While again watching the powerful BPD documentary, ““Back From the Edge - Living With and Recovering From Borderline Personality Disorder,” I was appreciating how well it addresses central questions that individuals and families ask about this painful disorder of emotion regulation. I really wanted to encourage the members of our DBT Family Skills Training to view this video on YouTube and benefit from the support it offers. My hope is that transcribing even a few of the responses could increase motivation just enough! What follows are excerpts from caring, thoughtful responses to these topics: 1) Why does my loved one harm her/himself?; 2) Sometimes, my loved one’s behavior feels manipulative to me. Is it?; 3) What is BPD and how does a diagnosis matter?; 4) Where does the family fit?; and 5) Is there hope to get better?
Please know that this is but a fraction of wise guidance offered on many topics, such as the biological basis for this disorder. Here are the family members and professionals included in the excerpts that follow: Christina Knight (CK), Kiera Van Gelder (KVG), Marsha Linehan (ML), John Gunderson (JG), Wayne Fenton (WF), Perry Hoffman (PH), Cindy Knight (CiK)
Why does my loved one self harm?
CK. Anytime that I’ve cut, it's been because my emotions were so intense that I needed a different outlet for them and to inflict physical pain on myself was a relief because I could focus on the physical pain and I didn’t have to focus on the emotional pain I was feeling.
KVG. To me it was like a cigarette break in a sense... a way of being able to manage feelings that I hadn’t found a way to do yet.
ML. There's no doubt about it at all. Cutting and physically damaging the self regulates emotions in this group of people. No one is clear on exactly why it happens and there's a lot of research on it.
JG. These self destructive behaviors of borderline patients can definitely serve to help them alleviate feeling states that they can’t stand... oftentimes, feeling states that they cannot even articulate.
ML. On the perfectly pragmatic side, the reason it’s a bad idea is it means you never solve the problem that generated the emotion in the first place. So it becomes like taking drugs. It's a way to avoid, distract, or get out of something, but it isn’t a way that makes you look at it and figure out how to solve it.
Are we, family members and friends, being manipulated?
KVG. Manipulation assumes someone has the skill to think about and then execute a plan. Manipulation in that sense, I think, cannot be applied to people with BPD because its all about knee jerk reactions and desperately trying to get something to feel secure and safe and okay again. So, for me when I was sending letters written in blood to people, one could say that was a tad manipulative. On the other, you could just as easily say I had no clue of what I was doing, I had no idea how to get people to pay attention to me in ways that would work.
ML. Manipulation is when you consciously try to get someone to do something for you without them knowing you actually got them to do it. These individuals very rarely have the interpersonal skills to figure out how to get you to do things in an unobtrusive way.
What is BPD and how does this diagnosis matter?
CK. The staff doctor treating me came in and told me, “I think that you have Borderline Personality Disorder and I immediately thought that meant I was on the borderline between sanity and insanity. He said, “No, that’s not what it is. And he explained the criteria.”
KVG. I was asked...Do you find that you fear abandonment? Will you desperately try to avoid it at all costs? YES. Do you find that you are really emotionally labile, up and down, and sensitive to the things around you and rejection? MY GOD, YEAH. Stormy relationships? Do you idealize people and when they disappoint you, do you devalue them? Do you experience paranoia when you are under extreme stress? YEAH.
JG . People, more often than not, find it a great relief to be diagnosed.
ML. "Oh my god, I’m something." The something is understandable. Somebody could actually understand me and if they understand me, maybe I can understand me, maybe other people are like me which means I am not so alone. I’m not different from everybody in the world. I’m not an outsider every place I am. And also there’s an enormous relief that there might be a treatment.
Where does the family fit?
WF. It would be fair to say that BPD can be hell for families. There’s something in the nature of this condition and its symptoms that can draw not only from families, but from trained clinicians, unhelpful responses.
ML. From my experience, the most common response other people who are around people meeting criteria for Borderline Personality Disorder is that their response is to say “shape up.” They know the person is emotional, but they don’t know why. They really don’t have the fundamental understanding that the person is actually doing the best they can. The real tragedy for the individual is they say “I can’t regulate” and the other person says “Yes, you can.“ So, of course, then they start feeling worse about themselves thinking that they can, but they just don’t want to.
