Introduction Dialectical behavior therapy (DBT) was created by Marsha Linehan, a clinical psychologist and Professor of Psychology at the University of Washington, to help treat individuals who have been diagnosed with borderline personality disorder (BPD) (Linehan, et al., 1999). The term dialectical means an integration of opposites; the opposing phenomenon’s are acceptance and change. The core of DBT consists of four different behavioral skills, distress tolerance, emotion regulation, interpersonal effectiveness, and mindfulness (Linehan 1993). Distress tolerance is used in DBT to teach the client how to actively cope and tolerate the pain and agony that one will inevitably experience in life (Linehan 1993). Emotional regulation attempts …show more content…
to teach the clients on how one is able to change their negative emotions (Linehan 1993). The target emotions are the internal sensations that reduce the quality of life, and are detrimental to one’s long term wellbeing. Interpersonal effectiveness focuses on teaching clients how to make their needs and beliefs known to those around them, while still maintaining their decency (Linehan 1993). The last behavior skill, Mindfulness, is explicitly unique to DBT in comparison to other forms of behavioral therapy. Mindfulness is an element of DBT that was contrived from Buddhist Zen practices that attempts to give on the capacity to be fully and objectively aware of what is occurring around the individual (Linehan 1993). Borderline personality disorder is defined by the DSM5 as a pervasive personality disorder that impairs one’s interpersonal self-functioning and negative attention seeking behaviors (American Psychiatric Association, 2013). Individuals with borderline personality disorder show traits of apathy, emptiness, impulsive behaviors and harmful behaviors (American Psychiatric Association, 2013). It has been 69 to 80% in the BPD population self-harm and up to 75% attempt suicide at least once (Black, et al., 2004; Gunderson, 1984; Linehan, Rizvi, Welch, & Page, 2000). Mental health providers and workers have been found to have negative attitudes towards borderline personality disorder patients due to the negative attention seeking behaviors and manipulative behaviors (Fallon 2003). Borderline personality disorder clients have reported that respond best with talk therapy and in times of crises (Nehls 1993). Dialectical behavior therapy attempts to treat the borderline personality disorder by emphasizing the major charactersistics of the disorder; lability, low interpersonal functioning and impulsivity (Linehan 1991).
DBT has strong empirical support behind it (Swenson, 2000) and the affect that DBT has on clients diagnosed with borderline personality disorder has been the most studied therapy compared to the variety of other approaches (Stoffers et al. 2012). However, there lacks research that has been able to mesaure the success of DBT on borderline clients. A viable objective approach to measuring how DBT affects its clients is measuring the neural responses of the borderline personality disorder cleints. Cognitive behavioral therapy has been studied and supported neurologically to have an effect on its clients (Ritchey et al. …show more content…
2011). The neurobiological research behind BPD is minimal, but research has supported that those with borderline personality disorder have increased activity in the amygdala, occipital gyrus and cerbellum, and significantly lower activitiy in the superior temporal gyrus and frontal lobe (Figure 1) compared to those are deemed psycholgically healthy (Koenigsberg et al. 2009). The contrasts in brain activity were measured by blood and oxygen levels (BOLD) using functioning Magnetic Resonance imaging (fMRI). It has been hypothesized that dialectical behavior therapy will reduce the blood flow in the amygdala; correlating with increase of emotional stability, and the occipital structures; correlating with the decrease of intensity of visual stimuli. It is also hypothesized that the middle temporal gyrus will increase in activity; correlating with increase of mindfulness, and increase in middle frontal gyrus; correlating with decrease in impulsive behavior and increase of the wise, rational mind. Even though borderline personality disorder manifests itself through different behaviors between different genders, the emotional instabiltiy is the same across the gender spectrum (American Psychiatric Association 2013), consequently is hypothesized that gender will not affect the change of neural emotional response. Lastly, it has been hypothesized that a client’s trauma history is limiting on the amount of change in BOLD due to the complexity and interaction that trauma has with a borderline personality disorder client. Method Participants Thirty adolescents (14-17-years-old) who are diagnosed with borderline personality disorder will be used as participants. Adolescents are going to be studied because BPD begins and increases in intensity during adolescence (American Psychiatric Association 2013). Both the legal guardians and the client must agree with the informed consent inorder for the individual to participate. Design The design of this study will be mixed pre-post study. The Within-Subject pre-post design will be used to compare the differences in neural activity and the Between-Subjects will be used to determine whether there is a correlation with gender and the neurological effects of DBT and the relationship between trauma history and DBT’s neurological effectiveness. Procedure Thirty adolescent borderline clients will initially be presented with a Trauma History Questionnaire (THQ), a self-report measure that records one’s possibly traumatic experiences (Hooper, et al 2011). After each individual completes the questionnaire, they will each go through baseline testing where they will