
vulnerability of these individuals this is postulated to result in a state of
'emotional dysregulation’, which combines in a transactional manner
with the Invalidating Environment to produce the typical symptoms of
Borderline Personality Disorder.
Patients with BPD frequently describe a history of childhood sexual
abuse and this is regarded within the model as representing a
particularly extreme form of invalidation.
Linehan emphasizes that this theory is not yet supported by empirical
evidence but the value of the technique does not depend on the
theory being correct since the clinical effectiveness of DBT does have
empirical support.
19

20. PATIENTS' CHARACTERISTICS
Linehan groups the features of BPD in a particular way, describing the
patients as showing dysregulation in the sphere of emotions,
relationships, behavior, cognition and the sense of self. She suggests
that, as a consequence of the situation that has been described, they
show six typical patterns of behavior, the term 'behavior' referring to
emotional, cognitive and autonomic activity as well as external
behavior in the narrow sense.
Firstly, they show evidence of 'emotional vulnerability' as already
described. They are aware of their difficulty coping with stress and
may blame others for having unrealistic expectations and making
unreasonable demands.
On the other hand they have internalized the characteristics of the
Invalidating Environment and tend to show 'self-invalidation'. They
invalidate their own responses and have unrealistic goals and
expectations, feeling ashamed and angry with themselves when they
experience difficulty or fail to achieve their goals.
These two features constitute the first pair of so-called 'dialectical
dilemmas', the patient's position tending to swing between the
opposing poles since each extreme is experienced as being
distressing.
Next, they tend to experience frequent traumatic environmental
events, in part related to their own dysfunctional lifestyle and
exacerbated by their extreme emotional reactions with delayed return
to baseline. This results in what Linehan refers to as a pattern of
'unrelenting crisis', one crisis following another before the previous
one has been resolved. On the other hand, because of their difficulties
with emotion modulation, they are unable to face, and therefore tend
to inhibit, negative affect and particularly feelings associated with loss
or grief. This 'inhibited grieving' and the 'unrelenting crisis' constitute
the second 'dialectical dilemma'.
The opposite poles of the final dilemma are referred to as 'active
passivity' and 'apparent competence'. Patients with BPD are active in
finding other people who will solve their problems for them but are
passive in relation to solving their own problems. On the other hand,
they have learned to give the impression of being competent in
response to the Invalidating Environment. In some situations they may
indeed be competent but their skills do not generalize across different
situations and are dependent on the mood state of the moment. This
20

21. extreme mood dependency is seen as being a typical feature of
patients with BPD.
A pattern of self-mutilation tends to develop as a means of coping with
the intense and painful feelings experienced by these patients and
suicide attempts may be seen as an expression of the fact that life is
at times simply does not seem worth living. These behaviors in
particular tend to result in frequent episodes of admission to
psychiatric hospitals. Dialectical Behavior Therapy, which will now be
described, focuses specifically on this pattern of problem behaviors
and in particular, the parasuicidal behavior. DIALECTICAL
BEHAVIOUR THERAPY The term 'dialectical' is derived from classical
philosophy. It refers to a form of argument in which an assertion is first
made about a particular issue (the 'thesis'), the opposing position is
then formulated (the 'antithesis' ) and finally a 'synthesis' is sought
between the two extremes, embodying the valuable features of each
position and resolving any contradictions between the two. This
synthesis then acts as the thesis for the next cycle. In this way truth is
seen as a process, which develops over time in transactions between
people. From this perspective there can be no statement representing
absolute truth. Truth is approached as the middle way between
extremes. The dialectical approach to understanding and treatment of
human problems is therefore non-dogmatic, open and has a systemic
and transactional orientation. The dialectical viewpoint underlies the
entire structure of therapy, the key dialectic being 'acceptance' on the
one hand and 'change' on the other. Thus DBT includes specific
techniques of acceptance and validation designed to counter the self-
invalidation of the patient. These are balanced by techniques of
problem solving to help her learn more adaptive ways of dealing with
her difficulties and acquire the skills to do so. Dialectical strategies
underlie all aspects of treatment to counter the extreme and rigid
thinking encountered in these patients. The dialectical world view is
apparent in the three pairs of 'dialectical dilemmas' already described,
in the goals of therapy and in the attitudes and communication styles
of the therapist, which are to be described. The therapy is behavioral
in that, without ignoring the past, it focuses on present behavior and
the current factors, which are controlling that behavior. THERAPIST
CHARACTERISTICS IN DBT The success of treatment is dependant
on the quality of the relationship between the patient and therapist.
The emphasis is on this being a real human relationship in which both
members matter and in which the needs of both have to be
considered. Linehan is particularly alert to the risks of burnout to
therapists treating these patients and therapist support and
consultation is an integral and essential part of the treatment. In DBT
support is not regarded as an optional extra. The basic idea is that the
therapist gives DBT to the patient and receives DBT from his or her
21

