Let's do Dialectical Behaviour Therapy (DBT)

[Phoenix_Rising]

Good afternoon DBT adventurers,
Welcome to part 2 of the introductory chapter of the DBT skills training manual. Once again I am trying to summarise...and once again I am finding it super difficult because it is ALL important. Oh well, here goes...

Understanding Emotion Dysregulation

Biosocial Theory: How Emotion Dysregulation Develops.
According to Linehan (2015), BPD is a severe mental disorder which results from serious emotion dysregulation. Linehan describes suicidal behaviour as being a response to unbearable emotional suffering (p. 5). I so very badly wish that more mental health professionals understood this. The stigma that continues to surround BPD is so crushing. I don't know how many times I have been told by mental health professionals that I am manipulative and attention seeking. I don't know how many times I have been told that I just need to grow up. How can we ever expect the broader community to understand BPD, when the mental health professionals hold such attitudes! I am so very VERY grateful for the wonderful people at SANE who truly "get" it.

The DBT Model of Emotions
According to Linehan (2015), emotions are brief, involuntary, full-system, patterned responses to internal and external stimuli (p. 6). Together, the following components make up an emotional response:

⦁ Emotional vulnerability to cues. The emotionally vulnerable individual is one who experiences a high level of negative emotions at baseline (i.e. when nothing at all is really going on), is super sensitive to emotional stimuli, experiences very intense responses to emotional stimuli, and takes a long time to return to baseline after being emotionally aroused.

⦁ Internal and external events that act as cues. Note that an event can only act as a cue if it is noticed. If you don't notice something, it won't elicit an emotion.

⦁ An appraisal and interpretation of the cue.

⦁ Response tendencies. These include neurochemical and physiological responses (i.e. things that happen in the brain and other parts of the body), experiential responses and action urges.

⦁ Nonverbal and verbal responses and actions.

⦁ The aftereffects of the initial emotion. This can include secondary emotions (e.g. feeling ashamed of having become so angry).

A core tenet of DBT is that by changing one component of this emotional system, you can change the entire system.

Emotion Dysregulation
According to Linehan (2015), emotion dysregulation is the inability, even when one's best efforts are applied, to change or regulate emotional cues, experiences, actions, verbal responses, and/or nonverbal expressions under normative conditions (p. 6). My favourite bit of this statement is even when one's best efforts are applied. Guess what? That means you can threaten me, shame me, and hand out aversive consequences as much as you like, it isn't going to help me to become better at regulating my big feelings. I am always doing the best I can - even if my best sometimes looks extremely chaotic to those around me.

Biological Vulnerabilities
Some people are born more impulsive, more sensitive to emotion cues, and more likely to experience negative emotions than other people. This is why it is unhelpful to compare people. If two people go through exactly the same experience, it is unfair to say that because one coped well with it, the other person should be able to cope well too. We are all born with different strengths and weaknesses...and that's ok.

The Caregiving Environment
As well as a person's natural disposition that we are each born with, the social environment also contributes to the development of emotion dysregulation. Linehan (2015) suggests that the family environment can contribute to the development of emotion dysregulation in three ways:

⦁ The child's emotions may be invalidated, and parents may not role-model how to appropriately express emotions.

⦁ The way family members interact may reinforce emotional arousal. That is, a child may learn that they need to express very intense emotions in order to get their needs met.

⦁ The child's natural disposition and the caregivers' parenting style may be a poor match.

The Role of the Invalidating Environment
From an evolutionary perspective, the purpose of emotions is to convey information. If someone expresses an emotion and it is invalidated (e.g. ignored, not heard, or labelled as somehow "wrong"), then it makes sense that the person will express the emotion more strongly in order to be heard. If the other person doesn't "get" what the person expressing the emotion is trying to convey, they will tend to try and shut the person down with further invalidation (e.g. ignoring, telling the person they are over-reacting, telling the person they shouldn't be feeling that way or to stop feeling that way). This becomes a vicious cycle; the person trying to be heard escalates their expression of emotion in order to be heard, and the more it is escalated, the more the other person responds in an invalidating way to shut it down, which escalates it more etc. etc. etc.