CiK. What really helped me was when I realized it wasn’t about me, that I wasn’t necessarily what she was angry at and the target of it, but I was just there to be somebody she could vent on and all of this feeling that was about something else.
CK. She just understands that I need to get it out and once I get it out, I feel a lot better.
JG. We have guidelines for families which suggests that when their borderline offspring or family member has one of these excessively angry reactions that they listen carefully, look for whatever is true about it and by validating that part of it which makes sense, it will calm the person down. To address the part of it which is excessive and inappropriate can and should only be done in a context of when the borderline person is calm.
PH. When you have a child with this disorder, it's not something you talk about at weddings. You often don’t talk about these kinds of things, so when family members go to a support group, it's an incredible process that happens for them because they feel that someone else understands them and understands what they’ve gone through.
KVG. BPD is so much a disorder of relations and the recovery really involves being able to get back into communities and have relationships and tolerate the stress and build up a life for yourself again.
Is there hope to get better?
PH. When family members call me for the first time, the first thing I want to give them is hope. I want them to know that people with this disorder get better. Borderline Personality Disorder is often called the good prognosis diagnosis and that’s because people get better. People recover from this disorder, they manage their lives in effective ways, they have children, they have careers.
ML. The emotionality that they have and the tendency to react quickly will probably always be there, but you can build a corresponding tendency to be able to regulate.
KVG. I developed the vocabulary to say to people, “I get triggered because of this or I’m having a borderline moment right now. I think you’re rejecting me.” When you get the diagnosis and a set of language to bring awareness to the interpersonal dynamic, things that used to destroy relationships become opportunities to build a new level of communication.
“Back From the Edge - Living With and Recovering From Borderline Personality Disorder” was created by the BPD Resource Center at New York-Presbyterian. Information on this wonderful resource can be found at bpdresourcecenter.org. Additional information on BPD and families at neabpd.org.
Understanding Emotion Dysregulation in Couple Conflict
(Applying Mindfulness in Relationship: Moving from Problem to Solution)
In this blog, you will find discussion of several key points from Alan Fruzzetti’s chapter on “Understanding Emotion in Relationship” from The High Conflict Couple: A dialectical behavior therapy guide to finding peace, intimacy, and validation.
Core Problem is Dysregulated Emotion:
Highly aroused, negative emotions lead to harmful behaviors during conflict…leading to unsupportive relating and increased misery among partners
Potential Solution starts with Skills:
We can learn skills to effectively, mindfully, & nonjudgmentally monitor and then manage negative emotions which leads to more accurate expression which allows increased understanding and validation…leading to more supportive relating that can eventually transform conflict into increased closeness (decreased suffering) among partners
The transactional model describes how the problem occurs inside, outside and between each person and partner. Understanding the problem in context can be used to identify the individual/couple strengths, resources and skills needed to move toward solutions, our values and goals, and the relationship intimacy that is indeed possible.
Fruzzetti offers this transactional model (see handout) as a contextual way of viewing those relationship problems that can cause so much pain and suffering; this model invites a mindful approach of greater understanding, compassion, as well as less blame than linear models.
“Alternative models do exist in which the individual’s problematic responses are not artificially disaggregated from the interpersonal or family context in which they develop and function currently. For example, if a person is sad, we may define the 'problem' as inside the person (e.g., she “is not producing enough serotonin” or has “maladaptive cognitions” or is not “active enough”) or outside the person (e.g., “the environment is very punishing” or “she was abused” or “her partner is consistently critical of her”). However, to achieve a more comprehensive conceptualization, we may describe the situation, problem, or transaction to include both parts (e.g., “in situation x [which focuses on the present, especially on interpersonal contingencies such as how a spouse or partner or parent responds to her disclosure of emotion, wants, thoughts], she has these particular thoughts, desires, urges, engages in these particular behaviors, and feels sad”). For both theoretical and empirical reasons, we think there is a lot of utility in trying to understand many problems…as transactional.” (cf. Fruzzetti, 1996).
Emotions are complex processes more than a thing. With practice, we can more accurately (less reactively) describe the elements of the emotional process we are experiencing, that is, our memories, images, thoughts, sensations, urges, and actions. We can become more mindful of how we (mis)label them, how we express them and how others respond in turn to us.
