I Hate You--Don't Leave Me - Jerold J. Kreisman [82]
Dialectical Behavioral Therapy (DBT)
Developed by Marsha M. Linehan, PhD, at the University of Washington, DBT is the derivation of standard cognitive-behavioral therapy that has furnished the most controlled studies demonstrating its efficacy. The dialectic of the treatment refers to the goal of resolving the inherent “opposites” faced by BPD patients; that is, the need to negotiate the borderline’s contradictory feeling states, such as loving, then hating the same person or situation. A more basic dialectic in this system is the need to resolve the paradox that the patient is trying as hard as she can and is urged to be satisfied with her efforts, and yet is simultaneously striving to change even more and do even better.5
DBT posits that borderline patients possess a genetic/biological vulnerability to emotional over-reactivity. This view hypothesizes that the limbic system, the part of the brain most closely associated with emotional responses, is hyperactive in the borderline. The second contributing factor, according to DBT practitioners, is an invalidating environment; that is, others dismiss, contradict, or reject the developing individual’s emotions. Confronted with such interactions, the individual is unable to trust others or her own reactions. Emotions are uncontrolled and volatile.
In the initial stages of treatment DBT focuses on a hierarchical system of targets, confronting first the most serious, and then later the easiest, behaviors to change. The highest priority addressed immediately is the threat of suicide and self-injuring behaviors. The second-highest target is to eliminate behaviors that interfere with therapy, such as missed appointments or not completing homework assignments. The third priority is to address behaviors that interfere with a healthy quality of life, such as disruptive compulsions, promiscuity, or criminal conduct; among these, easier changes are targeted first. Fourth, the focus is on increasing behavioral skills.
The structured program consists of four main components:
1. Weekly individual psychotherapy to reinforce learned new skills and to minimize self-defeating behaviors.
2. Weekly group skills therapy that utilizes educational materials about BPD and DBT, homework assignments, and discussion to teach techniques to better control emotions, improve interpersonal contacts, and nurture mindfulness— a term to describe objective consideration of present feelings, uncontaminated by ruminations on the past or future or by emotional lability.
3. Telephone coaching (a unique feature of DBT) to help patients work through developing stresses before they become emergencies; calls can be made to on-call coaches at any time, but are deemed inappropriate if made after a patient has acted out in a destructive manner.
4. Weekly meetings among all members of the therapist team to enhance skills and motivation, and to combat burnout. Each week, patients are given a DBT “diary card” to fill out daily. The diary is meant to document self-destructive behaviors, drug use, disruptive emotions, and how the patient coped with such daily stresses.
Systems Training for Emotional Predictability and Problem Solving (STEPPS)
Another manual-based variation of CBT is STEPPS, developed at the University of Iowa. Like DBT, STEPPS focuses on the borderline’s inability to modulate emotions and impulses. The unique modifications of STEPPS were partly built on a wish to develop a less costly program. STEPPS is a group therapy paradigm, without individual sessions. It is also designed to be shorter—consisting of twenty two-hour weekly groups (compared to the typical one-year commitment expected in DBT). This program also emphasizes the importance of involving the borderline’s social systems in treatment. Educational training sessions “can include family members, significant others, health care professionals, or