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Dialectical Behavior Therapy: A Treatment Option for Persons Living with Borderline Personality Disorder Prepared by/ Murad Abed

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Developed by Marsha Linehan, Ph.D. Skills Training Manual for Treating Borderline Personality Disorder Cognitive-Behavioral Treatment of Borderline Personality Disorder

Why use DBT?:

Why use DBT? Significantly reduced self-harm behaviors and self-harm urges Fewer psychiatric hospitalizations Decreased feelings of depression, hopelessness, anger More likely to stay and complete treatment

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Based on three principles: The principle of interreelatdness and wholeness The principle of polarity The principle of continous change

The principle of interreelatdness and wholeness:

The principle of interreelatdness and wholeness A system perspective on reality. Relates the part to the whole.. “ one thing cannot exist without the other ,that one acquire its properties from its relation to the other.. ”

The principle of polarity:

The principle of polarity embodies the truth that all manifested things have two sides, two aspects, two poles, or a pair of opposites with manifold degrees between the two extremes. "Everything is and isn't, at the same time" "all truths are but half-truths" "every truth is half-false" "there are two sides to everything"

The principle of continous change:

The principle of continous change Thesis and antithesis>>>synthesis Changes in the patient >>> transforming the therapy and therapist

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DBT is a combination of Cognitive Behavior Therapy and Eastern meditative practices. Seven well-controlled randomized clinical trials with varying research teams have established DBT as a valid and effective treatment for Borderline Personality Disorder.

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The concept of mindfulness is one of the primary Eastern meditative aspects of DBT and has become quite popular in many realms, not just as a psychotherapy treatment modality.

Understanding Dialectics:

Understanding Dialectics The term Dialectics refers to opposing forces that create a whole or a synthesis. DBT focuses on finding a balance in opposing forces. Opposing forces needing a balance can be found in many things all around us for example Sun and the moon Seasons

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Mindfulness is based on finding a balance between what Marsha Linehan (the developer of DBT) has coined the reasonable mind and the emotional mind. Learning to be in control of your own mind, instead of letting your mind be in control of you.

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In DBT there are three states of mind: Wise Mind Emotional Mind Reasonable Mind

Reasonable Mind:

Reasonable Mind This is the logical part of you brain. The part that thinks, plans and evaluates what is happening around you. Sometimes our emotions can get in the way of how well we do things. Whether we are in physical pain or emotional pain or any other kind of pain, it makes it harder to plan and think and organize every day activities we take for granted.

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Getting ready in the morning: drinking a cup of coffee, morning routine, taking kids to school etc. Building a house Following instructions Planning a vacation Doing math Driving

Emotional Mind:

Emotional Mind This is when your present emotional state controls most of your thinking and behavior. Anger -can spur and argument Love - you might sacrifice yourself for your children Anxiety -you might rush or be unable to concentrate When we as people are in a state of emotional reactivity our minds are often spinning with so many thoughts it is hard to find the off switch.

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Whether we are reacting to emotional pain , physical pain, physical or mental over load or any other emotionally heightened situation we are more prone to stress .

Wise Mind:

Wise Mind This part of our mind is a little more difficult to grasp . It is the integration of the reasonable mind and the emotional mind- this does not mean the ability to flip back and forth between the two or see both sides of coin. Additionally, you usually cannot evoke emotions through reason, and you usually cannot overcome emotions with reason.

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It is the part of the mind that gives you peace, and knows and experiences truth. Some people consider this to be the intuitive part of the brain. It integrates all ways of knowing including all of the senses-hearing, seeing, smelling etc. You will not always be in the wise mind, this doesn ’ t mean it is not there! Consider: when you have a hard decision to make, and after your choice your whole body feels confident, sure and relaxed, that you took the right course of action. (even if there might be consequences.)


Mindfulness Mindfulness is developed through meditative practice. Mindfulness happens any time you are completely focused on one thing, in that moment, without judgment. It is the repetitive act of directing your attention to one thing at one moment .

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Driving a manual car for the first time you are aware of each movement, later you can drive on automatic pilot, but at first you must be mindful. Eating dessert and noticing every flavor instead of attending to the conversation, or looking around, or eating too fast. Walking in the park and being present. Notice the trees, the children; what it feels like as your feet hit the ground etc, not being distracted by your thoughts and thus not noticing anything.

Mindful huh?:

Mindful huh? It is rare in our society for a person to be mindful. We are a society of multi-taskers . Typing and talking Eating and working Plotting out your day as you drive to work We are also often preoccupied with the future or the past Worried about what ’ s for dinner or what to wear, what our boss thinks, or how much money is in the bank Did I say the right thing, I should have … , I can ’ t believe I . . . , If only . . . Etc.

