People with borderline personality disorder can be challenging to treat, because of the nature of the disorder. They are difficult to keep in therapy, frequently fail to respond to our therapeutic efforts and make considerable demands on the emotional resources of the therapist, particular when suicidal behaviors are prominent.

Dialectical Behavior Therapy is an innovative method of treatment that has been developed specifically to treat this difficult group of patients in a way which is optimistic and which preserves the morale of the therapist.

The technique has been devised by Marsha Linehan at the University of Washington in Seattle and its effectiveness has been demonstrated in a wealth of research in the past decade.

DBT’s Theory of Borderline Personality Disorder

Dialectical Behavior Therapy is based on a bio-social theory of borderline personality disorder. Linehan hypothesizes that the disorder is a consequence of an emotionally vulnerable individual growing up within a particular set of environmental circumstances which she refers to as the Invalidating Environment.

An emotionally vulnerable person is someone whose autonomic nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to baseline once the stress is removed. It is proposed that this is the consequence of a biological diathesis.

The term Invalidating Environment refers essentially to a situation in which the personal experiences and responses of the growing child are disqualified or “invalidated” by the significant others in her life. The child’s personal communications are not accepted as an accurate indication of her true feelings and it is implied that, if they were accurate, then such feelings would not be a valid response to circumstances. Furthermore, an Invalidating Environment is characterized by a tendency to place a high value on self-control and self-reliance. Possible difficulties in these areas are not acknowledged and it is implied that problem solving should be easy given proper motivation. Any failure on the part of the child to perform to the expected standard is therefore ascribed to lack of motivation or some other negative characteristic of her character. (The feminine pronoun will be used throughout this paper when referring to the patient since the majority of BPD patients are female and Linehan’s work has focused on this subgroup).

Linehan suggests that an emotionally vulnerable child can be expected to experience particular problems in such an environment. She will neither have the opportunity accurately to label and understand her feelings nor will she learn to trust her own responses to events. Neither is she helped to cope with situations that she may find difficult or stressful, since such problems are not acknowledged. It may be expected then that she will look to other people for indications of how she should be feeling and to solve her problems for her. However, it is in the nature of such an environment that the demands that she is allowed to make on others will tend to be severely restricted. The child’s behavior may then oscillate between opposite poles of emotional inhibition in an attempt to gain acceptance and extreme displays of emotion in order to have her feelings acknowledged. Erratic response to this pattern of behavior by those in the environment may then create a situation of intermittent reinforcement resulting in the behavior pattern becoming persistent.

Linehan suggests that a particular consequence of this state of affairs will be a failure to understand and control emotions; a failure to learn the skills required for ’emotion modulation’. Given the emotional vulnerability of these individuals this is postulated to result in a state of ’emotional dysregulation’ which combines in a transactional manner with the Invalidating Environment to produce the typical symptoms of Borderline Personality Disorder. Patients with BPD frequently describe a history of childhood sexual abuse and this is regarded within the model as representing a particularly extreme form of invalidation.

Linehan emphasizes that this theory is not yet supported by empirical evidence but the value of the technique does not depend on the theory being correct since the clinical effectiveness of DBT does have empirical research support.

Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder