This selected review of the literature provides evidence that therapeutic interventions can be effective for people with BPD. DBT is identified as the approach for which there is to date the most solid evidence base. In exploring whether DBT is an appropriate approach for use by clinicians in public mental health services it is important to
elaborate more clearly what DBT involves. Linehan’s seminal work describes both the development and the process for delivering DBT as a therapy (1993a). Dimeff and Linehan (2001) describe the therapy as arising ‘out of a series of failed attempts to apply the standard cognitive and behaviour therapy protocols of the late 1970’s to chronically suicidal clients’ (p. 10). DBT was developed experientially through a process of evaluating the impact, either positive or negative of the application of various therapeutic techniques. The target group with whom Linehan worked were women who presented as having met the criteria for a diagnosis of BPD and also had
‘histories of multiple nonfatal suicidal behaviours’ (1993a, p. 4). The philosophical underpinnings of DBT are clearly outlined in this manual. Linehan describes her focus as follows:
One of the main goals of my theoretical endeavours has been to develop a theory of BPD that is both scientifically sound and nonjudgmental and nonpejorative in tone. The idea here is that such a theory should lead to effective treatment techniques as well as to a compassionate attitude (1993a, p. 18).
Linehan’s theory of BPD is a biosocial theory hypothesising that BPD arises from an interaction over time between a biological vulnerability or predisposition to emotional dysregulation and an invalidating environment (Linehan, 1993a).This cognitive behavioural treatment is described by Linehan as ‘for the most part, the application of a broad array of cognitive and behaviour therapy strategies to the problems of BPD, including suicidal behaviours’ (1993a, p. 19). She further notes that ‘each set of procedures has an enormous empirical and theoretical literature’ (1993a, p. 20).
However, Linehan (1993a, p. 20) clearly outlines the differences between standard cognitive and behaviour therapy and DBT. The following differences are outlined by Linehan as:
• A focus on acceptance and validation. This emphasis is identified by Linehan (1993a, p. 20) as arising from her studies in Eastern spirituality and meditation.
Validation is identified as a ‘core strategy’ of which there are two types. The first is described as a process in which the therapist ‘finds the wisdom, correctness or value in the individual’s emotional, cognitive and overt behavioural responses’ (p.
99). The second ‘has to do with the therapist’s observing and believing in the patient’s inherent ability to get out of the misery that is her life and build a life worth living’ (p. 99).
• An emphasis on ‘treating therapy-interfering behaviours’. Linehan (1993a) suggests that this focus is similar to ‘the psychodynamic emphasis on
“transference” behaviours’ (p. 21). This aspect of the therapy is often explained to people with BPD thus: ‘Therapy doesn’t work if you don’t come or if you don’t do your homework.’
• A strong focus on the importance of the therapeutic relationship as integral to the therapy. Linehan (1993a) notes that this emphasis arises directly from her clinical work with suicidal individuals. ‘At times, this relationship is the only thing that keeps them alive’ (p. 21). She further notes that this aspect of the therapy was strongly influenced by the work of Kohlenberg and Tsai (1991) who ‘developed an integrated behavioural therapy in which the vehicle of change is the relationship between therapist and patient’ (Linehan, 1993a, p. 21).
• A focus on dialectical processes. (Dialectics is examined in further detail later in this chapter).
Ten years after the publication of her text outlining the therapy, Linehan’s (2003) biography described DBT as combining:
the technology of change derived from behavioural science with the radical acceptance, or “technology of acceptance” derived from both eastern zen practices and western contemplative spirituality. The practice of mindfulness, willingness, and radical acceptance from an important part of her treatment approach.
It is important to note that for clinicians to work effectively as a DBT therapist requires not only an ability to deliver the therapy but also a comprehension of the way in which the therapy is intertwined with the biosocial theory of BPD to form two inseparable strands.
Dialectics
An understanding of the concept of dialectics and its implications for both research and practice development is warranted in clarifying the potential usefulness of DBT as a tool to facilitate change in clinicians’ behaviours towards people with BPD. Dialectics has been an important concept in both interpretive and critical social research. The Hegelian concept of dialectics, for example, was retained by Marx and is as seen as underpinning Marx’s view of history (Brooker, 1999; Crotty, 1998). Hegel’s dialectic (though apparently he never used this term, only the method) ‘holds not only the notion of thesis and antithesis standing over against each other but also the notion of their interaction leading to a synthesis’ (Crotty, 1998, p. 118). Linehan (1993a) describes DBT as grounded in the world view of dialectics. The concept of dialectics permeates the therapy with its paramount and all-encompassing target being ‘to increase dialectical behaviour patterns’ among clients with BPD’ (p. 120).
Linehan identifies three distinct characteristics of the dialectical perspective. Firstly, it assumes a focus on a holistic or systemic view of reality that sees analysis of parts of a system of little value without a view of the relationship of these parts to the whole.
Secondly, dialectics recognizes the complexity of any given system while at the same time focusing on the whole. Finally, dialectics recognizes synthesis between opposing viewpoints or positions as central and as a continuous process of change (Linehan, 1993ap.31-34)). Such an approach is intrinsically critical of dichotomous thinking, which is a major feature of BPD. Dichotomous thinking is viewed within the DBT model as evidence of ‘dialectical failure’ because it involves the maintenance of conflict between contradictory viewpoints and precludes the possibility of synthesis and transcendence (Linehan, 1993ap.35-36).
The practical application of this conceptualization led to the development of a therapy that incorporates strategies designed to encourage the development of dialectical thinking. It ‘requires the ability to transcend polarities and, instead to see reality as complex and multifaceted’ (Linehan, 1993a, p. 121). Again, Linehan (1993a) describes the overriding goal of DBT thus:
…not to get patients to view reality as a series of grays, but rather to help them see both black and white, and to achieve a synthesis of the two that does not negate the reality of either (p. 121).
A therapeutic modality grounded within the world view of dialectics thus provides a foundation upon which to challenge not only clients’ dichotomous thought patterns but also the tendency of many health professionals to hold rigidly to viewpoints that are ineffective in treating BPD.