Treating borderline personality disorder can seem like a no-win situation. If we try traditional cognitive-behavioral therapy (CBT) and emphasize change, patients feel unheard and invalidated; they may withdraw, quit, or even attack. But if we suggest ways to accept unhappy situations, they may feel we don’t understand their suffering.
A more effective approach is dialectical behavior therapy (DBT), first developed to treat highly suicidal persons with borderline personality disorder and used with other populations that have difficulty regulating their emotions.
This article describes how invalidating environments may damage emotional health and suggests how psychiatrists can use DBT’s methods when treating borderline personality disorder.
BIOLOGY PLUS ENVIRONMENT
For the patient, borderline personality disorder’s behavior clusters (Table 1):
- function to regulate emotions
- or result from emotion dysregulation.
DBT theory identifies emotion dysregulation as the primary deficit in borderline personality disorder. Biologically based emotional vulnerability is seen as interacting with an inability to modulate emotions because of a skills deficit.
Emotional vulnerability. Three characteristics—high sensitivity, high reactivity, and slow return to baseline emotional state—define high emotional vulnerability:
High sensitivity. The person reacts more quickly and to more things than do others in emotion-provoking situations. When walking, for example, they may pass someone who doesn’t say hello. Most people would shrug this off, but persons with high emotional sensitivity may quickly notice, assume there is a problem, feel they have done something wrong, then feel shame and anger.
High reactivity. Their emotional reactions are large, and the high arousal dysregulates cognitive processing.
Slow return to baseline. Events stack up because emotional reactions are long-lasting for persons with high emotional vulnerability. They don’t have time to get over one thing before something else happens.
DBT postulates that, over time, borderline personality disorder results from the transaction of biological emotional vulnerability and an invalidating environment. This therapeutic model asserts that biology and the environment are flexible, and interventions may influence both.
Invalidating environment. DBT acknowledges that invalidation occurs in all environments, even nuturing ones. It becomes detrimental when a vulnerable person is exposed to pervasive invalidation that is not related to the validity of the person’s behavior or to the person’s expressed emotions or thoughts.
An invalidating environment has three characteristic patterns. One is indiscriminate rejection of communication of private experiences and self-generated behaviors.
Case examples. Mary, age 8, says she’s been teased and it hurt her feelings. Her mother tells her she is making too much of the incident. Mary questions herself and searches the social environment for cues about how to respond to similar situations in the future.
Robbie, age 4, completes a drawing and shows it to his father with delight. His father points out some “sloppy” coloring. If his father repeatedly finds fault with his work, Robbie is likely to not show him his work or stop drawing, and his expressions of delight are likely to decrease.
Invalidating environments may also punish emotional displays and intermittently reinforce emotional escalation. Someone may show disapproval for or ignore a person’s genuine sadness or fear but attend to angry outbursts that result when the person feels ignored.
The third invalidating pattern is to oversimplify the ease of problem-solving and meeting goals.
Case example. As a child, when Susan asked for help, her mother would say “just do it,” without considering the skills her daughter needed to accomplish tasks. When Susan became frustrated, her mother demanded that she “just stop cying,” even though no person could modulate his or her emotions that quickly. As an adult, Susan now sets unrealistic goals and expectations for herself and despairs when she is unable to solve problems in her life.
These three invalidating patterns cause persons to search the social environment for cues about how to respond to situations. They may question themselves, their identity, and the appropriateness of any emotional expression. As a result, they may oscillate between emotional inhibition and extreme emotional styles, set unrealistic goals and expectations for themselves, and eventually despair of being able to solve their problems.
Specific to borderline personality disorder is that the environment ignores genuine emotional expression, and the individual’s emotions escalate. This pattern is reinforced when the listener finally rewards emotionally extreme behavior with attention or desired changes.
As the pattern is repeated over time, extreme emotional reactions become the norm rather than the exception, and the emotional chaos can make the person wish to die. Acting on that desire when past expressions of desperation have been ignored or invalidated can provide attention or interventions that would never happen after simple emotional expressions.