Book Review: Building a Life Worth Living: A Memoir by Marsha Linehan

The predominant and most widely-used school of thought in use for the psychotherapy of borderline personality disorder (BPD) is called dialectical behavior therapy (DBT). Marsha Linehan, a psychologist at the University of Washington, was the person who came up with the theory and treatment ideas. The treatment paradigm has been shown in studies to be somewhat effective in reducing some symptoms of the disorder, but mostly ineffective in helping patients solve their problems with love and work.

She believes that a combination of a genetic propensity to be over-reactive combines with a so-called “invalidating environment” to produce the disorder. Studies  that attempt  to identify genetic propensities tend to have a major flaws in distinguishing normal neural plasticity in response to the environment from purely genetic effects, although the combination of a baby that tends towards being reactive and a parent with attachment issues would be problematic – an example of gene-environment interaction rather than just genetics.

The invalidating environment is clearly that in the patient’s family of origin, although this is seldom spelled out in the DBT literature.

Interestingly, in 2011. Linehan, in a story in the New York Times, “…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."

So I was intrigued when she recently published her memoir. I was particularly interested in hearing about her family of origin and hints of any shared psychodynamic conflicts they may have had, a phenomenon that she appears to be clueless about with her patients. I had wondered why, if she came from such a family, she rarely wrote about how to address invalidating family members, as opposed to merely teaching patients “radical acceptance” of their parents’ ongoing behavior so they react much less.

So if she herself had BPD, and if an invalidating environment is one of two main causes of the disorder as she theorizes, I've long wondered how come she does not address this very much in her treatment plan. She says she sometimes does family therapy, but mentions it only briefly and without any details both in her memoir and her primary book about DBT.

While I cannot be certain of anything about her family based just on what she chooses to reveal in her memoir, the family’s conflicts over gender roles – particularly career aspirations for women – and religion just seem to jump off the page of her memoir. So the following forms the basis for my speculations.

She herself draws the parallel between her mother’s experiences growing up and her own conflicts with her mother. The mother’s parents were described as having lost their fortune and died young. The mother then took a job to support her two younger brothers but later moved in with a maternal aunt, who drilled into her head that she was to be a social butterfly and attract a successful businessman for a mate. Which she did. Yet she never seemed particularly enamored with her husband.

In particular, her aunt told her she had to lose weight to be more attractive. She did that. She never again had a paying job, but was extremely active doing charity work and also painting. Her art was admired and was hung up prominently in their house, but Marsha only found out that she was the artist much later. I guess traditional women could work as long as they didn’t get paid and thereby threaten their husband’s traditional image. Mom did all this work despite having six young children.

The author writes that marriage and children were most important for mother as they generally were for her generation where she grew up. But were they really, or was she just following her family’s rules?

When Marsha was a teen Mom tried compulsively to get Marsha to do the same thing her aunt made her do - unsuccessfully. Marsh was compared negatively with her younger sister who followed the supposed family philosophy re marriage and work. In particular, Mom constantly nagged Marsha about losing weight. Marsha was the only child in the family with a weight problem, so perhaps that wasn’t “genetic.” Marsha writes that the thing she wanted to do more than anything was to gain her Mom’s approval, but somehow she couldn’t manage to do this one simple thing - that her Mother had been able to do - in order to get it.

Marsha writes clearly that she knew that Mom’s relationship with her great aunt was the reason her Mom was so critical of her, but she seems to not understand exactly what made her family act out this issue in the first place nor exactly how it might be transmitted from a previous generation to her. Again, her solution in DBT seems to be “radical acceptance” – you just use mindfulness to accept this reality without trying to change anything, and to stay calm.

If she were my patient, I would start to explore the possibility that she actually was doing what her mother seemed to need her to do - in effect acting out her mother’s repressed ambition, so clear in her non-family activities – so mother could experience her success vicariously. And then trying without success to put up with her Mom constantly invalidating it. Meanwhile, sister Aline was acting out the other side of conflict and appeared to be Mom’s favorite. Mom even told Aline to stay away from Marsha. Aline late apologized to Marsha for this but only after Mom had passed away.

When it comes to religion, Marsha’s description of her behavior seems even more conflicted. She was a practicing Roman Catholic throughout her life, and says that her mother “gave” that to her. However, in the book she frequently criticizes the church for such things as its rampant sexism and for the belief of the Pope’s infallibility. She disputes the circular argument heard by many fellow parishioners that God is real because it says so in the Bible. She later started to mix Catholic ideas about God with Zen Buddhist ideas about the ultimate oneness of everything in the universe in ways which are basically incomprehensible.

