Using DBT in the treatment of suicidality in the context of Borderline Personality Disorder
I once had a Professor describe BPD to me in a way that has stuck with me ever since. He asked me to imagine I was a burn victim all over my body covered in bandages. He demonstrated himself walking through the door and bumping him arm a little against the handle and barely reacting. He then asked me to imagine doing the same thing as that burn victim and how performing the same action (lightly bumping the handle) would be experienced as so intensely different by each of us.
He told me to think of people with BPD from that day on as burn victims, not in a way to pity them, but in a way to honour their bravery for being able to walk around in the world so exposed to being hurt so intensely. Because for people with BPD, things that others may see as even minor inconveniences can feel catastrophic for them and with very few self-regulating skills these moments can lead to intense thoughts of wanting to end their life, punish themselves or externalise their pain by self-harming.
Suicidality with BPD
People who have a diagnosis of BPD often struggle with chronic suicidality and self-harming behaviours. It is stated that up to 10% of people with BPD will lose their life to suicide. Therefore, although the person may struggle chronically and even speak openly about wanting to end their life often, each episode/incident of suicidality should be treated seriously. The most effective treatment studied thus far for the treatment of BPD is DBT.
What is DBT and how does it help with suicidality?
Dialectical behaviour therapy (DBT) is a form of cognitive-therapy that aims to teach patients how to modify the regulation of their emotions by giving patients tools to learn how to regulate negative emotions in ways other than cutting or overdosing for example.
DBT deals in opposites and uses seemingly opposing strategies of “change” and “acceptance.” So you are accepted by the therapist as you are, but it is your responsibility to change your actions.
One strategy practiced in DBT is distress tolerance, this is about learning to cope in a crisis and practice acceptance when it is nearly impossible to change a situation. Tolerating distress for someone with BPD can be exceptionally difficult and this would often be when the pain was turned into an outward manifestation of the inward feelings and self-harming or suicide attempts would take place. By learning to sit with the distress without those “crutches,” clients gain the confidence in themselves to cope better in future.
Another tool used when partaking in DBT is to practice Mindfulness. Mindfulness is about focussing on the here and now and not trying to change it but accepting it for what it is. When people with BPD are ruminating about the past they can become depressed and when thinking about the future they may become anxious. Therefore by realising they are safe in the current moment, they are less likely to hurt themselves and learn to acknowledge their thoughts and feelings without judging them.
Lastly, people with BPD tend to struggle with interpersonal relationships and keeping long-term friends which can lead to feelings of isolation and suicidality. Therefore, interpersonal effectiveness which encourages clients to learn when to say “no,” be assertive, and properly ask for what they may want and need and finally, manage interpersonal conflicts in a way where they are able to maintain respect for themselves and the other person. When the person feels a sense of mastery over their emotions and conflicts in their lives, they will be less likely to act impulsively and self-harm or attempt suicide.
When DBT was used to treat BPD clients in randomized clinical trials, there were reductions in overdoses, in emergency room visits for suicidality, reduced frequency of self-harm, and reduced hospital admissions.
True DBT is usually run over a year, in a group format with individual sessions in between. However, the four skills listed above can be practiced with an individual therapist.
Author: Lauren Otto, MA Clinical Psychology
Lauren Otto is a Clinical Psychologist who primarily works with children, adolescents and adults. She has experience in many fields including emotion regulation and adjustment difficulties, as well as living with chronic pain. Her warm, non-judgemental yet practical approach to therapy fosters a positive relationship whilst allowing them to achieve their goals. Lauren also has a particular interest in Autism Spectrum Disorder.
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Paris, J. (2019). Suicidality in Borderline Personality Disorder. Medicina, 55(6), 223. https://doi.org/10.3390/medicina55060223