Research shows that the relationship between childhood trauma and the development of borderline personality disorder (BPD) is well established (Giarratano, 2008). A high percentage of those diagnosed with BPD have a childhood history of abuse (Soloff, Lynch, & Kelly, 2002).
One of the most researched and effective treatments for BPD is dialectical behaviour therapy (DBT). DBT is considered an appropriate model for working with survivors of childhood abuse, and is considered by many as 'best practice' in helping clients (particularly those diagnosed with BPD) who engage in life-threatening behaviours to cope with intense and unstable emotions (Henderson, 2006). These behaviours include: self-harm, suicidal acts, impulsive behaviours such as substance abuse, eating disorders, or engaging in an unsafe lifestyle. DBT is a skill-based therapy developed by Dr. Marsha Linehan (Department of Psychology, University of Washington) that provides practical and effective coping techniques (Linehan, 1993a).
DBT is based on a cognitive behavioural approach and emphasises an acceptance of the person as he/she is, combined with the expectation that current behaviours need to change. The tension that arises between this need for both acceptance and change is known as a 'dialectical tension'. Dialectics is the practice of finding the middle ground between two opposites (Linehan, 1993a).
DBT is usually at least a one-year treatment, involving considerable commitment on the part of both therapist and client. Concurrently, the client learns techniques such as
mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance in a 'skills group', whilst undergoing individual therapy and receiving support (between sessions) via telephone consultations (Linehan, 1993b). This model is costly and primarily only available in Australia in the private sector, although a few agencies have begun piloting it in the public sector (Henderson, 2006).
DBT focuses on the acquisition of four core skills:
- Mindfulness: Mindfulness skills are psychological and behavioural versions of meditation practices from Eastern spiritual teachings. In DBT, three primary states of mind are presented: 'reasonable mind' 'emotion mind' and 'wise mind'. A person is in 'reasonable mind' when he/she approaches information and knowledge intellectually. The person is in 'emotion mind' when her/ his thinking and behaviour are controlled primarily by her/his current emotional state. 'Wise mind' is the integration of the 'emotion mind' and 'rational mind'. 'Wise mind' adds intuitive knowledge to emotional experience and logical analysis (Linehan, 1993b, p. 63).
- Interpersonal effectiveness: Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include acquiring effective strategies for asking to have one's needs met, saying no, and coping with interpersonal conflict. Individuals with Borderline Personality Disorder frequently possess good interpersonal skills in a general sense but problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioural sequences when discussing another person dealing with a problem, but may be completely incapable of generating or carrying out a similar behavioural sequence when analysing his or her own situation. The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g. requesting that someone do something) or to resist changes someone else is trying to make (e.g. saying no). The skills taught are intended to maximize the chances that a person's goals in a specific situation will be met, while at the same time not damaging either the relationship or the person's self-respect (Linehan, 1993b, p. 70).
- Emotional regulation: Individuals with Borderline Personality Disorder and those who are suicidal tend to be emotionally intense and labile. They can be angry, intensely frustrated, depressed/and or anxious. These clients can benefit from learning to regulate their emotions. Dialectical behavioural therapy skills for emotional regulation include:
- Identifying and labelling emotions
- Identifying obstacles to changing emotions
- Reducing vulnerability to emotion mind
- Increasing positive emotional events
- Increasing mindfulness to current emotions
- Taking opposite action
- Applying distress tolerance techniques (Linehan, 1993b, p. 84).
- Distress tolerance: Many current approaches to mental health treatment focus on changing distressing events and circumstances rather than on accepting, finding meaning for or tolerating distress. This task has traditionally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical Behavioural Therapy emphasises learning to bear pain skilfully. Distress tolerance skills have to do with the ability to accept, in a non-evaluative and non-judgmental fashion, both oneself and the current situation. Although the stance advocated is non-judgmental, it is not one of approval either: acceptance of reality does not equate with approval of reality (Linehan, 1993b, p. 96). Distress tolerance behaviours are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons (Linehan, 1993b).