Further evidence of conflicts over beliefs and how they may have played into her issues regarding marriage: she couldn’t marry the guy who she most loved because he wanted to enter the priesthood. Even though he didn’t and eventually married. She wouldn’t marry her next boyfriend because he was an atheist. Going from one extreme to another and ending up in the same place - single - is a hallmark of an intrapsychic conflict.

Mixed messages from parents conflicted over the role of being parents is in my theory the hallmark of families with BPD members, and this one seems to qualify. Her mother having six children and no apparent career might be evidence for such a conflict. Dr. Linehan was hospitalized with self cutting and suicide threats for over two years just weeks before finishing high school. 

Mindfulness or Mindlessness?

“God grant me the serenity
to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference” ~ The Serenity Prayer

The latest fad in both psychotherapy and self help is “mindfulness.” Mindfulness, which is derived from Zen Buddhism and first made popular in psychotherapy by Marsha Linehan (founder of Dialectical Behavior Therapy [DBT] for borderline personality disorder [BPD]) and others, is basically a set of skills that one can use to better tolerate and cope with emotional distress.

Fads in psychotherapy are nothing new. For a while there seemed to be a new one every few weeks, from "neurolinguistic programing" to "solution-focused therapy." 

Even therapists who swear by the gods of empirical correctness that the techniques of Cognitive Behavior Therapy (CBT) - of which DBT is a variant - are so much more powerful than any other known therapy interventions are subject to fads just like anyone else. Besides mindfulness, there is  another current one, "Acceptance and Commitment Therapy (ACT)," which seems to all boil down to telling people that they "don't have to believe everything they think" in a variety of different ways. 

If CBT techniques are so darned powerful, why would practitioners need to keep discarding the old ones and coming up with replacements? Very amusing.

Anyways, getting back to mindfulness, Gregory J. Johanson, Ph.D. discusses it thusly: 

“For clinical purposes, mindfulness can be considered a distinct state of consciousness distinguished from the ordinary consciousness of everyday living (Johanson & Kurtz, 1991).  In general, a mindful state of consciousness is characterized by awareness turned inward toward present felt experience.  It is passive, though alert, open, curious, and exploratory.  It seeks to simply be aware of what is, as opposed to attempting to do or confirm anything. 

Thus, it is an expression of non-doing, or non-efforting where one self-consciously suspends agendas, judgments, and normal-common understandings.  In so doing, one can easily lose track of space and time, like a child at play who becomes totally engaged in the activity before her.  In addition to the passive capacity to simply witness experience as it unfolds, a mindful state of consciousness may also manifest essential qualities such as compassion and acceptance, highlighted by Almaas, R. Schwartz and others; qualities that can be positively brought to bear on what comes into awareness.

These characteristics contrast with ordinary consciousness, appropriate for much life in the everyday world, where attention is actively directed outward, in regular space and time, normally in the service of some agenda or task, most often ruled by habitual response patterns, and where one by and large has an investment in one’s theories and actions.

Mindfulness was even featured as a cover story on a recent issue of Time Magazine, pictured above. It often incorporates another concept pioneered by Marsha Linehan, radical acceptance. Radical acceptance means completely and totally accepting the reality of your own life. You stop fighting this reality and learn to tolerate it and go with the flow, so to speak. 

Practicing mindfulness techniques can indeed help you to stay calm when things are going badly without resorting to a tranquilizer or booze, although in a sense it accomplishes much the same thing. So therapists like to teach these skills to get their highly reactive, chronically upset, or emotionally unstable patients to calm down and not resort to acting out, such as cutting oneself or other self-destructive or self-defeating acts.

So, is there anything wrong with that?  Well, no, not intrinsically.  Certainly remaining calm and not going off the deep end in the face of adversity is a very useful skill.  Some people prefer learning skills to accomplish this over taking medication or having a stiff drink, although there’s nothing wrong with temporarily taking medications to keep calm either. 

But I started this post with the serenity prayer for a reason. Mindfulness is relevant to the first part of of the prayer – accepting things that one cannot change. What about changing things that need changing? Where does the wisdom to know which things can be changed and which cannot come from, and how does one go about changing them?

