Borderline Personality Disorder the Following

Borderline Personality Disorder

The following research report focuses on a population at risk, those diagnosed with Borderline Personality Disorder. The report is offered in three sections. Part I provides an examination which looks at statistics related to the disorder. A definition of the disorder is given, with implicit defining characteristics of the population at risk. Causes are discussed with a relevant literature review. Social justice issues are looked at, with a discourse offered on factors of social oppression related to the population at risk. Part II discusses two courses of treatment with associated issues related to Borderline Personality Disorder, with an in-depth review of Mentalization therapy Dialectical Behavior Therapy. Part III discusses the political and social context of the issues relevant to the population at risk. Research on the NASW Code of Ethics is offered. The strengths perspective is discussed and the role of the Advanced Generalist Model is examined for finding treatment solutions to the at-risk population of those diagnosed with Borderline Personality Disorder. A conclusion is offered to highlight the salient points of the report and to synthesize the topics.

The At-Risk Population: Borderline Personality Disorder

The population-at-risk chosen for the following report are those people that have been diagnosed with Borderline Personality Disorder (BPD). This population was selected due to their high rates of hospitalization, suicide attempts, and suicide. Suicide rates for this population are estimated at 8-10% (Paris, 2002). People diagnosed with BPD typically face a chronic and long-term debilitating psychiatric condition, for which traditional therapies have proven of limited effectiveness. The lifetime prevalence of those diagnosed with BPD in the general population is approximately 5.9% according to a recent study (Grant, et al., 2008), being equally prevalent between men and women (Grant, et al., 2008). Extreme states of physical and mental disability are features of this disorder, especially among women. Psychiatric hospitalizations of those identified with Borderline Personality Disorder are on the magnitude of 20% (BPD Today, 2010).

Borderline Personality Disorder Definitions

Borderline Personality Disorder is a disorder of emotional regulation. People with this diagnosis have extreme difficulty regulating their emotions. Approximately 50% are clinically depressed, and 25% are classified with Post Traumatic Stress Disorder as well (BPD Today, 2010). Sexual abuse as a child is strongly associated with development of BPD, and some studies suggest between 40%-70% of those with BPD have been sexually abused (Bohus, Priebe, Dyer, & Steil, 2009). People with BPD often report severe childhood emotional trauma. Additionally, people with BPD may have predisposing factors, such as genetics, brain and neurobiological issues, and other environmental variables. Moreover, BPD may result from an inability to effectively deal with adolescent stress events (Zanarini & Frankenburg, 1997).

The Diagnostic and Statistical Manual of Mental Disorders defines Borderline Personality Disorder in Axis II, Cluster B Axis II disorders include personality disorders and mental retardation. Category B. includes dramatic, emotional and erratic disorders, such as BPD (American Psychiatric Disorders, 2000). Some critics have stated that BPD should not be on the Axis II disorders, but should instead be moved to Axis IV, which includes psychosocial and environmental issues that contribute to the disorder, or Axis I, which includes clinical, learning, and major mental disorders (New, Triebwasser, & Charney, 2008).

People with BPD experience episodes of intense emotional instability, such as anger, anxiety, aggression, self-injury, or some type of substance abuse. These instances may last for a few hours to a day, yet be of a chronic, long-term nature. These people have distorted cognitions of themselves, and often view themselves as of low value, bad, and unworthy. Maintaining relationships is difficult for a person with Borderline Personality Disorder, and they may range from idealization of their significant other, to devaluation of that person, based upon some small infraction that is out of proportion to reality. Due to their intense emotional disregulation, people with BPD have trouble with social relationships as well. They are extremely sensitive to any criticism, perceiving these as some type of personal rejection. Responses to their emotional distortions on others are anger, distress, fear, aggression, and depression.

