A Proposed Treatment Connection for Borderline Personality Disorder (BPD)

Dialectical Behavior Therapy (DBT) and Traumatic Incident Reduction (TIR)

Ashley Doyle

• Publisher: Loving Healing Press
• Year: 2012
• eBook ISBN: 9781615998722
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

A large percentage of the population experiences some type of trauma in their lifetime; however, they don't all develop a diagnosable disorder. Even though no research can definitively predict what types of traumas will elicit a diagnosable disorder, there has been some indication as to who is more at risk for the development of trauma-related disorders, specifically Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD). Yet other disorders may also be elicited such as anxiety disorders, depressive disorders, or personality disorders. Children, the elderly, and the disabled are labeled at-risk due to their dependency on others, sparse coping strategies and resources, and economic disadvantages. Additionally, individuals who experience extra stressors, low-self esteem, and have a poor sense of self are also at risk of developing a disorder rather than use resiliency (Petersen & Walker, 2003). One extreme reaction to trauma exposure is the elicitation of a personality disorder, specifically Borderline Personality Disorder (BPD).

The focus of this paper is three-fold. First, it compares two treatment approaches: Dialectical Behavior Therapy (DBT) and Traumatic Incident Reduction (TIR). These are different in technique and philosophy when regarding the processing of traumatic events. Second, it reviews the evidence for co-morbidity (simultaneous occurrence) between BPD and PTSD. Finally, this paper will propose a strategic plan for the most effective treatment for individuals with BPD and PTSD symptoms.

Metapsychology Monographs #8

Dialectical Behavioral Therapy

Biosocial Theory

DBT is based on a Biosocial theory of personality functioning. The Biosocial theory identifies BPD as a pervasive dysfunction of the emotion regulation system. The dysfunction develops due to a combination of genetic predispositions for biological irregularities and invalidating environments (Linehan, 1993a).

As discovered by Bowlby (1980), the attachment between a caregiver and child is essential to the influence of development. Likewise, from the perception of the Biosocial theory, an invalidating environment during childhood is the catalyst for emotional dysregulation. Caregivers fail to teach their children how to properly label their emotions, regulate arousal, tolerate emotional distress, and when to trust their emotional cues as valid interpretations of the environment. As the BPD children develop, they invalidate themselves, look to others for validation, and will oversimplify complex situations. This inevitably leads to unrealistic thinking.

Additionally, the biosocial theory states that BPD individuals are predisposed to high sensitivity; specifically, the emotional reaction threshold is low and reactions are made quickly. In addition to a low threshold, BPD individuals experience a slow return to emotional baseline. The lingering effect of an emotional outburst creates an intense mood, which last much longer in someone with BPD than in an individual that does not have this disorder. During this slow return to baseline is when parasuicidal and suicidal behaviors occur (Linehan, 1993a).

Treatment Approach

Linehan’s (1993a) DBT model, a unique combination of numerous theoretical approaches including psychoanalytic and cognitive-behavioral, has been the only treatment with consistent clinically significant effectiveness. There are four elements to the DBT approach: individual therapy, group skills training, phone consultations, and team consultation meetings. Of these four components, the client directly utilizes individual therapy, group skills training, and phone consultations. Team consultation meetings are conducted in order ensure that team members are adhering to the DBT model of treatment and to support and motivate members treating individuals with BPD.

Individual therapy focuses on how the client is coping with daily conflicts and analyzing feelings with the therapist in the moment. The dual role of the therapist is emphasized. The therapist serves as a vehicle through which he/she can affect therapy, and the relationship itself is the therapy. The relationship can be therapy in itself if the therapist maintains a balance of compassion, sensitivity, flexibility, non-judgmental thinking, acceptance, and patience. When a client first begins a DBT program, establishing an attachment to the therapist is the first goal. Clients need to feel invested with their therapist and acknowledge that the therapist cares about them. After an attachment is made, the therapist can use their relationship as leverage to evoke change and growth while maintaining a safe environment and still validating the client’s feelings. [Ed. Note: This is distinctly different from the person-centered approach of Applied Metapsychology, but note that this population has special needs and would normally fall outside the guideline for the use of TIR and other Applied Metapsychology techniques.]

Group skills training sessions are used to educate BPD clients on skills that they can incorporate daily. The skills training groups are divided into three eight-week modules: emotion regulation, interpersonal effectiveness, and distress tolerance. These training groups are essential to the effectiveness in working with BPD clients. The education of skills training is a way of challenging clients’ negative expectations and interpretations of their environment, relationships, and sense of self.

The emotion regulation module skills assist in labeling emotions. Through the identification of emotions, clients are then able to identify obstacles to emotional change, engage in more positive activities, and eventually act independently from their mood. In short, it is a method of not letting their moods control their lives, rather showing clients that they are in control of their emotions.

The interpersonal effectiveness module focuses on teaching BPD clients strategies and techniques for asking for help, saying “no,” and coping with interpersonal conflicts. Each skill emphasizes that there is a way of making a request without damaging the relationship or the individual’s self-respect. For example, many individuals with BPD have difficulties with expressing what they want in an assertive way. The acronym DEAR MAN is taught to aid individuals to remember the seven skills that have been shown to be effective in getting a need/want met without discrediting, disrespecting, or damaging the relationship. DEAR MAN stands for Describe, Express, Assert, Reinforce, Mindful, Appear confident, and Negotiate.

The distress tolerance module introduces skills that can be used when the client is in crisis. For example, self-soothing skills enable clients to distract their thoughts by stimulating one of their five senses. Because of the intense emotions experienced in crisis, the stimulation of one of the senses should be of equal intensity. For example, when a client is in intense emotional dysregulation, a DBT therapist may suggest holding a piece of ice in their hand or immersing their face in a bath of ice water. The final skill of the distress tolerance module is “radical acceptance.” This skill challenges the client’s perception of themselves and their environment. Radical acceptance is a concept that life is as it should be, containing both the good and the bad. This enables a start of the process of making changes. Clients are reminded that acceptance is different from approval. Yet the focus remains; before c...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Borderline Personality Disorder
• Dialectical Behavioral Therapy
• Posttraumatic Stress Disorder
• Traumatic Incident Reduction (TIR)
• Theoretical Conflicts
• Possible Therapeutic Approach
• Conclusion
• References
• About the Author
• Metapsychology Monographs Series