What is BPD?

Borderline Personality Disorder is a mental health disorder characterized by the following 5 areas of dysregulation:

• Emotion dysregulation: intense, unstable, and hard-to control emotions; problems with anger

• Interpersonal dysregulation: chaotic, unstable, often stormy relationships; intense fears of abandonment

• Behavioral dysregulation: patterns of impulsive, destructive behaviors (e.g., substance use, unsafe sexual behaviors, reckless driving, stealing), non-suicidal self-injury

• Cognitive dysregulation: paranoia and dissociative episodes triggered by stress

• Self dysregulation: unstable sense of identity; poor self-esteem; chronic feelings of emptiness

What will be expected if I start DBT?

There are 4 stages of DBT treatment:

Pretreatment: The first stage of DBT is a Pretreatment phase that typically lasts about 3-5 sessions, and may be longer or shorter depending on the needs and commitment of the client and the openings available in our groups. Pretreatment sessions focus on orienting new clients to the DBT model and philosophy and explaining DBT-specific expectations so that clients are fully informed of the treatment they will take part in (e.g., clients must agree to target life threatening behaviors including self harm; clients commit to attending a full round of DBT skills groups and weekly individual therapy). Pretreatment also involves clarifying the client’s values-based goals and behavioral targets and establishing a therapy agreement between the client and therapist. Pretreatment ends when the client commits to engage in DBT for a specified period of time (one full round of the DBT skill modules, typically 6-7 months) and the client enters a skills group. Commitment is non-binding, in a financial and legal sense; we ask clients to make a personal commitment to themselves and their therapist to stay in DBT for a specified time and to ride out any urges to quit therapy that arise over time.

Stage 1 DBT: Once clients have committed to DBT, they begin Stage 1 of DBT, which involves attending weekly individual therapy (60 minutes), attending weekly skills groups (90 minutes), and using phone coaching with their therapist as needed throughout the week (5-10 minutes).

1. Individual Sessions (60 minutes): Individual sessions are active, collaborative sessions aimed at tracking client progress towards their goals and assessing, understanding, and replacing problem behaviors with skillful alternatives. DBT clients are expected to complete diary cards in order to self-monitor their own target behaviors, emotions, and skill use. Diary cards are reviewed at the start of each session and serve as a roadmap for setting the agenda. A behavior chain analysis is a tool used to collaboratively assess the factors that contribute to and maintain problem behaviors. Together, the therapist and client increase their understanding of key “links” in the chain and develop solutions analyses, finding skillful behaviors to replace problem links to gradually chip away at problematic patterns and build a life worth living. Individual DBT sessions balance acceptance and validation with change-focused interventions: depending on the individual client’s needs, sessions may include skills training, formal or informal exposures, cognitive techniques aimed at changing unhelpful thinking, and other individualized approaches.

2a. Adult DBT Skills Groups (1.5 hours): Adult skills groups range in size from 3-12 clients (ages 18+). The skills are broken into four content areas, or modules. Below is a typical timeline and overview of the skills covered in one cycle of the skills (26 weeks). Clients are asked to complete one full round of the cycle outlined below, and often clients choose (or are asked) to complete a second round, if needed.  New clients enter the group at the beginning of a module and thus the order of skills learned will vary based on entry points. Every new module begins with two weeks of orientation and mindfulness.

• Orientation & Mindfulness (2 weeks) - skills to focus attention, decrease reactivity and attachment to thoughts, feelings, and urges, and increase capacity be non-judgmentally aware and fully present in one’s life

• Distress Tolerance (6 weeks) - strategies to survive a crisis or endure intense distress without engaging in destructive behaviors

• Repeat Orientation & Mindfulness (first 2 weeks; see above)

• Emotion Regulation (7 weeks) - skills to recognize and label emotions, strategies to decrease vulnerability to negative emotions by increasing positive and meaningful daily activities, skills for changing unwanted emotions through effective problem solving, challenging unhelpful thoughts, and acting opposite to emotion urges

• Repeat Orientation & Mindfulness (first 2 weeks; see above)

• Interpersonal Effectiveness (7 weeks) – skills to clarify interpersonal priorities, strategies to be more effective when making requests (or saying NO to others’ requests), ways to work through conflict and maintain relationships, and skills to maintain greater self-respect in relationships

2b. Adolescent DBT Skills Groups (1.5 hours): Adolescents (ages 13-18) attend weekly multifamily skills groups (MFSGs) alongside their parents/caregivers and 2-4 other adolescent clients and their families. Below is a typical timeline and overview of the skills covered in one cycle of the adolescent multi-family skills group (25 weeks). Adolescent clients and their parents/caregivers are asked to commit to one full cycle, which typically lasts around 6 months. New clients enter the group at the beginning of a module and thus the order of skills learned will vary based on entry points. Every new module begins with 2 weeks of orientation and mindfulness. Adolescent DBT covers the same skills as Adult DBT with an additional module focusing on typical teen-parent dilemmas.

• Orientation & Mindfulness (2 weeks)

• Distress Tolerance (4 weeks)

• Repeat Orientation & Mindfulness (2 weeks, see above)

• Emotion Regulation (5 weeks)

• Repeat Orientation & Mindfulness (2 weeks, see above)

• Interpersonal Effectiveness (4 weeks)

• Repeat Orientation & Mindfulness (2 weeks, see above)

• Walking the Middle Path (4 weeks) – replacing either-or thinking with both-and thinking, finding dialectical solutions to common parent-teen dilemmas, skills to validate ourselves and others, strategies to effectively increase or decrease behaviors in ourselves and others.

3. Phone coaching: DBT therapists offer on demand phone coaching for extra support between sessions. Calls are brief (5-10 minutes) and follow a standard structure: the therapist clarifies what the problem is, the client explains what skills they have already tried, the therapist suggests 1-2 skills to try, and client commits to try at least one suggested skill and the call is ended.

Stage 2 DBT: Once clients have learned skills and eliminate life threatening behaviors, Stage 2 DBT focuses on targeting PTSD or complex trauma, as needed. If the client does not have trauma, Stage 3 begins.

Stage 3 DBT: Focuses on resolving problems of living and reducing residual mental health symptoms (i.e., anxiety, depression, poor self esteem, relationship dissatisfaction).

Stage 4 DBT: This final stage of DBT is sometimes considered a “maintenance phase;” clients focus on attaining a sense of joy and freedom in their lives. The client and therapist work together to determine when it makes sense to end therapy.

What will the DBT Skills groups be like?

DBT groups are not processing groups; they feel more like a class than traditional group therapy focused on processing individual challenges. Group members share about their personal lives to the degree that they are comfortable and always in the context of how they are practicing the skills. Clients in DBT skills groups are expected to complete a homework assignment each week, which usually involves practicing a skill and filling out a worksheet. In the adolescent groups, parents and teens learn skills alongside each other; all family members involved are expected to learn, practice, and complete homework.

 The general structure of DBT skills groups is as follows:

• Group mindfulness practice (5-10 minutes)

• Review of homework from last week (40 minutes)

• Break (5-10 minutes)

• New skill lesson (45 minutes)

Effectiveness of GVP’s DBT Program

Our DBT program has been shown to be extremely effective in reducing symptoms and hospitalizations, as well as visits to the psychiatric emergency room. Below, data from 75 clients in DBT display our program’s effectiveness at reducing hospitalizations and inpatient visits.

Below in yellow are rates of inpatient hospitalizations and visits to the psych emergency room before DBT at GVP. In green are hospitalization/psych emergency room visits for clients after starting our DBT program.