Brief History and Background of Client
Our client Kathy is a well-nourished 23-year old female presenting with significant emotional dysregulation. She grew up in a stable middle-class household and her family background appears to be non-contributory. She has an older brother and a younger sister. She has no history of substance abuse. She is neither suicidal nor parasuicidal. She is intelligent and exhibits a high level of cognitive awareness. She is employed as a computer software designer. Upon intake assessment her demeanor is hesitant and her affect is flat. She speaks uncertainly with every sentence seemingly ending in a question.
Specific Treatment Problems and Target Behaviors
She describes the following primary symptoms: (1) Social disinhibition. She feels shy and incapacitated in groups. She overcompensates by becoming gregarious, talking too loudly and dwelling on conversationally inappropriate topics, leading to subsequent feelings of rejection and ostracism. “I get stuck in these cul-de-sacs. I don’t know how to do what’s ‘normal’ and the more I try the less ‘normal’ I get.” (2) Unstable personal relationships. She never has been able to sustain an on-going romantic relationship. She flirts inappropriately. Although she says she cares for her parents and siblings she avoids contact with them. She feels lonely. (3) Lack of empathy. She is unable to read “social signals” and pick up expressive cues about other people’s feelings and moods. She is bored by their activities and concerns and doesn’t care what they think, either about her or topics of interest in their own lives. “I am living among strangers,” she avers, and she feels “like I’m in another country” where she can’t adapt to local customs or conventions. (4) Mood swings, emotional intensity and lability leading to anhedonia and feelings of vulnerability (including frustration, depression and anxiety). “I feel isolated and afraid.” She is mildly agoraphobic and often prefers staying at home to activities in the world. “I can spend hours sitting by the window feeling melancholic and despondent.” She cannot identify specific events precipitating these emotions. There are times however when she is euphoric with similar lack of correspondence to events in the world. “I could be one of those motorcycle guys at a county fair that spins around faster and faster in a centrifuge until they are parallel to the ground” (we referred her to a psychiatrist for evaluation of possible manic tendencies). (5) Progressive loss of capacity to function at work. Her job requires a high level of attention to detail. “I cannot concentrate and lose track of where I’m at and what I’m doing. (6) Constant derisory internal monologue leading to poor self-image. “I’m like a spectator in the balcony of the play of my own life but I’m also on stage and then I forget my lines. I thought I’d practiced but I guess not enough.”
Specific Treatment Goals
Our specific treatment goals are: (1) to restore Kathy’s ability to function practically in the world; (2) to relieve the personal distress she feels at her lack of coping skills; (3) to restore her confidence and expertise in social environments and group contexts; (4) to alleviate her derogatory self-image; and (5) to improve her own subjective impressions of the quality of her lived experience.
Specific Therapeutic Techniques Used
Upon intake assessment and review of the foregoing we tentatively diagnosed Kathy as having borderline personality disorder (BPD). We determined the best course of action would be to treat with dialectical behavior therapy (DBT), in particular utilizing theory initially developed by Marsha Linehan. DBT includes the application of four core skills: (1) Core Mindfulness Skills, (2) Interpersonal Effectiveness Skills, (3) Emotion Regulation Skills and (4) Distress Tolerance Skills). While Kathy’s therapy course included all four of these core skills, we have chosen to focus on emotion regulation skills.
The DSM-IV criteria for BPD (American Psychiatric Association, 2000) include “A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation;” “identity disturbance: persistent and markedly disturbed, distorted, or unstable self-image or sense of self;” “affective instability: marked reactivity of mood;” and “chronic feelings of emptiness.” In the leading text Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993a, p. 10) Linehan elaborates on the DSM-IV criteria with the following characteristic behavioral patterns:
1. Emotional vulnerability: A pattern of pervasive difficulties in regulating negative emotions, including high sensitivity to negative emotional stimuli, high emotional intensity, and slow return to emotional baseline, as well as awareness and experience of emotional vulnerability. ***
2. Self-invalidation: Tendency to invalidate or fail to recognize one’s own emotional responses, thoughts beliefs, and behaviors. Unrealistically high standards and expectations for self. ***
3. Unrelenting crises: Pattern of frequent, stressful, negative environmental events, disruptions, and roadblocks – some caused by the individual’s dysfunctional lifestyle, others by an inadequate social milieu. ***
5. Active passivity: Tendency to passive interpersonal problem-solving style, involving failure to engage actively in solving of own life problems. ***
6. Apparent competence: Tendency for the individual to appear deceptively more competent than she actually is. ***
Linehan devised DBT as a form of comprehensive cognitive-behavioral treatment for complex personality disorders such as BPD (Dimeff & Linehan, 2001). It particularly is appropriate for clients with a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image (Lieb & Zanarini, 2004). Treatment of these behavioral patterns usually is difficult. Medications typically have limited effect and until recently there was no psychosocial treatment approach with empirically demonstrated efficacy (Lynch & Robins, 1997).
