As for your first point, that people overuse boundaries: what does that (if it is true) have to do with me or any of my books?

Nowhere do I state that Limits with Love are more important that validation and other communication tools. Discussions of limits in my books take up no more space that communication tools. In fact, there isn’t even an entire chapter on limits in SWOE. It’s a section in one chapter.

I talk about Limits with Love as the FOURTH tool in Essential Family Guide, AFTER validation and other communications techniques, and after steps that do not involve the other person.

The essence of EFG is that steps must take place in a certain order. Step 2, on communication, validation, and creating a climate of cooperation, happens BEFORE the limits step (step 4) for very good reasons. The relationship needs this first, and the non-BP needs to be ready.

Absolutely: your BP will NOT welcome limits and WILL get upset, and will not observe them at first. Perhaps you missed my extensive discussion about extinction bursts, or countermoves, why that happens, and how to plan for it (a long process with five components). (I also talk about the MAN skills in DEAR MAN, btw.)

So why are they worth doing? Let me give you an example from The Essential Family Guide, the story of Jack and his borderline wife Loreen. Jack is a real person I interviewed for the book.
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Loreen was an alcoholic with a history of suicide attempts. She was under the care of a psychiatrist and taking medications. Jack was also seeing a therapist, who helped him put some limits in place after not having any for many years.

Jack says:

“Loreen’s rages were uncontrollable. She would go from zero to ten over almost anything. Once I went on a business trip and she shouted, “I hope you come back in a body bag.” She called me names and said things like, “You’ve destroyed my confidence in myself,” and “You’re making me drink because being drunk is the only way I can deal with you.”

“She threatened suicide all the time, yelling, “You probably want me to kill myself. So maybe I’ll just do it and it will be your fault.” I was always on edge, afraid of saying the wrong thing. Things got worse and worse.

“After I started talking to other family members online I realized two things: first, I was going to have to get strong and stay strong because this was really tearing me apart. And second, I had to start re-establishing boundaries.

“One day I found her on the floor after another suicide attempt. The ambulance came and they were trying to revive her. It hit me that even though I had been trying not to offend her for years, she was still suicidal and drinking. Whatever I was doing wasn’t working. I was scared.

“My therapist explained that her actions were out of my control. That was a harsh thing to hear. Living like this was going to kill me. So I decided to try boundaries. I had nothing to lose.

“I told her, “What we’re doing isn’t working, and things are going to have to change around here.” I said if she started raging and calling me names, I was going to leave and pick up the conversation at a different time. That sounds simple, but it wasn’t. It just fired her up, made things ten times worse. She screamed that I was a control freak and that’s why she was so sick.

“But I was prepared. I had convinced myself ahead of time that leaving was the best course of action. It helped that members of her family had told me I had been giving in to her and I needed to be firm.

“I ended up leaving the house several times. I just said, “I just can’t be here with you” and walked out the door. Some days I stayed away for a day or two. She called me, asked when I was coming home. I said, “I honestly don’t know. I’ve assessed my life and decided that things have to get better because this is destroying me.” She knows I am loyal and I would never walk away if there had been any other choice.

“Eventually, it started to sink in to her that I was serious. Finally, one day she called me and apologized. This was the first time she had ever said she was sorry for anything. I just about fell off the chair. That’s when I started to realize this boundary thing is working. And it did. It took time, but it got better.

“She even started apologizing more, saying things like, “I’m sorry, I didn’t mean to say that,” or “I know I reacted badly to that.” She was starting to feel responsible for her actions.

“Finally, we got to a place where we could have a real heart-to-heart talk, and I could say, “This bothers me a lot.” I had been afraid to do that because she was so volatile. She really started listening to me.

“I learned you have to take care of yourself, because BPD is like an incredibly powerful vacuum that will just pull you in, whoever you are. Setting boundaries was a way of saying, “I care about our relationship. If this keeps happening, I can’t stay, and I want our relationship to continue.”

