September/October 2006

journey in healing

From hopelessness
to hope

BY WENDY UNDERHILL

“Hopelessness” is not an officially designated mental health diagnosis, but it well describes something otherwise known as “borderline personality disorder” (BPD). Those with BPD perceive the world differently than others, in a more problematic and intense way. Their experiences include being dismissed by therapists, avoided by friends and family, involved in repeated police incidents, habitual cutting or stabbing of themselves, and suicide attempts, as well as a host of other disruptive and dangerous behaviors. There’s nothing “borderline” about the difficulty of these lives; it’s a constant, frantic struggle to stay afloat.

As Ann Noonan, a clinical coordinator in Boulder County’s Behavioral Health Division, says, being labeled as borderline “is like being diagnosed with Stage Four cancer; you’re given the diagnosis that you’re untreatable.” In a word, hopeless.

That is, until recently. Now, a 15-year-old therapeutic technique known somewhat obtusely as “Dialectical Behavior Therapy” (DBT) has changed the prognosis. Developed by Marsha Linehan, Ph.D., the director of Behavioral Research and Therapy Clinics at the University of Washington, DBT was designed for these hard-to-treat, severely disordered patients. The technique combines several modalities to put hope back in a hopeless situation. While it’s no panacea, it has repeatedly proven to be more effective than standard therapeutic treatments for BPD.

A caveat: DBT is not for everyone. It is not designed for the average person who might seek help from a therapist. DBT is probably not appropriate or necessary for fairly “normal” people who might need therapy to cope with this or that mild neurosis. It’s best for those with more intense or advanced disorders. While many DBT candidates have been diagnosed with BPD, other severely disordered or self-injuring clients can benefit as well.

Julia was a perfect candidate. For 13 years, Julia (a pseudonym) had been constantly on probation. She was both a victim and a perpetrator of domestic violence. She had gone through Alcoholics Anonymous, psychotherapy and coaching in several guises from public agencies. Then, 18 months ago, she began participating in DBT at a Boulder mental health clinic. Since that new beginning, she has used alcohol only twice, had only one encounter with police (and controlled herself so that she didn’t end up in four-point restraints) and now is making plans to move to where her child lives. This is a huge success for a woman who hadn’t been able to keep family, friends, jobs, or stability together—ever.

Julia, typical of other DBT clients, seems to have been born with a predisposition to over-the-top reactions to just about everything. She also grew up in a difficult, neglectful home. It is the combination of these two factors—called “emotional vulnerability” and an “invalidating environment”—that give rise to BPD. Over time, people such as Julia have learned to respond with maximum emotion even in the face of minimal stimulation, and dangerous behavior is the result.

Noonan explains this learned overreaction with a soda machine analogy. If you put money in a soda machine and nothing comes out, you’ll joggle the handle, then perhaps tap the machine, and later you’ll shake it. If a Coke came out, the next time you’ve got a problem with a soda machine, you’re likely to go right to shaking without bothering with joggling and tapping first. When the “soda machine” is one’s ability to cope, the shaking may become suicide attempts, self-cutting, sabotaging relationships, eating disorders, impulsive, explosive episodes or substance abuse. Pretty soon, this high-wattage emotional state overrules all else, and life becomes a “fight or flight” response, 24/7.

The good news, says Noonan, is that if people have learned dysfunctional behaviors, they can learn other behaviors as well. And that’s the focus of DBT.

In fact, DBT is as much about teaching skills as it is about processing traumas and feelings, a very different emphasis from other forms of therapy. What else makes it unique?

• Unlike some forms of psychoanalysis, group therapy and talk therapy, DBT downplays the retelling of difficult events.
• Rather than focusing on a theoretical understanding of the past, DBT focuses on being in present time and offers practical   tools for changing problematic behaviors.
• DBT includes mindfulness training, and teaches clients to simply be aware of their thoughts and emotions, without   necessarily needing to act on them.
• Therapists participate in their own consultative groups, meeting to support each other as they work with what’s considered a   very difficult client population, hone their techniques, and perhaps offer new perspectives on difficult cases.

While those items are all parts of the program, they don’t really describe the core philosophy. “The basis of DBT is acceptance,” says Cassandra Katz, LCSW, a DBT trainer in the north Denver area. “If your car is stuck in the mud, until you can accept that it’s stuck, you won’t be able to call a tow truck. We don’t expect the client to have the skills for acceptance, so we teach them.”

Acceptance is hard for people such as Julia, says Katz, but they can learn with practice.

The assumption is that clients can’t accept the great pain they experience daily, and therefore they have developed maladaptive behaviors to block it. That behavior is addressed at the start of DBT, with the number one goal being to reduce and then eliminate life-threatening behaviors; most therapists ask for a commitment from their clients to stop any form of self harm. Once they’ve gotten the tools to make everyday life a little less tumultuous, then therapy can look at deeper, causative issues, and still later, clients can begin to consider life goals and spiritual questions. But for starters, it’s all about learning to respond and behave in ways that are less chaotic and destructive.

So, to promote acceptance instead of denial and shame, DBT uses language that is descriptive and non-judgmental. For instance, ”emotional disregulation” may sound like therapese, but it avoids the pejorative overtone of “bitchy” to describe the same state. The language is also direct, with no sugarcoating, and that has proven to be validating—even when what is being validated is a horrible state of affairs. For instance, when a client says that she tried to kill herself, the therapist accepts it, not negating it, ignoring it or moving too quickly to change it. By example, the client begins to accept it and not judge it harshly, either. In the suicide attempt example, the therapist might say, “That must have been painful. I’ll bet you were doing the best you could at the time.”