The point at which our attention orients to escape is when emotion dysregulation and mood-dependent behavior begins according to Fruzzetti. In this way, “being dysregulated is NOT the same as being upset when we can still make effective decisions.” When we become so emotionally aroused that we are less able to: 1) inhibit emotion-driven, problematic behavior, 2) soothe our intense feelings and body sensations, 3) redirect and broaden our attention, 4) move toward our valued, goal-directed actions, that is when we can recognize we are in the “red zone.”
Factors that make us vulnerable to high negative emotional arousal and the “red zone” of emotion dysregulation, include: sensitivity (situation, bio-social history, vulnerabilities), reactivity (how loud, rapid or intense is the wave of emotion), duration (how long until we can return to baseline equilibrium). See the Bio-Social Self Survey to better appreciate and validate the factors that contribute to your and your loved ones' emotional vulnerability.
Patterns of Responding to Disagreements are on a continuum from constructive engagement on one end to critical, hostile, or avoidant behaviors at the other end. We apply our skills toward increasingly more constructive engagement and mindfully identify when and how we find ourselves reacting in the three problematic patterns.
Constructive Engagement. Partners can tolerate the disagreement, regulate their own emotion, assume a curious and nonjudgmental stance, listen and respond with validation, and still enjoy each other.
Mutual Avoidance. Partners mutually trigger dysregulation; they tend to avoid the conflict which brings temporary relief, while closeness fades.
Destructive Engagement. Conversations eventually trigger dysregulation and both partners express hostility, invalidating words and ineffective behaviors.
Engage-Distance. Partners are moving in opposite directions that eventually triggers intense negative emotions, defensiveness, blame, and hopelessness.
Practice. You may want to use the Red Zone Worksheet to help you monitor the particular emotions that tend to become dysregulated and then prompt those behaviors that interfere with the effective communication and closeness you want with your partner.
Fruzzetti, A. E. (2006). The high conflict couple: A dialectical behavior therapy guide to finding peace, intimacy, and validation. Oakland, CA: New Harbinger Press.
Fruzzetti, A. E. & Iverson, K. M. (2004). Mindfulness, acceptance, validation and “individual” psychopathology in couples. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 168- 191). New York: Guilford Press.
A member of my DBT Family Skills Training recently asked me, “So, how exactly do you do mindfulness when you are emotionally dysregulated and in the ‘Red Zone’?”
Great question! I think of times when I have been angered by my children’s behavior when they were teens, distraught about the loss of a relationship, or battling anxiety before a public talk. Then my honest answer is “Ugh, I didn’t do it well.” In these cases, my responses often made my emotional reactivity more intense (and created more problems).
It is extremely difficult to practice mindful awareness when one is emotionally flooded. By definition, when we are emotionally dysregulated, we are more likely to act on urges of mood dependent behaviors, to find it difficult to soothe or establish a balanced, effective level of physiological arousal, to redirect or reorient our attention toward valued actions which move us closer to our goals. This makes mindlessness a lot more likely than mindfulness. And we may humbly admit to have seen the unpleasant consequences that followed.
And yet at other times, we were able to become more mindful.
So what can we do--how can we apply mindfulness when in the red zone? I posed this question to a panel of experts, that is, members of our DBT Grad Group. Their names have been changed for purpose of confidentiality. They have been through the DBT Skills Group at least a year and most have been in Grad Group for several years. Their responses show what is actually possible to learn when practicing these skills to take hold of the mind using observe, describe or participate in nonjudgmental, one-mindful, and effective ways.
Cathy: As one who's been in the red zone of late, I can say what works for me is changing my body chemistry in some way. Vigorous exercise, even if it means dropping to the floor and doing abs, seems to shake me up enough to cause a change in my mood. Also, getting outside gives more space for the many racing thoughts. It also helps to get the sunlight. And the biggest opposite action is for me to tell someone how I feel; instead of staying in isolation.
Beth: I agree with Cathy about talking with someone when you feel terrible, instead of isolating, which is the default, for me. Getting outside sometimes helps me, too, noticing the little things that can take you out of yourself. Conscious breathing. Self-soothing. Restorative yoga with props and sometimes with a guided tape. The senses 5-4-3-2-1 game (noticing 5 shapes/colors, 4 sounds, 3 sensations, 2 smells and 1 taste).
