UNDERSTANDING BORDERLINE PERSONALITY-
Dr Linehan, Phd Prof of Psychiatry and Psychology, Washingon
1 in 4 people meet the criteria for BPD
Many therapists end up alternately getting angry at people with BPD and then feeling bad if the person threatens suicide.
DBT (Dialetical Behavior Therapy) is a quite effective approach for BPD situations.
There is a lot of prejudice against BPD
BPD is caused by both Biological and Environmental factors
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Borderline Personality Disorder...what IS it? It is a disorder that got it's name because of it being on the borderline between neurosis/psychosis. ("I'm a mess, can't handle this anymore. I need to die.")
Emotional Dysregulation- depression, anxiety, irritability, anger (responses by the BPD person become highly REACTIVE)
Interpersonal Dysregulation- fear of abandonment, relationships are chaotic, intense and difficult.
Behavior Dysregulation- extreme and problematic impulsivity, spending, sexual conduct, binging, reckless driving, suicide attempts.
Cognitive Dysfunction- de-personalization, delusion, dissociation
Dysregulation of Self- emptiness, lack of self-identity
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Emotional Regulation Dysfunction- Emotional Vulnerability, Unable to handle resulting emotions.
BPD could be the result of intrauterine trauma or other kinds of trauma- biological dysfuntion
( difficult inhibited child)
Environmental factors- invalidating environment-believing/being constantly told that his responses are incorrect, inappropriate, unaccepted (culture)
-failure of the BPD person to regulate himself, needs to be taken SERIOUSLY! (we tend to say "Calm down! Stop exaggerating!" and they can't!)
Emotional stability consists of Intrapersonal, Self, Behavior, Cognitive
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Death and Suicide Attempts
Many people believe that death will make them feel better, because they will be out of the pain, so what the therapist first needs to do, is to shake up that belief that things will be better if the person is dead.
Suicide attempts bring relief but have long-term consequences.
We need to realize that If suicidal people people could make life better on their own, they would.
We need to help the suicidal patient improve his/her capabilities of coping.
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The Therapist
* Almost all therapists are already doing 80% of DBT. So find the 20% of the info from DBT that you can use and that you like, and apply it to your practice. Don't use the rest.
Therapist: her job is to encourage, push, cajole, drag the patient
Team: another professional therapist/colleague. Both therapists on the team, need to carry a magnifying glass to notice the progress of each other and to point it out.
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The Approach in Therapy- antithetic (where two opposites meet to produce change)
Balance for a BPD person comes through the very acceptance that things might NOT change, but in realizing that THEY can choose to change personally.
In Dialetic Behavior Therapy:
Confrontation is balanced by Change Strategies
Problem solving is balanced by Validation
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Techniques for Therapist to use with Patient
DEARMAN
Describe the situation
Express feelings
Assert- say NO
Reinforce
Mindful of objections
Appear confident
Negotiate possible solutions
Deal with interpersonal chaos- fear of abandonment
Use Imagery
find meaning and value in the pain
prayer
relaxation
One thing at a time
take vacations
Allow natural change and instability into the patient/therapist relationship
Assess- "what is MISSING?" The therapist asks the BPD person what she feels is missing from the "big picture", or the therapist evaluates this herself.
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Suicide:
crisis of self- injury
others tell you about what they see
or you discover it
you get a referral.
**Note: Many patients ONLY get attention when they are suicidal.
If taken seriously when they try to kill themselves but at no other time, the patients will keep trying to kill themselves.
**BPD- a predictor of suicide because emotional pain can't be reduced or tolerated.
Phase I- pre-treatment assessment meets criteria for what? (many will not APPEAR to fit the criteria)
If a person does not want help from you, tell her "either you can be a chronic or you can work toward and be well. There are only those 2 options." (Ask about option #2: Is that an option y ou might consider?)
As a therapist, YOU need to: believe in the patient, believe in yourself and have someone YOU can vent to.
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Goals in treatment- People with BPD have skill deficits and need to learn new skills
They are inhibited from being skillfull or have faulty beliefs about themselves, others or situations.
Replace maladaptive behavior with appropriate, effective behavior:
Improve the patient's motivation to change: Use individual psychology, group counseling, phone consultation, meetings for therapy.
Ancillary treatment: medication, inpatient treatment, day treatment, case management, 12 step programs.
Therapist- orientation of patient, have patient agree on treatment goals.
Target life-threatening behavior first. Address problems that affect their quality of life. Teach coping skills vs dysfunctional behavior.
Attend to therapy- deal with interfering behaviors Say to the patient: "If you or I do anything that creates a problem for therapy, we'll work on that.")
Generalize skills into daily life.
Core-strategies- validate the patient's problems and teach her how to solve them (use empathy, listen, reflect back to the patient, keep the patient in the present
Find the VALID and then VALIDATE it... Then teach problem-solving.
The therapist helps the patient make sense of her own behaviors.
Help the patient to figure out what she could do differently- solution analysis.
Analyze, find the solution, get a commitment.
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(Kick in the butt)
BPD's appreciate confrontation, exaggeration, and your drawing attention to what the patient does not want attention on. (this helps the patient to think differently)
Call their bluff: "Why would you NOT want to be in a therapy where we let you kill yourself? Why are you here where we try to prevent you from doing this?"
This is called Reciprocal Communication- You must allow the patient to "move" you.
DBT- help the person to focus on the moment they are in, to be PRESENT in the moment. Balance the rational with the emotional
Identity confusion produces emptiness, cognitive, dysregulation
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INTERPERSONAL EFFECTIVENESS FOR THE BPD:
how to say no
how to ask for what you want
Distress Tolerance
How to get through and survive when you can't change:
distracting
self-soothing
improving the moment
evaluation of pro's and cons of actions for determining proper response
dealing with impulsive behaviors, suicide threats, self-injury
Emotional Regulation- help the BPD person to deal with:
anger
fear
shame
sadness
** Keep in mind that sometimes the patient will REWARD the therapist behaviorally for unsuccessful therapy and PUNISH the therapist for successful therapy.
The treatment team (how a therapist helps the other therapist with her therapy, since many times a therapist can become discouraged and want to quit)
reinforce therapy, use DBT on therapist, validate, correct therapist, ask "what can we do differently," keep the fellow-therapist in the treatment frame.