The DSM-IV-TR gives the following diagnostic criteria for Borderline Personality Disorder (summarized): frantic efforts to avoid abandonment; a pattern of unstable relationships; unstable image of self; impulsive self-destructive behavior; recurrent low-injury threshold suicide attempts and self-mutilation; highly reactive mood states such as irritability; feelings of emptiness; frequent displays of temper; and stress-related ideation (American Psychiatric Disorders, 2000, p. 710).

Causes

Genetics

Borderline Personality Disorder may be attributed to physiologic biochemical factors, brain abnormalities, environmental factors, or trauma-related issues. Abuse and neglect, often as a child, are strong predictors of developing Borderline Personality Disorder, especially if the child has been identified as ADD or ADHD, with increased risk if accompanied by factors of Conduct Disorder before age 15 (Zanarini & Frankenburg, 1997). A combination of genetics and environment is thought to contribute to BPD; first-degree biological relatives with BPD indicate a five-fold increase in the possibility of developing Borderline Personality Disorder than compared to the general populace (American Psychiatric Disorders, 2000).

Being a victim of some type of violence, especially rape, is a strong predictor of an adult developing BPD. If the violent event has resulted due to poor judgment or risky behavior, these factors support a diagnosis of Borderline Personality Disorder as well (Bohus, Priebe, Dyer, & Steil, 2009).

People diagnosed with BPD often display abnormal brain neural circuitry regulation in emotion regulation. The prefrontal cortex of the brain is involved in dampening fear and stress responses which originate in the amygdala, located in the deep brain structures. MRI imaging of people with BPD show a marked decrease in prefrontal regulation of amygdala-generated neural responses (Ruocco, Medaglia, Ayaz, & Chute, 2010). Additionally, people with BPD have decreased activity in certain brain neurotransmitters, such as serotonin, dopamine, acetylcholine, and norepinephrin, likely due to genetic factors that are aggravated in stress situations (Steele & Siever, 2010). Drugs that act to enhance and sustain levels of these neurotransmitters in the neuron's pre-synaptic gap for longer periods tend to reduce symptoms of Borderline Personality Disorder. Drugs that stabilize the inhibitory neurotransmitter GABA are shown to help stabilize the mood of those with BPD as well, reducing the ideation-mood disturbance episodes common in BPD (Stoffers, Vollm, Rucker, Timmer, Huband, & Lieb, 2010).

While there is a complex interplay of the causes and triggers of BPD, studies exist which attempt to explain discrete elements of the causes of the disorder. Distel et al. (2009) report that 35-45% of the variance in BPD can be explained by genetic factors, though the study did not find much evidence of the cultural transmission of the disorder from parent to offspring, suggesting a strong role for genetics (Distel, et al., 2009).

Bornovalova et al. (2009) state that results from longitudinal twin studies supports a causal link for genetics and environment in BPD, with an overall decline of BPD characteristics with advancing age. This last factor also supports the role of genetics being influenced by the environment in BPD, as greater stability in work, social, and personal relationships tends to be increase in the fourth decade of life and beyond (Bornovalova, Hicks, Iacono, & McGue, 2009).

Abuse, Neglect, Violence, and Trauma

People with Borderline Personality Disorder have reported to be the victim of some type of traumatic event, most likely a violent abuse situation, with sexual abuse being the most commonly reported abuse for women. This event typically occurs in childhood, though BPD can result from adolescent and adult-related trauma as well (Paris, 2002).

McLean and Gallop (2003) report that women who have experienced sexual abuse as a child had significantly higher associations of developing BPD than if they experienced the abuse as an adult, though both groups exhibited early symptoms of both Borderline Personality Disorder and post-traumatic stress disorder (McLean & Gallop, 2003).

People with BPD often verbally attack and verbally abuse those they have relationships with. Indeed, the BPD person was often similarly verbally abused in their past as well. Borderline Personality Disorder often follows the patterns of abuse that the person with BPD has experienced in the past, with the BPD person inflicting domestic (spousal) abuse, physical and emotional abuse of strangers, child abuse, and self-abuse. Breaking the cycle of pain and abuse entails a comprehensive therapeutic approach in both cognitive psychiatric services and pharmacological intervention (Grant, et al., 2008).

