A Matter of Personality

From borderline to narcissism.

Why Does the Predominant Treatment Paradigm for Borderline Personality Disorder Neglect Family Dynamics?

What is invalidation and what role does it play?

Marsha Linehan is the creator of what is currently the most prominent psychotherapy paradigm used to treat Borderline Personality Disorder (BPD). Her Dialectical Behavior Therapy  (DBT) is often said to be the most "empirically-validated" of all such psychotherapy treatments. Actually, DBT is only "empirically validated" mostly for the treatment of one symptom of BPD called parasuicidality. But I digress.

Dr. Linehan's theory of the cause of BPD, for which she cited no actual scientific evidence when she first described it (although there has been some since), is called the "biosocial model." BPD, she believes, is created primarily by two factors. The first is the patient's genetic tendency to become emotionally dysregulated. Individuals with the disorder are highly reactive. They respond quickly and very strongly to environmental events and are slow to recover from this "dysregulated" state.

Whether the tendency towards becoming emotionally dysregulated is something purely genetic in origin or is the result of environmental factors in genetically-vulnerable individuals is an open question. Clearly both genes and environment contribute to most personality traits, but how much of each is required? I will mention some evidence for the answer to this question later in this post.

The second causal factor in the genesis of BPD, according to Linehan, is what she refers to as an invalidating environment.

Invalidation, as used in psychology, is not merely people disagreeing with something that another person said. It is rather a process in which individuals communicate to another person that the opinions and emotions of that person are meaningless, irrational, selfish, uncaring, stupid, most likely insane, and wrong, wrong, wrong.

Invalidators let it be known directly or indirectly that their target's views and feelings do not count for anything to anybody at any time or in any way. In some families, the invalidation becomes extreme, leading to physical abuse and even murder. However, invalidation can also be accomplished by verbal manipulations that invalidate in ways both subtle and confusing. 

Dr. Linehan wrote only briefly in her book (Cognitive-Behavioral Treatment of Borderline Personality Disorderabout which environment she is talking about as being invalidating (page 56-59), and she barely mentions it in her talks and videos. It is the family environment in which the person grew up.  Really, what else could it be? Of course, your spouse and friends can also invalidate you, but why would you choose to fall in with an unpleasant group like that if you were not already accustomed to this sort of treatment?  

When it comes to DBT, however, most of the energy in the psychotherapy treatment described by Dr. Linehan is directed at helping the patients accept themselves as they are, without much said about how they got that way in the first place, combined with teaching patients other skills that are helpful in reducing their emotional reactivity. These are referred to sometimes as self-soothing skills, and are presumed by many DBT therapists to be something that patients with the disorder just never learned.

I sometimes give my patients with BPD handouts which describe these skills from Dr. Linehan's Skills Training Manual. I usually find that patients have already tried at least some of these techniques on themselves without having had any instruction at all. That makes me wonder if perhaps their apparent lack of knowledge about the techniques in some interpersonal environments actually reflects a strong, fear-induced desire not to use such skills, rather than an actual absence of them.

In her book, Dr. Linehan does say that she focuses on the patient's interpersonal skills later in the therapy process. She even mentions that family therapy might be included. Mentions it once or twice. The first time on page 420 of her book. She does not say anything about what that family therapy might entail.



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David M. Allen, M.D., is a Professor of Psychiatry at the University of Tennessee and author of the book How Dysfunctional Families Spur Mental Disorders.

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