People feel emotional pain for the same reason they feel physical pain – it is a signal to the person that something in the environment is wrong and needs attention.  A metaphor I’ve used before:  What if another person is walking behind you continually stabbing you in the shoulder with a pen knife.  If I am a doctor, I can give you an opiate so you don’t feel the pain, and you can go on with your life.  But would it not be much better to get the guy with the knife to stop stabbing you?

Most of the non-psychotic people in therapy who are highly reactive, upset and emotional, and who are not in the midst of an episode of a major affective disorder, are reacting predominantly to the environment. Specifically, the social environment. Even more specifically, as anyone who reads this blog should know by now, the family social environment. Biological psychiatrists and some cognitive behavioral therapists seem to think that it’s all going on inside a patient’s head and has nothing to do with other people.  Bull.

Marsha Linehan herself acknowledges this.  In her Skills Manual for Treating Borderline Personality Disorder, she lists the following goals of the "skills training" portion of DBT treatment.

Goals of Skills Training: To learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems in living, that is, those causing misery and distress.

Specific Goals of Skills Training:

Behaviors to decrease:

1.      Interpersonal chaos

2.      Labile emotions, moods

3.      Impulsiveness

4.      Confusion about self, cognitive dysregulation

Behaviors to Increase:

1.      Interpersonal effectiveness skills

2.      Emotion regulation skills

3.      Distress tolerance skills

4.      Core Mindfulness skills

Notice that she talks about becoming more effective in dealing with the interpersonal environment before she even gets to her distress tolerance skills - numbers 2, 3, and 4.

Unfortunately, in practice, dealing with specific dysfunctional family interactions is one of the last things many DBT therapists get to, if they get to them at all. Marsha Linehan believes – with precious little of her beloved “empirical” evidence by the way - that the reactivity of patients with borderline personality disorder is both biologically innate AND caused by an “invalidating environment.”  As I pointed out in an earlier post, the invalidating environment is not described well or very specifically - although it seems to be the patient's family of origin - nor is there anything written about what makes family members act that way.

The Skills Training Manual is 180 pages long, including a section containing handouts that starts on page 105 and goes to the end.  Of the first 104 pages, only 14 are devoted to interpersonal effectiveness skills, and most of that strongly implies that the interpersonal problems experienced by someone with BPD are due to their own skill deficits rather than the fact that they are dealing with people who are difficult (if not nearly impossible) or frankly abusive or distancing.  Blaming the victim.

In the handout section, interpersonal effectiveness skills are only addressed from pages 115-133. The rest is all about emotional regulation. Almost all of the skills described in the interpersonal skills section are basic assertiveness skills or are descriptions of “myths” about interpersonal effectiveness such as “I can’t stand it when someone gets upset with me.”  Is that really the worst thing that can happen in a family?

Listing "myths" in a way that classifies them as some of cognitive therapy's irrational beliefs means that the problem is being thought of as a flaw that exists squarely in the mind of thinker. Paradoxically, telling a person with BPD that their thinking is skewed is incredibly invalidating!

Besides, when the patient with BPD says "The other person would get upset with me," what they REALLY mean most usually is "All hell would break lose!"

In all of the DBT handouts, I find only one mention of the fact that it may be the environment that is the problem, not the person in the environment.  In the Interpersonal Effectiveness Handout #3 on page 117, it concedes that "Characteristics of the environment make it impossible for even a very skilled person to be effective."

So what happens if someone with BPD gets assertive with their families? In order to find out the true answer to this question for patients in therapy, the therapist usually needs to ask a version of the Adlerian Question such as: "What would happen if I could wave a magic wand and you could fearlessly stand up for yourself with your parents, and tell them to quit mistreating or invalidating you?

So what are the answers I get when I ask for details - without letting the patient go off on a tangent - about exactly what would happen next if the parents were "upset" with the patient?

Oh, nothing much, he said sarcastically. Just responses that include such minor inconveniences as violence, suicides, suicide threats, increased interpersonal chaos, increased drinking and drug use, parental infidelity or a break up with the patient being blamed for it, further invalidating the patient, taking anger out on other family members, literally exiling the patient or giving him or her the silent treatment for weeks on end. Just to name a few. Nothing too bad, really.

So back to the serenity prayer. Are these things one can change?  You betcha!!  It’s not easy, or the person could easily figure out how to do it and would have already proceeded. It’s emotionally trying.  It requires patience, persistence in the face of adversity, and ingenuity. It usually requires the services of a therapist who knows a little about the family dynamics of BPD.

So if your therapist is telling you to just tolerate the person stabbing you in shoulder with the pen knife, fire your therapist and find one who can actually help you.