Social Justice Issues

The concept of social justice has different meanings in different paradigms of study and thought; for purposes of this report, social justice refers to those diagnosed with Borderline Personality Disorder who have experienced inequality and unfairness due to their disorder. This social justice aspect of the disorder contributes to the risk that this population is encountering.

People who have BPD encounter difficulty in the work environment. This presents a challenge to employers as they struggle to deal with the disability issue at hand. The employee with BPD may not be recognized as having a mental illness, and instead seen as a disruptive element in the workplace. They may be ostracized, demoted, or even fired from employment (McDonald, 2002).

People living with mental illness are often marginalized, demeaned, and seen as being outside the normal boundaries of society. For people with BPD, this is doubly painful as it reinforces their sense of worthlessness and victimization, and may even lead to suicide attempts. For those who can recognize they have BPD, yet not know how to deal with it, the social stigma may lead them to attempt to cope with the disorder on their own rather than seek medical treatment. This is a failed situation that has no good outcome (Paris, 2002).

As chronic sufferers of BPD are often victims of abuse themselves, the pain associated with the early trauma may turn into a perpetuating cycle of repeated suffering as they struggle to cope with their disorder. As one doctor notes, there are nine potential symptoms of the disorder, and over 200 potential presentations; the possibility that the disorder may be misunderstood by society and by therapists is high (Hoffmann, 2007). A concept known as 'surplus stigma' is attached to the disorder, due to misunderstandings associated with the disorder. These misunderstandings resulting in surplus stigma include the schizophrenogenic-mother concept, a refusal by therapists to treat those with BPD, unfavorable public information about the disorder, and controversy over the legitimacy of the disorder as a true clinical disorder worthy of treatment (Hoffmann, 2007).

Avirim et al. (2006) report that BPD is viewed negatively by therapists and clinicians. This negativity affects the treatment that the BPD sufferer receives. In society the person with mental illness is often marginalized and stigmatized, with great social distance put between them and the 'normal' population. Therapists may perpetuate this distancing by emotionally distancing themselves from their BPD patients. While the therapist's response may be one related to self-protection in dealing with the BPD patient, the response is one that may be expected when relating to the person with Borderline Personality Disorder who is unusually sensitive to criticism and rejection. Therefore the consequence of such a therapist/BPD patient relationship perpetuates the cycle of mental illness, as the BPD patient does not receive the treatment that they need and instead receive treatment that reinforces their mental illness due to the stigmatization given to them by their therapist (Avirim, Brodsky, & Stanley, 2006).

Summary of Part I

People who have been diagnosed with Borderline Personality Disorder have intense emotional disregulation and an inability to deal with relationships. They are often victims of abuse themselves, and causes of the disorder are a complex mix of environmental factors and genetic factors. A person may be predisposed to BPD if they are a first degree biological relative of someone who has BPD. Additionally, there may be inherent genetic factors that are aggravated by stress or trauma and that predispose a person to developing Borderline Personality Disorder. Sexual abuse in childhood is a predictor of developing BPD for abused women; Post Traumatic Stress Disorder may also accompany BPD, along with associated mood disorders such as depression and anxiety. People with BPD often act inappropriately with others, exhibiting aggression, irritability, disassociation, blame, and ideation. Social injustice issues related to those living with BPD relate to a misunderstanding by society of the disorder which contributes to marginalization and stigmatization. Therapists also may perpetuate the cycle of the mental illness by treating their patients with surplus stigma, and distancing themselves from their patient which exacerbates the condition. People with BPD have high suicide attempts and suicide rates, and often engage in self-mutilation and self-abuse. The need to find effective treatments for the population living with Borderline Personality Disorder is paramount. Effective treatment would result in better social outcomes for the BPD person and their families. Work relations would improve, and BPD patients could enjoy positive social experiences that are self-reinforcing. Rates of hospitalization would decrease for this population, resulting in a decrease in the burden on the healthcare system in treating these patients within a crisis situation, which is often costly. Decreasing suicide rates, enabling BPD patients to enjoy a life of optimum mental health and not just a life with minimized discomfort, and reducing hospitalizations would all benefit the social system within which this population resides.

