Posted by: carolg1849 | June 20, 2009

New York Times – Q&A with Marsha Linehan

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Recently, readers asked about borderline personality disorder on the Consults blog. Marsha Linehan, professor of psychology at the University of Washington and the developer of dialectical behavior therapy, a technique to treat the disorder, responds.

Question

Suicide Threats and ‘Manipulative’ Behavior

I realize that the term “manipulative” is pejorative and disfavored, yet it accurately describes my sister (diagnosed with borderline personality disorder, among other things) who uses the threat of self harm very effectively to get whatever she wants, such as money, undivided attention, etc. I am so tired of her holding my parents hostage with her constant suicide threats and non-lethal (yet scary) self-harming behavior that I find myself thinking some very awful things (like how much better off we would all be if she would just get it over with…)

How would you recommend helping my parents deal with this situation? My parents were not saints when we were growing up, but my sister has exacted her revenge on them and then some. FYI, my sister has already been through a dialectical behavior therapy program, which did not help her one iota, from what I can observe.

Jill

Answer

Dr. Linehan responds:

Oh, my friend! Sounds like you and your parents have had a really difficult time. It is true that people — including therapists — who spend time around people with borderline personality disorder often feel manipulated and feel like they are held hostage. Behaviors such as suicide threats often have that effect on people. It is really a tragedy for both parties when that happens.

It is rare, however, that a person with borderline personality disorder is actually trying to “manipulate,” that is, to manage, control or influence in a subtle, devious, or underhand manner (Oxford dictionary); or to handle with mental or intellectual skill (also from the Oxford dictionary). A suicide threat or attempt is certainly not subtle or devious. It is right out in the open!

I think it is safe to say that folks with borderline disorder are usually not skillful in their interpersonal communication styles. The problem is that they often can only express their emotional pain by screaming out how much they want to be dead, which is likely true. Self-harm, alas, regulates emotions for many.

Effective treatment requires that a therapist teach families how to respond in ways that do not reinforce suicidal behaviors while, at the same time, not punishing the individuals for their pain. It is, unfortunately, extremely tricky and often takes a lot of coaching from a very competent therapist.

As for dialectical behavior therapy: First, it does not help everyone, even when expertly applied. But in your case I am wondering several things. How well trained were her therapists? Did the treatment consist of comprehensive dialectical behavior therapy, or just some D.B.T. skills? Did the therapist bring in the family, which is often crucial in dialectical behavior therapy?

My heart goes out to you, your family and your sister. I have talked to many sisters of people with borderline disorder and I know that you are in an extremely difficult place that is often not understood by anyone. I wish I could be of more help.

Question

Getting Help for Those Who Don’t Think They Need It

Do you have advice for helping someone to get help, especially when they don’t believe that anything’s wrong with them? (”It’s not me, it’s the world that’s crazy” — that’s a direct quote.) (I should add that this person is my mother, and that she’s in her 50s, and has had the symptoms since she was young.)

rather not say

Answer

Dr. Linehan responds:

If another person does not see the need for getting help, it is their right to not do it. Sorry. In those cases, you might want to find a friends and/or family group. In our clinic, for example, we teach a skills course for friends and families. It is open to friends and families of anyone who is difficult to care for, work with or be around, and the focus is on how to live a skillful life no matter what people are intimately involved in your life.

Question

When a Mother Has Borderline Personality Disorder

My situation is like that of “rather not say.” With my mother, I “pay attention to the feeling,” not the situation, and am able to diffuse conflict, but getting her to act and do something seems impossible.

Her advancing age provides another challenge to the situation, as we want her to make decisions she just doesn’t seem to want to make (or seem capable of making): choices like getting into an independent living facility, having joint surgery to relieve pain, and on and on. Instead she chooses to live like a bag lady.

When they’re faced with “traumatic” choices, how do you help a BPD navigate stressful situations?

LR

Answer

Dr. Linehan responds:

To be perfectly honest, you seem to be doing a lot of the right things with your mother. Her problem sounds common to a lot of people as they age, not just to folks with borderline personality disorder. Continuing to love her and support her emotionally, and giving your mother sage advice and options may be all that you can do for her. You might want to look into a support group for yourself.

Question

Is Someone With Borderline Personality Disorder Dangerous?

How dangerous is the person who has the disorder? How should a friend react to the psychosis?

Pat Devono, Akron, Ohio

Answer

 

Dr. Linehan responds: 

There is no evidence that persons with mental disorders, including borderline personality disorder, are any more dangerous than anyone else. Psychotic episodes are not common in BPD. If you suspect a friend is having a psychotic episode, talk to someone in his or her family or, if a family member is not available, be sure the person is still seeing his or her therapist on a regular basis.

Question

When Dialectical Behavior Therapy doesn’t Work

I have borderline personality disorder and bipolar disorder, and I attended ten weeks of dialectical behavior therapy (DBT). I don’t feel that it has helped me very much at all. I’m recently on Zeldox, which is doing more for me than DBT has. Should I take another workshop? I fear I may not have grasped it completely and I could use a non-pharmaceutical way of dealing with my rapidly shifting emotions and for when I’m in crisis.

Thank you.

Amanda

Answer

Dr. Linehan responds:

It is fabulous that you are looking for effective treatment. Alas, perhaps you did not receive comprehensive dialectical behavior therapy. Dialectical behavior therapy is not a workshop; it is an integrated treatment program that includes a therapist and/or skills trainer who can give you a lot of coaching on using new skillful behaviors and strategies to replace or overcome difficulties.

Remember, that at its core, D.B.T. is cognitive behavior therapy. Therefore, it must include a good clinical assessment of the factors that are causing you your problems together with a strategic plan and treatment aimed at treating the problems that you have. We have very good data suggesting that D.B.T. skills training is effective for many. But, coaching is almost always needed.

You must also remember that no therapy, no matter how good, works for everyone. A behavioral assessment that is specific to you and focuses on yourproblem behaviors and emotions rather than just on a diagnosis is essential to effective D.B.T. (or any psychotherapy). With bipolar disorder, you will need skills but also most likely you will need to stay on medications. I wish you well.

Note: Dr. Linehan also advises readers in search of additional information to visit two Web sites in particular:

The Web site of the National Education Alliance for Borderline Personality Disorder, www.borderlinepersonalitydisorder.com, where visitors can listen and watch for free over 50 videos and 90 audios specifically on BPD; and

The TARA (Treatment and Research Advancements) National Association for Personality Disorder Web site, at www.tara4bpd.org.

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