“You have to be willing to accept that things will get worse before they get better. But it may be the only chance you have.”
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We are going to have to agree to disagree on limits not helping the relationship on the basis that the person with BPD finds them threatening and gets angry. In Dialectical Behavior Therapy, therapy does not begin without limits. Every patient gets a list of things that can and can’t do (in fact, you could call them rules) such as the need to not miss sessions, not coming to sessions on drugs, phone guidelines, working with therapists, etc. These kinds of limits save lives. Other limits save relationships—such as yours.

If you hadn’t been able to set that medication limit with your wife (and perhaps other similar ones) you would not be able to stay in the relationship at all. My guess is that you would be upset and angry and not as able to work with her on other issues. On that basis alone, I’m not sure why you say limits don’t work when they do.

In this space, I can’t go into a full discussion of how you use Limits with Love, because how you use them, and in which order, and how you communicate them makes ALL the difference. And that takes a lot of space that covers three different chapters.

I will add that in the planning process, you need to take a very deep look at how limits are your values and beliefs in action. And readers may find that they and their BP do not share these beliefs and values. I believe it is better to think about this and know it and deal with it, than it is to drag on in a day-to-day existence knowing this but never really examining it.

Like Jack, when implementing limits people may find that their BP would rather adjust what they do than lose the person they love, because as hard as limits can be to them, losing the other person is worth. Staying with someone with BPD is a very loving thing to do—and limits make it possible to do that and have your own life at the same time. Each non-BP deserves to have his or her own life and get some of their own needs met. That message, I believe, needs to be made loud and clear.

Randi Kreger
http://www.BPDCentral.com
Author, “The Essential Family Guide to Borderline Personality Disorder: New Tips to Stop Walking on Eggshells”
Stop Walking on Eggshells
Stop Walking on Eggshells Workbook

Rather than provide a blow-by-blow response to each of your points, I’d like to respond to the ones that I find most foggy and on which you and I differ. You said: “In order to help your family member, you have to help yourself first.” I agree with this assessment for the most part, although I believe that this can be done through skills acquisition and personal emotional skills. No need to talk about that anymore, since we agree on that point.

I believe there are 3 parties involved in the loved one/person with BPD relationship. These are: the loved one, the person with BPD and the relationship itself. The problem that I have with the use of boundaries and limits is two-fold… One is the over-emphasis of this tool. Too many people use only limits/boundaries in their relationship, not understanding that this tool is one EXCLUSIVELY for the loved one. It doesn’t help the relationship at all. In mentalization-based treatment, Bateman and Fonagy have posited 3 tools for when a person with BPD experiences a “failure to mentalize” (i.e. when the train starts to derail and the relationship is suffering). Those are: 1) Stop, Listen, Look; 2) Stop, Rewind, Explore and 3) Stop and Stand. The third one is the application of boundaries and it is to be used when the relationship goes completely off the tracks. The first two are tools to understand the point at which a relationship has started to derail and to get it back on the tracks so it can continue.

You see, my problem with the over-emphasis of boundaries and limits is that many people believe that those tools will actually help the relationship. This is not the case. In fact, if you use the third tool (Stop and Stand, the application of boundaries) the relationship will suffer. Why? Modern fMRI research on BPD (see “Dysfunction in the Neural Circuitry of Emotion Regulation–A Possible Prelude to Violence” Richard J. Davidson,* Katherine M. Putnam, Christine L. Larson and “Quieting the Affective Storm of Borderline Personality Disorder” notes from presentation of Marianne Goodman, M.D., Erin A. Hazlett, Ph.D., Antonia S. New, M.D., Harold W. Koenigsberg, M.D., and Larry Siever, M.D.) shows that the “resting state” of the brain’s of people with the disorder is not the same as those without the disorder. The resting state of a person with BPD is one of more pre-frontal cortex activation in those with BPD. The result of this brain state means that a person with BPD will be actively scanning the environment for potential threats (particularly emotional ones). When a threat actually occurs (or is perceived), the pre-frontal cortex goes “off-line” and the limbic system lights up. The effect of this is that the person with BPD will react reflexively and impulsively to threats; however, the decision-making process becomes inhibited. This reaction, in combination with the person with BPD’s preoccupation with attachment relationships, means that it is likely for the attachment person (particularly a parent or partner) to be a trigger of the reaction. So, the amygdala lights up and the “fight or flight” response begins. That in concert with the activation of the anterior cingulated cortex portions of the brain (which is the personalization part on the top of the limbic system) makes a person in this state (which I call emotional dysregulation in my book, although it might be better described elsewhere) feel that there’s a threat, the threat is to them and the ability to make a wise decision goes-off line. They react and usually react impulsively.