Part II: Practice Approaches in Treating Borderline Personality Disorder

Traditional therapeutic approaches of cognitive behavioral therapy and medication management have proven to be of limited effectiveness is treating those with BPD. Low rates of compliance for pharmacological management and a tendency of this population as a whole to terminate psychotherapy have perpetuated the negative effects of this disorder for those diagnosed with the disorder and for those dealing with the person with BPD. There is a clear need for a better treatment approach, a best-practices model for treating Borderline Personality Disorder. Traditional approaches of limited efficacy include conflict resolution and social learning theory. A brief look at the role of conflict resolution in treating Borderline Personality Disorder is offered to set the stage for a discussion on more effective therapies. A discourse follows on the conflict resolution review, which examines two different practice approaches: Mentalization in the group approach, and dialectical behavior therapy at the individual level.

Conflict Resolution

This brief review is offered as contextual material for understanding the limitations of therapeutic approaches that do not deal with the base personality disorder, which relates to the distorted cognition of those with BPD.

Conflict resolution has been used as treatment strategy in Borderline Personality Disorder to help people management their relationships better. The downside is that it ignores the root causes of the problem and so offers only a partially effective treatment with an unknown effective duration. However, conflict resolution can be very helpful in BPD patients to learn how to approach and effectively deal with issues arising in their relationships, with relevance to the nature of their disorder. A person with BPD encounters a base dysphoria that may be broken by episodes of anger, extreme sarcasm, or another marked reactivity of mood. This can cause a serious hardship in the relationships of the person with BPD, especially upon family, children, and co-workers. Using conflict resolution strategies can enable those with BPD to have an acceptable and appropriate framework for approaching relationships in a positive manner (Sperry, 2003).

Not surprisingly, people with BPD are reported to have difficulties in attentional neural networks associated with the ability to resolve conflict. Posner et al. (2002) report that BPD patients showed greatly reduced ability to resolve conflict among various study stimulus dimensions than did temperament-matched controls, notably in the areas of a reaction-time task and self-reported effortful control (Posner, et al., 2002). Clearly there is a role for incorporating conflict resolution strategies within a larger therapeutic framework, yet this method should be seen as an adjunct to therapy which deals directly with the cognitive problem of the personality disorder.

Mentalization

Mentalization is a form of psychodynamic psychotherapy with an aim of revealing the underlying psychic tensions of Borderline Personality Disorder. It was developed especially for BPD patients, with a theory that BPD patients have not developed a normal Mentalization framework for attachment relationships (Bateman & Fonagy, 2008). Mentalization refers to the ability to understand oneself and others based on obvious behaviors; Mentalization is also seen as a form of mental activity that allows one to recognize behaviors based on internal mental states (Busch, 2008). Four major aims of Mentalization-based treatment are to improve behavior, mood stability in response to stimuli (affect regulation), have better relationships with others, and have the ability to go after goals in life (Bateman & Fonagy, 2008).

Treatment typically involves a two-week cycle of treatment, with the therapist alternating the treatments between individual and group treatments. For purposes of this particular review of Mentalization, the focus will be on group treatment. In Mentalization therapy, the therapist attempts to form an attachment bond with the patient. This establishes a safe and appropriate attachment bond that the patient can relate to, thereby increasing their ability to understand their own behavior and the behavior of others; this process is increasing the patients Mentalization (Busch, 2008). In these safe attachment bonds the patient is encouraged to explore issues of their cognition, recognize those problems, and develop positive psychological mechanisms. Through the safe attachment bond, the affect recognition arousal issues can be moved from the state of dysfunctional disorganized attachment to positive and appropriate attachment Mentalizations (Bateman & Fonagy, 2008).