be placed in a fMRI and then will be presented variety of slides from the international affective picture system (IAPS). IAPS are a set of normative visual stimuli that vary in intensity of arousal and positive and negative valence that were created to study the neural effects of different emotions (Bradley & Lang 2007). The fMRI will record the change in blood flow within the brain when the stimuli are presented. After the baseline testing, the participants will attend group DBT outpatient treatment 3 hours a day, 5 days a week for 4 weeks; following the model of a local behavioral health facility, Rogers Memorial Hospital. The groups will consist of 10 clients, the groups will rotate on what time of day that they will attend treatment. The treatment times will be from 08:00-11:00, 12:00-15:00 and 16:00-19:00. If an individual misses more than two treatment sessions, their data will be thrown out. After the treatment has been completed, the same fMRI study will be conducted to determine whether there has been a significance change in blood and oxygen levels in the targeted brain regions. If any individual experiences any traumatic events during the treatment period, their data will be thrown out. Results The raw data in this study will be the change in BOLD recorded by the fMRI. The thirty adolescents will be compared using 1 sample t-test to determine whether the changes within each participant are significant. A Pearson’s correlation test will be utilized to determine whether there is a relationship between effectiveness of DBT and trauma history and effectiveness of DBT and gender. Discussion The results and findings of this study will be compared to the initial hypotheses. If the hypotheses are supported, the study will increase the support for Dialectial behavior therapy for individuals diagnosed with borderline personality disorder. The results from this study will also give the clinical community a better understanding and measurement of the effects that DBT has on its clients. A limitation of the study is the generalizability of this study. The study will only be able to determine the neurological effects that DBT has in an outpatient, group setting. The research will not able to be applied to an inpatient, residential nor a one-on-one therapy setting. Literature Cited American Psychiatric Association. (2006). American Psychiatric Association Bradley, M. M. & Lang, P. J. (2007). The International Affective Picture System (IAPS) in the study of emotion and attention. Handbook of Emotion Elicitation and Assessment. 29-46. Branstrom R, Duncan LG, Moskowitz JT (Mar 2011). "The association between dispositional mindfulness, psychological well-being, and perceived health in a Swedish population-based sample". Br J Health Psychol 16 (2): 300–16. Fallon P. (2003) Travelling through the system: the lived experience of people with borderline personality disorder in contact with psychiatric services. Journal of Psychiatric and Mental Health Nursing 10, 393–400. Harold W. Koenigsberg, H.W., Siever, L.J., Lee, H., Pizzarello, A., New, A.S., Goodman, M., Cheng, H., Flory, J., Prohovnik, I., (2009) Neural correlates of emotion processing in borderline personality disorder. Psychiatry Research: Neuroimaging, Volume 172, Issue 3, 192–199 Hooper, L., Stockton, P., Krupnick, J., & Green, B., (2011).
Development, use, and psychometric properties of the Trauma History Questionnaire. Journal of Loss and Trauma, 16, 258-283. doi: 10.1080/15325024.2011.572035 Linehan M.M., Armstrong H.E., Suarez A.,et al. (1991) Cognitive behavioural treatment of chronically suicidal borderline patients. Archives of General Psychiatry 48, 1060–1064. Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292. Neacsiu A.D., Ward-Ciesielski E.F. & Linehan, M.M. (2012) Emerging approaches to counseling intervention: dialectical behavior therapy.Counseling Psychologist 40, 1003–1032. Rizvi S. (2011) Treatment failure in dialectical behaviour therapy. Cognitive and Behavioural Practice 18, 403–412. Stoffers J.M., Völlm B.A., Rücker G., et al. (2012) Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews (8), CD005652. Swenson, C. (2000). How can we account for DBT’s widespread popularity? York: Guilford
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People with Borderline Personality Disorder tend to view the world as simple as possible. People who view the world like this, confuse the actions of others. (Hoermann et al, 2005) Recurrent thoughts about their relationships with others, lead them to experience extreme emotional reactions, great agony which they have a hard time controlling, which would result in engaging in self-destructive behaviors. Diagnosing a patient with this disorder can be challenging which is why is it is labeled as one of the difficult ones to diagnose. (Hoermann et al, 2005)
Stern, Richard. "Behavioural-Cognitive Psychotherapy Training for Psychiatrists." Pb.rcpsych.org. The Royal College of Psychiatrists, 1993. Web. 24 Feb. 2014.
DBT is effective when working with clients experiencing anxiety disorder and depression. Individuals in DBT therapy are taught to notice, rather than react to thoughts and behaviors. DBT teaches clients to accept their emotional reactions and learn to tolerate distress while being mindful of their present experiences. DBT has four stages for therapy. In stage one the pre-commitment stage is where the therapist explains what types of treatment the client will receive. In this stage the client must agree to stop all self harm behavior and work toward developing other coping skills. In stage two the goal is to assist the client into controlling her emotions. Stage three and four involve assisting the client to gain the ability to develop self respect (Waltz, 2003).
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. American Journal Of Psychiatry, 160(7), 1223--1232.