Book Review: Transcending the Personalty Disordered Parent: Psychological and Spiritual Tactics.

Self-help books for the adult offspring of highly dysfunctional, personality-disordered parents are in woefully short supply. Children raised in such households often grow up to have high emotional vulnerability,  a poor self image, and a high degree of confusion about what kind of people they are supposed to be or what they should expect from their relationships.  Worse yet, they sometimes become just like their parents in some way, even if they try to do things in an exactly opposite way.

If they do not have access to a therapist for whatever reason, is there anything they can do in order to better understand what has happened to them, and how to think about the problems that have resulted from their bewildering and traumatic upbringing? 

In a new book, academic psychiatrist Randy Sansone and academic psychologist Michael Wiederman attempt in ordinary language to help such individuals recognize the dysfunctional parenting styles they had been subjected to, and to understand a little bit about what makes their parents act the way they do. 

They describe in detail how such parents may do any or all of the following, among other things:  

• ·     They act like monsters with their family members, but are liked and highly-respected outside of the home - creating an almost Jeckyl and Hyde situation. 
• 
  
• ·     They seem to think that their children should be taking care of them - but undermine any effort the children make to actually try and do so.
• 
  
• ·     They seem to see children a big burden, yet won’t them go.
• 
  
• ·     They pit one of their children against another, creating even more widespread family discord.
• 
  
• ·     They accuse their children of the very negative traits that they themselves display in spades.
• 
  
• ·     They seem to over-react to seemingly minor transgressions made by family members, and in response become abusive and bullying.
• 
  
• ·     They seem to be in a constant state of denial about past misdeeds.  Or are they maybe just lying about it?
• 
  
• ·     They oscillate between intruding on the lives of their children when they don't need help, and neglecting them when they do.

The authors go on to suggest ways in which readers who have grown up with parents like these can conceptualize and think about their family experiences. 

Although they do not cite her by name, many of their recommendations seem to stem from the concepts of “mindfulness” and "radical acceptance" that come from the work of Marsha Linehan with personality disordered patients.  These ideas involve the adult children giving up trying to completely make sense of their dysfunctional parents, completely accepting their situation as it is, stopping efforts to make their parents change, and viewing their experiences as an opportunity for growth rather than as an obstacle to it.

As I mentioned, there is a serious need for a book like this, and I applaud the authors for their efforts. I also think many of their suggestions are indeed helpful, especially for those who are not seeing a family-systems oriented psychotherapist for whatever reason.

I do, however, have some quibbles with their explanations for the personality disordered parents, and I frankly strongly disagree with a couple of their recommendations.

The authors do try to be somewhat empathic with the plight of the dysfunctional parents, but their descriptions of them, understandably, veer away from that. The authors could benefit from an understanding of family systems theory. They come ever so close to Murray Bowen’s three generational understanding of the origins of self-destructive behavior, but just miss it.

For example, they discuss how the reader may have been given what Transactional Analysts call a “script” by their parents – in which the recipients of the script act out in ways that seem to be for the benefit of their parents at the expense of their own happiness. The authors do not mention, however, that perhaps the dysfunctional parent is also the unfortunate recipient of such a script from the grandparents.

In the same vein, the authors, like Marsha Linehan herself, mix up the personality disordered parent’s true self with his or her false self or persona. Is the exemplary behavior seen by outsiders the "true" nature of their personalities, or is it within their hidden-from-view dysfunctional family behavior?  This issue is somewhat analogous to my problem with Linehan’s idea of apparent competence – that somehow people can demonstrate through performance an ability they do not in fact have. How is that possible?

One father who they describe was a physician who was loved and idealized by his patients, but treated his children like crap. The authors seem to assume that the father’s “real” personality was the one he exhibited at home, while the one he exhibited at work was a fraud. Could it not be in fact the other way around?

I disagree with the authors recommendation that children of dysfunctional parents give up the idea of ever truly understanding their parents' behavior. I believe that through the use of three generational family histories called genograms that it is indeed possible to understand parental misbehavior (which, BTW, does not entail approving of it).

The authors also seem to be saying that nothing will ever change in their relationship with their parents, and that there is nothing the child can do about it. Those who read this blog know that I believe that, while adults (not children) are indeed powerless to change their parents, they  certainly do have the power to change their relationship with those parents.