In the group therapy sessions, the therapist guides the patient to form safe attachment bonds with members of the group. The group dynamic offers a way for the BPD patient to understand 'how' to form safe attachment bonds and understand their own distorted cognitive processes. In one study, those patients treated with Mentalization therapy showed significant improvement over those treated with standard group treatment therapy options in measures of reduced suicide attempts, reduced emergency room visits, reduced use of pharmacological therapy in a five-year follow-up (Bateman & Fonagy, 8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-based treatment vs. Treatment as usual, 2007).

Bateman and Fonagy (2009) looked at the effect of MBT (Mentalization based therapy) and structured clinical therapy for BPD in a randomized clinical trial. They report that patients in both therapy groups improved significantly, with those receiving MBT showing a quicker response to therapy based on reductions in suicide attempts, self-injurious behaviors, and hospitalizations (Bateman & Fonagy, Randomized Controlled Trial of Outpatient Mentalization-Based Treatment vs. Structured Clinical Management for Borderline Personality Disorder, 2009).

In Mentalization therapy, the mind of the BPD patient is the frontline of treatment. The person finds out more about how and why they think the way they do. Karterud and Urn (2004) report that for those people undergoing day treatment programs of short duration and high intensity, that Mentalization processes work well in the group setting. Components included in the group therapy setting were art group therapy, cognitive group therapy, problem-solving group therapy, and both large and small group therapy (Karterfud & Urnes, 2004).

Bateman and Fonagy (2008) report the effects of Mentalization therapy for those having co-morbid antisocial personality disorder and Borderline Personality Disorder. In both disorders, the path to anger and aggression is enabled through suspending the Mentalization process. In the group therapy setting, the patient is encouraged to focus on mentalizing and realizing their own mental states when their personal integrity is under attack. Mentalization therapy for people with these co-morbid diagnoses is effective in addressing root behavioral problems and changing distorted cognitive processes (Bateman & Fonagy, Comorbid antisocial and Borderline Personality Disorders: Mentalization-based treatment, 2008).

Mentalization is based on attachment theory. In order for the young child to develop normally both socially and emotionally, they need to be able to form a secure bond with an adult caregiver figure and be in that person's proximity. Children use these safe figures as bases from which to explore from, and to which they can safely return to. Without this adult figure present, problems in attachment can occur, leading to wrong development of the child's psyche (Fonagy, 2001 ). Where some people form strong attachments, others are not able to and in Borderline Personality Disorder, this holds especially true. As noted, oftentimes the person with BPD has undergone some type of trauma, usually in childhood. It may be abuse, neglect, or both. Mentalization helps people with BPD keep 'mind in mind' as they seek to understand the processes underlying their lack of Mentalization; hence, they improve their Mentalization and are able to form safe attachments (Busch, 2008).

Mentalization strengths include the facets of empathy, support, exploration of affective dissociations on a moment to moment basis, identification of hypersensitivity, exploration of problems in communicating, and identification of issues from many points-of-view (Bateman & Fonagy, Mentalization-Based Treatment for BPD, 2008). Criticisms of Mentalization therapy include the view that the therapy is just a repackaged form of psychotherapy, and nothing exceptionally new. Additionally, some hold that Mentalization is simply jargon (Busch, 2008).

However, the difference between the process of people being 'aware' of their feelings through cognitive behavioral therapy and the process of Mentalization, is that MBT is provided as a clinical basis for personality disorder: Borderline Personality Disorder. Mentalization in this sense refers to attachment theory (Fonagy, 2001 ). People with BPD are characterized as having disorganized attachment issues, with underdeveloped Mentalization processes. MBT is way to restart that process of Mentalization that should have occurred in early childhood, but did not (Bateman & Fonagy, Mentalization-Based Treatment for BPD, 2008).

