Question 1

Given the strong link between BPD and trauma, I was wondering if DBT is helpful in dealing with trauma?

Clive Robins · Accepted Answer

There is indeed a higher prevalence of trauma in the histories of individuals diagnosed with BPD than most other diagnoses. Most people with BPD meet criteria for one or more Axis I disorders and PTSD is prominent among those. For those with BPD and PTSD, standard DBT alone, at least in research trials of one year of treatment, is actually not very effective in treating PTSD, even when it reduces many of the behaviors associated with BPD. The treatments found to be effective for treating PTSD all have in common the element of repeated exposure to representations of the trauma, along with other elements that differ somewhat from one treatment to another. The evidence is strongest for Prolonged Exposure, developed by Edna Foa and colleagues. Equally strong effects have been found for Cognitive Processing Therapy, developed by Patricia Resick, but so far there have been fewer randomized trials of CPT than of PE. Eye Movement Desensitization and Reprocessing (EMDR) also has some support and also involves imaginal exposure. All of these treatments inherently result in strong emotional responses while re-imagining the trauma. For clients with BPD who are currently suicidal or self-injuring, this can be very risky. These clients typically are trying to escape difficult emotions by those behaviors. They are not ready to do trauma-focused work in an outpatient setting. However, when sufficiently stabilized and able to demonstrate that they can  contact difficult emotions and tolerate them without such extreme escape behaviors, they can benefit from exposure work. In fact, Melanie Harned and Marsha Linehan have developed DBT-PE, a protocol in which, once a client has been in standard DBT and shows sufficient stability (please refer to Melanie's work for details) for at least 2 months, individual weekly PE sessions are conducted in addition to usual DBT individual and skills group. Randomized trial data suggest it is very effective in treating PTSD while continuing to benefit the BPD behaviors. An adaptation of DBT for PTSD by Martin Bohus and colleagues that does not require waiting until there is no self-injury has also shown very good results, but please note that that is in a long-term (by US standards) inpatient setting in Germany.

Question 2

What do people with BPD think of DBT?

Clive Robins · Accepted Answer

I am not aware of any research that exactly addresses that question, though there is a little research on which skills people found the most helpful (perhaps surprisingly, because it is difficult, radical acceptance was one many found most helpful). Anecdotally, as a therapist and as a consultant to many DBT programs, responses of people with BPD to DBT vary tremendously. Some hate the idea at first, reluctantly agree to start and end up becoming huge advocates. Others do not, and drop out. Some (fewer) begin with high expectations and become discouraged that progress can be slow and intermittent. I think it is very important that potential DBT clients, with or without BPD, are provided with a clear and thorough orientation to what DBT is and is not, and in what ways it might help them to change problematic behaviors that bother them or get them into trouble, and how that can help them achieve some of the things they want out of life. I like to learn what, if anything, they have heard about DBT and try to clear up any misconceptions. Particularly if potential clients say they have "been in DBT and it didn't work", I'll want to learn more details about what the treatment was (not comprehensive DBT, in fact, quite often) and point out what might be different about actual DBT. It is also common in orienting to treatment and getting a commitment to it to use the "devil's advocate" strategy of emphasizing that treatment involves a lot of hard work, will be difficult, etc., in part in hopes that the client will argue for why they really need it, and also because it is true and we want them to go into it eyes fully open.

Question 3

How can DBT help when the issues resulting from BPD are so disruptive that therapy is unable to focus on the underlying maintaining factors (e.g. trauma and self-worth issues)?

Clive Robins · Accepted Answer

I would like to make several points her. First, trauma and self-worth issues are not necessarily the underlying maintaining factors in all cases of BPD, though they are important in many. Clients with BPD do report high rates of trauma but it is far from universal. Second, by issues being "disruptive", I'm guessing that you may be thinking of the string emotional dysregulation they often experience and the behaviors that leads to such as self-injury, substance abuse, anger outbursts and so forth. Indeed it is difficult and even unwise for therapy to focus on trauma when a person is showing by their behaviors that they cannot currently handle the strong emotions that trauma-work necessarily generates. Similarly, it is hard for someone to have much feeling of self-worth when they frequently engage in behaviors that wreck their lives. Therefore, in DBT, we take a staged approach to treatment, in which some behaviors need to be the primary focus first. If there are life-threatening behaviors or behaviors on that spectrum like strong suicidal ideation or deliberate self-injury, that is the first priority. If a client comes to a session and that has occurred, it will be the primary focus of the session. If not, behaviors lower in the priority hierarchy can be addressed, which might include therapy-interfering behavior or quality-of-life interfering such as substance abuse or depression or phobia. If the person has PTSD symptoms such as nightmares, startle response, dissociation, then at this initial stage of treatment, we try to help with skills to manage and reduce those problems, but do not directly address the trauma. For some clients, when there is greater stability of behavior, less dysregulation, there may be a second stage of treatment focused on trauma or more generally on reducing avoidance of difficult emotions and their cues. This is when empirically supported treatments for PTSD such as Prolonged Exposure or Cognitive Processing Therapy would commence. Not all clients require or desire this stage of treatment. A third stage of treatment would focus on helping the client who is now behaving in less disruptive ways to develop greater self-esteem, improve their relationships with others, etc.