The authors provide an example (p.187) purportedly showing the futility of getting personality-disordered parents to even admit that they did anything wrong in the past:  

“A patient was on the telephone with her highly dysfunctional mother. The mother was intoxicated with prescription analgesics, which was typical for her. The patient broached the issue of a babysitter who molested her and her sister for an entire year during their childhoods. At the time, both girls had told their mother about the molestation by the female sitter, but the mother continued to employ the sitter anyway. During the telephone conversation, the mother defensively stated in a slurred voice, “She only molested you girls a few weeks,” as if this nullified the injustice. Understandably, the patient exploded and proceeded to call her mother a number of obscenities.”

The authors concluded that the mother lacked the ability to validate her daughters feelings. The daughter therefore would never be able to get this validation, for which she longed.

I completely disagree. Let’s look at what happened in more detail. First of all, the daughter called the mother when the mother was intoxicated. I understand that it might be difficult to find a time to call when she was sober, but that fact alone guaranteed that the daughter would fail in her efforts to obtain validation. Second, I suspect that the way that the daughter brought up the molestation made it obvious to the mother that the daughter was highly critical of the mother’s lack of responsibility - as obvious as that lack of responsibility was. To the both of them, I might add. 

When anyone is attacked, they tend to respond with defensiveness, flight, or a returned attack. This is especially true in this case since I would wager that the mother really did, covertly, feel terrible about what she had done, and believed that the daughter was right to hate her for it.  Furthermore, I find that such parents feel they deserve hatred, and that their children are really better off without them.  

Mother therefore responded in a very hateful manner, which very helpfully gave the daughter more righteous justification for her hatred, and pushed her away to a place in which the mother viewed the daughter as safe from the mother’s pernicious influence.

If this daughter really wanted validation, she went about asking for it in exactly the wrong way, and the horrific response was entirely predictable.

Not that the right way is something easy to devise or to do, or that the complicated techniques that do in fact work are obvious. And this problem is further complicated by the fact that the right approach is different in every family and must be customized to each family member's sensitivities. Generic assertiveness skills are often useless.

Confronting maladaptive family patterns may in fact be extremely dangerous if done poorly. It almost always requires the coaching of a therapist who does this sort of work. As I have said repeatedly in this blog, finding such a therapist is well worth the effort.

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 (http://www.nytimes.com/2011/06/23/health/23lives.html?_r=2&pagewanted=all) 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] 116–125).

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.

How to Disarm a Borderline, Part I

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If you are an adult in a relationship with another adult, either through blood or through a romantic liaison, who fits the description of a patient diagnosed with borderline personality disorder (BPD), then you already know that you have your hands full.  A New York Times blog post about BPD drew 470 rather contentious comments (http://well.blogs.nytimes.com/2009/06/16/understanding-borderline-personality-disorder/?apage=1#comments) from people who were dealing with BPD relatives and other people who themselves have the disorder.  Although I am in neither category (hopefully), I wrote a few posts myself. 

I wrote about some of the ideas that I describe below.  A couple of people who said they were dealing with BPD parents did not like what I wrote, but showed that they had adopted some of the very behavior they were complaining about in their parents, as evidenced by their responses to me (more on why this might happen shortly).  I was being nice, so I didn't point that out to them.

Some people say that the only way that you will surely survive a relationship with someone with BPD is by cutting all contact with the "toxic" individual.  Some therapists even say this.

If you are in a romantic relationship with a person with BPD, that might indeed be the best course.  Has the relationship already been going on for quite a while?  You won't like hearing this, but this means you: you need to ask yourself why you are attracted to such a difficult person in the first place.  Please don't give me the usual crap like, "I didn't know what (he or she) was like that at first, but now I'm involved and I can't get out.  (He or she) was so charming at the beginning of the relationship!" 

Puh -leeeze!  You are like the wife who insists her husband is not having an affair while she looks for the stain remover to get the lipstick off her husband's shirt collar. Sorry, but most people run at the first sign of BPD behavior.  It is not subtle, and one does not often have to wait very long before one first sees it.

Well, you might object, the person threatens suicide if I tell them I'm going to leave them!  So, let me get this straight.  You're planning to sacrifice your whole life because someone might stab themselves in the heart in front of you and then quickly hand the knife to you before they die so your fingerprints are all over it?  If you feel so responsible for other people that you respond to this kind of threat by caving in to it, please, get some therapy.

When it comes to parents with BPD, however, the strategy of divorcing one's family, while better than remaining in a toxic relationship with them, creates other problems.  First of all, it's kind of lonely to have no family.  You will be faced with a cavernous hole in your life. 