DBT has proven to be highly effective. In a one-year randomized controlled trial (plus one year of post-treatment follow-up) DBT was associated with better outcomes than other therapies in most target areas (Linehan et al., 2006). Increasingly clinicians are integrating the strategies it proposes into clinical packages (Holmes, Georgescu & Liles, 2006). Although BPD may persist it does not last forever and most clients respond well to DBT therapy (Paris, 2005).
For DBT to be clinically effective Kathy must acquire a repertoire of emotion regulation skills. These include: (1) identifying and labeling emotions; (2) identifying obstacles to changing emotions; (3) reducing vulnerability to “emotion mind;” (4) increasing positive emotional events; (5) increasing mindfulness to current emotions; (6) taking opposite action; and (7) applying distress tolerance techniques (Linehan, 1993b, p. 84). We determined to concentrate on (1) – (3) and (5).
1. Identifying and Labeling Emotions. At our first session with Kathy we introduced her to emotion regulation skills, which is the first step in Linehan’s approach. Emotion regulation skills include observing and describing (a) the event prompting a particular emotion; (b) how one (cognitively) interprets it; (c) how one (subconsciously) experiences it (including autonomic nervous system response); (d) the behaviors that express it; and (e) how it affects functioning (Linehan, 1993b, p. 84).
Therapist: Today we’re going to look at something called “emotion regulation.” People with BPD tend to have intense and strong emotions that change frequently. Being able to understand them will give you the skills you need to take back control.
K: Are you saying that my emotions are bad?
Therapist: Not at all – whether happy or sad, emotions are valuable and an essential part of life. However if they make you suffer unnecessarily then it’s important to assert control over them. First we’re going to discern where your emotions originate and then learn ways to manage them. This will reduce your vulnerability to negative emotions. You will become able to experience positive emotions and limit the undesirable pain in your life that your emotions are causing.
K: That sounds great but everything makes me emotional!
Therapist: To understand why let’s start with a few basic ideas. There are two kinds of emotional experiences: reactions to events in your environment and reactions to your own thoughts. Can you give me an example from your own life of the former?
K: It would be like when my mom calls and I get upset because she is nagging me about not visiting her often enough.
Therapist: That’s good – what about an example of a reaction to your thoughts?
K: Sometimes when I can’t figure out what to do at work I’m disappointed with myself and feel ashamed, like I should have done better.
Therapist: Yes, I see – can you give me another example from your life but this time when emotions have been useful?
K: When I feel ashamed about not doing something the right way it makes me try even harder the next time and usually I do better. The shame actually ends up motivating me.
Therapist: What about a time when emotions have been destructive?
K: I hate feeling embarrassed in front of my friends. Even a little thing like mispronouncing a word makes me feel like I’m such an idiot. Then I get mad at my friends and defensive and I start blaming them for being mean to me. I storm out of the room.
Therapist: Let’s take a closer look at what you just said. What is the emotion that caused the conflict?
K: My anger. It made me yell at my friends.
Therapist: In other words, you felt anger and it was destructive but your first emotion was embarrassment. This was your primary emotion. Your second emotion was anger. Your primary emotion caused you to have a secondary emotion, which was even more destructive.
K: You’re right, the embarrassment caused the anger.
Therapist: See, you’re becoming aware of your emotions. It may seem like a weird way to characterize them but you need to view them either as primary or secondary. Many times it’s the secondary emotion that is causing the problems. When you reassess each emotion’s relative influence it helps you better understand the roles they play.
2. Identifying Obstacles to Changing Emotions. After emotions have been identified and labeled Linehan’s second step is identifying obstacles to changing them. By deploying emotions one can control other’s behavior and reinforce one’s own perceptions and interpretations of events, both of which are powerful inhibitors to emotional change (Linehan, 1993b, p. 85).
Therapist: Let’s discuss the purpose of emotions. Emotions communicate to others. We communicate our emotions verbally and nonverbally. Nonverbal communication is more important than verbal communication. For the most part when someone’s body expressions don’t match what someone says most people are inclined to believe the nonverbal behavior. Even if it isn’t a correct indicator it’s still powerful. Have you ever felt misread by others because of mismatched nonverbal communication?
K: Yes. I remember once when I was at work I was feeling great and not upset at all but my boss thought I was mad because (according to her) I looked brooding and upset. I had no idea what she was talking about because I was happy.
Therapist: It’s always important to be aware of both your verbal and nonverbal communication. In order to communicate effectively they need to match up. When they don’t, that’s when you run into the problem of people not fully understanding you.
K: Yes that makes sense. I need to be more aware of this distinction.
Therapist: Our reactions to people and events also give us information. Emotions help us communicate with ourselves. For example if you are walking alone and feel uneasy about someone who is following you, then your emotions are telling you that you might not be safe. They help us act on our instincts. But you’ve also got to be aware of how emotions can get carried away. You can communicate something to yourself that’s more extreme than necessary.
K: So while I can use my emotions to help me understand certain situations I may be in, I also need to be careful to not use my emotions to prove a point to myself?
Therapist: Yes. You shouldn’t use your emotions to convince yourself that what you’re perceiving is the best take on whatever situation you may be in, the environment in which you find yourself. Can you give me an example when your emotions were self-validating like this but caused more problems than were necessary?
