Cognitive Behavioral Treatment of Borderline Personality Disorder
If there was ever a manual that wasn’t called a manual, it’s Cognitive Behavioral Treatment of Borderline Personality Disorder. It’s the manual for dialectical behavioral therapy (DBT), but it doesn’t have the word “manual” – nor any of the components of DBT – in the title. I’d previously reviewed DBT Explained, which sorted some of the essential mysteries about the therapy practice, but at roughly one-quarter the size of this book, it summarized some of the details.
Suicide Connection
I need to pause and explain that the reason for the interest in DBT is because it’s an effective treatment for people who have suicidal ideation or a history of previous attempts. The connection isn’t obvious until you realize that patients with borderline personality disorder (BPD) are prone to “self-injurious acts.” Linehan quotes the rate at 70-75% of BPD patients based on other studies. It’s not surprising that she and her colleagues encountered suicidal ideation, attempts, and death by suicide during their careers.
Manipulation
One of the commonly lobbed labels for suicidal patients is that they’re being manipulative. Too often, we hear, “They’re not really serious.” The belief that patients who attempt suicide are not serious is pervasive. Farberow and Shneidman wrote (edited) The Cry for Help, which demonstrates how little the perspective has changed since 1965. In my review of The Suicidal Person, I shared the stark difference between the healthcare provider perspective of manipulation compared to attempter. Healthcare providers perceive manipulation where there is none.
However, for the moment, let’s accept the assertion that it is manipulative, and pause before we accept the pejorative judgement about it. We’re manipulated every day. We wear seatbelts because of laws and peer pressure. We buy one brand over the other because of the manipulation of price discounts and sales. Why is manipulation even a problem?
The problem, as expressed in Compelled to Control, is that everyone wants to be in control, and no one wants to be controlled. The sense that we’re manipulated means that someone else is controlling us. That sense is unacceptable to most of us. (Work Redesign makes it clear there are some people exist who do want to be controlled – probably through conditioning.)
Healthcare professionals resent the sense that others are manipulating them – but at some level, we have to accept that the behaviors are because their lives are unacceptable. There’s too much uncertainty, pain, or suffering, and they want to find a way out. Who among us wouldn’t try to find ways to escape unimaginable pain?
Abuse
Another staggering statistic is that up to 76% of women meeting criteria for BPD are victims of sexual abuse during childhood. It’s the tragedy pointed to in The Assault on Truth. The human race is reticent to admit that there are such horrors being perpetrated on our children. We’d rather turn a blind eye to the problems than confront our failure to protect them.
Synthesis
It’s convenient, but incorrect, to view the world as static and unchanging. We see things as fixed rather than flux, because it’s easier for us to process. The truth, however, is that things are constantly in a state of flux. They’re constantly changing in both predictable and unpredictable ways. It’s easier to see things as independent parts, but it’s harder to see them as parts of a broader whole.
From the universe with galaxies pulling on one another, to the orbit of planets around a star, down to even the atoms that make up our bodies, what we perceive as safe, solid, and stable are actually arrays of predictable forces and motions. Most of the space that atoms fill up are actually space, as the electrons form shells around their nuclei.
When we view people as fundamentally stable and fail to accept the times when they’re not how or what we expect them to be, we fundamentally misunderstand reality.
Validation and Change
The fundamental tension in DBT is the tension between the absolute necessity to validate the person so that they know they are seen and understood and the need to support and encourage their change. In the context of either counseling or considering suicide, something isn’t right, and it needs to change. Since we only ever have control of ourselves, we need to find ways for us to change. (See Compelled to Control for more about our inability to control and therefore change others.)
It’s too easy to invalidate. It’s too easy to say that the world really isn’t that way. It didn’t happen that way. It’s hard to start from the perspective of “I can understand and accept that you experienced it that way.” This invites the challenge of whose perception is “right” but opens the possibility that there are multiple ways to experience something. It’s difficult to navigate from here to a place of mutual understanding where every experience is acceptable. It is, in fact, the way the event was processed. However, there is the need to be open to alternative views.
The real gift is in understanding how to give feedback – and how to help people receive it. Thanks for the Feedback councils people on how to receive feedback better, including how to identify the triggers that might prevent them from reacting well. Books like Crucial Conversations and Difficult Conversations offer additional advice about ensuring the transition from acceptance to change is managed well.