This very much sums up my entire life, and yes, it was tricky reading this because it raises a whole lot of painful "if only's..." in my mind, which in turn make my tummy ache. I very much hold core beliefs of "no one hears me," "no one believes me," "I do not matter." Therefore, some of the most comforting words for me are "I hear you" and "I believe you." One of the things I find so super amazing here in Forum Land is the way in which I can use my calm voice to ask for support, and support appears. You have no idea how novel this experience is for me, and I'm not sure if I will ever grow tired of experiencing it here. I think I probably need to experience it about a bazillion times in order to negate the bazillion experiences I have had of not being heard.

Anyway, back to the story...
So...biological vulnerability (nature) and social environment (nurture) can interact in one of four ways:

⦁ Someone who is biologically predisposed towards developing emotion dysregulation and who also then experiences an invalidating environment, is at super high risk of developing emotion dysregulation.

⦁ Someone who is NOT biologically predisposed towards developing emotion dysregulation, but who experiences a particularly invalidating environment (e.g. where there is severe abuse or neglect), is also likely to develop emotion dysregulation.

⦁ In contrast, if someone was born biologically predisposed to emotion dysregulation but was raised in a very supportive and validating environment, then they are likely to become a well adjusted albeit sensitive adult. This demonstrates that biology (or innate nature) is certainly not destiny.

⦁ The ideal of course is to be born without the biological predisposition towards developing emotion dysregulation AND be fortunate enough to grow up in a nurturing and validating environment. Such a combination tends to lead people towards becoming emotionally healthy well-adjusted adults.

I recognise that I fall very much into the first of these categories. Being Aspie, I am naturally superly duperly sensitive. I can see that if my family dynamic hadn't been so complex and unhealthy, and if the icky abuse stuff hadn't happened, I would have become a successful albeit socially awkward and quirky adult. Again, the "if only's" are weighing heavily in my thoughts right now.

Reading this conceptualisation of how emotion dysregulation develops caused me to reflect again on the fact that people try to differentiate between BPD and complex PTSD. I am yet to find anyone who can explain to me how one would do a differential diagnosis between these two labels. People try to argue that not everyone with BPD has a history of trauma. This is quite correct. According to Linehan (p. 9) it is estimated that 60-75% of people with BPD have a history of childhood trauma. However, it is entirely possible for someone to be naturally superly duperly sensitive such that even a relatively healthy environment is experienced as invalidating, leading to emotion dysregulation. Equally, as described above, it is possible to be born with a naturally resilient disposition, but experience such severe invalidation (through abuse or neglect), that emotion dysregulation develops. The end result is the same. Therefore I genuinely have no idea how any clinician can ever label someone as having both BPD and complex PTSD. I am super open to anyone trying to explain this to me because right now I view this very much as an example of using two labels when one would be perfectly sufficient

Ok, well I think that is probably more than enough for today. All comments, thoughts, reflections and questions are warmly welcomed (not that I am going to guarantee I will have any answers for you ). The next installment will be about the consequences of emotion dysregulation. Stay tuned. 

[Phoenix_Rising]

@Faith-and-Hope most importantly, now I superly duperly want @CheerBear to make me a tiny turtle rug to snuggle into when I'm in her pocket. 

[Faith-and-Hope]

😊😊😊 @Phoenix_Rising .....

[CheerBear]

Thank you so much for sharing your thoughts, insight and summary of the points you made above @Phoenix_Rising.

I came across this point (on p.318 - not referencing it correctly today) that said that individuals who experience high emotional sensitivity, have often been "overdosed" with comments and suggestions that fall along the lines of "if you would just change your attitude, you could change your feelings". These messages come often from people who model high emotional control as well as strong disapproval of emotional expression. Linehan touches on theory that suggests "emotional distress is due to secondary responses (eg., intense shame, anxiety or rage) to primary emotions". I am not 100% clear on this yet, however I'm assuming that these secondary responses may be largely due to invalidating/unsupportive/punishing responses to a person's expression of emotion, by others (particularly significant others), from within their environment.

