- DBT is generally effective in treating behavioral symptoms of BPD.
- Stabilization of the sense of self requires other techniques that can be used with DBT.
- Consistency in stabilization of sense of self can lead to greater emotional stability and better mood.
Borderline personality disorder (BPD) is defined by instability in relationships, emotion, and sense of self (APA, 2013). Dialectical behavior therapy (DBT) is often recommended to those who suffer from BPD. While DBT offers a very helpful set of tools for those who struggle with BPD, significant symptoms of the disorder often persist even when these tools are fully embraced and used effectively. Understanding the limitations of DBT in treating BPD and the need for these techniques to be integrated with other approaches to treatment will lead to the optimization of treatment outcomes.
Many individuals diagnosed with BPD are referred for DBT in outpatient and inpatient settings. These individuals often have great hope that this set of behavioral techniques will bring them relief from the suffering associated with the instability they suffer daily. Many find that even though the DBT techniques are helpful in many ways, they do not stop their suffering. This often leads to an abandonment of the DBT techniques and a sense of hopelessness regarding the efficacy of treatment.
What DBT Does Well
The target of behavior therapy is to change behavior, and this is what DBT is best at. Individuals with symptoms of BPD who use DBT effectively generally experience more stable behavior. DBT targets impulsivity and offers tools for making more thoughtful, or mindful, decisions that are generally associated with better outcomes.
This is likely to reduce the angry lashing out at others that is very common with this disorder. The reduction in lashing out at others increases the stability of relationships and improves social functioning.
DBT also offers benefits by teaching methods of coping with strong emotions, especially anger. This decreases emotional dysregulation, including anxiety, and offers a greater sense of self-control. This is likely to increase confidence and improve social functioning.
DBT is most helpful in stabilizing behavior and significantly helpful in stabilizing some emotional dysregulation. For many individuals with symptoms of BPD, this is not sufficiently motivating to sustain optimal use of these tools, and the benefit can wane or disappear altogether.
Where DBT Needs Supplementation
Behavior therapy does not target the integration of an unstable sense of self. Many individuals with symptoms of BPD experience frequent and painful shifts in their perception of themselves. For example, perceived slights by others can result in feelings of worthlessness and associated impulsive or even reckless behavior. Related to their tendency to view others in black-and-white terms, they also view themselves in either ideal terms or devalued terms. Feelings of worthlessness interfere with the optimal use of DBT tools because they are emotionally overstimulating and overwhelm the cognitive mediation of emotion that DBT offers. This is accentuated by the emotional dysregulation that many individuals with symptoms of BPD suffer. Further adding to the inhibition of the use of DBT skills is the loss of motivation toward self-help/self-improvement that comes with self-devaluation.
Stabilization of the self starts with self-definition. This involves taking a personal inventory of which aspects of character are most important to you. Examples of desirable character traits include kindness, thoughtfulness, genuineness, generosity, gentleness, etc. Once having identified character traits that are desirable, you must exercise every opportunity to express these characteristics. For example, if you aspire to be a kind person, then you must be kind in all circumstances, not just when things are in your favor or you feel like it. You must be kind to people who you don’t like and to people who might not be kind to you. This does not mean that you sacrifice the need to protect yourself—just do so with kindness.
Corey is a 48-year-old single person. She sees herself as a good person who is kind, empathic, honest, and highly ethical. She struggles every day to feel well. Dark moods always hover around her. When things don’t go her way, she has very dark thoughts about hurting herself and getting even with others that have hurt her. When things do go her way, she feels better, but things don’t seem real. It always feels like something bad will happen. She took two different courses of DBT and uses the techniques when she is not angry or upset, but she does not feel well most of the time.
“Each morning I wake up wondering what the day will bring and how I can feel OK. I don’t know what I am looking for but usually within the first hour, something goes wrong and kills the day. It could be anything: a bad dream, the way someone looks at me in the elevator, or a line at Starbucks, and I feel worthless. It seems like the sun shines on everyone but me.”
Despite seeing herself as kind and empathic, she tended to respond aggressively to circumstances that displease her. When she does not like the way someone looks at her, she calls them out: “What are you looking at?” When the line at Starbucks is long, she cuts the line by claiming that she was in the line but had to handle an emergency before she could order her beverage. These persistent departures from her view of herself as kind and empathic leave her feeling unstable and empty.
Finally, Corey committed to herself that she would be kind, empathic, honest, and ethical in all aspects of her life. She learned to use her DBT skills to respond differently in uncomfortable social situations. When others look at her on elevators, she still feels like calling them out, but instead smiles at them and wishes them a nice day. She welcomes this as an opportunity to strengthen her good qualities and no longer feels victimized by a stranger’s wandering eye. She no longer cuts the line at Starbucks, although she feels the desire to do so. She rather uses this as an opportunity to express her commitment to ethics and an opportunity for self-improvement.
Consistent utilization of DBT skills to inhibit impulses in conjunction with directed self-definition will gradually increase her sense of stability as she gets better feedback from others (they don’t get annoyed with her), which then starts the process of stabilizing her mood.
*Case study is a composite from clinical practice.
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American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing Inc. 2013.