Standing on Shaky Ground

Linehan, 1993

Marsha Linehan takes us through the first of our two (14 year old…) trips across the shaky ground of personality disorder. When Jim told us in class today that it is a “mess,” I figured the thicket of conflicting ideas, incomplete theories, and constructs that fell apart upon scrutiny. Though this may be the case broadly, I was actually fairly impressed with how Linehan was able to make a strong case for her position on one of the most contentious of disorders.

I should insert a bit of personal disclosure before I continue: I have, in recent years, had much direct contact with (and consequent from) an individual with BPD. Indeed, she was treated by the selfsame Dr. Gunderson -- using DBT -- who is cited throughout the article (e.g. p. 8) during the time I knew her. As such, many of the positions I hold on this matter are strongly influenced by this experience (as is the case, it seems, for many people who have had close relationships with people with BPD), and I may therefore make statements stemming from my n of 1 that may not otherwise generalize.

A quick note on the interpersonal relationships section (p. 9): yes, I know what they mean by the various criteria, but it seems these should be awfully difficult ideas to get good interrater reliability on, since almost everyone who has been in serious or complex relationships has experienced “intolerance of aloneness,” “stormy relationships,” “abandonment concerns,” or some confluence of them. The criterion I am most concerned about, though, is the “treatment regressions” one. I understanding this to be byproduct of BPD as we understand it now, but to include it as an inclusion criterion for the disorder seems to belie the whole notion of trying to come up with good treatments for it in the first place! What if DBT or its successors end up minimizing regression in the vast majority of cases? Does this mean they’ve “cures” a symptom of BPD?

One thing I appreciate about Marsh Linehan is her perspective on individuals with BPD. While many clinical psychologists view the disorders they treat or research through a clinical (in the sterile or… pejorative… sense) lens, it seems that this approach is a double-edged sword. On the one hand, you maintain scientific objectivity and appropriate distance. On the other hand, one may lose sight of the actual issues facing individuals with the disorder; to cite Allison’s quote in her Blog of the child who spoke at the Autism: the Musical Q&A “A person with autism can't tell you what it's like to not have autism and a person without autism can't tell you what it's like to have autism. It's part of me, I don't know what it's like.” This is problematic in a practical, and, perhaps, ethical sense. Linehan, however, seems to have no qualms playing the role of advocate and empath for her patients (and this is reflected in her treatment methodology). Her sympathy for them is particularly evident in her damning of the “pejorative” terminology that’s often associated with the diagnostic criteria for BPD (see pp. 17-18). Though I’m not sure all clinical researchers need hold such a sympathetic position (though, perhaps they do?), it does seem to be an important position to exist to keep us from going so far down the pure science route that we lose sight of who we’re working for in the first place.

Given Linehan’s position, I must say that my biggest concern stems from an unlikely source. Again, this is coming largely from my subjective experience with one individual who met criteria for BPD, but it seems that the goal of DBT doesn’t seem to address the underlying distress of individuals with the disorder. Indeed, this seems to be a natural position for many CBT-derived treatments to take (“we’re not trying to eliminate the unwanted thoughts you have, just how you react to them”). Though this makes sense functionally, I believe it is important to see it as a starting point, not a conclusion, for treatment targets. Even Linehan’s own studies bear out somewhat the phenomenon I’m addressing, when she finds “no differences between groups in self-reported depression” and that “DBT was not more effective… in raising subjects’ rating of their own success in accepting and tolerating both themselves and reality.” (p. 24) These self-report measures (read: subjective) haven’t changed much under treatment. This is precisely what I saw with my friend, whose dangerous behaviors declined, but still came home daily reporting on a slew of upsetting interpersonal interactions which where often based upon “unusual perceptual experiences” (DIB-R term). It was, of course, wonderful to see her living more safely; I also hoped that DBT might begin to help her intervene in her own head to decrease her distress. Though I know this is, of course, a latent construct I’m pointing to, it certainly isn’t one for her (and, I imagine, others with BPD). Is there any hope, when the research is populated by observational measures and practice is slowly being engulfed by EST-CBT, for treatment of these symptoms to emerge as a target – if only an incremental one?

Speaking of increments, the value of the “face” of DBT is perhaps an interesting one. By this, I am speaking of the Zen basis for DBT, and its consequent “hippie-dippy” and decidedly unscientific presentation when examined by a casual observer. It is evident after reading Linehan’s introduction that these facades are, for the most part, a mask for sound, integrative behavioral and cognitive-behavioral approaches. Even the purported exceptions to this -- e.g. “emphasis on the therapeutic relationship as essential to treatment” (p. 20) -- are dubious at best. How, then, do we reconcile this with the scientific goal of parsimony? Perhaps, it is on the grounds of what might be called incremental utility. While it may be that behavioral principles have tremendous therapeutic power, if people are typically wary of them (gasps of fear and horror!), is it not incumbent upon the purveyors of treatment technology to consider this in the design process? Perhaps Linehan is on to something when she couches DBT in her “Eastern” terms. If doing so will increase the willingness of individuals to enter treatment, and their receptivity once they get there, has she not then increased the value – the utility – of the treatment, even if it had already existed in some form before? This is an idea I’ve been batting about for some time now (Jim & Allison, my apologies if I unduly exposed you to it in several of our past interactions), but one about which I’m curious as to others’ thoughts.