22. colleagues. The approach is a team approach. The therapist is asked
to accept a number of working assumptions about the patient that will
establish the required attitude for therapy: 1. The patient wants to
change and, in spite of appearances, is trying her best at any
particular time. 2. Her behavior pattern is understandable given her
background and present circumstances. Her life may currently not be
worth living (however, the therapist will never agree that suicide is the
appropriate solution but always stays on the side of life. The solution
is rather to try and make life more worth living). 3. In spite of this she
needs to try harder if things are ever to improve. She may not be
entirely to blame for the way things are but it is her personal
responsibility to make them different. 4. Patients can not fail in DBT. If
things are not improving it is the treatment that is failing. In particular
the therapist must avoid at all times viewing the patient, or talking
about her, in pejorative terms since such an attitude will be
antagonistic to successful therapeutic intervention and likely to feed
into the problems that have led to the development of BPD in the first
place. Linehan has a particular dislike for the word "manipulative" as
commonly applied to these patients. She points out that this implies
that they are skilled at managing other people when it is precisely the
opposite that is true. Also the fact that the therapist may feel
manipulated does not necessarily imply that this was the intention of
the patient. It is more probable that the patient did not have the skills
to deal with the situation more effectively. The therapist relates to the
patient in two dialectically opposed styles. The primary style of
relationship and communication is referred to as 'reciprocal
communication', a style involving responsiveness, warmth and
genuineness on the part of the therapist. Appropriate self-disclosure is
encouraged but always with the interests of the patient in mind. The
alternative style is referred to as 'irreverent communication'. This is a
more confrontational and challenging style aimed at bringing the
patient up with a jolt in order to deal with situations where therapy
seems to be stuck or moving in an unhelpful direction. It will be
observed that these two communication styles form the opposite ends
of another dialectic and should be used in a balanced way as therapy
proceeds. The therapist should try to interact with the patient in a way
that is: 1. accepting of the patient as she is but which encourages
change. 2. centered and firm yet flexible when the circumstances
require it. 3. nurturing but benevolently demanding. The dialectical
approach is here again apparent. There is a clear and open emphasis
on the limits of behavior acceptable to the therapist and these are
dealt with in a very direct way. The therapist should be clear about his
or her personal limits in relations to a particular patient and should as
far as possible make these clear to her from the start. It is openly
acknowledged that an unconditional relationship between therapist
and patient is not humanly possible and it is always possible for the
22

23. patient to cause the therapist to reject her if she tries hard enough. It
is in the patient's interests therefore to learn to treat her therapist in a
way that encourages the therapist to want to continue helping her. It is
not in her interests to burn him or her out. This issue is confronted
directly and openly in therapy. The therapist helps therapy to survive
by consistently bringing it to the patient's attention when limits have
been overstepped and then teaching her the skills to deal with the
situation more effectively and acceptably. It is made quite clear that
the issue is immediately concerned with the legitimate needs of the
therapist and only indirectly with the needs of the patient who clearly
stands to lose if she manages to burn out the therapist. The therapist
is asked to adopt a non-defensive posture towards the patient, to
accept that therapists are fallible and that mistakes will at times
inevitably be made. Perfect therapy is simply not possible. It needs to
be accepted as a working hypothesis that (to use Linehan's words) "all
therapists are jerks". PATIENTS' AND THERAPISTS' AGREEMENTS
This form of therapy must be entirely voluntary and depends for its
success on having the co-operation of the patient. From the start,
therefore, attention is given to orienting the patient to the nature of
DBT and obtaining a commitment to undertake the work. A variety of
specific strategies are described in the Linehan's book (Linehan
1993a) to facilitate this process. Before a patient will be taken on for
DBT she will be required to give a number of undertakings: 1. To work
in therapy for a specified period of time (Linehan initially contracts for
one year). and, within reason, to attend all scheduled therapy
sessions.
2. If suicidal or parasuicidal behaviors are present, she must agree to
work on reducing these.
3. To work on any behaviors that interfere with the course of therapy
('therapy interfering behaviors').
4. To attend skills training.
The strength of these agreements may be variable and a "take what
you can get approach" is advocated. Nevertheless a definite
commitment at some level is required since reminding the patient
about her commitment and re-establishing such commitment
throughout the course of therapy are important strategies in DBT.
The therapist agrees to make every reasonable effort to help the
patient and to treat her with respect, as well as to keep to the usual
expectations of reliability and professional ethics. The therapist does
not however give any undertaking to stop the patient from harming
herself. On the contrary, it should be make quite clear that the
23

24. therapist is simply not able to prevent her from doing so. The therapist
will try rather to help her find ways of making her life more worth living.
DBT is offered as a life-enhancement treatment and not as a suicide
prevention treatment, although it is hoped that it may indeed achieve
the latter.
MODES OF TREATMENT
There are four primary modes of treatment in DBT :
1. Individual therapy
2. Group skills training
3. Telephone contact
4. Therapist consultation
Whilst keeping within the overall model, group therapy and other
modes of treatment may be added at the discretion of the therapist,
providing the targets for that mode are clear and prioritized.
The individual therapist is the primary therapist. The main work of
therapy is carried out in the INDIVIDUAL THERAPY sessions. The
structure of individual therapy and some of the strategies used will be
described shortly. The characteristics of the therapeutic alliance have
already been described.
Between sessions the patient should be offered TELEPHONE
CONTACT with the therapist, including out of hours telephone contact.
This tends to be an aspect of DBT balked at by many prospective
therapists. However, each therapist has the right to set clear limits on
such contact and the purpose of telephone contact is also quite clearly
defined. In particular, telephone contact is not for the purpose of
psychotherapy. Rather it is to give the patient help and support in
applying the skills that she is learning to her real life situation between
sessions and to help her find ways of avoiding self-injury. Calls are
also accepted for the purpose of relationship repair where the patient
feels that she has damaged her relationship with her therapist and
wants to put this right before the next session. Calls after the patient
has injured herself are not acceptable and, after ensuring her
immediate safety, no further calls are allowed for the next twenty four
hours. This is to avoid reinforcing self-injury.
SKILLS TRAINING is usually carried out in a group context, ideally by
someone other that the individual therapist. In the skills training
groups patients are taught skills considered relevant to the particular
problems experienced by people with borderline personality disorder.
There are four modules focusing in turn on four groups of skills:
24

