Dialectical Behavior Therapy: Dialectical Dilemmas and BPD

The lives of people with Borderline Personality Disorder (BPD) can appear contradictory and chaotic. They are frequently highly emotional and have difficulty regulating the expression of their emotions, which leads them to feel out-of-control. However, they often don’t trust their emotional responses and have high, unattainable expectations for themselves. At one moment, they may be desperate for help and want to give up, while at others they are seemingly skilled and capable. Often, people with BPD experience constant stress with immediate and extreme emotional reactions, but they hold back the expression of grief and sadness.

There are many theories that have been developed over the years to explain the behavioral and emotional experiences of people with BPD. The dialectical dilemma’s described by Marsha Linehan, Ph.D., in her book Cognitive-Behavioral Treatment of Borderline Personality Disorder, are not considered universal. However, in her development of DBT, she found three common dialectical dilemmas experienced by people with BPD. These 3 dilemmas are each defined by their opposite poles. The process of investigating and synthesizing these apparently contradictory characteristics and behaviors often helps individuals with BPD understand problematic behaviors like self-injury.

The three dialectical dimensions include emotional vulnerability versus self-invalidation, active passivity versus apparent competence and unrelenting crisis versus inhibited grieving.

Emotional Vulnerability versus Self-Invalidation

Emotional vulnerability is an extreme sensitivity to emotional stimuli. This is the person who has strong and persistent emotional reactions to even small events. Emotionally vulnerable people have difficulty with such things as modulating facial expressions, aggressive action and obsessive worries. On the other end of the dialectical pole is self-invalidation. Self invalidation involves discounting one’s own emotional experiences, looking to others for accurate reflections of reality and over-simplifying problems and their solutions. The combination of these two characteristics leads to oversimplifying problems and how to achieve goals and extreme shame, self-criticism and punishment when goals are not met.

Active Passivity versus Apparent Competence

Active passivity is the tendency to approach life’s problems helplessly. Under extreme stress, an individual will demand that the environment and people in the environment solve his or her problems. Apparent competence, on the other hand, is the ability to handle many everyday life problems with skill. Often, people with BPD are appropriately assertive, able to control emotional responses and successful in coping with problems. These competencies, however, are extremely inconsistent and dependent on circumstances. The dilemma of active passivity and apparent competence leaves the individual feeling helpless and hopeless with unpredictable needs for assistance and fear of being left alone to fail.

Unrelenting Crisis versus Inhibited Grieving

With unrelenting crisis, repetitive stressful events and an inability to recover fully from one before another occurs results in urgent behaviors such as suicide attempts, self-injury, drinking, spending money and other impulsive behaviors. The individual would need urgent care to avoid these consequences from happening. Inhibited Grieving is the tendency to avoid painful emotional reactions. Constant crisis leads to trauma and painful emotions, which the individual frantically attempts to avoid.

These three common dialectical dilemmas are intended to help the therapist understand and relate to the individual’s experience. Although the concept of these dilemmas was originally developed by Linehan in her work with people with BPD, DBT is currently used successfully with people with a wide variety of issues. It is likely that these dilemmas a relevant for a wide variety of people.

Linehan M. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press, 1993.

7 Replies to “Dialectical Behavior Therapy: Dialectical Dilemmas and BPD”

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  2. I am interested in this blog, both as an interning counselor and as a parent of a teen girl who may be BPD. We’re into our 10th month of suicide attempts, blah living, crises, roller coasters, hospitalizations and scary day-in/day-out family life. I look forward to reading this blog as I am am slightly familiar with Marsha’s work and there are limited therapists trained in this field in my area I live in.

    1. DBT resources can be difficult to find depending on where you live. I hope the blog continues to be helpful for you. If you are looking for DBT Treatment in your area, you might try http://www.behavioraltech.com. Under DBT Resources they have a Clinical Resource Directory, which has many of the DBT providers from around the country.

  3. I have been participating in DBT for 2 years & am also starting a 6-month DBT program specializing in eating disorders. I have bipolar 1 disorder & share many of the symptoms of those w/borderline personality disorder. DBT has been incredibly helpful for me. I’ve been able to get off an anti-psychotic medication I’ve been on for 15 years (& needed to be on; it was very helpful & necessary at the time) but I have now developed metabolic syndrome as a side effect & w/the improvement from DBT my meds provider has been amazed & agreed to let me try to get off the anti-psychotic (which I have now been off successfully) & also have lowered dosages of other meds & gotten off some sedating meds as had chronic insomnia previously; DBT mindfulness has helped. I hope to continue DBT indefinitely! It is more like a class than therapy. We have a manual & learn new skills & have homework to do. It has been very focused & helpful for me & I’ve been through many different therapies & therapists w/not much relief until DBT.

    These might be helpful:

    http://www.alawebpages.com/webquestbpd (a webquest on borderline personality disorder by Amy Allison)

    “Helping Someone You Love Recover From Borderline Personality Disorder”
    “Taking Control of Your Thoughts Workbook”

    At your bookstore you can get:
    “Skills Training Manual for Treating Borderline Personality Disorder” by Marsha M. Linehan
    “The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder–Using DBT to Regain Control of Your Emotions and Your Life” by Sheri Van Dijk, MSW
    “The Dialectical Behavior Therapy Skills Workbook–Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance” by Matthew McKay, PH.D, Jeffrey C. Wood, PSY.D, Jeffrey Brantley, MD
    “Stop Walking on Eggshells” (Taking your life back when someone you care about has borderline personality disorder) by Paul T. Mason, MS, Randi Kreger. This also has a workbook that accompanies it. http://www.BPDCentral.com

    There is a DBT book that focuses on eating disorders & it is available at the local bookstore, but it is pretty expensive.

    Recovery, Inc. is a self-help group that is recommended if DBT is not available in your area. I went to a Recovery, Inc. group many years ago & it does teach similar skills.

  4. Apologies for posting this in the comments, and I would like to subscribe to an RSS feed of the DBT section you have here… I dont see a way to subscribe just to the DBT items though. Am I missing something? Or could I even subscribe via eMail?

    Thank you! Found you in looking for ‘apparent competence’ and this whole article is a lot of help in understanding what is going on in my life.

    1. Glad the article was helpful. I’ll check into whether it’s possible to subscribe to a single blog.

      1. The subscribe button is now back up on the left hand side under the categories. Thanks for pointing out that it was missing.

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