As explained by Morgan (2000), narrative therapy promotes a core belief that individuals are the experts in their own lives while problems are separate from people. People have many skills, competencies, beliefs, values, commitments and abilities to help them reduce the impact of problems in their lives. By understanding and re-authoring, 'recovery' can occur through particular 'tellings' and 'retellings' of an individual's story. The narrative approach is interested in history and the broader context of people's lives (Morgan, 2000).
Michael White (1991) wrote that it is through narrative or stories that we learn about ourselves and others, and construct meaning of our experiences. He explained that stories shape how people live their lives as they largely determine which aspects of their experience people select for expression.
Consistent with the narrative approach, research shows that the meaning in the present assigned to past experiences may have a greater impact on the current functioning of the survivors than what actually happened (Giant & Vantanian, 2003). Therefore, in order for treatment to be effective, it is less important to determine the accuracy of the memories than it is to help the survivor deal with the meaning that she/he assigns to what she/he remembers about the experiences.
Narrative therapy for survivors is usually understood in the context of a feminist framework, with a strong belief in a collaborative approach. The therapeutic environment employs a feminist model focussing on principles of pluralism, egalitarianism and building on strengths. This creates an inclusive, safe and empowering environment that promotes shared decision-making. Participants are agents of their own process, while facilitators provide support (Asher et al., 1994, cited in Henderson, 2006).
Using Collaborative Narrative Group Work
A model of group work developed by van Loon & Kralik (2005b) uses a narrative framework to help make sense of issues participants perceive to be important. In describing the impacts of child sexual abuse the women in this study talked about many emotions and feelings but most commonly shame, blame, guilt, anger, fear and love. The group work sought to negotiate a less structured way to define these problematic feelings and explore them. The process focused on the way such feelings shaped the woman's view of herself and informed a life script which determined particular responses to those emotions, feelings and thoughts. Narrative processes were used to explore feelings and unpack the power dimensions and socio-cultural influences on the participants' feelings.
A narrative framework was used as a vehicle to make sense of each participant's life, and a narrative conversation was used to facilitate the quest for meaning and identity and to explore the ways participants view themselves within a social group and how they are viewed (van Loon & Kralik, 2005a).
Psychotherapy has been demonstrated to be valuable to adult survivors of childhood abuse (Price, Hilsenrothb, Petretic-Jacksonc, & Bongec, 2001), and to patients with Borderline Personality of which many are survivors of childhood abuse (Stevenson & Meares, 1992).
Psychotherapy is a broad term for a range of therapeutic models in which the therapist creates a 'safe space' within which individuals or groups can explore feelings, experiences and behaviours (and understand how they impact on the 'self'). The psychotherapeutic relationship, rather than any specific set of techniques is pivotal to the process (Kaplan, 1991, cited in Henderson, 2006). Psychotherapists understand the way the self of the therapist impacts upon the self of the client, and vice versa, and uses that knowledge to enable the client to explore their responses to relationships and the environment, and to make links with past experience. The relational framework upon which psychotherapy is based includes self, other, transference, countertransference, idealisation, empathic attunement, and emotional support and forms the basis for many 'talking therapies' and counselling models (Henderson, 2006).
A study by Stevenson & Meares (1992) evaluated the effectiveness of well-defined outpatient psychotherapy for patients with Borderline Personality Disorder and found that participants showed statistically significant improvement from the initial assessment to the end of the year follow-up on every measure. Moreover, 30% of the subjects no longer fulfilled the DSM-III criteria for Borderline Personality Disorder. This improvement had persisted one year after the cessation of therapy.
A study by Alexander & Anderson (1994) posits that attachment theory (and consideration of the nature of the parent-child relationship) provides a framework for understanding the wide array of symptoms and interpersonal problems exhibited by adult survivors of childhood abuse. Few studies relate the four main categories of adult attachment (secure, preoccupied, dismissing, and fearful/unresolved) to their anticipated effects in the therapy relationship. Drawing from research on adult attachment and clinical impressions of survivors, the authors present the probable therapeutic issues (including transference and countertransference) associated with each attachment category as well as suggested therapeutic strategies for dealing with clients from each.