Ch 3 Behavioural Patterns - Dialectical dilemmas (Linehan 1993)

Question 1

What are the main dialectical dimensions in patients?

Answer 1

1. Emotional vulnerability vs self invalidation
2. Active passivity vs apparent competence
3. Unrelenting crises vs inhibited grieving

Question 2

How does Linehan structure the model of the main dialectical patterns for the patient?

Answer 2

As 3 intersecting lines. Each line has one side of a dilemma on one end and the corresponding opposite on the other end. Where all the lines cross in the middle they are bisected into two sides. On one side is the patterns that have been more influenced by biological development of emotion regulation (Unrelenting crises, emotional vulnerability, active passivity) While the ones on the other side are influenced more by the social consequences of/reactions to their emotional expression

Question 3

What is a crucial factor in treatment

Answer 3

understanding and keeping in mind emotional vulnerability

Question 4

Why might someone with BPD respond negatively to/fear praise?

Answer 4

Because they have learned that praise leads to increased expectations, and them failing to meet those higher expectations and punishment

Question 5

What analogy does Linehan make for emotional vulnerbaility

Answer 5

Being a 3rd degree burn victim, having no emotional skin

Question 6

What are the 4 effects of an invalidating environment

Answer 6

1. Pressure to inhibit negative emotional expression results in not developing postural and muscular expressive changes associated with emotions
2. Does not learn to label emotions accurately
3. Unable to trust self: Does not learn when to trust her own emotional responses as valid reflections of situations/events
4. Adoption of invalidating behaviour change tactics. Unrealistically high expectations of the self and the use of punishment rather than reinforcement

Question 7

What two factors contribute to the preference for punishment over reinforcement as a method of behavioural change?

Answer 7

1. It is the only tactic she knows, therefore the idea of not using punishment leads to extreme fear of dyscontrol
2. An environment that emphasizes individual responsibility and teaches that transgressions should be punished

Question 8

What is the Emotional vulnerability vs self invalidation dialectical dilemma for the patient?

Answer 8

Who is to blame for her predicament: herself or the environment.

Who is right, her or the environment?

See pages 74-75 for more detail.

Question 9

What is the Emotional vulnerability vs self invalidation dilemma for the therapist

Answer 9

That both trying to induce change and expressing sympathetic understanding of the client as she is are equally likely to be experienced as invalidating

Question 10

How could sympathetic understanding and acceptance (non change oriented approaches) of a client as she is be experienced as invalidating?

Answer 10

panic at the idea that life will never improve. She is right and has been right all along therefore the current situation is the best than can be hoped for.

Question 11

How could trying to induce change in a client be experienced as invalidating?

Answer 11

Client could assume that the therapy was thought that she has been wrong all along and that the invalidating environment is right.

Question 12

What is active passivity

Answer 12

approaching problems passively and helplessly
and
demand solutions to problems from the environment
(people in their lives the therapist)

Question 13

What is a possible result of the patient demanding immediate solutions?

Answer 13

The therapist often will not be able to provide one, this is invalidating to the client, client will escalate demands, therapist will feel helpless and might blame the client which leads to a vicious cycle of further escalating demands

Question 14

What characteristic contributes to active passivity?

Answer 14

passive regulation style

Question 15

How does a passive regulation style develop?

Answer 15

In part temperamental disposition
History of failed attempts to regulate negative emotions and associated behaviour
Environment where problems are minimized

Question 16

How does active passivity relate to attempts to avoid abandonment?

Answer 16

When people can’t solve problems or regulate distress for themselves they must either tolerate the distress, or rely on others to help them. This results in emotional clinging and dependency

This dependency leads to fear of loss of the significant relationship and frantic attempts to avoid abandonment

Question 17

What is Apparent Competence

Answer 17

Tendency for borderline patients to appear competent and able to cope with everyday life at some times BUT at other times behave as though the observed competencies did not exist

Question 18

What is an example of apparent competence?

Answer 18

Someone who acts appropriately assertive in a work environment where she feels confident and in control but is unable to act appropriately assertive in intimate relationships where she has less control

Question 19

What are the main factors that are responsible for apparent competence among borderline patients?

