Understanding and Treating Borderline Patients J Ryan Fuller PhD NewYorkBehavioralHealthcom How likely is it that a clinician will treat someone with BPD 11 of all outpatients 19 of inpatients ID: 434188
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Dialectical Processes & Behavioral Therapy:Understanding and Treating Borderline Patients
J. Ryan Fuller, Ph.D.
NewYorkBehavioralHealth.comSlide2
How likely is it that a clinician will treat someone with BPD?
11% of all
outpatients
19% of
inpatients
33% of outpatients with Axis II
63% of inpatients with Axis IISlide3
Why are Borderline Patients so difficult to treat?Slide4
What are the components of effective therapy?
Strong Therapeutic Bond
Clear Treatment
Planning
Ongoing Assessment
Use of Effective Treatments
Client
Motivation
Therapist Motivation
HomeworkSlide5
What are their symptoms?
Intense Emotional ResponsesSplitting
Emptiness, Loneliness, & Desperation
Unrelenting Crises & Self Injurious Behavior
SuicideSlide6
Effective Therapy & BPD Symptoms
BPD Symptoms
Intense Emotional Responses
Splitting
Emptiness, Loneliness, & Desperation
Unrelenting Crises & Self Injurious Behavior
Suicide
Elements of Therapy
Strong
Therapeutic Bond
Clear Treatment Planning
Ongoing Assessment
Use of Effective Treatments
Client Motivation
Therapist Motivation
HomeworkSlide7
Who are they and what do they look like?
WomenAngry & AggressiveSelf
Injurying
Alcohol & Drug Abusing
Promiscuous
Apparently CompetentSlide8
Hollywood’s Portrayal
Heroine? Femme Fatal? How would she be imagined?Can anyone name a film that may have a realistic or caricature of someone with BPD?Slide9
Fatal AttractionSlide10
What’s in a name?
Borderline Personality Disorder
Parasuicidal
Behavior
Gestures
ThreatsSlide11
DSM: Borderline Personality Disorder (1)Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity
disturbance:
persistent and markedly disturbed, distorted, or unstable self-image or sense of selfSlide12
DSM: Borderline Personality Disorder (2)Impulsivity
in at least two areas that are potentially self-damaging Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Affective instability due to a marked reactivity of
moodSlide13
DSM: Borderline Personality Disorder (3)
Chronic feelings of emptiness. Inappropriate, intense anger or difficulty controlling anger Transient, stress-related
severe
dissociative
symptoms or
paranoid
ideationSlide14
Behavioral Patterns: Linehan
Emotional Vulnerability
Self-
invalidation
Unrelenting
Crises
Inhibited
Grieving
Active Passivity
Apparent CompetenceSlide15
Primary Mechanism
Emotional DysregulationEmotional Vulnerability
Sensitive
to stimuli
High intensity
Slow return to
baseline
Inability to regulate
Slide16
Developmental EtiologyBiological Predisposition
EnvironmentDiathesis Stress ModelTransactional ModelSlide17
Developmental Etiology (2)Biological Predisposition
Nervous SystemGenetic Link to ComorbiditiesEnvironment
Childhood Sexual Abuse
Invalidating EnvironmentSlide18
Dysregulation Experience
PhenomenologyChaotic StormExperienced by others as an “Emotional Burn Victim”Slide19
Clinical ApproachStudy the scientific efficacy literature
Complete the necessary coursework or independent study of theory and techniquesReceive clinical training and supervisionSlide20
Efficacy Literature
Dialectical Behavior Therapy (DBT)Schema TherapyTransference Focused Therapy (TFT)
Mentalization
Based TherapySlide21
Basic Theory
Learning PrinciplesBehavior TherapyDialectical PerspectiveSlide22
Learning Principles
Classical ConditioningOperant ConditioningModelingSlide23
Behavior Therapy
ExposureBehavioral ContractingRelaxation
FBASlide24
Dialectical Perspective
DefinitionDialectical DilemmasSlide25
DBT Delivery Package
Individual TherapySkills TrainingSupportive Process Group Therapy
Telephone Consultation
Case Consultation Meetings for TherapistsSlide26
What can we take from DBT into our practice now?
StylePhilosophySkillsSlide27
Therapeutic Style & Communication
CollaborativeIrreverentSlide28
DBT AssumptionsPatients are doing the best they
canPatients want to improvePatients need to do better, try harder, and be more motivated to changePatients may not have caused all of their own problems, but they have to solve them anyway
The lives of suicidal, Borderline individuals are unbearable as they are currently being lived
Patients must learn new behaviors in all relevant contexts
Patients cannot fail in therapy
Therapists treating Borderline patients need
supportSlide29
Skills Training
MindfulnessEmotion RegulationDistress Tolerance
Interpersonal
EffectivenesSlide30
Clinical Interventions
Problem SolvingExposureSkills TrainingContingency Management
Cognitive ModificationSlide31
Cognitive Modification
Teaching patient to identify nondialectical thinkingCost Benefit Analysis for that thinking
Developing alternativesSlide32
Nondialectical Thinking
Arbitrary InferencesOvergeneralizationsMagnification
Inappropriate attribution
Labeling
Catastrophizing
Hopeless expectanciesSlide33
Integration SummaryDialectical conceptualization of cases
Careful attention to FBAStylistic and Language ChangesSelecting Skills to study and obtain supervision
Self-care & Support for ClinicianSlide34
Further Structure
Primary Behavioral TargetsSecondary Behavioral Targets
Tertiary
Behavioral
Targets
Spiritual Targets
(Optional)Slide35
Primary Behavioral Targets (1)Decrease Suicidal Behaviors
Decrease Therapy-Interfering BehaviorsHonoring agreementsCompleting/Attempting Homework
Participation in Therapy
Collaborative ApproachSlide36
Primary Behavioral Targets (2)Decreasing Behaviors That Interfere with Quality of Life
Increasing Behavioral SkillsCore Mindfulness Skills
Distress Tolerance Skills
Emotion Regulation Skills
Interpersonal Effectiveness Skills
Self-Management Skills
Decreasing Behaviors Related to Posttraumatic StressSlide37
Secondary Behavioral Targets
Increasing Emotion Modulation; Decreasing Emotional ReactivityIncreasing Self-Validation; Decreasing Self-InvalidationIncreasing Realistic Decision Making and Judgment;
Decreasing Crisis-Generating Behaviors
Increasing Emotional Experiencing; Decreasing Inhibited Grieving
Increasing Active Problem Solving; Decreasing Active-Passivity BehaviorsSlide38
Tertiary & Optional
Tertiary TargetsIncreasing self respectAchieving individual goals
Spiritual (Optional)Slide39
DBT Evolves
Dive ReflexNon-pharmacological Benzo
StrategySlide40
Final Thoughts“I’m not going to be ignored.”
Life is sufferingThere but for the grace of G-d go ISlide41
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