OK, so, why am I bothering with this? It is because boundaries (and even more so “detaching with love”) feel like a HUGE threat to the person with BPD. They can’t take tough love. While boundaries can make YOU feel better, they make the person with BPD feel decidedly worse. That dynamic, and the resultant impulsive BPD behavior, hurts the relationship. What family members don’t understand is that boundaries have this function. I have seen many, many people recommend boundaries as a tool for the relationship, rather than as a tool for you, as a family member, to keep your sanity.

I will give you an example from my life. I have a boundary for myself that I will not go outside the house with my wife if she has been over-medicating (something that she does, though not as much, from time-to-time). If she is over-medicated, I tell her, “No, I will not go out with you when you’re in this state.” For me, it is an effective tool, yet it inevitably causes RAGE in her. The reason is that she experiences it as a threat of rejection, which is painful for her, and impulsively strikes back at me. Partners of people with BPD need to understand that the application of their own personal boundaries will most likely trigger this reaction. I personally expect it and know that it is coming, yet I have this boundary (for me) and I am consistent about this boundary. And yes, I have communicated the boundary to her. Why does she “not observe it”? Because she doesn’t feel like it at the time. I say that not flippantly at all. Her emotions are engaged in such a way that she is not thinking about me or my boundary at all. She is experiencing the brain reaction I described above. The “not observing other people’s boundaries” is usually situational, yet the reaction to the application of boundaries is typically pain, shame and impulsive behavior.

So, when the family member applies boundaries to a person with BPD, they are expecting it to be effective in the relationship. Then, they are surprised when the natural BPD reaction occurs and feel that the person with BPD is trying to manipulate them into changing their mind about the boundary. It becomes characterized as “pushing limits”. However, that is NOT the case. I try to explain in my book and in my blog postings that the application of a boundary is solely to help YOU and that, when it is done, you should EXPECT rage, judgment, criticism and impulsive behavior from the person with BPD. It is based on the neurobiology of BPD. Boundaries should only be used for yourself and should be used sparingly – only in the most extreme cases of situations you don’t want to participate in. In my case I use that boundary when she’s in that state because I feel uncomfortable and experience emotional pain myself when we’re out and she’s over-medicated. Yet, when I apply that boundary, I expect fireworks.

The second problem with boundaries is that many, many people confuse boundaries with rules. This is not your fault at all, Randi. I think you have done a pretty good job of explaining that boundaries are tools for YOU, not to be applied to the other person. The problem I see (and perhaps this is why you said “the B word”) is that boundaries in the context of child-rearing really ARE rules. If I tell my son he has to go to bed at 9 PM, that’s a rule, not a boundary. Unfortunately, the word is commonly used in a variety of settings and is inaccurate in its application. The effect of the Internet amplifies this misunderstanding. That is why I talk so much about boundaries and try to clarify the differences between boundaries and rules. I guess that’s why you choose “limits” rather than boundaries in your new book. Maybe “guidelines for self” would be even better, as klunky as that is.

If a person DOES start issuing rules to a person with BPD (calling them boundaries, limits or anything else), then fur is going to fly again. I think you would agree with me that you can’t change the behavior of another person through rules. It is the threat of punishment which, if the person would like to avoid, enacts the behavior change. However, positive reinforcement works better than punishment threats, as you know. Plus, a person with BPD, because of the great shame that they feel on a daily basis, will take punishment threats seriously and to the heart. My experience is that people with BPD live in a kind of dread of punishment and will avoid blame at all costs specifically because if they have done something wrong, then they are ALL wrong as a person.