Distress Tolerance
Though much of what Mischel found in The Marshmallow Test hasn’t been replicated, there’s an interesting core to the work. What is the impact of learning to tolerate short-term discomfort for long-term rewards? Mischel’s answer was a better life. Einstein’s perspective was, “Compound interest is the 8th wonder of the world.” Invest, rather than spend today and harness, its power for your good. Spend more than you earn, and you’ll suffer needlessly.
Teaching distress tolerance is a key piece of DBT. Effectively, the tools that are taught in DBT aren’t that different than the tools used by the children in Stanford’s child care center. Distraction and removing focus from the pain are the key starting points. Admittedly, DBT does add mindfulness and practices that a child looking for a marshmallow wouldn’t have. They also attempt to engage in a better appraisal of long-term implications. If there is value to the pain, they try to find it. Nietzsche said, “He who has a why to live for can bear almost any how.”
Emotional States
For too many, emotions are scary, uncharted territory. It’s a place where they dare not go. When they find themselves feeling or expressing emotion, they’re embarrassed. Too many were raised in homes where emotional expression wasn’t acceptable. To be a good child, an acceptable child, there could be no expression of emotion. When emotions were expressed, they were sent away or, worse, told “If you keep crying, I’ll give you a reason.” The result of this constraint of emotions is that when they flow, people are confused and overwhelmed.
Imagine a child who is taught that all anger is bad. They’re taught if they get angry, they’re bad. The result is that when they get angry, they also feel guilt and shame. Instead of processing one emotion, they’re overwhelmed by two or three. Anger is an important and necessary emotion. Aristotle said, “Anybody can become angry – that is easy. But to be angry with the right person and to the right degree and at the right time and for the right purpose, and in the right way – that is not within everybody’s power and is not easy.” Here, Aristotle is implying the universal nature of anger – and both the power and difficulty of harnessing it. Because anger isn’t acceptable, people never learn to interact with it in a way that allows them to find ways to harness it.
Another emotion that is stifled is the sense of sadness, including loss and grief. Borderline personality disorder patients think, “If I do cry, I’ll never stop.” They’re afraid that once they let the “monster” out of its cage, they’ll never be able to put it back. The research on emotion doesn’t matter. To them what is real is the threat that emotions are things that can overwhelm and overpower reason. At some level, this is truth. After all, as Jonathan Haidt explains in his elephant-rider-path model, it’s the emotional elephant, not the rational rider, that is in control. (See The Happiness Hypothesis and Switch.) However, at another level, we know that emotions cannot maintain control of us over the long term.
We know that emotions, once expressed appropriately, tend to fade. (See How Emotions Are Made, Emotion and Adaptation, and Emotional Awareness for more on expressing emotion and the relationship to moods.) The safest thing to do with emotions is to let them out and let them pass. Dan Richo in How to Be an Adult in Relationships encourages acceptance and allowing. Buddhist philosophy suggests detachment and mindfulness, where emotions are acknowledged and then set free.
Inaccessible Territories
We like to believe that our minds are reliable processors of information, but we know through research that this isn’t truth. We know from Kurt Lewin’s work that there are psychological states, and that the transition between states requires energy. The path between states may be mediated by other states, and it can be that we perceive that there is no path from where we are to the place we want to be. For instance, in moments of intense grief, it’s impossible to see how to be happy again.
We also know that our frame of mind dramatically shapes our responses. Judges grant more pardons after lunch than before. It makes no sense, but blood sugar and hunger shape our decisions in ways that cannot be seen. (See Willpower.) We know that priming people with safety words makes them more likely to take risks. (See Thinking, Fast and Slow.) Capture explains how we can get into self-reinforcing states – that end badly.
After the Mistake
Mistakes are, in life, a fact. It’s not if you’re going to make a mistake but when. As a result, it’s not that informative when a mistake happens. What’s really informative is how we respond to mistakes. Do we apologize? (See Anatomy of an Apology for how to apologize well.) Do we make it right? Or do we hope that the mistake isn’t noticed? John Gottman in The Science of Trust explains that repair attempts are a vital part of our relationship health.
Don’t Feel
When someone is ashamed of their emotions, they’ll sometimes tell themselves not to feel. They try to will their way away from their current emotion by overpowering it. However, this strategy is doomed to fail. As mentioned above, it’s the emotional elephant that is really in charge. More than that, we know that cognitively this doesn’t work.
