Applied Behavior Analysis in the Treatment of Symptoms Associated with Borderline Personality Disorder

Applied behavior analysis is used to provide specific behavioral interventions to address symptoms of Borderline Personality Disorder (BPD) through operant conditioning techniques, most commonly incorporated into a hybrid therapy called Dialectical Behavioral Therapy (DBT).

Borderline Personality Disorder is a frightening affliction that tears apart the lives of patients and families. The disorder has no certain cause and no definitive treatment, meaning it can neither be entirely prevented nor completely cured.

Symptoms of BPD can include:

  • Real or imagined abandonment issues.
  • A pattern of unstable relationships and extreme mood swings.
  • Distorted and unstable self-image.
  • Impulsive and dangerous behaviors.
  • Suicidal behaviors.
  • Chronic depression and anger problems.
  • Severe dissociative symptoms, such as feeling outside oneself or feeling disconnected from daily life.

BPD has only been an official diagnostic category since 1980 and many psychologists continue to debate the precise list and degree of symptoms designating the disorder. Originally thought to be a type of schizophrenia, BPD still overlaps with a number of other mental disorders, including:

  • Substance abuse problems
  • Depression
  • Eating disorders

Around ten percent of patients diagnosed with BPD ultimately commit suicide. And the disorder may be under-diagnosed, meaning that more than the official 1.6 percent of the population may suffer from the disorder.

Personality disorders, as a diagnostic category, do not really have a place in the theory of operant conditioning that underlies applied behavior analysis. ABA treats all behaviors as situational, not as enduring artifacts of an underlying, and unseen affect of personality. Nonetheless, ABAs have a valuable toolbox of concepts and techniques with which to treat the symptoms exhibited by BPD sufferers.

Behavior Analysis Treats the Symptoms Rather Than the Disorder

BPD is characterized by an unusual resistance to conventional psychotherapeutic treatment techniques. The failure of conventional psychotherapy, the prevailing treatment modality at the time BPD was originally described as a separate disorder, was in fact one of the factors that led to it being established as a unique diagnosis. BPD patients do not consistently respond to pharmacological therapies, either, significantly limiting treatment options.

With no solid basis for cognitive talk-therapy, many practitioners began to turn to operant conditioning techniques to address problematic behaviors associated with BPD.

Because of the fuzzy diagnostic status and the inability of applied behavior analysis to look into underlying emotional or personality afflictions, behaviorists have broken BPD down into the abnormal behaviors that characterize the disorder. These can include:

  • Suicidal behaviors
  • Self-mutilation
  • Affective instability
  • Inflexible behaviors in the face of changing stimuli
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ABAs conduct a functional behavior analysis, or FBA, of these behaviors to isolate the so-called ABCs of applied behavior analysis:

  • Antecedent – The prompt, or initial situation that leads to a behavior.
  • Behavior – The action or behavior in response to the antecedent.
  • Consequence – The reinforcement mechanism associated with the behavior.

The difficulty for BPD patients is that the long-term consequences are ultimately destructive, but the short-term consequences tend to reinforce those behaviors nonetheless. For example, self-harm can create obvious medical problems, but the act of cutting provides a perceived relief from anxiety or gets attention that the person is craving.

The challenge for the ABA, once the FBA is completed, is to devise short-term consequences that reward more positive behaviors and discourage negative behaviors. The full range of operant conditioning methods can be used for this purpose, including:

  • Exposure therapy – Controlled and increasing exposure to disturbing antecedents with carefully engineered positive reinforcement; for example, situations that make the patient anxious might be intentionally constructed, but with consequences leading to rewards designed to extinguish the anxiety.
  • Activity scheduling/displacement therapy – Replacing problematic behaviors with healthier alternatives by programming personal schedules to leave no room for impulsive abnormal behavior.
  • Chaining – Introducing step-by-step behavioral reinforcement to build complex normal behaviors; for example, in social situations, therapists might role-play each step of an interaction to gradually introduce normal conversational skills to a BPD patient with extreme social anxiety.

ABAs have a certain advantage in treating BPD in that they do not differentiate between BPD-related behaviors and other associated behavioral issues. They are free to customize a behavioral intervention plan (BIP) that addresses each behavior that causes problems for the individual, rather than attempting a single, cookie-cutter BPD treatment. In many cases, this allows them to treat the patient more effectively than other practitioners with a more narrow range of tools.

Dialectical Behavior Therapy Combines Talk Therapy With Behavior Analysis for Greater Impact

The complexity of BPD cases does not lend itself to relying exclusively on any single therapeutic method. Instead, combinations of different approaches, both behavioral and cognitive, have been found to be most useful. One of the most successful is DBT.

DBT is a form of cognitive behavior therapy (CBT), which combines the traditional talk-therapy approach with operant conditioning techniques. DBT was developed from CBT specifically to treat BPD patients.

One pilot study undertaken with a group of female veteran’s demonstrated that the therapy lead to significant decreases in numbers of suicidal acts, anger events, and dissociation episodes.

DBT emphasizes the psychosocial aspects of CBT treatment, minimizing behavioral aspects at first. Instead, a therapist using DBT will initially concentrate on discussion with the patient to help them identify emotional swings and problematic behaviors themselves. DBT is characteristically supportive, looking to build on strengths rather than address weaknesses, so the therapy attempts to switch focus from negative behaviors to positive ones.

As these are identified, the therapist may begin to introduce applied behavior analysis techniques to help reinforce those positive behaviors.

Preparing for a Career in Applied Behavior Analysis Treating BPD

Applied behavior analysts tend to encounter BPD patients through two different fields of practice:

  • Social work
  • Private therapy clinics

In either case, practitioners will usually need to obtain a Board Certified Behavior Analyst (BCBA®) certification from the Behavior Analyst Certification Board. The BCBA® requires that you obtain a master’s degree or higher in either applied behavior analysis, psychology, or education.

Because of the prevalence of DBT therapy in BPD treatment, a strong psychology background is the best preparation for these roles. In fact, most therapists in private practice will also be licensed psychologists who hold a doctorate in psychology.

There are two competing certifications for dialectical behavior therapists, the DBT-Linehan certification, and the DBT Certification offered by the Dialectical Behavior Therapy National Certification and Accreditation Association. Either of these can provide valuable groundwork for treating BPD patients using DBT techniques.

ABAs treating BPD patients through social services agencies do not need advanced qualifications and will likely treat a much wider range of problems and disorders.

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Additional Resources for Applied Behavior Analysis Interested in Learning More About Treating BPD

The National Education Alliance for Borderline Personality Disorder – A non-profit with information and resources on BPD treatment for providers, patients, and their families.

The Linehan Institute DBT Resource Page – Resources for therapists interested in Dialectical Behavior Therapy.

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