25. 1. Core mindfulness skills.
2. Interpersonal effectiveness skills.
3. Emotion modulation skills.
4. Distress tolerance skills.
The 'core mindfulness skills' are derived from certain techniques of
Buddhist meditation, although they are essentially psychological
techniques and no religious allegiance is involved in their application.
Essentially they are techniques to enable one to become more clearly
aware of the contents of experience and to develop the ability to stay
with that experience in the present moment.
The 'interpersonal effectiveness skills' which are taught focus on
effective ways of achieving one's objectives with other people: to ask
for what one wants effectively, to say no and have it taken seriously,
to maintain relationships and to maintain self-esteem in interactions
with other people.
'Emotion modulation skills' are ways of changing distressing emotional
states and 'distress tolerance skills' include techniques for putting up
with these emotional states if they can not be changed for the time
being.
The skills are too many and varied to be described here in detail. They
are fully described in a teaching format in the DBT skills training
manual (Linehan, 1993b).
The therapists receive DBT from each other at the regular
THERAPIST CONSULTATION GROUPS and, as already mentioned,
this is regarded as an essential aspect of therapy. The members of
the group are required to keep each other in the DBT mode and
(among other things) are required to give a formal undertaking to
remain dialectical in their interaction with each other, to avoid any
pejorative descriptions of patient or therapist behavior, to respect
therapists' individual limits and generally are expected to treat each
other at least as well as they treat their patients. Part of the session
may be used for ongoing training purposes.
STAGES OF THERAPY AND TREATMENT TARGETS
Patients with BPD present multiple problems and this can pose
problems for the therapist in deciding what to focus on and when. This
problem is directly addressed in DBT. The course of therapy over time
is organized into a number of stages and structured in terms of
hierarchies of targets at each stage.
25

26. The PRE-TREATMENT STAGE focuses on assessment, commitment
and orientation to therapy.
STAGE 1 focuses on suicidal behaviors, therapy interfering behaviors
and behaviors that interfere with the quality of life, together with
developing the necessary skills to resolve these problems.
STAGE 2 deals with post-traumatic stress related problems (PTSD)
STAGE 3 focuses on self-esteem and individual treatment goals.
The targeted behaviors of each stage are brought under control before
moving on to the next phase. In particular post-traumatic stress
related problems such as those related to childhood sexual abuse are
not dealt with directly until stage 1 has been successfully completed.
To do so would risk an increase in serious self injury. Problems of this
type (flashbacks for instance) emerging whilst the patient is still in
stages 1 or 2 are dealt with using 'distress tolerance' techniques. The
treatment of PTSD in stage 2 involves exposure to memories of the
past trauma.
Therapy at each stage is focused on the specific targets for that stage,
which are arranged in a definite hierarchy of relative importance. The
hierarchy of targets varies between the different modes of therapy but
it is essential for therapists working in each mode to be clear what the
targets are. An overall goal in every mode of therapy is to increase
dialectical thinking.
The hierarchy of targets in individual therapy for example is as follows:
1. Decreasing suicidal behaviors.
2. Decreasing therapy interfering behaviors.
3. Decreasing behaviors that interfere with the quality of life.
4. Increasing behavioral skills.
5. Decreasing behaviors related to post-traumatic stress.
6. Improving self esteem.
7. Individual targets negotiated with the patient.
In any individual session these targets must be dealt with in that order.
In particular, any incident of self harm that may have occurred since
the last session must be dealt with first and the therapist must not
allow him or herself to be distracted from this goal.
The importance given to 'therapy interfering behaviors' is a particular
characteristic of DBT and reflects the difficulty of working with these
patients. It is second only to suicidal behaviors in importance. These
26

27. are any behaviors by the patient or therapist that interfere in any way
with the proper conduct of therapy and risk preventing the patient from
getting the help she needs. They include, for example, failure to attend
sessions reliably, failure to keep to contracted agreements, or
behaviors that overstep therapist limits.
Behaviors that interfere with the quality of life are such things as drug
or alcohol abuse, sexual promiscuity, high risk behavior and the like.
What is or is not a quality of life interfering behavior may be a matter
for negotiation between patient and therapist.
The patient is required to record instances of targeted behaviors on
the weekly diary cards. Failure to do so is regarded as therapy
interfering behavior.
TREATMENT STRATEGIES
Within this framework of stages, target hierarchies and modes of
therapy a wide variety of therapeutic strategies and specific
techniques is applied.
The core strategies in DBT are 'validation' and 'problem solving'.
Attempts to facilitate change are surrounded by interventions that
validate the patient's behavior and responses as understandable in
relation to her current life situation, and that show an understanding of
her difficulties and suffering.
Problem solving focuses on the establishment of necessary skills. If
the patient is not dealing with her problems effectively then it is to be
anticipated either that she does not have the necessary skills to do so,
or does have the skills but is prevented from using them. If she does
not have the skills then she will need to learn them. This is the
purpose of the skills training.
Having the skills, she may be prevented from using them in particular
situations either because of environmental factors or because of
emotional or cognitive problems getting in the way. To deal with these
difficulties the following techniques may be applied in the course of
therapy:
1. Contingency management
2. Cognitive therapy
3. Exposure based therapies
4. Pharmacotherapy
27