When in the red zone during an interaction with someone: connect to your body, even if it is your pinky finger only; think and do "soft belly"; breathe consciously; focus on what they are really saying rather than your own reaction. Sometimes the only solution for me is pushing away, even though that is kind of the opposite of mindfulness.
Probably the most important is: connection with someone else.
Earl: For me it starts with acknowledging that I am in the red zone, and doing the best I can to be gentle with myself, and saying it out loud (naming it) – “I am in the red zone.” This has the effect of grounding me just enough to break away somehow with a mindfulness exercise (counting my breaths, a pattern on a shirt, counting foot taps).
Virginia: This is what I do when I get to the red zone: First recognize the red zone, then take 3 deep breaths slowly no matter what. Then there are several options: walk away from the object of dysregulation by saying something like, "This is not a good time for me to talk. I'll be back." Then keep walking (or riding my bike) until some of the emotional energy dissipates. Then observe and describe your emotions as if you were talking to a friend about the issue. Start each sentence with "I feel..." and do not let yourself descend into blaming the other person(s) or thing(s). So something like, "I feel offended and hurt by..." and not "I feel that you are an idiot..." Even the practice of writing down what you feel will dissipate some of the emotional energy. The key is to center on what I feel and not the perceived faults of the other person(s) or thing(s). Then I tell myself that everyone is doing the best they can whether I believe that at the time or not.
Lastly, I return to the scene of emotional dysregulation and discuss what I feel and what the other person feels. It is important to listen without attaching myself to the other's emotions and not letting their emotions dysregulate me. If anything happens to start the red zone climb I start the process all over again.
Jane: First, I have to know that I'm IN the red zone…and to say a mantra involving my Higher Power. It helps me to keep a "neutral" mind, at least for a while! Also, exercise is fantastic for changing my mood. I have tix for plays in the future to look forward to and doing some creative activity is a big help.
I find these creative responses from our DBT grads to be so helpful. We can see practical and specific ways to one-mindfully observe and nonjudgmentally describe which can lead to more ways to effectively participate. And while still difficult, its possible to do so in the most challenging of emotion mind moments!
Here’s a summary of our experts’ (DBT Grads) recommendations for navigating through the red zone.
· Recognizing that we are in the red zone.
· Change body experience or awareness.
· Re-direct attention to an ally or valued actions.
· Take a break from the situation.
· Mindfully observe and describe emotion.
· Recall “we are doing the best we can.”
· Talk with someone you are close to who can really listen.
· Validate and be validated.
Let’s imagine (just for a minute!) a painful interaction that you experienced with your partner. Chances are that the pain you experienced was in response to something that either you or your partner did (or didn’t do).
Now let’s take a quick look at whether either of you were: 1) “snagged” at a high level of emotional/physical arousal of anger, fear, or shame (or extremely under aroused if depressed), 2) that made it difficult to refrain from acting on that emotion in a way that was later regretted, 3) while also finding it difficult to redirect your attention in a more positive or effective direction, and 4) which got in the way of acting toward your healthy goals of how you want to be in this relationship. These four tasks of emotion regulation (modulate physiological arousal, redirect attention, refrain from mood dependent behaviors, and organize constructive behavior in the service of our values and goals) are compromised when we are emotionally imbalanced or dys-regulated.
Typically, our painful interactions are marked by dysregulated emotions. We might describe this as a time of “emotional flooding” or the “red zone.” Knowing when you or your partner are in or are approaching this “red zone” intensity of emotional dysregulation can be potentially useful to help contain a painful conflict or misunderstanding.
DBT offers an approach that is uniquely suited to addressing the role of emotion regulation in our relationships. Many problematic behaviors and difficulties in communication are caused by these times of imbalanced or dysregulated emotions.
In our Family & Couple Skills classes, we use a “Red Zone Worksheet” to identify our personal scale (from 10-100) of increasing levels of emotional intensity (available below). This becomes a personal road map with our unique signposts for when we are approaching the red zone of emotional dysregulation and the likely problem behaviors that cause us regret and our loved ones pain. These signposts include the unique thinking, body experiences and urges that occur at each level of a particular emotion, say fear or anger. We can then begin to notice these signposts when we are in emotionally vulnerable or activating situations.