Second, you came from them.  If they are monsters, what does that make you?  You undoubtedly share at least some of their toxic behaviors whether you like to admit to it or not, because one can not grow up in a toxic household without adapting to it in ways that are both problematic themselves and very hard to stop later on in other social contexts. 

Especially with your own children.  Attachment studies clearly show that the best predictor of one's relationship with one's children is......one's relationship with one's parents or other primary caretakers.  Some people from abusive households wisely decide not to have children for fear that they, too, might become abusive.  But is that what you really want to do?

Besides, you cannot completely divorce yourself from your family, because you carry them around with you in your head. Literally. We in the biz call these mental representations schemas.

Your choices are not just limited to these two:
1) To either to continue to be mistreated, or
2) to cut off all contact with your family.

A third choice is to change the nature of your relationship with your parents so that you are not being mistreated but are still in contact with them.  Impossible, you say?  I disagree.  While you do not have the power to "fix" your parents, you do have the power to fix your relationship with them.  If you change your approach to them in a consistent manner, that will force them to change their approach to you. 

However, there is a big problem that you will face in doing this: since you have been in a relationship with them your whole life, they have developed a whole repertoire of behaviors, include recruiting other family members, to give you the powerful message, "You're wrong.  Go back to responding the way you used to."  If one strategy does not work, no worry.  There are plenty more where that came from. Scary to be sure, but not insurmountable if  you can enlist a therapist who knows something about the family dynamics in people with BPD.

Therapists like myself who work primarily with patients with BPD, regardless of their "school" of psychotherapy or their theoretical ideas about the causes and cures for the condition, all have independently developed some ways of getting BPD patients to be more cooperative with them.  (That is, cooperative just with the the therapist. Unfortunately, not with anyone else). We seem to have all come up with these little tricks of the trade independently, yet they are all very similar, as I described in a paper called, "Techniques for Reducing Therapy-Interfering Behavior in Patients with Borderline Personality Disorders: Similarities in Four Diverse Treatment Paradigms" (Journal of Psychotherapy Practice and Research 1997; 6:25-35). 

Marsha Linehan of DBT fame, Otto Kernberg of psychoanalysis fame, Lorna Smith Benjamin of interpersonal therapy fame, and myself (with my not-at-all famous treatment paradigm called Unified Therapy) all do pretty much the same things at the beginning of treatment.  (We then start to diverge considerably).  These strategies are survival skills for us.  Therapists used to come up to me all the time and ask me how I could stand to work with several patients with BPD at the same time, but it really is not a big problem if you know the "tricks."  I had to devise them a long time ago because I built up a private practice by taking referrals of these patients whom no one else wanted to treat.

As I mentioned, it is much harder for someone who is already enmeshed with a relative with BPD than it is for a therapist who has just met a patient with BPD.  One reason is the aforementioned repertoire of behaviors they have designed over many year specifically with you (the enmeshee) in mind.  They know all of your weaknesses and exactly how to take advantage of them.   Second, as a therapist, I do not have to deal directly with a bunch of interfering relatives like the enmeshee does.

The third reason has to do with something behaviorists call a variable intermittent reinforcement schedule.  This schedule is why slot machines in casinos are so successful.  You never know when the damn thing is going to pay off, and it pays off just often enough, so you keep pulling the lever until you lose your shirt.

I should mention that, as John Rosemond is fond of saying, people are not lab rats that blindly respond to rewards and punishments. However, if a person has a goal, and their behavior helps them to reach it, reinforcement schedules kick into play. It is not the person being "rewarded," but the behavior. It is not rewarding to have people hate you.

The goals of the worst of the behavior exhibited by people with BPD, for reasons I will not discuss here, is to cause in their targets one of three reactions.  The first two of these invariably lead to the third.  The three reactions they shoot for in their targets are a sense of anxious helplessness, a sense of anxious guilt, and overt hostility. 

The great big secret, however, is that folks with BPD are often highly ambivalent about getting these reactions.  They will try like hell to get them - and believe me, they are real professionals at it - but they secretly wish to fail. (How do I know this?  Experience.  But I can not prove it - because there is literally no way to set up an "empirical" experiment that would fill the bill - so readers can call this highly speculative if they wish).

If the persons with BPD succeeds at getting one of three reactions, they will continue to draw for it.  Pull out all the stops in order to get them, in fact.  If they fail at getting the reactions, however, they will suddenly become more conciliatory.  However, because of the variable reinforcement schedule, if they only occasionally succeed in getting one of the reactions with a person with whom they have already been interacting for a long time, they will keep trying much longer. 

