Monday, June 27, 2011

Why Does the Predominant Treatment Paradigm for Borderline Personality Disorder Neglect Family Dynamics?

Marsha Linehan is the creator of what is currently the most prominent psychotherapy paradigm used to treat Borderline Personality Disorder (BPD). Her "Dialectical Behavior Therapy" (DBT) is often said to be the most "empirically-validated" of all such psychotherapy treatments. Actually, as I pointed out previously, DBT is only "empirically validated" mostly for the treatment of one symptom of BPD called parasuicidality. But I digress.

Dr. Linehan's theory of the cause of BPD, for which she cited no actual scientific evidence when she first described it (although there has been some since), is called the "biosocial model."  BPD, she believes, is created by the patient's genetic tendency toward being highly emotionally reactive and slow to recover from an emotionally "dysregulated" state, combined with what she refers to as an invalidating environment.

Invalidation, as used in psychology, is not merely people disagreeing with something that another person said. It is, as I said previously, a process in which individuals communicate to another that the opinions and emotions of the target are invalid, irrational, selfish, uncaring, stupid, most likely insane, and wrong, wrong, wrong. Invalidators let it be known directly or indirectly that their target’s views and feelings do not count for anything to anybody at any time or in any way. In some families, the invalidation becomes extreme, leading to physical abuse and even murder. However, invalidation can also be accomplished by verbal manipulations that invalidate in ways both subtle and confusing.

Bonus question: Do DBT therapists validate parking?

Dr. Linehan wrote only briefly in her book (Cognitive-Behavioral Treatment of Borderline Personality Disorder) about which environment she is talking about as being invalidating (page 56-59), and she barely mentions it in her talks and videos.  It is the family environment in which the person grew up.  Really, what else could it be?  Of course, your spouse and friends can also invalidate you, but why would you choose to fall in with an unpleasant group like that if you were not already accustomed to this sort of treatment? 

When it comes to DBT, however, most of the energy in the treatment described by Dr. Linehan is directed at helping the patients accept themselves as they are, without much said about how they got that way in the first place, combined with other techniques for reducing emotional reactivity. 

At some point in her treatment as described in her book she does say that she focuses on the patient's interpersonal skills later in the therapy process.  She even mentions that family therapy might be included.  Mentions it once or twice.  The first time on page 420.   She does not say anything about what that therapy might entail.

If an invalidating environment is one of two main causes of the disorder as she theorizes, how come she does not address this very much in her treatment plan?

Now comes a story in the New York Times ( which may shed light on this question.  Dr. Linehan admits that when she was younger, she "attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on." She added, “I felt totally empty, like the Tin Man."  Self injurious behavior and feeling empty are two of the hallmark symptoms of BPD.  Did she have the disorder?  According to the article at least, BPD is a diagnosis "that she would have given her young self."

I have only met Dr. Linehan once very briefly, and she was perfectly appropriate and personable.  However, I had heard the occasional rumor from other researchers that she has a little bit of the BPD in her.

So why has she so studiously avoided family dynamics in her treatment paradigm when an "invalidating environment" is fully half of her theory about the cause of borderline personality disorder?   And why would she include an invalidating environment in her theory if she, as someone who has struggled with the disorder, had not been invalidated herself?  If her theory is true, she of all people would have experienced that.

The Times article does describe her family a bit, but there does not seem to be a whole lot of dysfunction in the description:

          "Her childhood, in Tulsa, Okla., provided few clues. An excellent student from early on, a natural on the piano, she was the third of six children of an oilman and his wife, an outgoing woman who juggled child care with the Junior League and Tulsa social events. People who knew the Linehans at that time remember that their precocious third child was often in trouble at home, and Dr. Linehan recalls feeling deeply inadequate compared with her attractive and accomplished siblings. But whatever currents of distress ran under the surface, no one took much notice until she was bedridden with headaches in her senior year of high school.  Her younger sister, Aline Haynes, said: “This was Tulsa in the 1960s, and I don’t think my parents had any idea what to do with Marsha. No one really knew what mental illness was.”

Sounds like she was just mentally ill, and that that is the whole explanation for her behavior, does it not?  Just a somehow messed up brain.  But that would only be half of her DBT theory, and a problematic part of the theory at that. 

In one study by researcher extraordinaire Andrew Chanen and others, adolescents who presented for the very first time with BPD did not show the hippocampal and amygdala (parts of the brain's limbic system) volume reductions previously observed in many adult BPD samples - two of the MRI findings of adult BPD considered to be the most significant. They did, however, show small changes in one other part of the brain compared to controls.  (Psychiatry Research: Neuroimaging 163 [2008] 116125).

This finding could mean that some of the brain phenomena that may create high emotional reactivity come primarily as the effect of some other factor or factors.  An effect, not a first cause. What factors might they be?  An environmental factor?  I would suspect so.  Perhaps the invalidating environment?

So, again, why does Dr. Linehan relegate changing family behavior to what is basically a footnote in her treatment text?  Of course I have no way of knowing. 