28. The principles of using these techniques are precisely those applying
to their use in other contexts and will not be described in any detail. In
DBT however they are used in a relatively informal way and
interwoven into therapy. Linehan recommends that medication be
prescribed by someone other than the primary therapist although this
may not be practical.
Particular note should be made of the pervading application of
contingency management throughout therapy, using the relationship
with the therapist as the main reinforcer. In the session by session
course of therapy care is taken to systematically reinforce targeted
adaptive behaviors and to avoid reinforcing targeted maladaptive
behaviors. This process is made quite overt to the patient, explaining
that behavior, which reinforced can be expected to increase. A clear
distinction is made between the observed effect of reinforcement and
the motivation of the behavior, pointing out that such a relationship
between cause and effect does not imply that the behavior is being
carried out deliberately in order to obtain the reinforcement. Didactic
teaching and insight strategies may also be used to help the patient
achieve an understanding of the factors that may be controlling her
behavior.
The same contingency management approach is taken in dealing with
behaviors that overstep the therapist's personal limits in which case
they are referred to as 'observing limits procedures'.
Problem solving and change strategies are again balanced
dialectically by the use of validation strategies. It is important at every
stage to convey to the patient that her behavior, including thoughts
feelings and actions are understandable, even though they may be
maladaptive or unhelpful.
Significant instances of targeted maladaptive behavior occurring since
the last session (which should have been recorded on the diary card)
are initially dealt with by carrying out a detailed 'behavioral analysis'.
In particular every single instance of suicidal or parasuicidal behavior
is dealt with in this way. Such behavioral analysis is an important
aspect of DBT and may take up a large proportion of therapy time.
In the course of a typical behavioral analysis a particular instance of
behavior is first clearly defined in specific terms and then a 'chain
analysis' is conducted, looking in detail at the sequence of events and
attempting to link these events one to another. In the course of this
process hypotheses are generated about the factors that may be
controlling the behavior. This is followed by, or interwoven with, a
'solution analysis' in which alternative ways of dealing with the
28

29. situation at each stage are considered and evaluated. Finally one
solution should be chosen for future implementation. Difficulties that
may be experienced in carrying out this solution are considered and
strategies of dealing with these can be worked out.
It is frequently the case that patients will attempt to avoid this
behavioral analysis since they may experience the process of looking
in such detail at their behavior as aversive. However it is essential that
the therapist should not be side tracked until the process is completed.
In addition to achieving an understanding of the factors controlling
behavior, behavioral analysis can be seen as part of contingency
management strategy, applying a somewhat aversive consequence to
an episode of targeted maladaptive behavior. The process can also be
seen as an exposure technique helping to desensitize the patient to
painful feelings and behaviors. Having completed the behavioral
analysis the patient can then be rewarded with a 'heart to heart'
conversation about the things she likes to discuss.
Behavioral analysis can be seen as a way of responding to
maladaptive behavior, and in particular to parasuicide, in a way that
shows interest and concern but which avoids reinforcing the behavior.
In DBT a particular approach is taken in dealing with the network of
people with whom the patient is involved personally and
professionally. These are referred to as 'case management strategies'.
The basic idea is that the patient should be encouraged, with
appropriate help and support, to deal with her own problems in the
environment in which they occur. Therefore, as far as possible, the
therapist does not do things for the patient but encourages the patient
to do things for herself. This includes dealing with other professionals
who may be involved with the patient. The therapist does not try to tell
these other professionals how to deal with the patient but helps the
patient learn how to deal with the other professionals. Inconsistencies
between professionals are seen as inevitable and not necessarily
something to be avoided. Such inconsistencies are rather seen as
opportunities for the patient to practice her interpersonal effectiveness
skills. If she grumbles about the help she is receiving from another
professional she is helped to sort this out herself with the person
involved. This is referred to as the 'consultation-to-the-patient
strategy’, which, among other things, serves to minimize the so-called
"staff splitting" which tends to occur between professionals dealing
with these patients.
Environmental intervention is acceptable but only in very specific
situations where a particular outcome seems essential and the patient
29

