Thursday, March 11, 2010

If you try to fail and succeed in doing so, which have you done?

Marsha Linehan is the current high guru in the community of therapists who treat Borderline Personality Disorder (BPD). Her "Dialectical Behavior Therapy" or DBT is touted as the most "empirically-validated" of all psychotherapy treatments for BPD. This claim is wildly overblown, as DBT is only empirically validated for the treatment of one symptom of BPD called parasuicidality. Parasuicidality includes suicide attempts as well as non-suicidal self-injurious behavior (SIB) such as cutting or burning oneself. Even improvement in that symptom seems to dissipate after two years in her studies. Patients in DBT are also hospitalized less that other BPD patients, but that is probably because DBT therapists will not hospitalize a BPD patient under most circumstances when other types of therapist might.

Another bone I have to pick with Dr. Linehan is the idea of hers that BPD patients show "apparent competence." What this means is that BPD patients often appear to have very good social skills, but they often do not seem to be able to use in emotionally-charged situations. Apparently, Dr. Linehan thinks that BPD patients do not really have these social skills, so the skills must be taught to them in her skills groups. Patients in DBT have to attend these groups in addition to individual psychotherapy.

My question is this: How can you demonstrate a competency that you do not have through repeated performance? Oh, you might fool someone once or twice, but BPD patients can demonstrate social skills over and over again. In fact, they are excellent judges of character, and can determine another person's vulnerabilities quicker than almost anyone else, in order to provoke from another person any reaction they want. They are well known to be master manipulators. How can they do that if they lack social skills? This question also brings into question their often-seen tendency to "split," or act as if they think people are either all good or all bad. Supposedly they can not "integrate" good and bad images of others, but more on that in a future post.

I think it more likely that they have the compentencies in question, but are choosing not to use them in certain situations. It is far simpler to fake incompetency than competency.

Some readers may have seen the movie "The Killing Fields" about the genocide in Cambodia. The Khmer Rouge killed anyone with an education. In the true story portrayed in the movie, a physician survives by pretending to be an illiterate peasant. In this case, acting as if he were incompetent was the most competent thing he could have done.


  1. Hi Dave,
    I find your critical analysis quite fascinating and true. The part that gets to me is how dangerous her non judgement therapy is which is mindfulness taken from Buddhism. There is no critical thinking involved or self judgement. Where is a balance created of both loving yourself and being able to judge your actions and control your emotions with appropriate criticism? She has simply found a way to split. Viola, now you are all good and everything you do is worthy and you didn't mean it. This gross lack of level of insight into herself tells me that she still has very serious problems. That balance is a sign that is part of every mentally healthy person, and in the head of every competently trained person in the field. I sure don't see it. This practice is very dangerous. There is a story I know of someone who knew such monks. They went up in the hills to practice mindfulness and never solved any problems and many a disaster happened. They had severe problems getting back to critical thinking and integrating their feelings and emotions because their judgement was very impaired. It is an extreme childish form of magical thinking that all is good and loving.
    It's hard to say which one is the real topper of insane ideas, but saying that they don't manipulate and are trying to get unmet needs met because they didn't learn them in childhood is dangerous. BPD has a component of Psychopathy. Normal children can learn to self soothe and figure things out on their own and don't need to be told what to do as she believes. She blames all of their problems on the parent. What about the people who develop the disorder that were not abused and validated? This is no different than the Schizophrengic Mother. Isn't Freud and his cronies dead yet? They are in my world

  2. Wow I as a BPD, I am conflicted in your appraisal of BPD. You "sort of "get it but THEN YOU "DON"T GET BPD AT ALL". Dr. Linehan is right about "apparent competency" sometimes we seem completely competent but in other junctures we aren't when we should be.

    You seem to ascribe this as us being manipulative, but I can ASSURE you that it is just part of the disease and we are not being consciously manipulative in this regard. We truly can't see the forest for the trees and it is an inherent part of the illness. As is splitting. We truly split as much as you want this to be from our trying to be manipulative it isn't. We wish we were that cunning because that would mean an adequacy that quite frankly we do not have (even though at times we appear to have it.

    I am not saying that DBT is the end all be all. It is not a cure by any means. It kind of helps. a drug would help better, but we haven't found anything that helps us there either. OHH how we suffer. That is what you don't seem to understand the level of pain that is in BPD

    1. Hi anonymous,

      I suspect you're thinking that I'm saying patients with BPD act the way they do for their own gain, when, if you've read some of my other posts, you'll see that I think they are sacrificing themselves for what they perceive to be good of their families. And that's why they do indeed suffer terribly. I'm not disputing that they are suffering in any way.

      And the things they do are often performed automatically and without conscious thought, much like you can drive a familiar route and not even remember how you got to work. But at some level they are aware of what reactions they are eliciting.

      I don't believe for a second that you are a stupid individual who is somehow blind to what usually happens when you act in certain ways, or who doesn't know that people are neither all good nor all bad. Sorry if I am respecting your intelligence!