Ch 3 Behavioural Patterns - Dialectical dilemmas (Linehan 1993) Flashcards
What are the main dialectical dimensions in patients?
- Emotional vulnerability vs self invalidation
- Active passivity vs apparent competence
- Unrelenting crises vs inhibited grieving
How does Linehan structure the model of the main dialectical patterns for the patient?
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
What is a crucial factor in treatment
understanding and keeping in mind emotional vulnerability
Why might someone with BPD respond negatively to/fear praise?
Because they have learned that praise leads to increased expectations, and them failing to meet those higher expectations and punishment
What analogy does Linehan make for emotional vulnerbaility
Being a 3rd degree burn victim, having no emotional skin
What are the 4 effects of an invalidating environment
- Pressure to inhibit negative emotional expression results in not developing postural and muscular expressive changes associated with emotions
- Does not learn to label emotions accurately
- Unable to trust self: Does not learn when to trust her own emotional responses as valid reflections of situations/events
- Adoption of invalidating behaviour change tactics. Unrealistically high expectations of the self and the use of punishment rather than reinforcement
What two factors contribute to the preference for punishment over reinforcement as a method of behavioural change?
- It is the only tactic she knows, therefore the idea of not using punishment leads to extreme fear of dyscontrol
- An environment that emphasizes individual responsibility and teaches that transgressions should be punished
What is the Emotional vulnerability vs self invalidation dialectical dilemma for the patient?
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.
What is the Emotional vulnerability vs self invalidation dilemma for the therapist
That both trying to induce change and expressing sympathetic understanding of the client as she is are equally likely to be experienced as invalidating
How could sympathetic understanding and acceptance (non change oriented approaches) of a client as she is be experienced as invalidating?
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.
How could trying to induce change in a client be experienced as invalidating?
Client could assume that the therapy was thought that she has been wrong all along and that the invalidating environment is right.
What is active passivity
approaching problems passively and helplessly
and
demand solutions to problems from the environment
(people in their lives the therapist)
What is a possible result of the patient demanding immediate solutions?
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
What characteristic contributes to active passivity?
passive regulation style
How does a passive regulation style develop?
In part temperamental disposition
History of failed attempts to regulate negative emotions and associated behaviour
Environment where problems are minimized
How does active passivity relate to attempts to avoid abandonment?
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
What is Apparent Competence
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
What is an example of apparent competence?
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
What are the main factors that are responsible for apparent competence among borderline patients?
- Situation specific learning
- Mood dependent learning
- Failure to communicate vulnerability clearly to others (Nonverbal cues of negative emotions suppressed, which impairs communication of her vulnerability even when vocalized)
- Large discrepancy between capabilities when they perceive they are in a supportive, nurturing, and secure and stable relationship, vs when they are not
What is the active passivity vs apparent competence dilemma for the client
What is the active passivity vs apparent competence dilemma for the therapist
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
Are the dialectical patterns universal?
NO, they are common but NOT universal
MUST be assessed and not assumed
Who should be made aware of the dialectical patterns?
The therapist and the client, the patterns often resonate with the client
What are 4 characteristics of high emotional arousal that make things particularly challenging for BPD clients?
- 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)
- Emotional arousal interferes with with other behavioural responses (e.g., may interfere with planned, regulated, functional coping behaviours)
- High emotional arousal and the inability to regulate it lead to a sense of being out of control/ sense of unpredictability about the self
- 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
What is self-invalidation?
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
What does self-invalidation lead to?
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
What are the both the ingredients and outcome of a synthesis between vulnerability and invalidation?
patience, acceptance, and self-compassion along with gradual attempts at change, self-management, and self-soothing
What is the analogy that Linehan uses to explain how acceptance can also be invalidating?
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.
How does DBT deal with the dialectical dilemma of acceptance vs change?
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
What is the defining characteristic of active passivity?
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.
What differentiates active passivity from learned helplessness?
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
What are the 3 factors that influence apparent competence
- Competence is variable and unpredictable (behavioural skills that do not generalize across mood states) patient and others have a hard time predicting competence
- Failure of patient to effectively communicate vulnerability
- The influence of interpersonal relationships on competence
How do interpersonal relationships impact competence?
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