30. does not have the power or capability to produce this outcome. Such
intervention should be the exception rather than the rule.
EMPIRICAL EVIDENCE
The effectiveness of DBT has been assessed in two major trials. The
first (Linehan et al, 1991) compared the effectiveness of DBT relative
to treatment as usual (TAU). The second (Linehan et al, in press)
examined the effectiveness of DBT skills training when added to
standard community psychotherapy.
In the first randomised controlled trial, there were three main goals:
Firstly, to reduce the frequency of parasuicidal behaviors. This is
clearly of importance because of the distressing nature of the behavior
but also because of the increased risk of completed suicide in this
group (Stone, 1987).
Secondly, to reduce behaviors that interfere with the progress of
therapy ('therapy interfering behaviors'), as the attrition rate from
therapy in borderline women with a history of parasuicidal behaviors is
high.
Finally, to reduce behaviors that interfere with the patients' quality of
life. In this study this latter goal was interpreted more specifically as a
reduction in in-patient psychiatric days, which is hypothesized to
interfere with the patient's quality of life.
Participants all met DSM-IIIR criteria for BPD, and were matched for
number of lifetime parasuicide episodes, number of lifetime
admissions to hospital, age and anticipated good or poor prognosis.
There were 22 patients in each group. The experimental group
received standard DBT as outlined above. The experience of the
patients in the treatment as usual group was variable; some received
regular individual psychotherapy, others dropped out of individual
therapy whilst continuing to have access to in-patient and day-patient
services. All participants were assessed on number of parasuicidal
episodes and a range of questionnaire measures of mood. Patients
were blindly assessed at pre-treatment, 4, 8 and 12 months and
followed up at 6 and 12 months post-treatment. Measures of treatment
compliance and other treatment delivered (e.g. in patient psychiatric
days) were also taken. At pre-treatment there were no significant
differences on any of the measures between the control and
experimental groups including demographic criteria.
30

31. With regard to the first aim of the trial (i.e. the reduction of suicidal
behavior), during the year of treatment patients in the control group
engaged in more parasuicidal acts than DBT patients at all time
points. The medical risk for parasuicidal acts was higher in the control
group than in the DBT group.
Patients in the DBT group were more likely to start therapy and were
more likely to remain in therapy than those in the control group. The
one year attrition rate in the DBT group was 16.7% compared to 50%
for those in the control group who commenced the year with a new
therapist. The DBT patients reported more individual and group
therapy treatment hours per week than the TAU group, which reflects
the intensive nature of DBT treatment. However, the control patients
reported more day treatment hours per week.
With regard to the third goal of the trial, patients in the control group
had significantly more inpatient psychiatric days per person than those
receiving DBT (38.6 days per year as compared to 8.46 days per year
for the DBT group).
These results were considered to indicate the superiority of DBT over
treatment as usual. However, one major criticism of the trial is that the
variable and patchy therapeutic experience of the control group may
be considered to favor DBT. This criticism can be challenged,
however, since one of the treatment aims of DBT is to keep the patient
in therapy. This it seems to have succeeded in doing. However, it is
still pertinent to enquire how well DBT would compare to a consistent
treatment alternative. An attempt was made to explore this by
comparing the DBT patients with those in the TAU group who received
regular individual therapy. It was found that the gains of the patients in
the DBT group over the TAU group remained even using this more
rigorous comparison.
Despite the more intensive nature of DBT it remained cheaper than
TAU, largely because of the reduction in the number of in-patient and
day-treatment days received by the DBT patients.
It is of interest that, although the DBT patients showed significant
gains across the three areas of interest (number of parasuicides,
treatment compliance and inpatient days), there were no between-
group differences on any of the questionnaire measures of mood and
suicidal ideation. During the follow-up year, patients in the DBT group
had higher Global Assessment Scores and a better work performance
than the patients in the TAU group. In the first 6 months, DBT patients
had fewer suicidal acts, lower anger scores and better self-reported
social adjustment than TAU patients. In the final 6 months, DBT
31

32. patients had fewer in-patient days’ treatment and better interviewer
rated social adjustment than TAU patients.
The second trial had two parts. Firstly, it compared standard
community psychotherapy (SCP) plus the group skills component of
DBT with SCP alone without added skills training. Secondly, it
compared the SCP group from the first part of the present study with
the experimental group in the previously described randomised control
trial. In this latter comparison, assignment to conditions was not
random. However, all subjects were screened in the same way, during
the same time frame and were all subject to blind assessment.
The results of the first part of this study indicated that the addition of
DBT skills training to SCP for this group of parasuicidal borderline
women did not confer any additional therapeutic benefit. In this part of
the study the skills training was truly ancillary in that there were no
meetings between the individual therapists and the group therapists,
nor were any attempts made to assist the patient to generalize the
skills learnt in the group to her everyday life.
In the second part of the study there were some pre-treatment
differences between the two groups. The DBT patients were less
depressed than the control group and reported higher levels of
unemployment. These differences were not considered to be
particularly important for three reasons. Firstly, depression was not
correlated with any of the outcome variables. Secondly, although the
lower depression scores favored the DBT group, the lower
unemployment favored the SCP group. Finally, the levels of
depression did not differ between the two groups after the pre-
treatment point.
During the treatment year there were no significant differences
between the groups with regard to staying in therapy. There were
some slight differences in the distribution of therapeutic hours, with
DBT patients reporting more group treatment hours than the SCP
group. Most importantly, however, there were no significant
relationships between number of treatment hours and any of the
outcome variables. Over the treatment year, standard DBT patients
compared to SCP patients had fewer parasuicidal episodes, fewer
episodes leading to medical treatment and fewer psychiatric in-patient
days. DBT patients also reported less anger than the SCP patients.
This research then provides some evidence for the therapeutic
efficacy of DBT. This evidence is primarily derived from one
randomised control trial in which DBT was found to be superior on a
number of variables to treatment as usual. Clearly this finding requires
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33. replication. There is also some evidence to suggest that DBT is
superior to other forms of psychotherapy with this group of patients.
However, this result comes from a comparison made using only a sub-
sample of patients in the randomised trial (Linehan et al, 1991) and
from a further comparison between two groups from different studies
(Linehan et al, in press). Consequently, the effectiveness of DBT
compared to other alternative treatments awaits further exploration.
This will remain a challenge, particularly given the high drop-out rates
from treatment of this group of patients.
SUMMARY AND CONCLUSIONS
Dialectical Behavior Therapy then is a novel method of therapy
specifically designed to meet the needs of patients with Borderline
Personality Disorder and their therapists. It directly addresses the
problem of keeping these patients in therapy and the difficulty of
maintaining therapist motivation and professional well-being. It is
based on a clear and potentially testable theory of BPD and
encourages a positive and validating attitude to these patients in the
light of this theory. The approach incorporates what is valuable from
other forms of therapy, and is based on a clear acknowledgement of
the value of a strong relationship between therapist and patient.
Therapy is clearly structured in stages and at each stage a clear
hierarchy of targets is defined. The method offers a particularly helpful
approach to the management of parasuicide with a clearly defined
response to such behaviors. The techniques used in DBT are
extensive and varied, addressing essentially every aspect of therapy
and they are underpinned by a dialectical philosophy that
recommends a balanced, flexible and systemic approach to the work
of therapy. Techniques for achieving change are balanced by
techniques of acceptance, problem solving is surrounded by
validation, confrontation is balanced by understanding. The patient is
helped to understand her problem behaviors and then deal with
situations more effectively. She is taught the necessary skills to
enable her to do so and helped to deal with any problems that she
may have in applying them in her natural environment. Generalization
outside therapy is not assumed but encouraged directly. Advice and
support available between sessions and the patient is encouraged and
helped to take responsibility for dealing with life's challenges herself.
The method is supported by empirical evidence, which suggests that it
is successful in reducing self-injury and time spent in psychiatric in-
patient treatment.
REFERENCES
33

