DBT-Informed Art Therapy

Mindfulness, Cognitive Behavior Therapy, and the Creative Process

Susan M. Clark

• Publisher: Jessica Kingsley Publishers
• Year: 2016
• Print ISBN:
  9781849057332
• eBook ISBN:
  9781784501037
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Understand DBT-informed art therapy, and how to apply it to your practice. Dialectical Behavior Therapy (DBT) treats problems with emotion regulation, and is especially effective in treating chronic self-harming and suicidal behaviors associated with Borderline Personality Disorder. Combining the structure and skill development of DBT with the creativity and non-verbal communication of art therapy can be a significant advantage in treating patients who are resistant to talking therapy.

This book gives a comprehensive overview of the growing literature and research on DBT-informed art therapy, drawing upon the work of pioneers in the field to explain different types of DBT-informed art therapy and the 'Three Ms' at its core: Mindfulness, Metaphor and Mastery. It also includes creative visual exercises and activities for developing the skills of core mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance, and non-judgemental acceptance among clients.

Part 1

THE
BACKGROUND

Chapter 1

STANDARD DBT AND ITS ADAPTATIONS

Borderline personality disorder: a disorder of emotion regulation

Dialectical behavior therapy (DBT) was originally developed to treat chronically suicidal and self-injuring women, many of whom were diagnosed with borderline personality disorder (BPD)—a ubiquitous, and frequently reviled, psychiatric label in modern mental health care. BPD is the most common personality disorder (Aguirre and Galen 2013); between 6 and 15 million US citizens meet its diagnostic criteria. Individuals with BPD comprise approximately 15–20% of those receiving inpatient psychiatric treatment, as well as 10–15% of those receiving outpatient mental health services (Gunderson 2011; Leichsenring et al. 2011). They present in hospital emergency rooms as a result of extreme, life-threatening behaviors and show limited response to psychotropic medications (Gunderson and Links 1984/2008). These clients’ seemingly endless cycling through community mental health systems and other clinical milieus (as well as their disproportionate consumption of resources) without significant improvement has historically tended to dishearten—and often anger—their treatment providers. Indeed, BPD’s challenging traits can provoke a myriad of intense emotional responses in clinicians (Gerity 1999; Koerner and Dimeff 2007; Kreisman and Straus 1989; Linehan 1993a). Renowned psychotherapist and author Irvin Yalom has called borderline “the word that strikes terror in the heart of the middle-aged comfort-seeking psychiatrist” (Yalom 1989/2012, p.215).

To receive a formal diagnosis of BPD, the individual should demonstrate a number of specific characteristics and symptoms. The most recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association 2013) indicates that a person with BPD will exhibit “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts” (p.663).

This pattern must contain a minimum of five of the following traits and/or behaviors: A precarious, and frequently situation-dependent, self-image/identity; an enduring sense of internal emptiness, engagement in highly impulsive (and often risky, dangerous) acts; brief pseudo-psychotic episodes such as paranoia and dissociation, typically triggered by stressful events; chronic emotional instability and reactive mood states; problems with extreme, inappropriate anger; recurring suicidal thoughts, gestures, attempts, and/or threats (as well as self-injuring, e.g. cutting—without suicidal intent); a profound fear of abandonment; intense, and highly unstable interpersonal relationships that might involve the individual with BPD “alternating between extremes of idealization and devaluation” (p.663).

Aguirre and Galen (2013) point out that these nine criteria result in 256 possible symptom combinations. Furthermore, there can be marked differences in functioning within those numerous potential BPD profiles—running the gamut between individuals who can maintain stable relationships and employment, and those who make repeated suicide attempts and contend with extreme, unrelenting emotional distress and life chaos. For the latter, “visible scars from self-injury and their ways of behaving make it obvious to others that they are struggling with some form of mental illness” (p.11). Other common symptoms not included in the DSM-5 (American Psychiatric Association 2013) include feeling misunderstood, self-hatred, extreme sensitivity to other people’s emotional states, preoccupation with being right at the expense of being effective (especially in interpersonal situations), an impaired sense of continuity of time and self, perfectionism, and being considered manipulative by others (Aguirre and Galen 2013).