Therefore, if you already have a history with them, and they have a track record of making you react in any or all of the three ways, their behavior will get much worse before it gets better.  If you can not keep your cool and occasionally react the wrong way, it becomes even harder to get the BPD's to change their behavior toward you than if you react the wrong way all the time!

In later posts, I will share with readers the therapist's tricks for avoiding "rewarding" the bad behavior of persons with BPD, but most people who are already enmeshed with a BPD family member will find it nearly impossible to employ them successfully without the help of a therapist who understands the family dynamics of those who suffer with the BPD traits, and who can prepare them for your "adversary's" formidable defenses.  I will start in an upcoming post with what not to do.

Validating Invalidation

Invalidation, as used in psychology, is a term most associated with Dialectical Behavior Therapy and Marsha Linehan. Invalidating someone else is not merely disagreeing with something that other person said. It is 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.


Marsha Linehan


Linehan theorizes than an “invalidating environment” is, along with a genetic tendency to be over-emotional, one of the two major causes of borderline personality disorder (BPD). She does not really specify which environment she is talking about, but it is obviously the family in which the person grew up.

When I first read Linehan, I thought of a similar concept that I had read about in a classic book in family systems theory by Watzlawick, Beavin, and Jackson first published way back in 1967 called Pragmatics of Human Communication. They called this concept disqualification. I at first thought that maybe Linehan was re-discovering the wheel, but then I went back to the old book to look at how they defined disqualification. To my surprise, disqualification is something one does to oneself, not someone else. One disqualifies oneself when one is afraid to say what one really feels and means for fear that others will reject it. Hence disqualifiers say things in a way that allows them “plausible deniability.” They can claim they were misinterpreted if the other family members object.

They accomplish this through wide range of deviant communicational phenomena, “…such as self-contradictions, inconsistencies, subject switches, tangentializations, incomplete sentences, misunderstandings, obscure style or mannerisms of speech, the literal interpretation of metaphor and the metaphorical interpretation of literal remarks, etc." (p. 76).

Now why would anyone disqualify themselves? The answer has to do with something that the psychoanalysts, who got a lot of things wrong, got right. They thought problematic behavior resulted from an unresolved conflict within the individual between two opposite courses of action. Now the analysts assumed that the conflict was between biological impulses like sex and aggression and a person's internalized value system, otherwise known as his or her conscience.

While certainly one can feel conflicted over those things, the focus of the analysts was far too narrow. Experiential therapists like Fritz Perls and Carl Rogers felt that the basic conflict was over one’s need to express one’s true nature (self-actualization) and doing what was expected by everyone else. Family systems pioneer Murray Bowen framed this as a conflict between the forces of individuality and the forces of togetherness.

Those with such a conflict suppress parts of themselves that do not seem to conform to what they believe other important family members expect of them, but the suppression is never complete. Such a person will disqualify what they are trying to get across just in case it is unacceptable to others. If it is, then they can claim that they were merely misunderstood.

Unfortunately, when someone disqualifies what they are saying in this manner, the other people listening are on shaky ground when trying to determine what is being communicated to them. The communications are very confusing. In fact, just when listeners think they have a fix on it, the person may contradict themselves, leaving listeners to start to doubt their own perceptions about what was just said. In other words, when someone disqualifies themselves, they are often invalidating the person listening to them. The two concepts are not just similar to each other, they go hand in hand!

This leads to the proposition that when family members seem to be invalidating another family member, the apparent invalidators may really be disqualifying themselves.  Listeners would have no way of knowing this, and would be inadvertently led to believe that they were being mistreated by the apparent invalidator. Most therapists think this as well.

In families that produce children who grow up to develop BPD, this whole process is rampant and pervasive compared to the average family, as Linehan suggests. Because the person with BPD has frequently been invalidated, they start to disqualify their own opinions. In doing so, they invalidate everyone else. In other words, they end up giving every bit as good as they get.

Because of other factors which I will not go into here, the specific needs that patients with BPD tend to disqualify in themselves are their need to find a good balance between being cared for by others and self-actualization. As a result, they end up invalidating anyone who tries to form an intimate relationships with them.

If you have to deal with people who do this, there are well-established ways to prevent them from invalidating you. In future posts, I will detail some of them. They can all be found in my book for psychotherapists, Psychotherapy With Borderline Patients: An Integrated Approach.