A person with Borderline Personality Disorder often has trouble maintaining relationships. Childhood trauma is often an indicator of BPD. Lack of proper attachment building during childhood leads to a lack of Mentalization, and a deficit in understanding one's own behavior and the behavior of others (Busch, 2008). MBT helps people mentalize their actions and thoughts. Group therapy using MBT involves the therapist establishing safe attachment bonds with the patient, and helping the patient understand the causes of their affective behavior when they are challenged (Bateman & Fonagy, Mentalization-Based Treatment for BPD, 2008). The patient is encouraged to form safe bonds with other group members, such as family and loved ones.

Dialectical Behavior Therapy

People with Borderline Personality Disorder who seek psychological treatment often have terminate sessions early due to problems of therapist prejudices and perceived personal attack. Traditional approaches to managing this disorder have included pharmacological management, social learning theory, and conflict resolution (Avirim, Brodsky, & Stanley, 2006). Conflict resolution has a window of opportunity in helping people with DBT learn how to effectively 'deal' with other people, but it does not get at the root cause of the personality disorder (Sperry, 2003). The efficacy of traditional treatment approaches for BPD is dismal, and has led to the need for better therapies that are geared to the specifics of the disorder (Posner, et al., 2002). One approach is Mentalization based therapy, which has been recognized as having clinical bases in the etiology of the disorder via attachment theory. Another promising avenue of therapy practice for treatment of Borderline Personality Disorder is dialectical behavior therapy (DBT) (Bohus, Priebe, Dyer, & Steil, 2009).

Dialectical behavior therapy combines cognitive behavior therapy with emotion regulation techniques, utilizing therapist directed and patient self-tests of reality through a framework of mindfulness (Linehan, 1993). A fundamental aspect of DBT is the establishment of a strong therapist and patient relationship, and a willingness by the patient to undergo treatment. In this model, therapists need to move themselves out of the role of adversary in the patient's view, which seeing others as adversaries, especially therapists, has been a chronic problem for those with BPD. The therapists recognize during DBT that the borderline patient requires a great deal of validation, while having the patient accept that criticism is not an attack and to accept responsibility for treatment (Dimeff, Linehan, & Koerner, 2007).

Lynch et al. (2006) studied potential mechanisms of change that result from DBT. They distilled the research review to finding that DBT reduces nonproductive behaviors resulting from emotional disregulation. Further, they report that DBT helps patients cope with life in a positive way even when they are in the grip of an intense emotional episode, through using mindfulness and other DBT techniques (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). This is an empowering mechanism, and may underlie one of the core strengths of the dialectical behavior therapy approach.

Koons (2008) reports on the success of DBT in reducing suicide rates and hospitalizations among women diagnosed with Borderline Personality Disorder. Koon describes aspects of DBT that the therapist can begin to use in the clinical setting such as structure and focus' of treatment (Koon, 2008). Linehan et al. (2006) studied the effects of DBT vs. non-behavioral psychotherapy in women with BPD. The study included 101 women with a clinical diagnosis of Borderline Personality Disorder, who had attempted suicide or had caused themselves self-injury in the 5-year period preceding the study, with at least one incident within 8 weeks of the study. The participants were randomly assigned to either the DBT group or the non-behavioral psychotherapy group, over a two-year period of treatment. Results indicate a significant reduction in suicide attempts among the DBT group vs. The control group, though no difference was noted for self-injurious behavior reduction. Additionally, those women assigned to the DBT group were more likely to continue with therapy (Linehan, et al., 2006).

The success of DBT for Borderline Personality Disorder patients is likely due to the approach over traditional methods. The therapy course of DBT has four major modules, which include mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness (McKay, Wood, & Brantley, 2007). Diary cards can be utilized that record the BPD patient's affective behaviors during therapy that interfere with therapy goals (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).