In spite of this great variety in presentation and functioning, the BPD label has historically attracted a tremendous amount of derision and stigma within the mental health treatment community. Consider this particularly scathing description by novelist Jonathan Kellerman, a retired clinical psychologist:

…borderlines never really get better. The best you can do is help them coast, without getting sucked into their pathology. At first glance they look normal, sometimes even supernormal, holding down high-pressure jobs and excelling. But they walk a constant tightrope between madness and sanity, unable to form relationships, incapable of achieving insight, never free from a deep, corroding sense of worthlessness and rage that spills over, inevitably, into self-destruction. They’re the chronically depressed, the determinedly addictive, the compulsively divorced, living from one emotional disaster to the next. Bed-hoppers, stomach pumpers, freeway jumpers, and sad-eyed bench-sitters with arms stitched up like footballs and psychic wounds that can never be sutured. Their egos are as fragile as spun-sugar, their psychic structures irretrievably fragmented, like a jigsaw puzzle with crucial pieces missing. They play roles with alacrity, excel at being anyone but themselves, crave intimacy but repel it when they find it. Some of them gravitate toward stage or screen; others do their acting in more subtle ways… Borderlines go from therapist to therapist, hoping to find a magic bullet for the crushing feelings of emptiness. They turn to chemical bullets, gobble tranquilizers and anti-depressants, alcohol and cocaine. Embrace gurus and heaven-hucksters, any charismatic creep promising a quick fix of the pain. And they end up taking temporary vacations in psychiatric wards and prison cells, emerging looking good, raising everyone’s hopes. Until the next letdown, real or imagined, the next excursion into self-damage. What they don’t do is change. (Kellerman 1989, pp.132–133)

Even today, after the advent of DBT and other effective treatment models, it is not uncommon for clinicians to be so focused on how a client with BPD is negatively affecting them that they forget (or utterly fail to recognize) her profound misery. These individuals are said to possess a “low emotional ‘immune system’ that makes them predisposed to painful emotionality—either too much or too little […] and extreme difficulty in returning to a ‘normal’ emotional state once their emotions have been triggered” (Ford Thornton 1998, pp.6–7). Linehan (1993a) describes people struggling with BPD as the affective equivalents of severe burn victims who have little protection from the environment: Emotional triggers are often intolerably painful and thus tend to be avoided. Kreisman and Straus (1989) liken the disorder to hemophilia in that an afflicted individual “lacks the clotting mechanism needed to moderate…spurts of feeling. Stimulate a passion, and the borderline emotionally bleeds to death” (p.8). It is somewhat ironic, then, that self-mutilation, seen by some clinicians as morbid, masochistic, and/or calculating, “may in fact be a way of regulating the psychological and biological equilibrium when ordinary ways of self-regulation have been disturbed by early trauma” (van der Kolk 1996, p.201).

Indeed, the rates of damaging childhood events (physical and sexual abuse, in particular) reported by clients with BPD are remarkably high. Research estimates that as many as 60–70% of people diagnosed with BPD are survivors of severe early trauma (Briere and Zaidi 1989; Herman, Perry and van der Kolk 1989; Linehan 1993a; Ogata et al. 1990; Paris and Zweig-Frank 1997; Zanarini 1997, 2000). Many view BPD as a trauma spectrum disorder related to posttraumatic stress disorder (PTSD), and even dissociative identity disorder (DID) (Farber 2008; Herman 1992; Horevitz and Braun 1984; Howell and Blizard 2009; Ross 1989/1996; Zanarini 1997, 2000). However, it can and does develop in individuals lacking a trauma history (Gunderson 2011; Linehan 1993a; Paris 1994, 2008).

BPD is also associated with certain neurobiological abnormalities. Two critical brain structures are the amygdala and the prefrontal cortex (PFC). The amygdala (a pair of almond-shaped clusters of neurons located deep within the right and left brain hemispheres) processes emotional data, then facilitates behavioral responses appropriate to the prompting stimuli; a well-known example of this is the fight-or-flight response. People with BPD often possess overactive amygdalas, which may result in extreme emotional reactions—and, consequentially, “big” behaviors (Aguirre and Galen 2013, p.39). Brain imaging research shows increased amygdalic activity in individuals diagnosed with BPD compared with normal subjects, especially when they are also experiencing suicidal ideations (Soloff et al. 2012).

The PFC, like the amygdala, is part of both brain hemispheres. It lies directly behind the forehead in the cerebral cortex and controls executive functions (e.g., predicting consequences of behavior, self-monitoring, making choices between right and wrong, good and bad, cognitive flexibility) (Brefczynski-Lewis et al. 2007; Newberg and Iversen 2003). The PFC also regulates the amygdala, and, when working properly, tempers its emotional responding. Individuals with BPD show less activity in the PFC (Goyer et al. 1994), which is associated with impulsive aggression (Spoont 1992). Aguirre and Galen (2013) note that “most brain-scanning studies reveal that people with BPD show disordered functioning in the PFC, compared to people without BPD, and this is particularly true if the person with BPD also suffers from PTSD” (p.45). Individuals with BPD also appear to have lower levels of serotonin, a neurotransmitter implicated in depression, anxiety, impulsive aggression, self-injury, and suicide attempts (Aguirre and Galen 2013; Goodman and New 2000; Lidberg et al. 2000; New et al. 1997).