I think it is really important for people to be aware that intense emotions can be difficult enough to experience, and that relationships and environments are crucial factors in influencing how they are worked through/resolved (or not).

[Phoenix_Rising]

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@CheerBear wrote:

Linehan touches on theory that suggests "emotional distress is due to secondary responses (eg., intense shame, anxiety or rage) to primary emotions". I am not 100% clear on this yet, however I'm assuming that these secondary responses may be largely due to invalidating/unsupportive/punishing responses to a person's expression of emotion, by others (particularly significant others), from within their environment.

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Hi @CheerBear, I really like this idea that a lot of distress is due to secondary responses. This is one area in which I really have got a better handle on things now than I did in years gone by. Feelings are feelings and they are ok. It is ok to be sad or angry. It saddens me when I see people in Forum Land telling themselves that they "shouldn't" feel a certain way and that they are angry or ashamed for feeling what they feel. I totally agree with you that these messages stem from a history of being told by others that whatever the person is feeling is somehow wrong.

I think a really good example of this is the way in which I experience a-typically intense grief. In a bazillion instances over the years, I have been shamed for this and told that I'm over-reacting etc. In contrast, when CherryBomb left Forum Land, @NikNik, @Former-Member @Former-Member and @Former-Member provided (and continue to provide) a huge amount of support around that. The attitude I experienced from them was that my grief simply is what it is and we will work through it as it is. This has made SUCH a difference to the way I have been able to process the loss. I know that my level of grief over CherryBomb's leaving is atypical. But that's all it is - atypical. It isn't wrong or bad. And having people be able to sit with me in it, rather than complicate it with secondary feelings of shame, has made it a vastly different experience compared to the bazillion other losses I have had in my life.

I wonder if anyone else has any examples of how sitting with feelings and accepting them as they are, has created a different experience compared to if you feel guilty, ashamed etc. for having those feelings?

[Phoenix_Rising]

Are People With BPD Manipulative?

So...last night the wonderful @NikNik ran topic Tuesday, which was focused on BPD. You can read it here: Topic-Tuesday-Living-with-BPD-your-questions-answered. It was super cool (even if it did mildly fry my brain). One of the issues that was discussed was whether or not people with BPD are manipulative. I found it intriguing that several people with BPD self-identified as being manipulative. Personally, I do not self-identify as being manipulative despite being told a bazillion times by others that I am. I subscribe to the view articulated by Marsha Linehan. The following is her perspective on whether people with BPD are manipulative, and I would be very interested in hearing what other people think about this perspective. The remainder of this post is taken directly from pp. 16-18 of the following source:

Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

The verb "manipulative" is defined as "to influence or manage shrewdly or deviously" in the American Heritage Dictionary (Morris, 1979, p. 794) and as "to manage or control artfully or by shrewd use of influence, often in an unfair or fraudulent way" by Webster's New World Dictionary (Guralnik, 1980, p. 863). Both definitions suggest that the manipulating individual intends to influence another person by indirect, insidious, or devious means.

Is this typical behaviour of borderline individuals? In my own experience, it has not been. Indeed, when they are trying to influence someone, borderline individuals are typically direct, forceful, and, if anything, unartful. It is surely the case that borderline individuals do influence others. Often the most influential behaviour is parasuicide or the threat of impending suicide; at other times, the behaviours that have the most influence are communications of intense pain and agony, or current crises that the individuals cannot solve themselves. Such behaviours and communications, or course, are not by themselves evidence of manipulation. Otherwise, we would have to say that people in pain or crises are "manipulating" us if we respond to their communications of distress. The central question is whether or not borderline individuals purposely use these behaviours or communications to influence others artfully, shrewdly, and fraudulently. Such an interpretation is rarely in accord with borderline individuals' own self-perceptions of their intent. Since behavioural intent can only be measured by self-report, to maintain that the intent is present in spite of the individuals' denial would require us either to view borderline individuals as chronic liars or to construct a notion of unconscious behavioural intent.