In White Bears and Other Unwanted Thoughts, Daniel Wegner explains how we cannot not think about something without first thinking about it. This paradoxical situation means that the more we try to actively avoid thoughts, the more consuming they become.
The only working strategy is to allow feelings to run their normal course.
Fear of Getting Better
One of the challenges of therapy is that people may decide they enjoy the process so much that they’d rather stay in the process than recover. It sounds odd, but one of the barriers to successful completion of therapy is that sometimes the person wants to stay in therapy. As explained in Immunity to Change, there are sometimes these hidden barriers that stop people from making the change you want them to make.
In the context of therapy, the greatest loss is the relational loss with the therapist. If they get better, then they will no longer have a reason to stay in the relationship. Of course, this is a barrier to them getting better – whether they’re conscious of it or not.
Responsible for What You Become
The tragic reality is that most people will encounter a trauma in their life. It’s a part of the human condition, which very few will escape. While trauma is inevitable, continued suffering is not. We’re often not responsible for the trauma that happened to us, but we are responsible for how we respond to it. (See also Hurtful, Hurt, Hurting for a similar concept.)
What You Cannot Do
There is a misalignment of image that can occur between the person themselves and the therapist – or other caring person. Internally, a person may be consumed by self-hate. (See Compassion and Self-Hate for more on self-hate.) One’s self-image may be such that even if there is no self-hate, there is also no opportunity for pride or positive feelings. There may be no opportunity for self-esteem or self-agency. This can come in stark contrast to the perception of others.
When the therapist (or other person) suggests that there is capability and possibility, it may be met with the retort, “If you knew me, you wouldn’t ask me to do what I cannot do.” For that person, they literally cannot accept the possibility that they can do what is being asked – even if they’ve done it before or demonstrated the behavior.
This can become a problem for the therapist as well. Once someone has demonstrated a behavior, they expect it can be replicated, while the person may steadfastly insist that it’s not possible.
The opportunity here is to help the person see that they are capable – but this can take time.
Threat Response
One of the dysfunctional power dynamics that sometimes happens is that the patient exerts control over the therapist, often by threatening suicide. There are numerous techniques that are described that refocus the power of the relationship such that the patient isn’t manipulating the therapist. One of the ways that this is done is by “extending.” This is, in essence, taking the patient more seriously than they take themselves. If they say something like, “If I can’t get an appointment next week, I’ll kill myself.” An artful response might be, “How can we talk about a mundane topic like scheduling when your life is in danger?”
Arbitrary Change
One of the challenges in change is connecting the change with reasons and theories of operation, so that the change made isn’t arbitrary but, instead, is relevant and powerful. Of course, the real challenge when working with people is identifying which changes are relevant. Without a clear understanding of the factors driving people – either in the specific or in general – it becomes hard to identify what influences what – and therefore what small thing may be capable of making a large change in the back end.
As the therapist improves their understanding of the person, including their history, perspectives, and values, they’re better positioned to develop or adapt working theories to accommodate the person and the change that’s being proposed.
When Praise is Invalidation
It seems like praise should be a good thing. The person being praised should experience it as a positive – but that’s not always the case. Sometimes, when you’re receiving praise, you recognize that the other person’s sense of you and the situation are very far from your sense. It can feel as if they don’t understand. This lack of understanding can be invalidating. As a result, praise often needs to be strong enough to move the person’s self-esteem and sense of personal agency forward, but not so far ahead of them that they feel as if you don’t understand.
One approach is to start by recognizing that there were possibilities for improvement – which the person is likely focused on – but that the overall experience or activity was good. By allowing for imperfection, you make it easier for someone to accept the praise.
Another fear associated with praise is that the person who is doing the praising will withdraw support. The historic experience is that, after the praise, support is withdrawn, and therefore praise is associated with a new sense of vulnerability – one that is quite often unwelcome. In these cases, it’s useful to reinforce continued support with the praise. “You’ve done a good job of managing the relationship with your mom. I’ll continue to be here if you need me.”
Forming the Chains
Too often, we can’t connect the things that we do and the outcomes that we get. We take actions, and the results are so erratic, inconsistent, and delayed that we can’t make the connection. Instead of seeing how things connect to one another, we perceive them as completely random or beyond our control. In some cases, the sense of randomness is real – but in other cases, our behaviors have a real and measurable impact on the outcome.
