Thus, an environment that does not recognize or validate genuine emotional expression can reinforce suicidality.
Table 1
Diagnostic criteria for borderline personality disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
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| Source: Adapted and reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders (4th ed, text revision). Copyright 2000. American Psychiatric Association. |
SOLVING NO-WIN THERAPY
Pitfalls with emphasizing change. Therapy that emphasizes solving problems and getting things to change typically triggers high arousal in persons with borderline personality disorder. Feeling out of control, they respond by trying to get in control, including attempts to control the therapist.
Similarly, they see attempts to get them to change their behavior as invalidating their experiences or, worse, who they are. Intense emotions aroused by the message they hear—that they are the source of their problems—impair learning and intensify their efforts to gain control. In a battle for control, collaboration and therapy cannot occur.
Case example. Ms. K wants you to understand how difficult her life is because of difficulties with her boss. You start talking about what Ms. K can do to change the situation, without acknowledging how difficult it is to deal with her boss.
Ms. K feels upset and says you don’t understand. For her, the interaction has led to emotion dysregulation and impaired cognitive processing.
Pitfalls with emphasizing acceptance. Most persons who come to therapy very distressed want something in their lives to change. If your primary message is acceptance instead of change, they may lose confidence in you.
Case example. Ms. K wants help dealing with her boss, who is making life quite difficult. As her therapist, you respond with warmth and acceptance but offer no suggestions as to how she might change the situation. Ms. K likes the way you listen to her but abandons therapy. after several sessions.
At first, patients with borderline personality disorder may like the warmth of client-centered acceptance approaches. Over time, however, they may feel their therapy sessions are out of control. They may think the therapist doesn’t understand the situation, doesn’t know how to help, or that situations that are troubling them cannot be changed.
Balanced therapy. DBT solves the change-or-acceptance dilemma by attempting to help patients with borderline personality disorder change themselves and their lives while offering strategies for accepting themselves and their situations.1,2 DBT includes problem-solving and acceptance strategies (Table 2).
Table 2
Strategies used in dialectical behavioral therapy
| Structural strategies | Organization of sessions, attending to the treatment hierarchy, reviewing progress, checking on other modes of therapy |
| Problem assessment strategies | Defining problems with specificity, conducting chain analyses, developing and testing hypotheses |
| Problem solving strategies | Providing didactic information, generating and evaluating solutions, teaching skills and coaching on use of skills, generalizing skills to the real-world environment |
| Contingency management | Use of reinforcement, extinction, aversive contingencies, and principles of shaping. |
| Exposure-based procedures | Both formal and informal |
| Cognitive strategies | Contingency clarification, observation and description of cognitions, cognitive modification |
| Validation strategies | Appearing interested, accurately reflecting, correctly articulating things that have not been fully expressed, explaining behavior in terms of learning history or biological factors, acknowledging validity of responses in terms of current events, interacting in a radically genuine manner, communicating belief in the patient |
| Reciprocal communication strategies | Being responsive, expressing warm engagement, being nonjudgmental, using self-disclosure, maintaining a reasonable power equilibrium |
| Irreverent strategies | Engaging in a matter-of-fact manner, directly confronting dysfunctional behavior, using unexpected, irreverent or humorous responses |
| Dialectical strategies | Using a balanced style, balancing acceptance-oriented strategies with change-oriented strategies, magnifying tension, using metaphor, modeling dialectical thinking and behaviors, moving with speed and flow. |
| Case management strategies | Following a model of consultation to the patient when long-term outcome is more important than short-term outcome; intervening in the patient's environment when short-term outcome is more important than long-term outcome |