Question 4

What tips can you give to help with clients who are not practising or utilising strategies to help regulate their emotions?

Clive Robins · Accepted Answer

This is a fairly common difficulty. The first step in DBT is always to assess, to figure out what is causing the problem. Inadequate treatment is very often the result of inadequate assessment. The first thing I would assess is the extent to which the client is committed to the goals and tasks of treatment. A common problem arises when the therapist or agency, or a parent or other person, decides what the client's goals should be based on what they perceive as problem behaviors. There may indeed be problems that are getting in the way of the client having what most of us would consider a reasonable quality of life, but unless the client also views it that way, treatment will keep running into an impasse. This happens frequently with adolescents but is not uncommon with adults too. So first make sure you have helped the client to figure out what their goals are for therapy. How do they want their life to be different? Then try to help them to see how changing some of their behaviors is important or even necessary for them to move toward those goals. Get verbal commitment to work on changing those behaviors. Assuming this has been done (and often one has to return to these goal-setting, targeting, and commitment issues during treatment), but the client is not currently practicing or using emotion regulation strategies (or other skills they may have learned), then assess what else may be getting in the way. For example, do they feel hopeless that the skills will make any difference. One might validate that learning a skill takes practice and at first it may not be as effective as maladaptive ways of regulating emotions such as self-injury or substance use. In that case, one could have the client list the pros and cons of practicing the skill and the pros and cons of doing the maladaptive behavior. The emotion regulation benefits of a skill are likely to increase with practice. Another possibility is that the client believes they can't do the skill "right". In-session practice can be helpful here, with gentle corrective feedback, coaching, and reinforcement of approximations (shaping) when necessary. Willfulness might be the issue. Again assess why the client feels willful. Do they fear what will happen if the skill is helpful, such as fearing it proves others were right all along, that they can change if they just try. Or are they angry with the therapist about some other issue? These are just examples of common reasons for no-compliance with practice. The key is first to understand, then solutions tend to present themselves.

Question 5

Is there a specific order in which DBT skills should be taught and practised with clients with BPD?

Clive Robins · Accepted Answer

DBT skills are organized into modules of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Mindfulness skills are considered "core" skills because, in order to use any of the other skills effectively, one needs to remain mindful of one's goals, and of one's actions and their effects, without judgment. Therefore, mindfulness skills should be taught first. Skills usually are taught and practiced in a group context, which is optimal not only for the efficiency of teaching several clients at one time but more importantly for the opportunities it provides for clients to role-play or rehearse new behaviors with one another, to provide validation and support to one another and learn from each other's discussions of attempts to practice during the week for homework, and questions raised about the skills, among other things. If it is a closed group, i.e. a cohort of clients begin group together and go through all modules together with no new clients allowed to join, the skills manual suggests beginning with mindfulness, then interpersonal skills, as these may be the least likely to lead to clients feeling invalidated because we are helping them to change their interpersonal environment, rather than focusing on changing their own tolerance for distress or their emotional responses. Following that, mindfulness skills module again, then emotion regulation, mindfulness again, then distress tolerance. As you can see, the mindfulness module, though short (typically only two sessions) gets lots of repetition for deeper learning and practice, to emphasize its importance, and to help clients connect mindfulness skills to the longer (typically 5 to 7 sessions) module that follows. However, in my experience, most clinics and clinicians do not run closed groups, as there are likely to be dropouts over the course of a 6-month curriculum while at the same time there may be a waiting list for group. I usually recommend that new clients be allowed to join a group if there is room each time the mindfulness module comes around again. As a result, different clients will get the other skills in different orders. To my knowledge, there has been no research on whether order matters, but anecdotally from my own experience it does not seem to. If for some reason you are doing skills training just with an individual, perhaps because of extreme social anxiety or a client who has proved to be too disruptive to the group or too few clients to do a group, we recommend having a different clinician do the skills training in a different session than the DBT individual therapy. Otherwise, it is too easy for client and therapist to abandon the curriculum in favor of discussing whatever clinical situation seems urgent that day. If that is not possible, an individual clinician can try to do both in separate weekly sessions, and in the worst case scenario where perhaps finances get in the way of that, I would do individual therapy and try to weave in teaching whatever skills are most relevant to the clinical situation being problem-solved that day. This is far from ideal however. Whether the skills are taught in group or individually, and in whatever order, I recommend that the individual therapist provide at least some training and handouts on the subset of distress tolerance skills referred to as "crisis survival", particularly with suicidal and self-injuring clients.