The etiology of BPD remains uncertain. However, an interaction of genetic temperamental traits and environmental factors/adverse life events (Leichsenring et al. 2011; Torgersen 2000) seems to often result in the disorder. Other theories concerning possible causes include problems with attachment during infancy and the presence of invalidating environments throughout the developmental stages of childhood and adolescence (Linehan 1993a, Wagner and Linehan 1997).

The course of BPD

BPD usually manifests by early adulthood, but some traits (e.g., mood lability and self-harming behaviors) can appear in adolescence (Gunderson 2011). Over time, many individuals with BPD experience symptom remission, especially around the frequency and intensity of suicidal ideation and attempts, self-injury, impulsive/self-destructive acts, psychiatric hospitalizations and use of other mental health services (Gunderson 2011). However, it is important to note that 8–10% of individuals with BPD complete suicide (Black et al. 2004; American Psychiatric Association 2013; Paris 2008). They often describe hating themselves intensely. Chronic feelings of emptiness, unworthiness, and depression may instigate impulsive behaviors, pursued in the hope that they will provide relief. Unfortunately, such actions often backfire and tend to only increase these individuals’ shame and self-loathing. Suffering through daily emotional torment leads many to consider killing themselves; sadly, it could seem like the only solution. Linehan urges us to have empathy for our BPD clients’ profound misery while simultaneously holding them accountable for their actions and working toward staying alive and ultimately developing “a life worth living” (1993a, p.85).

Understanding and treating BPD

Before the success of DBT, BPD was widely regarded as a hopeless condition. In I Hate You—Don’t Leave Me: Understanding the Borderline Personality, psychiatrist Jerold J. Kreisman shares his own ambivalence around counseling individuals with the disorder. He acknowledges a common desire of mental health professionals for these clients to “either get well or disappear” (Kreisman and Straus 1989, p.121). One of the most frustrating aspects of treating BPD is the phenomenally slow (or nonexistent) pace of clinical progress. These clients also tend to respond to therapists as within other personal relationships: in a particularly intense manner that often perpetuates the abandonment they so fear, and—at the very least—results in such pejorative labels as needy, demanding, and manipulative. Linehan offers an alternative, compassion-evoking perspective when she argues that people with BPD who present as “needy” do so because they are experiencing intense distress in an environment where appropriate, effective resources are scarce: “When burn or cancer patients…act in a similar manner, we do not usually call them ‘needy supplicants.’ My guess is that if we withheld pain medications from them, they would vacillate in exactly the same manner…” (1993a, p.18).

The term borderline first appeared when Adolph Stern (1938) used it to classify patients who did not fit neatly into either of that time period’s two primary diagnostic categories: neurotic or psychotic. Stern (as well as clinicians before and after him) observed that they responded poorly to the psychoanalytic process. Not only was the Freudian approach ineffective, it often precipitated rapid, severe psychiatric decompensation (Gunderson 1984/2008; Linehan 1993a), to the point that many patients had to be hospitalized. The thinking was that borderlines lacked the ego strength to cope with their intense feelings toward the clinician, exploration of childhood events, and the challenging of defenses that occurred in classical analysis.

Yet for many decades the main therapy for BPD was psychodynamic! Most treatments involved several sessions per week over the course of years. Somewhat more present-focused than Freudian psychoanalysis, the work of Masterson (1976/2008) and others (Kernberg 1975/1995; Waldinger and Gunderson 1987) ranged in ambition from merely improving the quality of the patient’s thoughts (and encouraging more adaptive behavioral coping mechanisms) to actually restructuring the borderline personality to a state of psychological health/maturity. Emphasis on insight and transference (the unconscious act of assigning emotions and attitudes from early relationships onto the patient–therapist interaction) varied depending on the approach (Cauwels 1992; Kreisman and Straus 1989). Such therapies lacked sufficient empirical support, however, and could be iatrogenic. The following is a client’s description of her negative experience with the unresponsive style typical of psychoanalytically oriented clinicians...

Table of contents

• Cover
• Title Page
• Contents
• Introduction
• PART 1. The Background
• PART 2. DBT-Informed Art Therapy
• Colour Plates
• PART 3. The Activities
• PART 4. Stage 2 DBT-Informed Art Therapy and Beyond
• References
• Subject Index
• Author Index
• Acknowledgements
• Dedication
• Copyright
• Of Related Interest