Despite decades of research, there are still many who believe Borderline Personality Disorder (BPD) is untreatable. Nothing could be further from the truth. Over the years, I have experienced firsthand the resilience of people in the face of serious BPD and difficult life situations. And I have seen firsthand how effective DBT can be when clients are committed to obtaining the mindful awareness and skills needed to create a life worth living.
Dialectical Behavior Therapy (DBT) reduces the suffering of people with Borderline Personality Disorder (BPD). Research consistently shows DBT improves over-all functioning and social adjustment, not only for BPD but many other disorders as well. That said, some BPD symptoms are easier to treat than others. Treatment is more effective in decreasing anger, suicide attempts and self-harm than fears that others might leave or feelings of emptiness. The overwhelming good news is full-blown BPD symptoms rarely come back after remission.
What Causes BPD?
A combination of genetics, traumatic experiences and changes in the brain likely cause BPD. The disorder is five times more likely if a person has a first degree relative with BPD. People with BPD have structural and functional changes in the brain, mostly in the areas that control impulsivity and emotional regulation. More than half of people with BPD report early childhood or adolescent trauma. But not all people with BPD have any or all of these risk factors. And many people who have these risk factors do not have BPD. So what’s going on?
Biosocial Model Explains Behaviors
Marsha Linehan’s biosocial model helps explain what’s going on and gives insight into what makes DBT effective in treating BPD. When clients and their families have a better understanding of what drives their actions and emotions then empathy, acceptance, and change become easier.
According to Linehan’s biosocial model, neurotransmitters function differently in people with BPD, making them more emotional, aggressive, or reactive – and more prone to intense emotions.
People with BPD usually have been invalidated throughout their lives which leads to emotional hypersensitivity. Invalidation can take many forms, including emotional, physical or sexual abuse. More often, however, invalidation is more subtle. Imagine a frustrated young boy trying to communicate with his parents being told his feelings don’t matter time and again. Imagine a young girl repeatedly told “boys don’t like girls who get angry.”
Invalidation effectively teaches children their feelings are wrong and that they need other people to know what they are feeling and if their feelings are valid. They come to believe feelings are bad and to be avoided. As invalidated children grow up, they develop a deep-seated internal tension. On one hand, they believe they must live up to others’ expectations and avoid having negative emotions. At the same time, they resent feeling they have to live up to others’ expectations and feel worthless because they inevitably experience “bad” feelings. As they continue to grow up, they develop anger because they can never just be who they are.
A pattern develops. The tension builds up and emotions explode. The more their emotions explode, the more those around them come to expect the explosions. The teenager with BPD may subconsciously come to believe no one will believe their emotions are real without an out-of-proportion display of emotion.
People with BPD have been invalidated for so long they don’t trust what they feel unless their feelings take over the room. It’s only then that they can relax and say “I told you I was upset”.
Invalidated emotions also lead to all or nothing behaviors and beliefs. A person with BPD may swing wildly, feeling needy and dependent one day then distancing themselves entirely the next. Although the individual desperately wants love and approval, they have difficulty accepting love and approval due to their low self-esteem.
As children, pleasing people and avoiding negative emotions started out as necessary survival strategies. As adults, these strategies no longer work. The person with BPD feels chronically overwhelmed by distressing emotions. In distress, their behavior can become self-sabotaging and self-destructive when they can’t cope with their emotions. Emotionally needy people attract people equally needy so social and romantic relationships often end up reinforcing negative patterns.
DBT Encourages Acceptance and Change
To the person with BPD, just the thought of change may be invalidating. It implies there is something wrong with them. This is why DBT gives equal emphasis to finding the synthesis between acceptance and change, balancing radical acceptance and nonjudgment of self with the recognition change can create a life worth living.
Out of the biosocial model, Linehan developed four sets of skills needed to enable people with BPD to live richer, fuller lives. Over time, these skills have been researched and used to effectively treat many more disorders from substance abuse to anxiety and depression to eating disorders.
- Core mindfulness teaches acceptance of oneself and what is in the world. It is based on the notion that people can’t change what they don’t notice and can’t notice what they don’t accept.
- Distress tolerance teaches acceptance of distress. There is much that happens in life beyond anyone’s control. Distress tolerance skills help the person with BPD tolerate their emotions in situations that can’t be changed.
- Emotion Regulation teaches people to change how they interact with their emotions. These skills enable the person with BPD to regulate their emotions, so they don’t feel powerless against them.
- Interpersonal Effectiveness teaches people to change in order to get their needs met in a way that is kind and respectful of both themselves and the other person.
One could argue these are the skills most of us should have learned intentionally at some point in life but didn’t. To the extent we use them at all, they are so automatic we barely notice. This living on autopilot works to one degree or another when we had more-or-less good enough role models along the way. These skills are anything but automatic for people who have been chronically invalidated. While all of us could benefit from more mindful and intentional use of DBT skills, the skills can be life-changing for those who grew up in invalidating homes who have BPD.
Adapted in part from Recovery From Borderline Personality Disorder May Be Attainable by Ashley Brown, PhD, March 1, 2014.
Sandra Miller, MSW, LCSW and sometimes blogger, sees clients at St. Louis DBT four days a week. She is currently taking individuals and couples as clients.