“Anxious,” “exhausted,” “feeling ineffective.” These are words many therapists apply to the experience of serving a client who has borderline personality disorder (BPD). Marsha Linehan, the founder of Dialectical Behavior Therapy (DBT), contends that this is a typical and unfortunate result of attempting to manage a BPD client using traditional methods.
Interestingly, according to Linehan, traditional therapies (especially cognitive-behavioral therapies) may actually exacerbate the BPD client’s issues because the client experiences the techniques as invalidating. DBT, conversely, seeks to establish a validating environment.
Invalidation is easily explained. A well-meaning therapist may suggest reasonable and helpful behavioral changes and associated strategies. The client, however, experiences this as harsh criticism, because the client with this disorder tends to lack appropriate defenses. BPD clients experience themselves as unfinished, shameful, rotten, etc. Given this, they interpret suggestions as the therapist pointing out flaws, which is incredibly painful for them—in a word, invalidating.
Effective therapists must balance validation and acceptance with behavioral change. In DBT the therapist must practice mindfulness, acceptance and effectiveness. A therapist using this technique validates the client’s behavior regardless of how self-defeating or destructive it may be.
But validation does not equate to condoning. Rather, the therapist might say, “This self-injuring behavior makes sense given your history, anxiety, etc. It is what you always have done. I know you have experienced this as soothing in the past. At some level you think this works for you.” Never does the therapist say, “This is OK.”
When the validating environment is established with acceptance and unconditional regard, the therapist can begin to help the client create behavior change strategies. The therapist will draw from the skills the client is learning in DBT skills classes.
The client will learn more effective skills to replace the behaviors that are disrupting his/her life and impeding attainment of a life worth living. Moreover, DBT skills development helps alleviate therapy-interfering behavior.
The client learns four categories of skills: core mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. Within each of these categories are multiple specific skills. An example of a core mindfulness skill is the “wise mind” skill. This skill teaches the client ultimately to attend simultaneously to his/her emotional and logical mind. As a client is making a life decision or reacting to a situation, he/she accesses the messages from both parts of the mind. Synthesizing the opposing messages allows the client to make a decision from the wise mind.
For many DBT skills, Linehan has developed clever acronyms to help clients (and therapists) remember them. For instance, an interpersonal effectiveness skill, aimed at helping navigate relationships, is the G.I.V.E. skill:
G—be Gentle in your approach. I—act Interested in the other person.
V—Validate the other’s feelings.
E—use an Easy manner.
Notably, DBT requires that therapists be practicing these skills in their own lives as well.
Remaining effective as a therapist
The components of DBT are designed not only to help the client, but also to help the therapist remain effective and mindful. DBT buffers against the feelings expressed by therapists in the opening sentence of this article.
The components include individual therapy, skills training, and consultation team. The consultation team is designed to help the therapist stay true to the model, practice effective therapy, experience support, and remain mindful, thus providing a network of non-judgmental teammates to help the therapist feel invigorated.
In summation, DBT has demonstrated more effectiveness than treatment as usual in addressing BPD. Moreover, it helps practitioners remain mindful and effective.
Eric Schmidt, MSSW, LCSW, MBA, is CEO of New Roads Treatment Centers in Sandy, Utah. He has worked in the substance abuse and behavioral health field for the past 20 years, primarily in executive-level positions but also in providing clinical services such as individual, group and family treatment; diagnostic assessments; and psychosocial assessments. He is also an adjunct faculty member at the University of Utah School of Social Work. His e-mail address is firstname.lastname@example.org.