Question 6

When BPD occurs in combination with other diagnoses that each flare up frequently, how do you prioritise? And how do you stay focused on one area at a time with so many issues occurring?

Clive Robins · Accepted Answer

I have addressed this in large part in my responses to a couple of other questions posted here, but have something to add. As I've said elsewhere, DBT follows a hierarchy of targets to address: in stage 1 that is 1. life-threatening behaviors, 2. treatment-interfering behaviors, 3. quality-of-life interfering behaviors, and 4. increasing behavioral skills. It is , almost critical that the client complete a diary card or some form of monitoring of the behaviors (including emotions and action urges) that are their main problems on a daily basis and bring this to sessions. This is the main way that the therapist can organize how time is spent most effectively during the session, by looking at the diary card and thinking it through with the client in terms of the target hierarchy. So, for example a client may come to a session and you learn from their diary and/or what they tell you, plus what you have observed yourself, that they have cut themselves once during the week, took too many of prescribed pills but not near a lethal dose, missed attending skills group last week, had a big argument with their mother who is no longer speaking to them, failed to pay rent even though they are in danger of being evicted. Most of us would feel overwhelmed with trying to deal with so many problems. Spending 5 or 10 minutes on each of them is unlikely to be very effective. More effective would be to notice that cutting is the highest priority target among these. I would therefore ensure that we do detailed analysis of what led up to and followed this and discuss what skills and strategies the client might use in a similar situation in the future to avoid it. Hopefully, we would still have time to at least enquire further about the overuse of pills and missing group. The client may say that the cutting was days ago and they won't do it again and they really want to talk about their mother or about the landlord, but it is better to remain firm about the hierarchy. After all, the client's relationship with their mother or rent payment are a moot point if they wind up dead. If next week, there has been no self-injury, no big increase in suicidal ideation, then our highest priority might be to discuss how to repair the relationship issue. So prioritize according to the hierarchy and what has happened since your last session.

Question 7

Can DBT help a person overcome BPD or simply learn to manage it more effectively?

Clive Robins · Accepted Answer

If by "manage it more effectively" you mean their behavior improves a lot, but in some way they still have BPD, this may actually be a false dichotomy. As a behaviorist, I do not think of BPD as some internal thing a person "has", so that even if their behavior improves to the point where they have few if any "symptoms", they still really have it. But I'm not sure if that's what you meant. BPD, as defined in the DSM, is a collection of behaviors that go together often enough it is considered a diagnosis. If we change those behaviors, we change the diagnosis. Unfortunately, almost no trials of psychotherapy for BPD look at change in diagnosis as an outcome measure, rather focusing on changes in levels of various individual behaviors and "symptoms", so there's not much evidence regarding whether DBT or any other treatment helps a person "overcome" BPD.  However, in one trial that my colleague Cedar Koons and I conducted (Koons, Robins, Tweed, et al., 2001, Behavior Therapy) of 6 months of DBT versus treatment as usual in a women's VA mental health clinic, the women receiving DBT had a greater reduction in number of DBT criteria met (out of a possible 9, of which at least 5 are required for diagnosis, they went from a mean of 6.8 to 3.6, compared to the TAU moving from 6.7 to 4.2, a significant difference). 30% of those in DBT and 50% of those in TAU still met BPD criteria at the end of treatment. Anecdotally, I've had numerous clients go from meeting BPD criteria to no longer doing so over the course of treatment. This does not of course necessarily mean that they no longer had any problems in life or even did not need or benefit from further treatment, but I do believe DBT and probably other treatments can help clients not only live better lives but actually no longer meet criteria for BPD. Across different randomized studies, DBT has reduced hospitalization rates and days, suicide attempts, non-suicidal self-injury, suicidal ideation, substance use, eating disordered behavior, anger expression, dissociation, and depression, among other things.

Question 8

Why is DBT the commonly recommended therapy approach for BPD?