It is difficult to answer contentions by some theorists that borderline individuals frequently lie. With one exception, that has not been my experience. The exception has to do with use of illicit and prescription drugs in an environment that is highly controlling of drugs. My own experience in working with suicidal borderline patients has been that the frequent interpretation of their suicidal behaviour as "manipulative" is a major source of their feelings of invalidation and of being misunderstood. From their own point of view, suicidal behaviour is a reflection of serious and at times frantic suicide ideation and ambivalence over whether to continue life or not. Although the patients' communication of extreme ideas or enactment of extreme behaviours may be accompanied by the desire to be helped or rescued by the persons they are communicating with, this does not necessarily mean that they are acting in this manner in order to get help.

These individuals' numerous suicidal behaviours and suicide threats, extreme reactions to criticism and rejection, and frequent inability to articulate which of a number of factors are directly influencing their own behaviour do at times make other people feel manipulated. However, inferring behavioural intent from one or more of the effects of the behaviour - in this case, making others feel manipulated - is simply an error in logic. The fact that a behaviour is influenced by its effects on the environment ("operant behaviour" in behavioural terms) says little if anything about an individual's intent with respect to that behaviour. Function does not prove intention. For example, a person may quite predictably threaten suicide whenever criticized. If the criticism then always turns to reassurance, we can be quite confident that the relationship between criticism and suicide threats will grow. However, the fact of the correlation in no way implies that the person is trying or intending to change the criticizer's behaviour with threats, or is even aware of the correlation. Thus, the behaviour is not manipulative in any standard use of the term. To say then that the "manipulation" is unconscious is a tautology based on clinical inference. Both the pejorative nature of such inferences and the low reliability of clinical inferences in general make such a practice unwarranted in most cases.

[CheerBear]

Accepting Our Emotions

 Hi @Phoenix_Rising and others who may be reading 🙂

Phoenix_Rising you asked,

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@Phoenix_Rising wrote:

I wonder if anyone else has any examples of how sitting with feelings and accepting them as they are, has created a different experience compared to if you feel guilty, ashamed etc. for having those feelings?

---

In response, I wanted to share my experience of being supported to accept my emotions (this has been a different experience to what I have had a lot of in the past)

When I think of what it was like during my time in a refuge, I remember experiencing a huge range of intense emotions. I think my "primary emotions" at the time were grief, fear and anger. For a wide range of reasons, I was not particularly well supported through this time by certain people playing significant roles in the process. I recieved direct messages along the lines of:

"Focus on the positives"
"It could have been worse"
"At least you still have...."
"This was your choice"
"I don't understand why you are so...."
"You just have to let it go"
"Just don't worry about..."

As well as indirect messages including ignoring, dimissing, and even laughing about (yep that really happened) what was going on.

All of these reponses, whether direct/indirect, well-intentioned/malicious, understandable/incomprehensible etc. had the effect of adding "secondary emotions" of shame, guilt, mistrust, rage, confusion, and humiliation to the already very hard to work through mess of things I was experiencing. I think these feelings came about from what I percieved the underlying message of these direct and indirect messages were - that what I was feeling was wrong (and therefore that I should change them/not accept them).

In contrast, when I experience/d these in a supportive understanding environment, I have been able to also experience the natural process of working through it (sitting with and accepting that this is how it is right now).

As an example, here in forumland I feel safe and supported. Here I believe that people are genuinely caring and empathic, and willing to sit with me while I work through things. The messages I have recieved here have been along the lines of:

I can understand why you are feeling like this. I hear you. I am with you while you feel this way. I have felt a similar way/experienced a similar thing. I don't have any experience with what that might be like, but I can hear and feel that it is this way for you right now. It is ok to feel this way.

My counsellor is also someone really supportive. I believe that she wants to understand what it is like for me and that she believes "I've got this" (sometimes I just need someone to remind me of that and help me figure out how). She asks about my feelings including where and how I experience them in my body, what they look like, how I work through them, what they mean about who I am/what I value, and when I have felt like this before. She doesn't try and change them, instead she helps me to accept that this is what is happening, and trust that it is ok that it is.