Back to our imagined painful interaction with our partner…let’s say our partner is in the midst of a highly agitated state of anger or fear, how do we respond in a way that doesn’t make things worse? From a DBT perspective, there are a number of options. You can find several of these discussed in The High Conflict Couple: A DBT Guide to Finding Peace, Intimacy and Validation by Alan Fruzzetti. Another resource that couples might miss is called “The Five Steps Response.” In my experience, Shari Manning has provided a very useful outline that is simple enough to recall when one is faced with such a challenging interaction. You can read more about this in her very practical and helpful book, Loving Someone with Borderline Personality Disorder. In my opinion, this book can be helpful for anyone with an emotionally sensitive loved one, regardless of diagnosis. In part, this is because the focus of the Five Steps Response is on you, not your loved one. As Shari Manning reminds us, “At the end of the day, you can only change your own behavior—your responses to your loved one. The good news is that sometimes when you change your behavior, your loved one’s behavior will change also.”
Five Steps for Responding to “Red Zone” Behavior (adapted from Loving Someone with BPD by Shari Manning)
1. Regulate Your Own Emotion
4. Brainstorm and Troubleshoot
5. Get Info on Your Role and Updates on the Outcome
This can work, right? With practice, practice and more practice, the Five Steps can be very helpful. And the practice can start now. Again imagine your painful interaction with your partner…this time, see yourself pausing to breathe, to tense and release some of the body tension, and to give yourself some validation and encouragement. See yourself turning toward your partner with more caring and openness to express your recognizing and understanding what they are experiencing, feeling, or wanting. Imagine that you then gently ask him or her “Would you prefer that I really listen to how this is for you, or offer advice, or help you figure out what to do?”
Sometimes, the first of the Five Steps is the most difficult. When we are highly emotionally aroused, it can be quite a challenge to self-regulate. Recall, that the four tasks of emotion regulation may be compromised in that very moment for us. If this is the case, it can be helpful to take some time away from the situation and to temporarily separate yourself from your partner. You may simply need to take a break and use that time to regulate your emotional state so that you can re-engage more effectively. This is NOT the same as escaping, abandoning, rejecting, avoiding or punishing your partner. And this needs be clear to your partner! One way for this to be clear is for your partner and you to agree that you will experiment with constructively taking a break or a “time-out.” The analogy of a sports team taking a time-out is relevant here. When a basketball or football team takes a time-out, it is not a surprise because they have agreed in advance to allow this. Its also not a punitive act against the other team, it’s meant to be a constructive action to play more effectively. You will also notice that when a team calls a time-out, that they return when they have agreed. The team doesn’t hop on the bus, never to return. They return and re-engage in the game. Here are some suggested (and I believe, necessary) ingredients of effectively using a time-out.
Taking a Needed Break—How to Use Time-Outs
Take a few minutes to take a break or a time out so you can cultivate mindfulness, regulate emotions, and prepare to effectively engage your partner.
1. Recognize the escalating tension or arousal of negative emotion. Propose to take a time-out from the interaction to reduce the intensity of agitation to a more workable level. Propose when you want to return and discuss the issue further. Negotiate as needed.
2. Take the time apart for however long as been requested. What you do with this time makes a big difference. Continued blame or arguing in your mind leads to a predictable result. On the other hand, you can… Use the time to de-escalate, calm and regulate your emotions; cultivate mindfulness; take responsibility for your ineffective behavior and prepare to effectively engage your loved one. Breathe 3x. Clarify what your primary emotion is; consider how you can express this directly and effectively. Listening to Wise Mind (your inner knowing, intuition and compassion) and ask yourself what it is that you so deeply long for. Remind yourself of how you value having a caring, supportive relationship
3. Return at the agreed time. Negotiate another time-out again if you, your family member or friend needs additional time. Begin by stating what you are willing to change to be more effective in your behavior and in this discussion. Actively listen with efforts to validate your loved one’s experience.