A Splitting Headache

In my blog post of March 11, 2010, I described what I believe to be an absurdity that has been promulgated by the mental health profession about patients with borderline personality disorder (BPD). These individuals were said by theorist Marsha Linehan to have “apparent competency,” by which she meant that they appear to have certain abilities in some contexts which they in fact do not possess. I wondered how they were able to demonstrate competencies through performance that they actually lacked, and I opined that it is much easier to fake incompetence than competence. Perhaps it is the incompetence that is more apparent than real, and is in fact a highly-motivated but well-hidden choice.

Another popular idea in the field about patients with BPD is that they engage in something called splitting. Anyone who has treated a patient with the disorder in psychotherapy has ample eyewitness evidence that they often talk about other people as if they were, in their essence, either Gods or complete piles of horse manure, with nothing in between. This is splitting behavior. The fact that they sometimes act this way is an extremely valid observation, but what does it mean?

First of all, “splitting” others into “all good” and “all bad” categories was originally presumed by psychoanalysts to be a defense mechanism. A defense mechanism is a mental coping maneuver meant to both partly express and to ward off any feelings that a person might experience, as well as any accompanying impulses, that they find unacceptable in themselves. For example, a person who does not like to think of himself as angry at his father might “take it out” on someone else. This is an example of a defense mechanism called displacement.

Whenever we are faced with someone who does something heinous or who inspires us, we all have a tendency to “split,” or think of the person as all or mostly good, or all or mostly bad. This is completely normal. Many of us feel that child molesters, to take a common example, are monsters with no redeeming qualities whatsoever. Mother Teresa, on the other hand, is viewed by some as a true and flawless saint.

What happens in a situation in which someone else does something wonderful one day and something absolutely heinous the next, or vice versa? For example, what if your own father raped you one day when you were thirteen, and bought you a pony the very next day? (This actually happened to a patient I know of). Even therapists have trouble putting something like that together. Some therapists even accuse patients of making things like that up. Is it surprising that our patients might have to think about these characteristics separately in order to avoid severe cognitive confusion?

Along came a psychoanalyst named Otto Kernberg. He began to talk about “splitting” not as a defense mechanism but as a deficit. He believed that patients with BPD literally lacked the ability to see both good and bad in others or themselves simultaneously. According to his theory, future patients with BPD failed to negotiate a childhood developmental stage called rapprochement, which, according to the theory, takes place around the age of two. “Normal” two year olds supposedly then develop the ability to integrate good and bad images.

The problem with this formulation is that social psychologists have actually studied children to find out when normal children develop this ability, instead of just sitting around theorizing about it. In fact, three different studies using three completely different methods [Donaldson, S., & Westerman, M. (1986). Development of children’s understanding of ambivalence and causal theories of emotions. Developmental Psychology, 22(5), 655-662; Harter, S. (1986). Cognitive-developmental processes in the integration of concepts about emotions and the self. Social Cognition, 4(2),119-151; Selman, Robert. (1980). The Growth of Interpersonal Understanding. San Diego: Academic Press] all came to the same conclusion. Normal children do not begin to develop this ability until they reach the age of about eleven and a half. They do not get especially good at it until they are about fifteen years old.

Of course, analysts never read social psychology, so they are unaware that their theory is utter nonsense. They also ignore evidence from their own observations which should cause them to doubt the veracity of their “ego deficit” theory. They will readily acknowledge that patients with BPD are master manipulators. The patients with BPD know how to size anyone up in a very short time in order to best figure out how to make him or her personally feel either helpless, guilty, or angry in dealing with them. How could they do this so well if they were not able to gauge other people’s strengths and weaknesses simultaneously? This is an easy question to answer. They could not.

I once mentioned to an analyst that when any of my patients with BPD are in the right mood, they are easily able to list other people’s good and bad points at the same time. He responded that this observation does not prove that they are really able to see good and bad qualities simultaneously! I wondered: how on earth could a patient ever prove to this therapist that he or she is capable of anything?

Another point about splitting that applies to everyone, not just patients with BPD, is that when you are absolutely furious with someone else, you never feel like bringing up all their best qualities. Likewise, if you wish to butter someone else up, bringing up all of their faults is not in your best interests! Heaven forbid we should think of any of our patients as smart enough to know this.

In my opinion, splitting is only sometimes a defense mechanism, and it is never an ego deficit. It is rather an interpersonal strategy designed to elicit specific reactions from other people in the patient’s important relationships.

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.