These responses feel validating. They come from people who I believe are genuine and who I trust. They facilitate rather than hinder, the natural process I need to go through of coming to terms with my emotions and resolving them. They don't add to my challenges. Instead of fighting myself to not feel a certain way, my energy can be put into working it out.

In addition to feeling as if my feelings are "ok", another benefit of accepting my feelings at the time, is that I have also experienced that in doing so, they do change themselves. I have felt afraid that if I may never, ever, EVER stop feeling a certain way before (perhaps because fighting feelings can take from working through them). Through recent experiences with support through my emotions, I can really feel that they will pass and change and that they do not stay forever.

While I do believe there can be a place and time for supporting people with a gentle lift out of their 'muddle' (which can look like a whole lot of different things and there are different levels of "lift"), the danger in approaching it with a lack of sensitivity and without awareness of your how your own emotions at the time (frustration/impatience/fear etc) may come into play is that the message can be percieved as "there is something wrong with how you are feeling". As you said Phoenix_Rising, feelings are not wrong or bad. They might need some working out, but there is nothing wrong with feeling a certain way.

That's it from me today 🙂

[Phoenix_Rising]

Hi @CheerBear,

Wow, I can't believe people said some of those things to you during your time in a refuge. That is so awful. Just reading those comments, I can feel the pain of the invalidated feeling in my tummy. It amazes me how much people don't get it - even people in the helping professions.

I have real issues with the whole concept of positive reframing because I think so often it is done in a really clumsy way that ends up feeling super invalidating. I super like the concept of sitting with big feelings - hence why I spend most of my time out on the ocean riding waves. The idea of sitting with them rather than trying to push them away or fight them is definitely one of the biggest things I've got out of reading the DBT manual (the first time around ). It makes SUCH a difference. And as you said, CheerBear, if we sit with the feelings, we discover that they do actually pass and in fact, pass quicker than if we fight them or try to tell ourselves that we shouldn't feel that way.

I'm super glad that you have had positive experiences here in Forum Land of hearing messages that it is a bazillion percent ok to feel what you are feeling.

[Phoenix_Rising]

Good morning DBT adventurers,

This is an interesting article: http://www.abc.net.au/news/2017-10-04/the-myths-and-stigma-behind-borderline-personality-disorder/90...

I particularly like this bit:

"The idea that they're actually manipulating is actually quite incorrect if you look at it cognitively speaking," he said.

"What they're trying to do is get their needs met and also unburden themselves of this emotional distress which gets locked inside them.

I continue to be intrigued by the idea that some people with BPD self-identify as being manipulative. I am curious to know if people arrive at this conclusion themselves, or whether it is what they have been told by mental health professionals (and others). I am super interested in people's thoughts about this.

@NikNik

[Phoenix_Rising]

Good morning DBT adventurers. This is the last part of the introductory chapter describing Linehan's theoretical model of emotion dysregulation generally, and how it presents in BPD specifically. Hooray say all the people like @CheerBear who is busting to get to the doing bit. Thus without further ado, let's go...

The Consequences of Emotion Dysregulation

According to Linehan (2015), being able to regulate their own emotions is one of the most important skills that a child needs to develop because without good emotion regulation, the child (and later the adult) will struggle to engage in goal-directed and prosocial behaviours. This is because all of the person's energy and effort is going into dealing with their overwhelming emotions.

Reading this bit, I was reminded of how many times I've been told that I'm "behaving in an infantile manner" and that I need to "just grow up." I remember talking about this with my very first therapist more than twenty years ago. He said that telling someone to "just grow up" is about as useful as telling them to "just get taller." I found that super validating. I KNOW that I can't do some things that other adults are able to do. But guess what? Shaming me about it and telling me to just do it, doesn't make me any more capable of doing it!!! One of the things I super like about DBT is that through it I have learnt (and I am continuing to learn) HOW to better do those things that I'm not so good at. DBT is purely pragmatic, without any judgement or conveying any sense that I am wrong, bad or defective for not being so good at some things.