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We make judgments about everything around us. “ He is a jerk ” , I ’ m glad I don ’ t dress like her ” “ It ’ s going to be a bad day, ” “ He doesn ’ t know what he ’ s talking about, ” “ I ’ m ugly, ” “ She doesn ’ t like me. ”

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We neglect needs in the face of the busy day. Ignoring how a headache developed (you just know you have one) Being tired (not recognizing how it affects your work or your mood) Being crabby and not realizing you drank too much coffee, but forgot to eat.

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If you take a coffee break, or go exercise to unwind, but all the while you are thinking and worrying about something- Are you really taking a break?


!!! Of course it is not always feasible or possible to be mindful at every moment in the day. However, without practice it is difficult to choose to be mindful because our inner dialogue has a way of taking us over.

Practicing Mindfully Mindfully:

Practicing Mindfully Mindfully The skills include: Observing Describing Participating Being non-judmental Being one mindful Being effective There are six different skills or ways to practice being mindful. This next portion of presentation is designed to be interactive- some of that will be lost in the lack of human contact- but let ’ s see how it goes.


Observe The goal of observing is to watch events, emotions, etc without trying to rid yourself of pain or prolonging a certain feeling. When you observe you simply notice what is-without judging it as good or bad. This skill focuses on being aware in the present moment.

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Observing and doing are different. (Just because you do something does not mean you are being aware.) Walking doing Noticing how fast you walk, how your feet feel hitting the ground, the sound your shoes make, how your muscles feel  observing Breathing  Doing Feeling your chest rise & fall, how deep you breath, the sound of an exhale, the muscles moving, the feel of your breath on your skin observing


Describe Describing is learning to put words to events and thoughts. Describing is just the facts NO judgments. Describing is more interested in the process than the conclusion or end result.

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Sometimes people make an assumption- “ They don ’ t like me. ” The description of this might look like- they don ’ t invite me to lunch, they don ’ t make a response when I try to join their conversation, they avoid me, they always have little secret jokes etc. The description does not warrant the conclusion there could be many different reasons people at work have cliques that have less to do with someone outside the clique than with some other factor. Automatically, judging why a behavior is occurring can prolong the behavior or create conflict or tension. When we allow this to happen we allow our feelings to determine the reality, and we may not even be aware of the descriptors- we automatically see the conclusion.


Participate This means entering fully into an activity- staying in each moment without separating yourself from the events. True participation means getting rid of self-consciousness and letting go of your worries or fears. (not planning what you are going to say or worrying someone is judging what you are saying etc.) Full participation is the ultimate goal in mindfulness.

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Have you ever had a conversation and found yourself nodding and giving facial cues?- your body is on automatic pilot while your mind is somewhere else. How often do you drive home without noticing and then suddenly you are home. Participation requires letting your mind and your body participate together in whatever you are doing. Every part of you is involved in what you are doing- No compartmentalizing.


Non-Judgmentally This is means you do things without evaluating them. Avoid judging something as good or bad; valuable or worthless etc.- It just is. It does not mean going from a negative judgment to a positive judgment. (it is not optimism.)

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In DBT, there is an emphasis on consequences of behavior and events, but that does not necessarily label it as good or bad. Change is initiated to create more desirable outcomes. (this reduces shame based feelings that can perpetuate behavior with negative outcomes) An extreme scenario You get drunk, attempt to drive home and hit a tree- Instead of focusing on how bad a person you are and how you are so dumb and why can ’ t you do anything right, what were you thinking, you know better etc etc. (probably driving yourself back to drinking or something else to avoid the bad feelings you now have about yourself) Non-judgmentally you can say- I need my car, I don ’ t like how I feel about myself when I get too drunk and loose control of my thinking, What could I do to get a better end result.


One-Mindfully This means learning to focus the mind and awareness on the current moment. Focusing completely on one activity at a time. Avoid reactions based on mood, negative thoughts, assumptions, expectations, worries etc. One- mindfully is how you participate.

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So back to your conversation with the friend, so you are no longer worrying about the future stuck in auto pilot, you are listening, but as she is talking you are preparing you response- oops this is not keeping your awareness on the present moment.

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This skill could be practiced when you are baking a cake, you put all your effort into that activity. You keep your mind all your thoughts fully on what you are doing with the cake. You focus on the measuring the textures the sounds, the smells, etc. When you are at home, you focus on home and stop thinking about that family at work that you are worried about, frustrated with etc. Do give yourself time to One-Mindfully process your feelings regarding that family. A time to fully participate with yourself (sit with an emotion) and acknowledge the whole of what you are feeling and what you want to do. THEN LET IT GO.