Answer 19

1. Situation specific learning
2. Mood dependent learning
3. Failure to communicate vulnerability clearly to others (Nonverbal cues of negative emotions suppressed, which impairs communication of her vulnerability even when vocalized)
4. Large discrepancy between capabilities when they perceive they are in a supportive, nurturing, and secure and stable relationship, vs when they are not

Question 20

What is the active passivity vs apparent competence dilemma for the client

Question 21

What is the active passivity vs apparent competence dilemma for the therapist

Answer 21

On one side: Might be too demanding or unresponsive to subtle communications of distress. Might attribute a of lack of progress to resistance or a lack of motivation rather than a lack of skill which is invalidating and also prevents the therapist from teaching the necessary skills

On the other side: assuming the patient doesn’t have the capacities when she does

Question 22

Are the dialectical patterns universal?

Answer 22

NO, they are common but NOT universal
MUST be assessed and not assumed

Question 23

Who should be made aware of the dialectical patterns?

Answer 23

The therapist and the client, the patterns often resonate with the client

Question 24

What are 4 characteristics of high emotional arousal that make things particularly challenging for BPD clients?

Answer 24

1. Emotions are full system responses and they have difficulty with modulating all components (e.g, they don’t just have difficulty modulating physiological arousal but also responses like facial expressions or interrupting obsessional thoughts)
2. Emotional arousal interferes with with other behavioural responses (e.g., may interfere with planned, regulated, functional coping behaviours)
3. High emotional arousal and the inability to regulate it lead to a sense of being out of control/ sense of unpredictability about the self
4. The sense of being out of control leads to fears that increase emotional vulnerability (1. fear of situations where she has less control like new situations or ones with past difficulty 2. fear of behavioural expectations from others)

see page 68-69

Question 25

What is self-invalidation?

Answer 25

When someone adopts the characteristics of the invalidating environment resulting in oversimplifying the ease of solving life’s problems; looking to others for accurate reflections of external reality

Question 26

What does self-invalidation lead to?

Answer 26

Attempts to inhibit emotional experience and expression

Not trusting self, which inhibits development of identity and self confidence

Self-hate for not reaching goals

see page 72

Question 27

What are the both the ingredients and outcome of a synthesis between vulnerability and invalidation?

Answer 27

patience, acceptance, and self-compassion along with gradual attempts at change, self-management, and self-soothing

Question 28

What is the analogy that Linehan uses to explain how acceptance can also be invalidating?

Answer 28

She compares it to being an expert swimmer with a life raft who is watching someone who can’t swim fend for themselves while shouting “You can make it, you can do it” in a soothing voice.

Question 29

How does DBT deal with the dialectical dilemma of acceptance vs change?

Answer 29

By combining the treatment strategies of supportive acceptance and confrontation/change in a flexible way, based on keen observation of client reactions

The dialectical balance that the therapist must strive for is to validate the essential wisdom of each patient’s experiences (especially her vulnerabilities and sense of desperation), and to teach the patient the requisite capabilities for change to occur

Question 30

What is the defining characteristic of active passivity?

Answer 30

Passive about solving problems on her own, but active in trying to get the environment or others to solve them for her

The tendency to approach problems passively and helplessly rather than actively and determinedly AND a corresponding tendency to demand solutions to life’s problems from the environment/others when under extreme duress.

Question 31

What differentiates active passivity from learned helplessness?

Answer 31

Actively seeking help from the environment

Both feel helpless in solving their own problems, but someone with learned helplessness gives up and doesn’t both seeking help from the environment

Question 32

What are the 3 factors that influence apparent competence

Answer 32

1. Competence is variable and unpredictable (behavioural skills that do not generalize across mood states) patient and others have a hard time predicting competence
2. Failure of patient to effectively communicate vulnerability
3. The influence of interpersonal relationships on competence

Question 33

How do interpersonal relationships impact competence?

Answer 33

Borderline individual has access to behavioural and emotional competence under 2 conditions
1. She is in the actual presence of a supportive, nurturing individual
2. Perceives herself to be in a secure, supportive, and stable relationship