It’s possible to discover previously unseen relationships between behaviors and outcomes with careful analysis – but this isn’t natural, and patients can resist the process of determining the connections between behaviors and outcomes. DBT calls this “chain analysis.” When worked backwards, this is often called “root cause analysis.”
The idea is that, given an outcome, we can identify the one root cause of that outcome. I prefer a slightly broader definition, where it’s not a single root cause but rather are a cluster of conditions that led to the outcome. Some of those conditions are the behaviors of the actors in the system.
Consider a situation where a family doesn’t have much savings, and they suddenly need to fix the car – but they don’t have money to pay for it and to feed the family. What is the root cause of the problem? Is it the failure of the car – or the failure to put aside an emergency fund? What additional conditions must be present? For instance, not having family members willing to help lend money. What happened that family members aren’t willing or able to lend money?
Threats to Way of Being
Sometimes the criticisms we receive aren’t perceived as being about some situation or behavior but rather as a threat to our very way of being. Rather than being an isolated case, it’s seen as a fundamental condemnation of the way that we think and act. This perception can incite anger or despair depending on whether the response is directed outwardly or inwardly.
Unfortunately, we view our identities from an unconscious and multifaceted lens. It’s not always possible to identify what another person would consider a threat to their way of being. That makes it important to be prepared to recover if you accidentally trip over something that someone feels is core to their identity.
You Don’t Know What I’m Going Through
A familiar trap that people, whether clinicians or not, fall into is saying to the other person, “I know what you’re going through.” The problem is this statement is false. We don’t know exactly what they’re going through. We didn’t grow up with their family of origin. We don’t know all the pressures on them at the current moment. A better response is, “I can understand some of that,” or perhaps indicating what aspects you believe you can understand. We can’t assume that we know what someone is feeling completely. Our experiences may be similar, but they are not the same.
Irreverent Communications
Sometimes a conversation is headed down a bad path. Irreverent communications can be sufficiently disruptive that he helps the other person “jump a track.” In other words, if the path the conversation is going down seems stuck, irreverent comments can break the pattern to allow a new pattern to emerge. It’s a strong driver for change, sometimes with hidden costs.
Too much irreverent communications, and the other person will believe you’re not taking them seriously. Not enough, and you may be stuck in patterns of communications that don’t lead to results.
Who Is on the Case?
It’s typical now for healthcare to include a case manager. This is a person whose job it is to help ensure that the patient is getting what they need. While this has been shown to be clinically effective in many cases, it may not be the best choice for BPD patients. DBT emphasizes patient agency. There’s extra value in having the patient take ownership of their care that case management or overly paternal approaches from the therapist can rob them of.
In general, the goal is for patients to speak up for themselves and only have healthcare workers (case managers or therapists) step in when the patient isn’t capable of supporting their own care – and only until this can be resolved. Every patient should be capable of advocating for themselves, they just need to be shown how to do it.
Friends and Family
Virginia Satir in The New Peoplemaking and The Satir Model explains the family systems that can keep someone stuck in a dysfunctional pattern. Rather than focusing on one person’s behavior, the model encourages us to look to how the system reinforces certain behaviors and discourages others. (See also Thinking in Systems for a primer on systems.) This highlights the powerful allies – or saboteurs – that friends and family can be when someone is making changes.
Change or Die points out that many successful substance use change programs intentionally change the environment that surrounds the addict to encourage positive behaviors. Kurt Lewin said that behavior is a function of both person and environment. While you’re working to change the person, you can change the environment. (For more of Lewin’s work, see A Dynamic Theory of Personality and Principles of Topological Psychology.)
Hospitalization
The sad reality of hospitalization is that it isn’t for the patient. It’s for the provider. They get to pass the buck and make someone else responsible should a patient die. The problem is that no one has ever shown that inpatient hospitalization is effective. On the contrary, we know that the period of greatest suicide risk is immediately after being discharged from an inpatient program. So why do many providers still subject patients to hospitalization?
The risk of suicide becomes too great, and they panic. They decide that they’re not throwing away their career because they can’t be certain a patient won’t attempt suicide. As a result, they give up. They decide that they’re not capable of helping the patient through Cognitive Behavioral Treatment of Borderline Personality Disorder.