34. Linehan, M.M. (1993a) Cognitive Behavioral Treatment of Borderline
Personality Disorder. The Guilford Press, New York and London.
Linehan, M.M. (1993b) Skills Training Manual for Treating Borderline
Personality Disorder. The Guilford Press, New York and London.
Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. & Heard, H.L.
(1991) Cognitive-behavioral treatment of chronically parasuicidal
borderline patients. Archives of General Psychiatry, 48, 1060-1064.
Linehan, M.M., Heard, H.L. & Armstrong, H.E. (in press) Dialectical
behavior therapy, with and without behavioral skills training, for
chronically parasuicidal borderline patients.
Stone, M.H. (1987) The course of borderline personality disorder. In
Tasman, A., Hales, R.E. & Frances, A.J. (eds) American Psychiatric
Press Review of Psychiatry. Washington DC; American Psychiatric
Press inc. 8, 103-122.
Barry Kiehn, Consultant Child and Adolescent Psychiatrist,
Gwynfa Adolescent Service, Pen-y-Bryn Road, Upper Colwyn
Bay, Clwyd, North Wales, LL29 6AL.
e-mail: b.kiehn@bbcnc.org.uk
Michaela Swales, Chartered Clinical Psychologist, Gwynfa
Adolescent Service and Lecturer in the Psychology of
Adolescence, University College of North Wales, Bangor,
Gwynedd, LL57 2DG.
e-mail: pss051@bangor.ac.uk
Eye Movement Desensitization and Reprocessing (EMDR)1 is a
comprehensive, integrative psychotherapy approach. It contains
elements of many effective psychotherapies in structured protocols
that are designed to maximize treatment effects. These include
psychodynamic, cognitive behavioral, interpersonal, experiential, and
body-centered therapies2.
EMDR is an information processing therapy (When a traumatic or very
negative event occurs, information processing may be incomplete, perhaps because
strong negative feelings or dissociation interfere with information processing. This
prevents the forging of connections with more adaptive information that is held in
other memory networks. For example, a rape survivor may “know” that rapists are
responsible for their crimes, but this information does not connect with her feeling
that she is to blame for the attack. The memory is then dysfunctionally stored
without appropriate associative connections and with many elements still
unprocessed. When the individual thinks about the trauma, or when the memory is
34

35. triggered by similar situations, the person may feel like she is reliving it, or may
experience strong emotions and physical sensations. A prime example is the
intrusive thoughts, emotional disturbance, and negative self-referencing beliefs of
posttraumatic stress disorder (PTSD)). and uses an eight phase approach to
address the experiential contributors of a wide range of pathologies. It
attends to the past experiences that have set the groundwork for
pathology, the current situations that trigger dysfunctional emotions,
beliefs and sensations, and the positive experience needed to
enhance future adaptive behaviors and mental health.
During treatment various procedures and protocols are used to
address the entire clinical picture. One of the procedural elements is
"dual stimulation" using either bilateral eye movements, tones or taps.
During the reprocessing phases the client attends momentarily to past
memories, present triggers, or anticipated future experiences while
simultaneously focusing on a set of external stimulus. During that
time, clients generally experience the emergence of insight, changes
in memories, or new associations. The clinician assists the client to
focus on appropriate material before initiation of each subsequent set.
Eight Phases of Treatment
The first phase is a history taking session during which the therapist
assesses the client's readiness for EMDR and develops a treatment
plan. Client and therapist identify possible targets for EMDR
processing. These include recent distressing events, current situations
that elicit emotional disturbance, related historical incidents, and the
development of specific skills and behaviors that will be needed by the
client in future situations.
During the second phase of treatment, the therapist ensures that the
client has adequate methods of handling emotional distress and good
coping skills, and that the client is in a relatively stable state. If further
stabilization is required, or if additional skills are needed, therapy
focuses on providing these. The client is then able to use stress
reducing techniques whenever necessary, during or between
sessions. However, one goal is not to need these techniques once
therapy is complete.
In phase three through six, a target is identified and processed using
EMDR procedures. These involve the client identifying the most vivid
visual image related to the memory (if available), a negative belief
about self, related emotions and body sensations. The client also
identifies a preferred positive belief. The validity of the positive belief is
rated, as is the intensity of the negative emotions.
35