K: Once I saw my then-best friend and my then-boyfriend having lunch together and I was furious. I automatically assumed they were “hooking-up” behind my back. I confronted both of them. It turned out though that they were planning a surprise birthday party for me. Even though this was so thoughtful I still felt the need to justify my anger level – so I still got angry with them! It’s like I wanted to prove to myself that I had a reason to be angry.
Therapist: That’s a good example of an obstacle that prevented you from expressing yourself more like the way you actually felt. If you’re able to understand what inhibits you from communicating your emotions then you’re one step closer to being more in control of them.
3. Reducing Vulnerability to “Emotion Mind.” This is Linehan’s third core emotion regulation skill. Emotions affect one’s physiological state. Environmental stress, for example, produces anxiety. It can be controlled by simple steps such as nutrition, getting enough sleep, and exercise. Mastering one’s emotions using these techniques is a form of expertise that can be learned just like any other form of specialized activity (Linehan, 1993b, p. 85).
Therapist: Let’s look at how you can reduce your vulnerability to negative emotions by emphasizing essential life skills. Take physical illness for example – how would you characterize your emotions when you’re feeling sick?
K: I would say I’m more on edge and have less patience.
Therapist: That’s not uncommon. If you’re unwell or have any kind of physical ailment it’s critical to seek treatment. The sooner you’re feeling better, the sooner you’ll feel less vulnerable to negative emotions. A balanced diet also really can help you feel better, both physically and emotionally. This might sound simple but it can have a huge impact on your life.
K: I definitely could benefit from eating better. I’m always busy and eat a lot of junk food. It makes me feel full but then I crash and feel gross. When I feel gross I’m not in as good a mood.
Therapist: That’s a great example. It’s vital to be aware of these types of life events. They seem trivial but really can put one in a negative place. Other habits that can lower our ability to deal with emotions are using drugs, not getting enough sleep and not getting enough exercise. These all help us to regulate our emotions. If one of these aspects is out of whack you’re not going to feel your best, which can cause negative emotions to occur more easily.
K: You’re right. I really need to be more aware of how I’m treating my body.
Therapist: You also can limit your negative emotions by participating in activities you’re good at. This will help you feel more competent, self-confident and in control. Do you have any hobbies or sports where you feel you excel?
K: I used to sing in the church choir when I was younger. I loved it. Now that you bring it up, I’ve wanted to start to sing again.
Therapist: That would be a great start. The more you take care of yourself both physically and mentally, the less likely you’ll be to accumulate negative emotional baggage.
5. Increasing Mindfulness to Current Emotions. Linehan hypothesized that after one experiences an emotion one starts to dissect, evaluate and judge it. Becoming mindful of an emotion, in a cognitive sense, is completely different than experiencing it. By doing so one can become discerning and develop criteria to distinguish between positive emotions and negative emotions (Linehan, 1993b, p. 85). One then can accentuate the positive ones and reduce the occurrence of the negative ones. This exercise must be undertaken impartially, without preconceived notions, and non-judgmentally. An additional benefit of being mindful of one’s emotions is that one can role-play and problem-solve by imagining hypothetical events (with their emotional correlatives) and then devise the appropriate (welfare-maximizing) emotional response. We implemented this strategy with Kathy by exposing her to emotionally threatening situations so she would learn not to react in a visceral, negative way. This enabled her to see that the situation was not as catastrophic as it seemed to her when her emotions were fully in control.
Therapist: When we are mindful of our emotions it means we’re observing and describing them just as they are. This technique of examining emotions allows you to create distance between yourself and your emotions so you can start to understand them and problem-solve. If you’re up for it, what I’d like to do is expose you to an emotionally unpleasant situation and have you practice letting go of your emotional suffering so you really can examine your emotions from this mindfulness perspective. I’ll talk you through this exercise so you can then use these skills in your everyday life. How does this sound?
K: OK with me, I’m willing to try it.
Therapist: You mentioned you had an argument with your boyfriend and best friend because you felt that they were fooling around behind your back. I want you really to focus on the emotions you were feeling. Can you reconstruct and re-feel them?
K: Yes, I am angry, betrayed and upset.
Therapist: Take a step back and look at your feelings. Acknowledge them but go to a place where you can feel outside of them enough to look at them. Experience them as coming and going. They have highs and lows, like a rhythm. Don’t block them; open yourself up to them. You’re not trying to get rid of them, you’re not trying to make them stay, you’re simply experiencing them as they are. You’re not defined by your emotions, they’re a state you’re in. Don’t fight them, or amplify them. They exist for a reason. You also can envision times you’ve felt the opposite of what you’re feeling now. By practicing this you can achieve better control over your emotions. You accept the anger and the hurt, but you don’t need to act it out.
K: Hmmm, because I took myself outside of the emotion I was feeling I was better able to discern its qualities. I felt the emotion but didn’t have a negative consequence from it because I didn’t act it out. I can see how if I had taken a step back when I got mad at my boyfriend and best friend then I could have avoided the argument we had. By understanding that out-of-control feeling better, it’s reduced. I feel more in control.
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*This paper was co-authored with Jessica Sloan.