Here you have three sets of tools to use when your partner and you are in a painful interaction. As you may have already noticed, these skills are just as relevant with other family or friends. First, you can employ your mindfulness skills to monitor the level of emotional intensity. The Red Zone Worksheet might help with that. Second, you can use the Five Steps to more effectively manage how you respond to your loved one. And third, you can use a Time-Out when needed to self-regulate so that you can validate yourself, your partner, and then complete the Five Steps. Warning--you may not experience immediate success. DBT reminds us that behavior change is a process: we learn about a skill, then we “practice, practice, practice” that skill until… eventually, we are able to apply that important skill in those situations when we most need to.
Good practicing! I welcome hearing about your experiences with these skills.
The Four Basic Assumptions
(DBT-Family Skills Training, Perry Hoffman, 1999, 2003)
1. There is no one truth or any absolute truth, but usually two or more truths.
2. Everyone is doing the best they can.
3. Everyone needs to try harder.
4. Interpret situations in the most benign way possible.
Here are a few thoughts and suggestions for family members and friends.
First, everyone is unique. What helps one person talk to a loved one is not going to necessarily work for someone else. How we communicate is often more important that what we say.
· Can you communicate with a full expression of caring and compassion using your GIVE (gentle, interested, validating, with easy manner) skills? Without this, a loved one might perceive judgment or yet another demand. Many of us will “shut down” when we perceive someone judging us.
· Can you ask your loved one if you can discuss something important, yet possibly awkward? Many of us don't open up when we are about to be told what we should do, especially when we haven't asked for advice or suggestions. Asking them if they are willing to discuss an important matter gives them a chance to agree or not. And if they agree, they may be more receptive to your hearing your concern for them.
No matter how much we love the person and have to offer them, we don't get to be in control of anyone but ourselves. For instance, the time when we are eager to share our knowledge is not necessarily the timing that will work for our loved one. Can we humbly accept these facts?
· Do you need to consult with wise friends or professionals on how to most effectively approach your loved one?
Sometimes we can encourage our loved one's willingness by...
· Using our Validation skills to affirm their experience, thoughts and feelings
· Letting them know that emotional sensitivity is not their fault
· Letting them know they are not "the problem' and that we are learning, benefiting from practicing skills, and working to be a better parent/sibling/relative/friend with them.
Sometimes loved ones will listen to our concerns and suggestions.
Sometimes loved ones will read useful, relevant information, such as articles or chapters by DBT therapists, like Marsha Linehan, Perry Hoffman, Alan Fruzzetti and Shari Manning.
Sometimes loved ones will watch an informative video, such as can be found at the websites of NAMI or NEABPD www.borderlinepersonalitydisorder.com.
Sometimes loved ones will read a page on a website like the above or at dbtselfhelp.org.
It can help to know if your loved one has wondered if therapy might help. How can you support that curiosity? What have they tried? What happened? It’s quite possible that they had a poor experience in a previous therapy or counseling session. They may need reassurance that this need not happen again. They may need help identifying a knowledgeable therapist or even to have a family member join them for the first session.
What else has made them reluctant? Are there fears that can be validated? Do they know that severe emotion dysregulation (BPD) can be successfully treated? Do they know that most people see significant improvement in 2 years? Having a good match with a DBT or other skilled therapist is essential.
Caution. If you believe your loved one is engaged or about to engage in life threatening behaviors, then an immediate response is called for. You can take them to their doctor or the Emergency Department. If they are in immediate danger and unwilling to seek help, the doctor or you can complete commitment papers with the magistrate so that law enforcement officers will transport your loved one for an evaluation and treatment.
In closing, knowledge about skills is truly wonderful. The good intentions of sharing this knowledge can be balanced with compassionate understanding and empathy of your loved one. In DBT, we are reminded again and again that effective change involves effective validation. It may take an initial focus on validation before a loved one is ready and willing to risk the prospects of change. And when in doubt, we can always pause, breathe and listen to our "wise mind" for some mindful, nonjudgmental and effective guidance on how to proceed.
May our families, friends and loved ones experience less suffering and more understanding,
John Mader, MA, LMFT | AAMFT Approved Supervisor | AAMFT Clinical Fellow | Co-Director, TADBiT
919.968.0231 x. 2 | email@example.com | www.dbtfamilyskills.com | triangleareadbt.com
~ Understanding Emotion Dysregulation in Couple Conflict