36. After this, the client is instructed to focus on the image, negative
thought, and body sensations while simultaneously moving his/her
eyes back and forth following the therapist's fingers as they move
across his/her field of vision for 20-30 seconds or more, depending
upon the need of the client. Athough eye movements are the most
commonly used external stimulus, therapists often use auditory tones,
tapping, or other types of tactile stimulation. The kind of dual attention
and the length of each set is customized to the need of the client. The
client is instructed to just notice whatever happens. After this, the
clinician instructs the client to let his/her mind go blank and to notice
whatever thought, feeling, image, memory, or sensation comes to
mind. Depending upon the client's report the clinician will facilitate the
next focus of attention. In most cases a client-directed association
process is encouraged. This is repeated numerous times throughout
the session. If the client becomes distressed or has difficulty with the
process, the therapist follows established procedures to help the client
resume processing. When the client reports no distress related to the
targeted memory, the clinician asks him/her to think of the preferred
positive belief that was identified at the beginning of the session, or a
better one if it has emerged, and to focus on the incident, while
simultaneously engaging in the eye movements. After several sets,
clients generally report increased confidence in this positive belief.
The therapist checks with the client regarding body sensations. If
there are negative sensations, these are processed as above. If there
are positive sensations, they are further enhanced.
In phase seven, closure, the therapist asks the client to keep a journal
during the week to document any related material that may arise and
reminds the client of the self-calming activities that were mastered in
phase two.
The next session begins with phase eight, re-evaluation of the
previous work, and of progress since the previous session. EMDR
treatment ensures processing of all related historical events, current
incidents that elicit distress, and future scenarios that will require
different responses. The overall goal is produce the most
comprehensive and profound treatment effects in the shortest period
of time, while simultaneously maintaining a stable client within a
balanced system.
After EMDR processing, clients generally report that the emotional
distress related to the memory has been eliminated, or greatly
decreased, and that they have gained important cognitive insights.
Importantly, these emotional and cognitive changes usually result in
spontaneous behavioral and personal change, which are further
enhanced with standard EMDR procedures.
36

37. 1
Shapiro, F. (2001). Eye Movement Desensitization and
Reprocessing: Basic Principles, Protocols and Procedures (2nd ed.).
New York: Guilford Press.
2
Shapiro, F. (2002). EMDR as an Integrative Psychotherapy
Approach: Experts of Diverse Orientations Explore the Paradigm
Prism. Washington, DC: American Psychological Association Books.
Thought stopping
Techniques > Conversion > Thought stopping
Undesirable thoughts | Preventing thoughts | See also
The principle of 'thought stopping' is first to stop people thinking about
those things which will distract or dissuade them from what they are
supposed to be thinking.
Undesirable thoughts
Distraction
Undesirable thinking can come in two forms. First, the person may be
distracted by innocuous thoughts when they should be concentrating
on a particular area. When I am reading or meditating, for example,
someone talking nearby would be a distraction and cause my mind to
wander onto the subjects about which they are talking. Distraction is
thus just a block to conversion, slowing it down.
People may also be taught thought-stopping methods as ways of
blocking out dissuasive arguments when they meet them. Just as a
child puts their hands over their ears and makes 'da-da-da' noises to
block out what they do not want to hear, so a group member may
distract their conscious, for example by reciting some form of litany to
themselves or otherwise avoiding having to experience the tension of
contradictory arguments.
Dissuasion
37

