Dialectical Dilemmas

From a review of DBT therapy:

Linehan groups the features of BPD in a particular way, describing the patients as showing dysregulation in the sphere of emotions, relationships, behaviour, cognition and the sense of self. She suggests that, as a consequence of the situation that has been described, they show six typical patterns of behaviour, the term ‘behaviour’ referring to emotional, cognitive and autonomic activity as well as external behaviour in the narrow sense.

Firstly, they show evidence of ’emotional vulnerability’ as already described. They are aware of their difficulty coping with stress and may blame others for having unrealistic expectations and making unreasonable demands.
On the other hand they have internalised the characteristics of the Invalidating Environment and tend to show ‘self-invalidation’. They invalidate their own responses and have unrealistic goals and expectations, feeling ashamed and angry with themselves when they experience difficulty or fail to achieve their goals.

These two features constitute the first pair of so-called ‘dialectical dilemmas’, the patient’s position tending to swing between the opposing poles since each extreme is experienced as being distressing.

Next, they tend to experience frequent traumatic environmental events, in part related to their own dysfunctional lifestyle and exacerbated by their extreme emotional reactions with delayed return to baseline. This results in what Linehan refers to as a pattern of ‘unrelenting crisis’, one crisis following another before the previous one has been resolved. On the other hand, because of their difficulties with emotion modulation, they are unable to face, and therefore tend to inhibit, negative affect and particularly feelings associated with loss or grief. This ‘inhibited grieving’ and the ‘unrelenting crisis’ constitute the second ‘dialectical dilemma’

The opposite poles of the final dilemma are referred to as ‘active passivity’ and ‘apparent competence’. Patients with BPD are active in finding other people who will solve their problems for them but are passive in relation to solving their own problems. On the other hand, they have learned to give the impression of being competent in response to the Invalidating Environment. In some situations they may indeed be competent but their skills do not generalise across different situations and are dependent on the mood state of the moment. This extreme mood dependency is seen as being a typical feature of patients with BPD.