Clive Robins · Accepted Answer

Because it has by far the largest base of empirical support from randomized controlled trials (RCTs). Several other treatments have demonstrated some merit in RCTs, including schema-focused therapy, mentalization therapy, and transference-focused psychotherapy, but they each have only one or two such trials. Standard DBT for BPD has been supported in at least 13 RCTs as of my last count a few years ago. This includes studies with participants diagnosed with BPD and recent suicidal behavior, and BPD and substance abuse. Adaptations of comprehensive DBT have also been supported in at least another 10 RCTs for participants with BPD and PTSD (the DBT-PE protocol of Melanie Harned and colleagues), BPD traits and an eating disorder, suicidal adolescents with BPD traits, mixed personality disorders, as well as participants who may or may not have BPD who had adolescent bipolar disorder, eating disorder, substance abuse, or childhood sexual abuse-related PTSD, and pre-adolescent children with disruptive mood-dysregulation disorder (Perepletchikova et al). The skills training component of DBT alone has also been supported in 2 RCTs with participants with BPD and as a stand-alone or adjunctive treatment in at least 12 RCTs for either eating disorders, mood disorders, ADHD or in transdiagnostic groups.

Question 9

How does DBT treat BPD that is co-occurring with eating disorders?

Clive Robins · Accepted Answer

First, I should make clear that I am not an expert in eating disorders. I can, however, give some general guidelines. DBT follows a hierarchy of treatment target priorities. In Stage 1 treatment, this is, in order, reducing life-threatening behaviors, reducing therapy-interfering behaviors, reducing serious quality-of-life interfering behaviors, and increasing behavioral skills to replace problem behaviors. So the first question to address is whether the eating disorder is currently life-threatening. For example, is the client seriously underweight and continuing to lose weight, or are they purging by vomiting frequently or severely enough that they risk damaging the esophagus or producing electrolyte imbalance. If this is suspected, evaluation by a specialist medical professional is very important and in severe cases, hospitalization may be necessary. Also, if the patient is underweight and severely restricting nutrition, their brain functioning may be compromised to a point where DBT or any other form of psychotherapy is not feasible and again medical attention is necessary first. In cases of severe restricting EDs, my approach has always been to require a medical evaluation, and consider referring to an eating disorders specialist or program to stabilize weight and restriction before doing DBT. However, in many cases, the ED, while serious is not as medically severe as described above. In that case, we would consider it a serious quality-of-life-interfering behavior (having a calorie-starved brain may also be a therapy-interfering behavior). So in a given session, the eating disorder may be the highest priority target, unless there has been an increase in life-threatening or serious therapy-interfering behavior, or some other target such as substance abuse is considered higher priority. How would the ED be treated? DBT incorporates use of other empirically supported behavioral treatments, such as the CBT-E program developed by Christopher Fairburn and his colleagues, which has some support for some types of ED in adults, particularly for binge eating disorder, bulimia and EDNOS, and Appetite Awareness Training developed by Linda Craighead. Many patients benefit also from standard DBT skills training, particularly in mindfulness (including mindful eating), distress tolerance, and emotion regulation, along with standard DBT strategies including behavioral analyses and solution analyses of binge and purge episodes. Several randomized trials  by Debra Safer, Christy Telch, Eunice Chen and their colleagues have supported such an approach, and Lucene Wiesnewski has written extensively about combining DBT and standard CBT for eating disorders. For children and adolescents with anorexia, the Maudsley model of family treatment is, I believe, the only treatment with any demonstrated support, and I am not aware of any treatment for anorexia in adults that has empirical support, although as I said, I am not an eating disorders expert, so there may be something recent of which I am not aware.

Question 10

What steps does DBT outline to approach therapy interfering behaviours?