Effectively This means do what works. The goal of this skill is to reduce a person ’ s tendency to be more concerned with being right, feeling good, or being justified instead of doing what is needed or asked in a particular situation. This skills means learning to give in and compromise when it leads to an effective or productive end result.

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Examples: You really want your significant other to do something special or ordinary for you and you think, he/she should know me well enough to do this. You are hoping it will happen. ( this is not effective. If you want something you may need to ask for it or resolve not to be disappointed when your sig. other doesn ’ t read your mind.) Maybe a client is sick of jumping through the probation officers hoops, but she wants her kids back, it is effective to jump the hoops even if they seem unfair, petty, etc. in order to reach the end result.

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Make a list Later- think about what things you are effective with and what things you might need to work on.


conclusion You can use these skills to re-center, to calm yourself, to better understand your emotions, to reflect or to train your brain to stay in the present moment. You could sit with your anxiety, instead of pushing it away and observe your thoughts. Listen to yourself. Acknowledge your fears, or apprehensions etc. In practicing these skills you can avoid getting caught up in power struggles with clients, taking things personally, you can listen more fully and understand others etc.

Borderline PD:

Borderline PD “ I hate you … .don ’ t leave me!

What is a Personality Disorder?:

What is a Personality Disorder? Maladaptive personality characteristics that have a consistent and serious effect on work & interpersonal relationships Affect approx. 10% of population DSM-IV – 10 categories (Axis II)

Borderline Personality Disorder:

Borderline Personality Disorder Central feature = instability Impulsive behaviours Emotionally unstable Brief psychotic episodes Suicide attempts Unstable interpersonal relationships Boundary problems Mood swings Identity disturbances (impaired ego integration)

How is it diagnosed?:

How is it diagnosed? The Diagnostic Interview for Borderlines, Revised (Gunderson & Kolb, 1989) Affect (e.g., chronic depression, anger, loneliness, emptiness, guilt, anxiety) Cognition (e.g., odd thinking, nondelusional paranoia) Impulse action patterns (e.g., substance abuse, manipulative sexual gestures) Interpersonal relationships (e.g., intolerance of aloneness, counterdependency, demandingness)

DSM-IV Criteria:

DSM-IV Criteria At least 5 of the following 9: Traits involving emotions: 1. shifts in mood lasting only a few hours 2. anger that is inappropriate, intense or uncontrollable “ People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement ” (Linehan)

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Traits involving behaviour 3. Self-destructive acts 4. Two potentially self-damaging impulsive behaviours Traits involving identity 5. Marked, persistent identity disturbance 6. Chronic feelings of emptiness or boredom

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Traits involving relationships 7. Unstable, chaotic intense relationships characterized by splitting 8. Frantic efforts to avoid real or imagined abandonment alternating clinging & distancing behaviours (I hate you, don ’ t leave me) difficulty in trusting sensitivity to criticism or rejection need for affection & reassurance 9. Transient, stress-related paranoid ideation or severe dissociative symptoms

BPD in adolescents v. adults:

BPD in adolescents v. adults Problems with diagnosing BPD in adolescents Perjorative label – stigmatizing May end up “ growing out of it ” Symptoms less stable in teens Can improve with treatment


Aetiology Multiple risk factors: Biological Temperament abnormalities (heritable) Decreased serotonin activity Psychological Trauma Emotional neglect Social Lack of support/emotional security Linehan ’ s theory – emotional invalidation Invalidating environment

Link with childhood trauma:

Link with childhood trauma Many people with personality disorder report a history of childhood abuse or neglect Children who are physically abused, sexually abused, or neglected are significantly more likely to develop a PD as a young person Sexual abuse [usually with emotional abuse and neglect] is most strongly associated with BPD in particular In BPD, childhood trauma may still be affecting the individual as an adult, to an extent that impairs daily functioning

Linehan’s theory:

Linehan’s theory Emotional invalidation: emotionally vulnerable individual + invalidating environment = BPD Limited opportunity to learn to label, understand or trust own feelings Looks to others for how to cope Oscillates between emotional inhibition to gain acceptance and emotional disinhibition to have feelings acknowledged Intermittent reinforcement = emotional dysregulation

The Course of BPD:

The Course of BPD Usually begins in adolescence 80% women Severe, chronic 1 in 10 suicide Impulsivity & emotional instability tend to decline over time

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