As with Mentalization, one component of the DBT treatment is in individualized therapist/patient sessions, and another component is in group therapy. Tools and methods are explored in individual sessions, and applied in group sessions. The four modules of DBT therapy relate directly to the personality disorder characteristics of a person who is considered borderline. Hence, the methods and process of DBT are especially effective for treating, recognizing, and empowering the BPD patient (Dimeff, Linehan, & Koerner, 2007).

Within the psychiatric treatment of those with borderline therapy disorders, a therapists approach is critical in setting the stage for a successful outcome. As noted, therapists have a tendency to emotionally distance themselves from the BPD patient (Hoffmann, 2007). In the case of a therapist utilizing dialectical behavior therapy, however, there is a noted adjustment on the part of the therapist to be involved with the patient for an optimal outcome (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).

Dialectical behavior therapy has shown success with a broader swath of the population in achieving successful outcomes. Rathus and Miller (2002) trialed DBT with suicidal adolescents who exhibited features of Borderline Personality Disorder. Participants in the study were assigned to either a DBT treatment group, or a TAU (therapy as usual) group. Those in the DBT group displayed significantly reduced hospitalization rates and significantly increased rates of therapy completion (Rathus & Miller, 2002). DBT is also a promising treatment for the elderly who have BPD. The elderly population has higher rates of suicide compared to the general population, which is compounded by BPD. The use of DBT may be of potential use in this critical population in reducing suicide attempts and suicides (Lynch T., 2000).

Robins and Chapman (2004) review evidence that DBT has a potential course for psychotherapeutic treatment not only for suicidal women with Borderline Personality Disorder, but also with co-morbid or unique presentations of eating disorders, depression, attention deficit disorder, and for use with prison inmates as well (Robins & Chapman, 2004). While DBT is useful for treating BPD and other disorders where restructured cognitive thinking is beneficial to the patient, Rusch et al. (2008) note that among women in DBT therapy who have been diagnosed with BPD, those that exhibit high levels of anger and low incidences of suicidal attempts, there is a tendency for higher dropout rates. The implication is that there may be subtypes of BPD that do not respond well to DBT simply due to unique presentations of the disorder (Rusch, et al., 2008).

Cultural Competence in Dialectical Behavior Therapy

The NASW Standards for cultural competence display a framework that recognizes the strengths of the individual, and the empowerment of practice approaches for client advocacy and benefit (National Association of Social Workers, 2007). Noting that the diversity of clients is broad in the general community requires a mindset of acceptance and dedication to serve and advocate for the culturally diverse populations requiring social services. Liberman et al. (2001) notes that DBT approaches can be effectively delivered through a recognition that individualized services may be best offered with a culturally competent based understanding by psychiatrists and therapists for the patient (Liberman, Hilty, Drake, & Tsang, 2001). Cornerstones of the DBT approach are that it is empowering, strengthening, and hopeful; these aspects are felt by both therapists and patients utilizing the DBT approach (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).

It is interesting to note that in light of established studies of therapist reluctance and prejudice in working with patients with BPD, the use of DBT has increased not only feelings of empowerment of the patient during the course of their treatment, but it has also empowered the staff working with them. Sheel (1999) noted in an earlier study that DBT was indeed empowering for nurses working with patients with BPD (Sheel, 1999).

Sly and Taylor (2003) found that DBT therapy in a structured living setting for BPD women that had attempted suicide allowed the patients to raise their self-esteem, become hopeful for the future, and enriching the health of both patients and therapists working with this at-risk population (Sly & Taylor, 2003). Additionally, Nehls (2000) reports that patients with BPD who initiate the therapeutic process and use cognitive behavioral restructuring as in the DBT approach find themselves becoming empowered to overcome their disorder and engage in a process of recovery (Nehls, 2000).

DBT utilizes a cultural competence for this at-risk population of those diagnosed with Borderline Personality Disorder. Noting the diversity of the population and the social justice issues surrounding treatment of such patients, the DBT approach delivers hope and strength to both patient and therapist, offering a new model of enriching treatment that provides the self-esteem to treat and the self-esteem to be treated for BPD population.