With my patients who do not want to look too closely at their family dynamics, however, the reason why is crystal clear.  They are very protective of their families, even if they complain unceasingly about them.  They really do not want anyone to think badly of their family, so they tend to keep the skeletons in the family closet to themselves, at least at first.

Maybe if you just ignore a problem, it will go away.  Not.


  1. I can think of another reason: it is probably more common than not that parents and siblings are often loathe to acknowledge that their own behavior towards and treatment of a family member with a psychiatric diagnosis can cause or exacerbate symptoms. One of the reasons that NAMI was such an easy mark for bio-psychiatry and big pharma.

    It is naive to think that people with a diagnosis of BPD--a label that was given to me in my young adulthood--have families that would #1 Accept that how they related to a child contributed to or caused their difficulties #2 Be willing to then participate in intensive family therapy to help the diagnosed member to recover.

    Remember, if the cause of BPD, is the person being invalidated by parents and/or other family members---I can't imagine it is very common for the families who have a member with this diagnosis are easily involved in or become invested in the therapeutic process??

    family dynamics and learned parenting are not things that are easily changed---it takes a lot of hard work and it seems to me that bio-psychiatry screwed the pooch on this more than anything else...people want to believe brain disease and chemical imbalances are "the cause" of emotional and behavioral difficulties a child or adult has; even more want to believe that psychiatric drugs are the solution. pretty convenient for those who don't want to examine, let alone possibly change their own behavior; or learn how to be a more effective and supportive parent...It is so much easier to delude one's self and say "it's all in their head, mental illness is a 'disease'" These people are easy recruits to NAMI which tells parents that to "support and advocate" for a minor or adult child with a psychiatric diagnosis, means to coerce and manipulate; and to maintain drug treatment compliance.

    If any psychiatric conditions are the result of interpersonal and intrapersonal conflicts and maladaptive coping strategies (and they are IMHO) It means WE all need to examine our behavior to see where each of us is part of the problem and how we can become part of the solution.

  2. FunctionalAnonBPDJuly 8, 2011 at 6:01 AM

    I can not change anyone but myself.

    Blaming others and her environment for all things awful is already what a BPD knows how to do. Learning to be responsible for my own behavior and learning how that behavior impacts others was key to my recovery and I didnt need my parents or siblings there to do it.

    The world contains hurtful, hateful, harmful people and its important to know how to take care of myself without requiring anyone else to be different.

  3. FunctionalAnonBPD -

    Blaming others is indeed part of the problem, although most of the patients with BPD I treat really secretly completely blame themselves even when they appear to be blaming everyone but themselves. "It's all my fault" and its opposite, "I had nothing to do with it," are both inconsistent with reality.

    When patients with BPD seem to be blaming others, they often do it in a way which invites others to condemn them, not the others. As an example, the commedianne Rosanne Barr insisted she clearly remembered being molested when she was six months old! After she said that, no rational persona would believe anything else she said.

    Yes, you can not change anyone but yourself, but you CAN change the relationship patterns you have with family members. That's what this series of posts is all about.

  4. I searched your blog to see whether you had made any comments on the other big (or perhaps, up and coming) psychotherapy for borderline personality diorder--mentalization based therapy--and I didn't see anything.

    I'm curious to know what you think of Fonagy and Bateman's work. I have read a few of Peter Fonagy's books, but I am not familiar with the specifics of the program for borderline personality disorder.

  5. Anonymous,

    Mentalization based therapy, for readers that are not familiar with it, is a psychoanalytically-oriented treatment model for BPD based on the assumption that patients with the disorder have a defective "theory of mind." According to this theory, they misread others and overreact to them because they lack the ability put themselves in others' shoes correctly, so to speak.

    I think Bateman and Fonagy got some things right and others wrong. In my opinion, individuals with BPD are in fact very good at reading other peoples' mental states. It is what makes them such good manipulators.

    However I believe (and I am not in the mainstream of psychiatric thought on this issue) that their "overreaction" is not due to a deficient theory of mind, but is instead an interpersonal strategy designed to elicit certain responses in others (see my initial post on how to disarm a borderline). It is a manfestation of a "false self" that has the analysts fooled.

    However, theory of mind does enter into the equation when pts with BPD try to understand why their family members act the way they do. In an extreme example I often use, how do you understand a father who rapes you one day and buys you a pony the next? Psychotherapists haven't really figured that out themselves.

    The conclusions the pt with BPD comes to are logical and consistent with the facts, but they are not completely correct.

    In my model, Unified Therapy, we trace the emotional roots of the parents' behavior (genogram). This often puts the parents' behavior in a whole new light. The pt with BPD learns things about the family dynamics that they would otherwise have no way of knowing.

  6. Thank you for your reply. I think that the concept of mentalizing is useful for non-BPD populations, though I'm not a therapist, just a sort-of case manager for MA DMH clients.

    I also think that anyone treating BPD patients ought to be mindful of Bateman's insight that psychotherapy (like any effective medical treatment) has the potential to be iatrogenic.

