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.

If an invalidating environment is one of two main causes of the disorder as she theorizes, how come she does not address this very much in her treatment plan?

A few months ago, a story in the New York Times about Dr. Linehan ( possibly shed some light on this question. Dr. Linehan admits that when she was younger, she "attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on." She added, "I felt totally empty, like the Tin Man." Self injurious behavior and feeling empty are two of the hallmark symptoms of BPD. Did she have the disorder? According to the article at least, BPD is a diagnosis "that she would have given her young self."

Marsha Linehan

I have only personally met Dr. Linehan once very briefly, and she was perfectly appropriate and personable. However, I had heard the occasional rumor from other researchers that she has a little bit of the BPD in her. 

So why has she so studiously avoided family dynamics in her treatment paradigm when an "invalidating environment" is fully half of her theory about the cause of borderline personality disorder? And why would she include an invalidating environment in her theory if she, as someone who has struggled with the disorder, had not been invalidated herself? If her theory is true, she of all people would have experienced that.

The Times article does describe her family a bit, but there does not seem to be a whole lot of dysfunction in the description: 

          "Her childhood, in Tulsa, Okla., provided few clues. An excellent student from early on, a natural on the piano, she was the third of six children of an oilman and his wife, an outgoing woman who juggled child care with the Junior League and Tulsa social events. People who knew the Linehans at that time remember that their precocious third child was often in trouble at home, and Dr. Linehan recalls feeling deeply inadequate compared with her attractive and accomplished siblings. But whatever currents of distress ran under the surface, no one took much notice until she was bedridden with headaches in her senior year of high school.  Her younger sister, Aline Haynes, said: "This was Tulsa in the 1960s, and I don't think my parents had any idea what to do with Marsha. No one really knew what mental illness was." 

This description makes it sound as if she were just mentally ill for some unknown reason, and that that was the whole explanation for her behavior, does it not? She just somehow acquired a messed up brain. But that would only be half of her DBT theory, and a problematic part of the theory at that.  

In one study by researcher extraordinaire Andrew Chanen and others, adolescents who presented for the very first time with BPD did not show the volume reductions previously observed in parts of the brain's limbic system in many samples of adults with BPD (the hippocampus and amygdala)  - two of the MRI findings of adult BPD brains considered to be the most significant. They did, however, show small changes in one other part of the brain compared to controls. (Psychiatry Research: Neuroimaging 163 [2008] 116-125).

Andrew Chanen

This finding could mean that some of the brain phenomena that may create high emotional reactivity arise primarily from the effects of some other factor or factors. An effect, not a first cause. What factors might they be? An environmental factor? I would suspect so. Perhaps the invalidating environment?

So, again, why does Dr. Linehan relegate changing family behavior to what is basically a footnote in her treatment text? Of course I have no way of knowing the answer to this question in her case.  

With my patients who do not want to look too closely at their family dynamics, however, the reason why is crystal clear. They are very protective of their families, even if they complain unceasingly about them. They really do not want anyone to think badly of their family members, so they tend to keep the skeletons in the family closet to themselves, at least at first.

(In cases where they do try to make their family members look bad, as some patients with BPD do, they often do so in a way which makes the listener doubt their truthfulness or their ability to remember things correctly. In other words, they do so in a way in which they invalidate themselves).

Maybe if you just ignore a big and recurring family problem, it will go away. Not.

Bonus question about DBT: Do DBT therapists validate parking? 

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