38. The second form of unwanted thoughts are when the person is
thinking about something that will dissuade them and persuade
otherwise from the thoughts that they should be having. This is far
more serious that distraction as it can cause a reversal in the process
of conversion, rather than a temporary pause.
Dissuasion may occur accidentally or deliberately. Accidental
dissuasion occurs, when the person reads, hears or sees something
that is not targeted directly at them, but causes them to think the
wrong thoughts.
Preventing thoughts
Isolation
Isolation from distractions is commonly used at least at two levels.
First, when practices such as meditation and prayer are used, then
individual isolation removes immediate distractions. At the second
level, individuals and groups may be isolated from the world, either to
avoid any dissuasion of individuals or to remove distractions.
Occupation
Another simple way of limiting undesirable thoughts is to keep people
busy with all kinds of physical and mental activities that gives them
little time for any action, talk or reflection that may lead to wrong
thoughts.
Carrot and stick
Operant Conditioning says that rewards causes behavior to be
repeated, whilst punishment leads to extinction of behavior. Reward of
right thinking and punishment of wrong thinking may thus be used to
persuade and dissuade.
Grounding Techniques
Grounding techniques are those that help you focus on the here and
now and remind you that you are not in the past traumatic experience.
Listen to music: Listen to your favorite type of music. Concentrate on
the lyrics. It may help to sing along with the lyrics as well.
Touch the things around you: Touch things in your surroundings
and name each thing as you touch it either in your head or aloud.
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39. Doing so will help you concentrate on your current circumstances and
reminds you that you are not in the past.
Repetitive phrases: Sometimes, repeating certain phrases will help
you come back to the present. You might tell yourself, "I am safe now"
or, "That was then, this is now." Keep repeating these phrases until
you feel better.
Talk/write it out: If someone is with you, and you can trust that
person, talk to him or her about what you are feeling. Call a trusted
friend and talk to him or her about what you are experiencing.
Alternatively, call your therapist to talk.
If no one is available, try writing down how you feel and what you are
experiencing. Remind yourself that while you feel you are in the past
traumatic experience, you are safe now.
Pets: Brush, pet, or play with your dog or cat if you have one. Animals
can be extremely therapeutic. Even being near your pet may help you
feel better.
Read: When you read, you must focus on the here and now. Read a
book you enjoy. Do not read something that may remind you of the
past trauma or could make you upset
Self-
Soot
he
In DBT, there are four categories of Distress Tolerance strategies. These are:
Distracting
Self-Soothing
Improving the Moment
Focusing on the Pros and Cons
These are strategies that short circuit or help you to cope with overwhelming negative
emotions or intolerable situations. They take a lot of practice, but as you get the hang of
using some of these techniques, you will see your relationship to the negative emotions
and intolerable feelings change. (This was the most amazing thing about DBT for me,
that things I though could never change or that I could never learn to deal with did
become better.)
39

40. It takes time and practice, and so I urge you to give the techniques plenty of practice.
You will find some things work better than others for you. And you will find that some
things don't work at first, but over time and practice you will see some results.
Self-Soothing Techniques
Some of us may recognize these techniques as things that we already use. But many of us
have never learned how to self-soothe, how to do those often simple things that makes us feel
better. These are mostly very physical techniques, that use different body senses. Some of us
have never had the feeling that we could do things to make ourselves feel better, calmer, feel
relaxation or pleasure. I urge you to experiment with these techniques until you find some that
are comfortable and helpful for you. And when you find these, practice them. Use them when
you are feeling distressed, when emotions feel overwhelming, when situations feel like you
can't stand them any more. Instead of doing something that hurts you, try something that
gives you pleasure and comfort,
SELF-SOOTHING has to do with comforting, nurturing and being kind to yourself. One way
to think of this is to think of ways of soothing each of your five senses:
Vision
Hearing
Smell
Taste
Touch
Check p. 167 in the manual, Distress Tolerance Handout 1, for lots of suggestions of
things that you can do to soothe and pleasure your five senses. A few examples:
With VISION:
Walk in a pretty part of town. Look at the nature around you. Go to a museum with
beautiful art. Buy a flower and put it where you can see it. Sit in a garden. Watch the
snowflakes decorate the trees during a snowfall. Light a candle and watch the flame.
Look at a book with beautiful scenery or beautiful art. Watch a travel movie or video.
With HEARING:
Listen to beautiful or soothing music, or to tapes of the ocean or other sounds of nature.
Listen to a baby gurgling or a small animal. Sit by a waterfall. Listen to someone
chopping wood. When you are listening, be mindful, letting the sounds come and go.
With SMELL:
Smell breakfast being cooked at home or in a restaurant. Notice all the different smells
around you. Walk in a garden or in the woods, maybe just after a rain, and breathe in
the smells of nature. Light a scented candle or incense. Bake some bread or a cake, and
take in all the smells.
40

41. With TASTE:
Have a special treat, and eat it slowly, savoring each bite. Cook a favorite meal. Drink a
soothing drink like herbal tea or hot chocolate. Let the taste run over your tongue and
slowly down your throat. Go to a potluck, and eat a little bit of each dish, mindfully
tasting each new thing.
With TOUCH:
Take a bubble bath. Pet your dog or cat or cuddle a baby. Put on a silk shirt shirt or
blouse, and feel its softness and smoothness. Sink into a really comfortable bed. Float or
swim in a pool, and feel the water caress your body.
Discussion
Many of us may feel like we don't deserve these comforts, and may find it hard to give
pleasure to ourselves in this way. Do you have these feelings?
Some of may also expect this soothing to come from other people, or not want
to do it for ourselves. Have you experienced this feeling?
You may feel guilty about pleasuring yourself in this way. It may take some practice to
allow yourself to experience these pleasures. These are really simple human pleasures
that everyone has a right to, and that will give us some good tools to use when we are
feeling bad.
Exercises
Try at least one of these self-soothing exercises this week. You may want to choose a
whole group of things, say all the visual things, or you may want to choose a single thing
to try. As you do what you have chosen, do it mindfully. Breathe gently, and try to be
fully in the experience, whether it is walking in the woods or watching a flower or taking
a bubble bath or smelling some fresh-baked bread.
As you begin to overcome your feelings that perhaps you do not deserve this, or guilt,
and start to enjoy one or more of these activities, you will be learning very useful tools to
help you deal with negative feelings and difficult situations.
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