Dialectical Behavior Therapy (DBT) has been used to treat Borderline Personality Disorder (BPD), alcohol abuse, drug abuse, and eating disorders.

1. Dialectical Processes &
Behavioral Therapy:
Understanding and Treating Borderline
Patients
J. Ryan Fuller, Ph.D.
NewYorkBehavioralHealth.com
Brooklyn Committee on
Alcohol & Substance Abuse

2. How likely is it that a
clinician will treat someone
with BPD?
 11% of all outpatients
 19% of inpatients
 33% of outpatients with Axis II
 63% of inpatients with Axis II

3. Why are Borderline Patients
so difficult to treat?

4. What are the components
of effective therapy?
 Strong Therapeutic Bond
 Clear Treatment Planning
 Ongoing Assessment
 Use of Effective Treatments
 Client Motivation
 Therapist Motivation
 Homework

5. What are their symptoms?
 Intense Emotional Responses
 Splitting
 Emptiness, Loneliness, & Desperation
 Unrelenting Crises & Self Injurious Behavior
 Suicide

6. Effective Therapy &
BPD Symptoms
BPD Symptoms
 Intense Emotional Responses
 Splitting
 Emptiness, Loneliness, &
Desperation
 Unrelenting Crises & Self Injurious
Behavior
 Suicide
Elements of Therapy
 Strong Therapeutic Bond
 Clear Treatment Planning
 Ongoing Assessment
 Use of Effective Treatments
 Client Motivation
 Therapist Motivation
 Homework

7. Who are they and what do
they look like?
 Women
 Angry & Aggressive
 Self Injurying
 Alcohol & Drug Abusing
 Promiscuous
 Apparently Competent

8. Hollywood’s Portrayal
 Heroine? Femme Fatal? How would she
be imagined?
 Can anyone name a film that may have a
realistic or caricature of someone with
BPD?

9. Fatal Attraction

10. What’s in a name?
Borderline Personality Disorder
Parasuicidal Behavior
Gestures
Threats

11. DSM: Borderline
Personality Disorder (1)
 Frantic efforts to avoid real or imagined abandonment.
 A pattern of unstable and intense interpersonal
relationships characterized by alternating between
extremes of idealization and devaluation.
 Identity disturbance: persistent and markedly disturbed,
distorted, or unstable self-image or sense of self

12. DSM: Borderline
Personality Disorder (2)
 Impulsivity in at least two areas that are
potentially self-damaging
 Recurrent suicidal behavior, gestures, or
threats, or self-mutilating behavior.
 Affective instability due to a marked reactivity of
mood

13. DSM: Borderline
Personality Disorder (3)
 Chronic feelings of emptiness.
 Inappropriate, intense anger or difficulty
controlling anger
 Transient, stress-related severe dissociative
symptoms or paranoid ideation

14. Behavioral Patterns:
Linehan
 Emotional Vulnerability
 Self-invalidation
 Unrelenting Crises
 Inhibited Grieving
 Active Passivity
 Apparent Competence

15. Primary Mechanism
 Emotional Dysregulation
 Emotional Vulnerability
 Sensitive to stimuli
 High intensity
 Slow return to baseline
 Inability to regulate

16. Developmental Etiology
 Biological Predisposition
 Environment
 Diathesis Stress Model
 Transactional Model

17. Developmental Etiology (2)
 Biological Predisposition
 Nervous System
 Genetic Link to Comorbidities
 Environment
 Childhood Sexual Abuse
 Invalidating Environment

18. Dysregulation Experience
 Phenomenology
 Chaotic Storm
 Experienced by others as an “Emotional Burn Victim”

19. Clinical Approach
 Study the scientific efficacy literature
 Complete the necessary coursework or independent
study of theory and techniques
 Receive clinical training and supervision

20. Efficacy Literature
 Dialectical Behavior Therapy (DBT)
 Schema Therapy
 Transference Focused Therapy (TFT)
 Mentalization Based Therapy

21. Basic Theory
 Learning Principles
 Behavior Therapy
 Dialectical Perspective

22. Learning Principles
 Classical Conditioning
 Operant Conditioning
 Modeling

23. Behavior Therapy
 Exposure
 Behavioral Contracting
 Relaxation
 FBA

24. Dialectical Perspective
 Definition
 Dialectical Dilemmas

25. DBT Delivery Package
 Individual Therapy
 Skills Training
 Supportive Process Group Therapy
 Telephone Consultation
 Case Consultation Meetings for Therapists

26. What can we take from DBT
into our practice now?
 Style
 Philosophy
 Skills

27. Therapeutic Style &
Communication
 Collaborative
 Irreverent

28. DBT Assumptions
 Patients are doing the best they can
 Patients want to improve
 Patients need to do better, try harder, and be more motivated to change
 Patients may not have caused all of their own problems, but they have to
solve them anyway
 The lives of suicidal, Borderline individuals are unbearable as they are
currently being lived
 Patients must learn new behaviors in all relevant contexts
 Patients cannot fail in therapy
 Therapists treating Borderline patients need support

29. Skills Training
 Mindfulness
 Emotion Regulation
 Distress Tolerance
 Interpersonal Effectivenes

30. Clinical Interventions
 Problem Solving
 Exposure
 Skills Training
 Contingency Management
 Cognitive Modification

31. Cognitive Modification
 Teaching patient to identify nondialectical thinking
 Cost Benefit Analysis for that thinking
 Developing alternatives

32. Nondialectical Thinking
 Arbitrary Inferences
 Overgeneralizations
 Magnification
 Inappropriate attribution
 Labeling
 Catastrophizing
 Hopeless expectancies

33. Integration Summary
 Dialectical conceptualization of cases
 Careful attention to FBA
 Stylistic and Language Changes
 Selecting Skills to study and obtain supervision
 Self-care & Support for Clinician

34. Further Structure
 Primary Behavioral Targets
 Secondary Behavioral Targets
 Tertiary Behavioral Targets
 Spiritual Targets (Optional)

35. Primary Behavioral Targets
(1)
 Decrease Suicidal Behaviors
 Decrease Therapy-Interfering Behaviors
 Honoring agreements
 Completing/Attempting Homework
 Participation in Therapy
 Collaborative Approach

36. Primary Behavioral Targets
(2)
 Decreasing Behaviors That Interfere with Quality of
Life
 Increasing Behavioral Skills
 Core Mindfulness Skills
 Distress Tolerance Skills
 Emotion Regulation Skills
 Interpersonal Effectiveness Skills
 Self-Management Skills
 Decreasing Behaviors Related to Posttraumatic
Stress

37. Secondary Behavioral
Targets
 Increasing Emotion Modulation; Decreasing Emotional
Reactivity
 Increasing Self-Validation; Decreasing Self-Invalidation
 Increasing Realistic Decision Making and Judgment;
Decreasing Crisis-Generating Behaviors
 Increasing Emotional Experiencing; Decreasing
Inhibited Grieving
 Increasing Active Problem Solving; Decreasing Active-
Passivity Behaviors

38. Tertiary & Optional
 Tertiary Targets
 Increasing self respect
 Achieving individual goals
 Spiritual (Optional)

39. DBT Evolves
 Dive Reflex
 Non-pharmacological Benzo Strategy

40. Final Thoughts
 “I’m not going to be ignored.”
 Life is suffering
 There but for the grace of G-d go I

41. More Information
 Books
 Newsletter
 PPT Video
 Worksheets
 Interest in Clinical Training (CBT & DBT)