    I also was impressed by a grand rounds presentation I saw online where Bateman presented data showing that patients who had participated in their partial program in London had continued to make gains after they stepped down from very intensive treatment and that this contrasted favorably with DBT.

    I have no data to support this, but it does seem that a wide-range of syndromes are diagnosed as BPD, and I am not sure that they are all the same disorder. Some people seem primarily to engage in self-harm and some seem quite "manipulative" while others are not succesful manipulators at all.

  7. Further, it also seems possible that one may be capable of understanding how another might feel, "putting himself or herself in another's shoes" without having an affective understanding.

    The lack of the latter could be a reason for being able to manipulate without remorse, no?

  8. Hi David,

    This is an interesting site. I believe Linehan's biosocial model totally eliminates responsibility for the BPD. Plus she says that it is never their fault. It is the therapies fault. Boy! Talk about a win win situation!

    It can't get any more narcissistic than that. She is doing them no good. If the BPD's narcissism is already high or even on the level of NPD this is a dream come true for them and a new huge social problem. We already have an epidemic of irresponsibility and a nation where radical leftist ideas are becoming a national treasure. We need to "radically accept" this reality and change it by holding people accountable and instilling moral values that do not include pathological entitlement.

  9. My impression of Linehan is that she has a whole lot of narcissism and histrionic elements still in her personality and is very patronizing.
    I have heard BPD's complain of feeling abused after her therapy. I am taking that very seriously because their complaints sound dead on to me.
    I am often approached about competent psychotherapies because I do have some formal and extensive self continued education in the field.

  10. This is something I've been wondering, too. I've been in therapy for over two years now following a period of major despression which was much worse than the chronic depression I've suffered from since I was about 10 years old (and I'm 47 now). My depression developed from a very invalidating family environment, and I consider myself lucky not to have developed full-blown BPD.

    The problem is, my family is STILL very invalidating, and I have no idea how to deal with that. Twenty years ago, I tried to explain to my father and brothers how miserable I felt growing up ("wrong, wrong, wrong" pretty much sums up how I felt all the time around my family), and they proceeded to tell me how great our family was, how much we all loved each other, and how I COULD NOT POSSIBLY have felt that way -- and since it was impossible, I did not, in fact, feel that way, and my supposed problem was simply non-existent. According to them, they knew how I felt much better than I ever did.

    Fast forward to the present, and nothing has changed. When I try to talk about the roots of my depression, they tell me I shouldn't feel angry about anything that has happened; it's all too far in the past for anyone to possibly care about any longer; my perception of everything that ever happened to me is faulty; my interpretation of events and behavior is almost always wrong; and if I would just make up my mind to be happy, I would be. (If only it were that easy! But according to them, it is.)

    Consequently, I have ZERO desire to spend any time with these people. I know it hurts them, because they genuinely can't understand why I am so angry about the past and so frustrated with the present -- they can't see their invalidating behavior at all, since they're just explaining the truth to me. And I feel very bad about hurting them, but at the same time, I am much, much happier with as little contact with them as possible.

    So now I keep wondering -- are there any success stories where a family like this is guided into actually respecting each other's feelings? I've mostly recovered from my depression, but I continue to have a strong aversion to my family thanks to the way they treat me. Part of me would like to try to fix things, but I can't find any advice on how to do this. If I just have to accept them as their invalidating selves ... I don't think it's good for me. Help!

    1. Ilex,

      Yes, there are success stories in achieving the goal of mutual respect in formerly invalidating families. It's not easy, and requires a complex understanding of a family's history and dynamics, as well as extremely careful planning as to how a person can undermine the defenses that the family normally throws up to such efforts.

      A therapist who is familiar with family dynamics and interpersonal process within dysfunctional families is usually required, but unfortunately they can be hard to find.

      The types of therapies that do this have different approaches and go by a variety of names (Bowen Family Therapy, Unified Therapy, Schema Therapy, and Interpersonal Reconstructive Therapy are some of them).

  11. Thanks for the quick response! This is a great site; I think I'll be spending a good long time reading your posts.

    I'll read up on the therapies you describe, but I'm not sure my family and I have much chance of doing any of these together since we all live very far apart. It's a shame that emotional disrespect is so damaging, and so hard to explain to people. If my family would even just acknowledge that my feelings are real, and that I have a right to them, it would make a huge difference. I'm not asking them to LIKE my feelings, only to respect them. But so long as they can't even accept that I was genuinely damaged by my upbringing, and continue to insist that my negative feelings are somehow imaginary, I just don't know how much hope I have for a satisfying future relationship with them.

    Sorry to go on for so long! Again, thank you.

    1. FYI, with my therapy paradigm, Unified Therapy, I have patients work on relationships with targeted relatives one at a time. If more than one family member is present, they gang up on you, in which case it is very hard for the patient to stick with the strategy we developed.

      If we can predict that a second relative will try to interfere with our strategy before the patient has a chance to implement it, the second relative has to be "de-triangulated" prior to the conversation with the targeted relative. Detriangulation also requires family-specific strategies.

      While speaking in person is usually better (unless potential violence is an issue), these interactions can be handled over the phone.