Clive Robins · Accepted Answer

This is a very important topic. Before answering the question directly, let me discuss the nature of the problem. In DBT, we define therapy-interfering behaviors (TIBs) as any behavior on the part of the client or the therapist that interferes with the effectiveness of treatment. At some level, many clients (and therapists) in many forms of therapy can engage in some degree of TIB that is better addressed than ignored. In the case of clients diagnosed with BPD, the frequency of such behaviors is likely to be higher, again for both clients and therapists, in part because the high degree of emotional sensitivity of these clients may lead to strong reactions to therapist behaviors perceived as invalidating. Clients may perceive tasks of therapy such as monitoring their behaviors and doing behavioral analyses of problem behaviors as blaming them rather than their environments for the problems, for example. Therapists may be more likely to engage in TIBs such as being overly controlling or, on the other hand, too passive, in the face of difficult responses by the client or fears of suicide. They may also be more likely to fire the client or behave in ways that drives the client out of treatment. Partly a result of these TIBs, research indicates a high dropout rate of around 50% over the course of a year in outpatient treatment-as-usual for clients diagnosed with BPD, which means many do not get a sufficient "dose" of treatment. For this reason, DBT places a strong emphasis on targeting and treating TIBs. In a priority hierarchy of treatment targets, as a class, TIBs are second only to behaviors on a life-threatening spectrum including non-suicidal self-injury, and ahead of serious quality-of-life interfering behaviors such as substance abuse, depression, homelessness, etc., with the rationale that if TIBS are not addressed, adequate treatment is unlikely to be received and treatment may even end prematurely. TIBs of clients can include behaviors that interfere with receiving the therapy, such as not completing diary cards, not completing agreed-on homework, refusing to analyze problem behaviors, repeatedly missing appointments or being late, walking out, coming to sessions intoxicated, or dissociating during sessions. Other TIBs may interfere with other clients (e.g. in group or in the waiting room) treatment. Finally, some behaviors are TIBs because they burn out the therapist by pushing their limits too far. So how are TIBs addressed? Basically, in the same way as any other problem behaviors. In the case of client TIBs, the first step is to clearly and behaviorally describe the problem to the client. So "being uncooperative" is not a specific enough description to know what to do. Behaviorally specific might be "you did not complete your diary card again" or "You stood up and yelled at another group member" or "You refused to try any of the suggestions I made when you called me for coaching". The second step is, together with the client, to do a behavioral analysis to better understand what prompted it and/or what its function is, then to come up with solutions of what will make it less likely in future or what replacement behavior is needed. This might include specifying positive or negative consequences contingent on more adaptive or desired behavior or the old behavior re-occurring. In the case of therapist TIBs, the therapist needs to follow the same steps of problem definition, behavior analysis, and solution analysis. This is one of many aspects of DBT in which seeking help from one's DBT consultation team can be useful.

Question 11

Though I am a therapist, I would like to join a DBT group as a client and learn the skills training.  Is this available?

Clive Robins · Accepted Answer

Yes, under certain conditions. The skills are helpful for all of us. We all can benefit from being more mindful, better able to tolerate distress, regulate our emotions, and assert ourselves effectively and respectfully, for example. Being a member of a group is probably also a more effective way to learn the skills than just reading the manual and trying to practice on your own. Then, as a therapist, you are in a better position to train your clients in the skills. In fact, I encourage new skills group leaders and coleaders to do the same homework each week that they assign to the clients. Aside from anything else, you develop empathy for how hard it can be at times to remember to do it! That being said, I notice that you say "as a client". This part is important. If you are not one of the skills group trainers, then you need to be a client, in my opinion. Being an observer who takes in the information only is disruptive to the group. If you are there to learn the skills, you have to be willing to practice them for homework and discuss your homework attempts in front of the group the same as other group members, including discussion of your attempts to deal with difficult situations in your life. All must be willing to be equally vulnerable. For me as a group leader, it would not matter whether or not you have a diagnosable condition, but I would insist on those conditions of full participation and vulnerability.

Question 12

Teenager 16y with suspected BPD, how can she be in contact with a DBT expert online? What is your advice?

Clive Robins · Accepted Answer

In the current pandemic, your options may be broader than usual, as many but not all state licensing boards are allowing therapists to provide remote treatment outside their own state and many insurance companies are now willing to cover it. So how to find an expert. Unfortunately, many therapists may say they do DBT but actually have inadequate training or have training but do not actually deliver the treatment with adherence. This concern led the treatment developer, Marsha Linehan together with colleagues to develop the DBT-Linehan Board of Certification. To be certified requires not only having certain training and passing a written exam and case conceptualization but more importantly to demonstrate adherence by submitting videotaped sessions of a consenting client that is coded by experts. This is a very high standard, as it should be. A directory of certified therapists can be found at www.dbt-lbc.org. Because certification has only been available for a few years and is an intensive process both for applicants and examiners, there are not yet a large number of certified DBT therapists. No doubt many more are adequately trained and may be perfectly competent but have not yet been certified. How to find them? There now are several reputable DBT training organizations. Most prominent perhaps is Behavioral Tech, the organization founded by Dr. Linehan herself and for whom I have long trained and consulted. They maintain a directory of DBT programs that have gone through their 10-day intensive DBT trainings, with no knowledge of the adherence or quality of services delivered of course. The directory can be found at behavioraltech.org. Several other training organizations are directed by people who at one time were Behavioral Tech trainers and who are certified DBT clinicians. These include the Treatment Implementation Collaborative, the Portland DBT Institute, Dr. Charles Swenson, and Dr. Alec Miller at Cognitive Behavioral Consultants. Besides a DBT-LBC certified therapist or program. someone listed in the Behavioral Tech directory or who can demonstrate intensive training by one of these other 4 organizations are the best resources, in my opinion.

DBT for Borderline Personality Disorder