Review by Stephen W. Hiemstra
One of the most difficult cognitive disorders is borderline personality disorder (BPD), which is diagnosed by ticking off at least 5 out of list of highly 9 provocative behaviors. Believed to be hopelessly unreachable, BPD patients were frequently shunned from treatment both because they routinely burn out their counselors and because insurance companies will not reimburse treatment, leaving families alone to deal with a highly dysfunctional and frequently abusive family member. The biblical picture of the BPD personality is Gomer, the wife of the Prophet Hosea, who is unfaithful, becomes a prostitute, and falls into slavery and who Hosea redeems from slavery much the same way as God redeems us from sin (Hosea 1:2; 3:2).
Hope for beleaguered families has recently come in a new approach to therapy, known as dialectical behavior therapy (DBT), which starts by answering the perplexing question posed by BPD: how could such as cognitive dysfunction persist over time with highly intelligent people who ought to be learning from their mistakes, like everyone else? Kelly Koerner, in her book—Doing Dialectical Behavioral Therapy— cites Marsha Linehan, who developed DBT (ix), in hypothesizing an answer to this question:
“…three biologically based characteristics contribute to an individual’s vulnerability. First people prone to emotion dysregulation react immediately and at low thresholds (high sensitivity). Second, they experience and express emotion intensely (high reactivity), and this high arousal dysregulates cognitive processes too. Third, they experience a long-lasting arousal (slow return to baseline).” (5).
In other words, BPD patients are very sensitive people whose learning process is effectively disabled by their hyper-sensitivity to criticism, sometimes arising from a history of child abuse or of pervasive invalidation (7). Because their sensitivity disables their ability to learn from their own mistakes, they repeat the behaviors that lead to those mistakes over and over again. These repeated mistakes disturb their family and friends, who respond with criticism of the patient which shames the patient even more than the mistake. Overwhelmed with negative feedback that the patient cannot process, the patient responds to the shame with avoidance behaviors (running away, using drugs, binging at the mall, jumping into bad relationships, staying up all night…) rather than correcting the underlying mistakes (11-12). The world of BPD is an unhappy world.
Koerner describes the purpose of her book as to: “show[s] why, when, and how to use the principles and strategies of dialectical behavior theory.” (xiii). DBT sets out to accomplish 5 functions:
- “Enhance client capabilities…
- Improve client motivation to change…
- Ensure that new client capabilities generalize to the natural environment…
- Enhance therapist capabilities and motivation to treat clients effectively…
- Structure the environment in the ways essential to support client and therapist capabilities…” (18).
Koerner writes in 7 chapters, which are—
- Tools for Tough Circumstances,
- Navigating to a Case Formulation and Treatment Plan,
- Change Strategies,
- Validation Principles and Strategies,
- Dialectical Stance and Strategies: Balancing Acceptance and Change,
- Assess, Motivate, and Move: Getting the Most from Each Interaction, and
- The Individual Therapist and the Consultation Team (xvii-xviii)
–and which are preceded by front matter (an author about section, note from the editor, foreword by Marsha Linehan, preface, and acknowledgments) and followed by a reference section and index.
A key concept driving DBT is the concept of pervasive invalidation, as Koerner writes:
“Bigger problems arise, however, when caregivers consistently and persistently fail to respond as need to primary emotion and its expression. Pervasive invalidation occurs when, more often than not, caregivers treat our valid primary responses as incorrect, inaccurate, inappropriate, pathological, or not to be taken seriously. Primary responses for soothing are regularly neglected or shamed; honest motives consistently doubted and misinterpreted.” (6)
The therapist practicing DBT works to observe instances of emotional dysregulation (see definition below) in the patient and works backwards from these incidents using behavioral chain analysis (see definition below) to determine precipitating events and vulnerability factors (42). Once these events and vulnerabilities are identified, then the patient is taught the skills necessary to avoid triggering the emotional dysregulation. The kicker is that highly sensitive patients may exhibit emotional dysregulation multiple times in a single counseling session. Consequently, the therapist must have a refined intuition as to when the patient begins to shut down and intervene to “validate” (see definition below) them in working to accomplish the goals for the session.
Let’s dial back into this last string of statements to define a few terms.
Koerner defines emotional dysregulation as:
“..the inability, despite one’s best efforts, to change or regulate emotional cues, experiences, actions, verbal responses, and/or nonverbal expression under normative conditions.” (4).
Where normally we might react to invalidating information by pausing to reflect, the patient here is firing up heated emotions (think door-slamming anger), even if no words are spoken, so that the therapy session cannot move to the next point until these emotions are dealt with.
Behavioral Chain Analysis
Koerner defines behavioral chain analysis as:
“…an in-depth analysis of events and contextual factors before and after an instance (or set of instances) of the targeted behavior. It is a way to identify the controlling variables for the behavior.” (42)
Typically, the therapist will stop the conversation, observe the patient’s behavior leaning towards emotional dysregulation, ask the patient if it is true, validate the patient, and then begin parsing back in the conversation to identify a triggering word or idea. Once a trigger is identified, the therapist engages the patient in a conversation about alternative responses to the trigger.
For BPD patients, change interventions require processing negative feedback appropriately and their sensitivity to such feedback makes it hard for them to hear, let alone respond to. Therefore, Koerner defines validation in these terms:
“With empathy, you accurately understand the world from the client’s perspective; with validation you also actively communicate that the client’s perspective makes sense…validation, in itself, can produce powerful change when it is active, disciplined, and precise. Used genuinely and with skill, it reduces physiological arousal that is a normal effect of invalidation and it can cue more adaptive emotions to fire.” (15).
Validation is more than “buttering the patient’s bread”, it communicates that the patient is truly understood, which may be the first time that they have experienced it and which helps enable the patient to trust the therapist.
Kelly Koerner is the director of the Evidence-Based Practice Institute, a clinical psychologist and DBT trainer. She has written a number of books. She received her doctorate from the University of Washington and studied under Marsha Linehan, who developed DBT.
Kelly Koerner’s Doing Dialectical Behavior Therapy is a fascinating book of obvious interest to counselors and other therapists working with difficult patients. I found her descriptions of the use of emotional wisdom in her case studies especially interesting, in part because they were both lengthy and detailed, as behavioral chain analysis requires.
1] The DSM –IV lists: 1. Feelings of abandonment, 2. Unstable relationships, 3. unstable self-image, 4. Impulsivity (in money management, sexual behavior, etc.), 5. Suicidal behavior, 6. instability of mood, 7. Feelings of emptiness, 8. Inappropriate levels of anger, and 9. Paranoid ideation (my abridgement). Also see: (Kreger 2008 25).
 BPD patients are about 2 percent of the general population but 12 percent of the male prison population and 28 percent of the female prison population. About 40 percent of the people using mental health services have BPD (Kreger 2008, 21).
 Spouses of BPD patients are a high risk of suicide.
 See discussion: (Stanford 2008, 197-212).
 Mental patients should not be confused with special needs individuals—mental patients often score very high on intelligence tests.
American Psychiatric Association (DSM-IV). 1994. Diagnostic and Statistical Manual of the Mental Disorders (fourth edition). Washington DC.
Kreger, Randi. 2008. The Essential Family Guide to Borderline Personality Disorder: New Tools and Techniques to Stop Walking on Eggshells. Center City: Hazelden.
Stanford, Matthew S. 2008. Grace for the Afflicted: A Clinical and Biblical Perspective on Mental Illness. Colorado Springs: Paternoster.