Question:
I am a therapist working for Devereux of Florida.
I have been intensively trained in Dialectical
Behavioral Therapy, which was designed by Marsha
Linehan to work with Borderline Personality
Disorders. Have you had any experience with this
type of counseling? If so, how do you rate it? My
understanding is that the literature of the day
speaks volumes to how great it works, but I did
not see it mentioned on your website.
Dr. Heller's Answer:
I have enormous respect for what Marsha Linehan
has accomplished, and I admire her work and her
efforts. Although the study was not truly blinded
for the absence of psychotropic medications, with
DBT she was the first to show significant
quantifiable improvement from psychological
counseling in treating borderlines, with a 50%
reduction in parasuicidal behavior
(self-mutilation and suicide attempts).
Dialectical Behavioral Therapy (DBT) has shown
effectiveness in substance abuse and other
psychiatric disorders as well. Based on a Zen
model (Dr. Linehan’s description), DBT principles
can be used by any therapist, although the
landmark BPD study used multiple therapists
working as a team. I’ve had some patients go
through DBT programs and rated it very highly,
particularly the reframing skills they learned.
I’ve also have a few who believed it didn’t help
them. There are many references to DBT on my
website, primarily in the "Ask the Doctor" and
"Medline research on the borderline personality
disorder" sections.
I believe all borderlines need
counseling, although a significant percentage
can’t afford it. Most BPD patients have told me
that counseling was of minimal or no benefit until
their medications were right.
Once successfully
treated medically, most borderlines have a
difficult time finding a good therapist. They need
a non-judgmental, knowledgeable, optimistic,
compassionate, dedicated, strong human being who
is willing to be truthful and unwilling to be
manipulated - whatever their specific school of
therapy. The focus needs to be on now and the
future, with minimal emphasis on the past. I
congratulate you on your training, and hope you’re
one of those people. There are many borderlines
out there who desperately need good therapists.
To
the best of my knowledge there have been no head
to head studies of one form of psychotherapy
versus another for BPD treatment, with or without
medications. Most research that I’ve encountered
advocates some form of cognitive/behavioral
therapy. I am not trained as a psychotherapist.
Dr. Gunderson from Harvard advocates psychodynamic
psychotherapy, but only by an extremely well
trained therapist. He believes this form of
psychotherapy "has been a serious disservice" to
BPD patients when the therapist isn’t adequately
trained or experienced.
Psychoanalysis doesn’t
work and usually makes borderlines worse,
particularly those who experienced childhood
abuse. Many patients have told me this, and there
is evidence for this conclusion in the literature.
Rehashing the past
usually makes borderlines worse.
Since I’m a
strong believer in the BPD medical model, my
preference is to get the medically treatable
symptoms treated first. I then emphasize
recognition and medical treatment of dysphoric
episodes, so that raging and self-destructive
behaviors can be prevented, reduced or controlled.
Dysphoric episodes cause most of the damage and
need to be treated aggressively. All it takes is
one bad episode to destroy a marriage or a life.
I’ve worked for over 15 years with therapist Mary
Sales. She focuses on helping borderlines
recognize when they need their as needed
medications for dysphoria, affirmations,
relaxation techniques, and cognitive/behavioral
approaches. I saw significant similarities to Ms.
Sales’ approach when reading Marsha Linehan’s
descriptions of how she interacts with patients.
I’m also a big believer in motivational and
"success" techniques that are used in the business
and personal growth arena, particularly Zig
Ziglar’s work. Learning how to be a success in
every area of life is a critical process for
recovery from the BPD. Borderlines often need
training in social and life skills, particularly
those who have been abused and/or those with ADHD.
Borderlines have to heal mind, body and spirit.
They need to "retrain the brain." There’s an old
saying: no executive on his death bed ever said "I
wish I’d spent more time at the office." The BPD
usually deprives them of healthy love
relationships. I believe that eventually being
able to have those kind of love relationships is
an important goal of treatment.
I’ve communicated
with therapists, patients, family members and
clinicians about DBT. This communication combined
with the medical literature from Medline (National
Library of Medicine) and the books I’ve read (such
as "Borderline Personal Disorder" - edited by Mary
Zanarini, PhD from Harvard) shows that DBT can be
helpful for many people, sometimes extraordinarily
helpful. Your statement "the literature of the day
speaks volumes to how great it works" overstates
what the literature actually shows, however. Most
DBT studies are short term, and the landmark study
only showed a 50% reduction in self-mutilation and
suicide attempts.
I got involved treating
borderlines because psychiatrists wouldn’t treat
my patients, and I was having success -
particularly after reading the medical literature
and the conversations I had with NIMH researcher
(and former acting director) Dr. Rex Cowdry. I see
4-6 new BPD patients per week and probably 5-8
follow ups per day as part of my regular practice.
I’ve treated thousands of individuals with the
BPD. With the correct medications, I expect all
unprovoked mood swings, chronic anger, chronic
irritability, and emptiness to be completely gone.
I don’t consider any self-mutilation episodes to
be acceptable. Mary Sales and I have learned a lot
over the years, and I believe a combination of
what we’ve learned with many aspects of DBT could
be sensational.
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