While CBT has many advantages, it alone does not encompass all of the concepts I believe are necessary to tackle a client’s needs. Therefore, I draw upon concepts from various theories to assist clients in achieving their goals. Pulling from Reality therapy, a key concept I utilize is focusing on what the client is doing and how to get them to evaluate whether they’re present actions are working for them. CBT does use some form of this in the sense that one must examine and establish their cognitive misconceptions; however, I prefer to extract this concept from Reality therapy because CBT tends to do so by focusing on the past. I am a firm believer that while the past can shape who you are, it does little good to remain focused on it. Focusing on overt behavior, precision in specifying the goals of treatment, development of specific treatment plans, and objective evaluation of therapy outcomes all come from Behavior therapy (Corey, 2013, p. 474). Behavior therapy is highly structured much like that of CBT. By utilizing this aspect of Behavior therapy, I am better able to closely observe where a client is currently and where they are headed. Lastly, I pull from Person-Centered therapy as the final key concept of my counseling approach. PCT focuses on the fact that client’s have the potential to become aware of their problems and resolve them (Corey, 2013). This Person-Centered therapy concept has overlap with CBT as
Borderline personality disorder is a hard-mental disease to diagnose, according to The National Institute of Mental health the definition of borderline personality disorder is: “… a serious mental disorder marked by a pattern of ongoing instability in moods, behavior, self-image, and functioning. These experiences often result in impulsive actions and unstable relationships” (pg 1). When we look at that definition alone this is a very vague description of the disorder that anyone that is experiencing just a rough time in life, can be diagnosed with this mental disorder. Roughly about 3 million Americans are diagnosed with borderline personality disorder a year. To find out who really has this mental disorder we should look at case studies,
This paper looks at a person that exhibits the symptoms of Borderline Personality Disorder (BPD). In the paper, examples are given of symptoms that the person exhibits. These symptoms are then evaluated using the DSM-V criteria for BPD. The six-different psychological theoretical models are discussed, and it is shown how these models have been used to explain the symptoms of BPD. Assessment of
Borderline Personality Disorder (BPD) has been a disability surrounded by stigma and confusion for a long time, and the time to bring awareness and public understanding to this disability is long overdue. The disability itself often gets misdiagnosed as an other disability since the symptoms overlap with many other disabilities (NIMH, n.d, para 16), or worse case scenario, a medical professional refuses to diagnose or treat the disability due to the belief that these people are untreatable because of a negative schema about the disability and clinical controversies on whether BPD is a legitimate diagnosis (Hoffman, 2007) . However, after nearly three decades of research, it has come to light that BPD does indeed exist, does have a good prognosis for remission with treatment (BPD Overview, n.d, para 3), and that there are many treatment options available such as three different types of psychotherapy (Dialectical Behavior Therapy, Cognitive Behavioral Therapy, and Schema-focused therapy), omega-3 fatty acid supplements, and/or medications (NIMH, n.d, para 29, 30, 31, and 39, 41). Even though the disability started as a psychoanalytic colloquialism for untreatable neurotics (Gunderson, 2009), BPD is very treatable and doesn’t deserve the stigma it currently carries throughout society.
Borderline Personality Disorder (BPD) affects about 4% of the general population, and at least 20% of the clinical psychiatric population. (Kernberg and Michels, 2009) In the clinical psychiatric population, about 75% of those with the disorder are women. BPD is also significantly heritable, with 42-68% of the variance associated with genetic factors, similar to that of hypertension. BPD can also develop due to environmental factors such as childhood neglect and/or trauma, insecure attachment, and exposure to marital, family, and psychiatric issues. (Gunderson, 2011)
In most cases Borderline Personality Disorder develops with comorbidity. Often times people cope or self medicate with alcohol, drugs, and food. Eating Disorders, Alcoholism, and other similar mental health issues develop in coax with BPD alo...
CBT has been known to cure a variety of disorders both in clinical environments and non-clinical environments. This type of therapy technique has been tested for efficacy and has proven to be highly effective. Furthermore, the future for CBT looks very positive as well. Researchers and theorist are now working on making this type of therapy available for suicide prevention, schizophrenia, and other psychopathologies.
Hollon, S. D. & Beck, A. T. (2004). Cognitive and cognitive behavioral therapies. Bergin And Garfield’S Handbook Of Psychotherapy And Behavior Change, 5 pp. 447--492.
Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy, specifically developed for borderline personality disorder (BPD), in which the clinician attempts to motivate the client towards change in behavior while simultaneously validating existing thoughts and feelings. (DeVylder) The goal of dialectical behavior therapy is to minimize maladaptive behaviors related to impulse control and emotion regulation, especially those that may result in self-injury or death. (DeVylder) The desired outcome of DBT is a resolution of maladaptive behaviors related to impulse control and emotion regulation, especially those behaviors that may result in self-injury or death. (DeVylder)
Linehan addressed the need for effective and empirically supported psychotherapeutic treatment for borderline personality disorder. She discovered important shortcomings in standard cognitive and behavioral (CBT) treatments (Chapman & Robins, 2004). DBT was developed to address difficulties faced when implementing standard CBT to ...
The history of BPD can be traced back to 1938 when Adolph Stern first described the symptoms of the disorder as neither being psychotic nor psychoneurotic; hence, the term ‘borderline’ was introduced (National Collaborating Centre for Mental Health, 2009, p. 15). Then in 1960, Otto Kernberg coined the term ‘borderline personality organization’ to describe persistent patterns of behavior and functioning consisting of instability, and distressed psychological self-organization (National Collaborating Centre for Mental Health, 2009, p. 15).