　

Self harm and suicidal behaviours.

I am guessing we probably all know that self-harm and suicidal ideation and behaviour is a key characteristic of BPD. All too often this is labelled as attention seeking and manipulative behaviour. However, according to Linehan (2015), self-injurious and suicidal behaviours can be thought of as maladaptive but highly effective emotion regulation strategies...suicide ideation, suicide planning, and imagining dying from suicide...can bring an intense sense of relief. Planning suicide, imagining suicide, and engaging in a self-injurious act (and its aftereffects if it becomes public) can reduce painful emotions by providing a compelling distraction (p. 9).

Reading this, I am again struck by how Linehan's attitude towards self-harm and suicidal thoughts/behaviours, differs so markedly from the attitude I have experienced from so many mental health professionals (and other people) over the years. When I engage in an act of self harm, or when I am talking about my suicidal urges to someone, I am doing so because I am trying to deal with overwhelming emotions and I am trying not to act on my urge to suicide. Does this make me demanding, manipulative and just attention seeking? If a person runs into the street screaming for help because their clothes have accidentally caught on fire, does this make them demanding, manipulative and just attention seeking? If a cancer patient in hospital is crying out for pain relief medication, does this make them demanding, manipulative, and just attention seeking? To me, in each of these examples the person is in extreme pain and crying out for help. They ARE seeking attention...but are they "just attention seeking." Why is it that in some instances when people seek attention they are attended to, whereas in other instances they are labelled as "just attention seeking???"

　

Poor sense of self.

Another key feature of BPD is a lack of a sense of self. According to Linehan (2015), this is due to chronic emotion dysregulation because emotional consistency and predictability across time and similar situations are prerequisites of identity development (p. 11). This is definitely something that I super struggle with - as evidenced by the fact that I am 40 years old and still don't know what I want to be when I grow up.

When I was at high school, we studied Shakespear's King Lear. There is a line in the play where Lear says who is it that can tell me who I am? I went to someone who I super trusted and told him that this line deeply resonated with me and that I didn't know who I was. He replied, "You are Phoenix_Rising, now go home." Two years later I saw my first therapist at the insistence of this same person. I still have a very poor sense of self - although it has definitely improved over the past few years. However, it still remains a big puzzle piece in the puzzle of where I might fit employment-wise.

　

Difficulties in relationships.

Again, I'm guessing that everybody is aware of the fact that any sort of interpersonal relationship with someone with BPD can be...er...interesting. According to Linehan (2015), difficulties controlling impulsive behaviours and expressions of extreme negative emotions can wreak havoc on relationships (p. 11). I think some of you are nodding so vigorously right now that I can see it through my computer screen.

I recognise that I do not have a strong sense of how challenging it can be engaging with...well...me. I only know that it is difficult, through what I have read. I don't have any lived experience of being in a relationship with someone with BPD. What I do know is that every person who I have ever loved, has left my world. I know that I've had four apprehended violence orders taken out against me, and I've had several other people threaten legal action if I didn't stay away from them. I know that I have never had a romantic relationship aside from the abuse stuff that happened when I was 14 and my "partner" was a 32 year old leader of the church youth group I attended. I know that my last friend walked out of my world in November, 2016. I know that my siblings and I parted ways after my mother died in 2004. I know that last year a psychologist refused to keep working with me, telling Victims Services that I had traumatized her. I know that if I was to die today, there isn't a person on the planet who would claim my body. So...I can't articulate to you exactly what it is about me that makes me difficult to be around, but I do accept there is SOMETHING about me that makes it that way. I am guessing that there are others around here (particularly carers) who have much greater insight into the challenges of being in an interpersonal relationship with someone with BPD than I do.

Well, that's it for me for today. I would be super interested to hear people's thoughts or comments, although I'm equally ok with people just reading along. Come to think of it, I'm also totally ok with having no one read along. For me, part of the magic of Forum Land is that I will never ever know who might be reading. I find that kind-of cool.