Once the client feels understood, there is often immediate relief: “Yes, I do feel things intensely. Yes, my life is a roller coaster. Yes, I get in conflicts all the time and I don’t know why.” Then clients, who are often highly resilient, intelligent and motivated, are very likely to work hard to get better. (An anecdote: one therapist in training for DBT work was reading her textbook at a coffeehouse. A complete stranger came up and said, “I see you’re learning about DBT. I want you to know that it saved my life.”)

Instead of long reports on life history or current crises, DBT clients may be asked instead to report on perhaps one situation that arose in the previous week. Validation is first. When the client is ready, then they talk about other skills that could be employed in similar situations. If this sounds like cognitive behavioral therapy, it is; DBT is a modification of that technique designed specifically for self-harming people.

Those skills probably will come from the weekly group classes DBT clients attend. One of these skills is “mindfulness”; each class begins with mindfulness practice and a short discussion of how that went. While mindfulness comes out of a meditative perspective from both Buddhism and western contemplative spirituality, the language of DBT is carefully constructed to avoid any religious bent. There are no mantras, ceremonial beads, gurus, or God-speak. DBT mindfulness practice focuses attention on the breath and on body and mind awareness. It doesn’t try to erase or supplant the pain the person feels; instead, clients simply notice their state of being, as painful as it may be, rather than rushing to respond to the pain with old and destructive behaviors.

Other skills such as “distress tolerance,” “interpersonal skills” or “nonjudgmental thinking” are taught, demonstrated, practiced, and then given as homework. These group sessions include no telling of stories; if everyone were to check in on how the week had gone, there would never be time for anything else.

A third key piece in DBT: phone coaching. In most therapy practices, clients are asked to call only when they’re in crisis; with DBT, frequent short “coaching” calls are encouraged. If the client has already alleviated the immediate crisis with a maladaptive behavior, such as stabbing herself or using alcohol, then the rule of thumb is, “Please don’t call me. You’ve dealt with the pain for now. Wait 24 hours or more and then we can talk about it.” Calls are appropriate when the client needs support to proceed in a positive way (or at least to avoid the worst).

Last? DBT therapists are connected through their own consultation groups; in these they can review and practice the skills they need (which can be quite different than the process-oriented skills used in most therapy), talk about cases they’re working on and look at their own responses to working with this highly volatile client group. The first goal of these groups is to head off life-threatening situations for clients, but the second is to head off therapist burnout, a common outcome for therapists working with this kind of highly unregulated patient.

Putting it all together, Dialectical Behavioral Therapy is about acceptance and about change, opposing ideas that actually fit together quite nicely in a dialectical sort of way. And when those two ideas are connected, then hope can rise again.

Wendy Underhill lives in Boulder with her husband, three daughters, 16 chickens, two rabbits, two cats and a hamster. She dabbles in, and writes about, traveling, gardening, running, and holistic practices.

According to the National Association on Mental Illness, signs and symptoms of Borderline Personality Disorder (BPD) include the following:
• Marked mood swings with periods of intense depression, irritability, and/or anxiety lasting a few hours to a few days
• Inappropriate, intense or uncontrolled anger
• Impulsiveness in spending, sex, substance use, shoplifting, reckless driving or binge eating
• Recurring suicidal threats or self-injurious behavior
• Unstable, intense personal relationships with extreme, black and white views of people and experiences, sometimes   alternating between "all good" idealization and "all bad" devaluation
• Marked, persistent uncertainty about self-image, long-term goals, friendships and values
• Chronic boredom or feelings of emptiness
• Frantic efforts to avoid abandonment, either real or imagined

Dialectical Behavior Therapy, see the following resources:

• Behavioral Tech, LLC ( www.behavioraltech.org) is a training company for DBT therapy started by Marsha M. Linehan, the   creator of DBT. It features a “Looking for a DBT Therapist?” function on its home page to help locate a therapist anywhere. It   also has an excellent FAQ on DBT.

• The Behavioral Research and Therapy Clinics at the University of Washington (www.brtc.psych.washington.edu/) are   where Linehan works, and professionals especially will appreciate this website.

• The National Association for the Mentally Ill ( www.nami.org) offers an authoritative fact sheet on borderline personality   disorder and treatment options. Go to “inform yourself” then to “about mental illness,” then scroll down to “by illness” and   then to “Borderline Personality Order.”

• Locally, the website of Colorado DBT trainer and practitioner Cassandra Katz (www.dynamicyouyes.com) offers a short   and especially good description of DBT. The website has an emphasis on DBT in relation to addictions.

• Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan (The Guileford Press, 1993)   is the guide to theory and practice of DBT. An associated skills manual is available as well. The intended audience is mental   health care professionals; lay people may find it offputting.

• Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control by Scott E.   Spradlin (New Harbinger Publications, 2003) is user friendly, relatively speaking, thanks to its workbook format. Anyone who   is emotionally overreactive—not just people with severe personality disorders—may appreciate this book.

• New Hope for People with Borderline Personality Disorder: Your Friendly, Authoritative Guide to the Latest in   Traditional and Complementary Solutions by Neil R. Bockian, Nora Elizabeth Villagran, and Valerie Porr (Prima   Publishing, 2002) addresses DBT and other options in (as it implies) an accessible way. It can help friends and family, too.