Finally, I’d like to address the use of DEAR in both of your books. Two things on that:
You left out the MAN part. In the case of DEAR MAN, the first portion DEAR is the “what” skill. The section one MAN is the “how” skill. Because you decided to drop the MAN part which is – Mindfully, Appear Confident, Negotiate – you are missing something essential to the skill. While the DEAR part provides a road-map for non-judgmental expression of your OWN feelings and desires, by dropping the MAN part, you are removing the give-and-take related to the relationship. If you’re not willing to negotiate and find a middle ground, then you’re providing a nice, non-judgmental way of saying “my way or the highway”.

Which leads me to my other point on DEAR. This skill (DEAR MAN) is probably the most “aggressive” of the skills within DBT. It is intended for a person with BPD, who may capitulate to other’s wishes because they don’t trust their own decisions and desires, to get what THEY want out of an interpersonal relationship. It is a tool entirely for the person using the tool – particularly when you remove the requirement to negotiate. So, if you apply that tool from DBT, and ONLY that tool, to the loved one, you’re again providing a one-way benefit that helps the loved one get what THEY wish, but doesn’t help the relationship at all. The DEAR MAN tool is intended to provide a non-blaming road-map to ask for what you wish, without it devolving into a shouting, demanding, raging mess. If there was any interpersonal effectiveness tool from DBT that I would place emphasis on it’s the GIVE FAST tool. That’s another discussion entirely. Yet, the DEAR MAN tool (like boundaries) is important for YOU, just not for the relationship.
I think that both of these instances, the tools are assumed by your readers to be beneficial to the relationship. I am saying neither helps the RELATIONSHIP, although both can help YOU. Unfortunately, if you apply only these tools, the person with BPD will experience emotional pain and be unable to make effective choices in the context of themselves or the relationship. It seems to me that both of these tools assume that the person with BPD is doing something “wrong” or nonsensical and neither encourages compassion, trust or empathy, which is the life-blood of an effective relationship, regardless of the disorder(s) involved. The choices and behaviors of a person with BPD make complete “sense” when a loved one understands the function of each. Usually the function is pain-avoidance. My book does include both boundaries and a DEAR-like tool (called “Inserting your feelings”), yet the main emphasis is on other inter-personal tools. The inter-personal tools that I emphasize are intended to cool the rages and to help the person get back to baseline from which they can make an effective decision about their behavior. And in the case of most loved ones, once the person with BPD begins to make more effective decisions and, therefore, behaves more effectively, the work is done. I don’t take this view… I believe the work has just started – because, for my daughter at least, I’d love to see her actually FEEL better, rather than just behave better. Many loved ones are so tied up in the person with BPD’s behavior they begin to believe that the disorder is just a case of the person behaving badly. You and I know otherwise. It is a real disorder and requires a lot of hard work on everyone’s part to help your loved ones with BPD and to build a trusting, loving and respectful relationship in both directions.

Take care,
Bon

Concerning validation, I used info in SWOE directly from Linehan. In the second edition, see p. 128 and 128, BPD-specific communication skills in which I cite Linehan, and p. 146 where I use the term validation.

In fact, if you compare Linehan’s communication skills to mine, I don’t believe you’ll see a lot of differences in either SWOE or The Essential Family Guide to Borderline Personality Disorder: New Tools and Techniques to Stop Walking on Eggshells. I researched her well before I wrote either book.

Now, here I am just confused:

In SWOE I said, “If you want the BP to change, you have to be willing to make some changes yourself if the person does not observe your limits. (page 157)”

Nowhere in that do I say the BP is “violating” limits. In fact, I took the phrase “observing limits” directly from Linhan. I also used Linehan’s limi-setting technique DEAR: Describe, Express, Assert, Reinforce. This is directly from the Linhan text (1993A) and workbook (1993B).

I do think your material is much more “staying” focused in the promotion and the purpose. The promotion of SWOE was all about getting people to read it, as back in 1998 no one had ever heard of BPD.

It is incorrect to say that my goal was to get people to leave the relationship. My goal was to help them understand BPD and make changes that would improve their own life WHILE improving the relationship. Because when you do one, you do the other! You don’t HAVE to choose between you and your BP.

This is from my new book, The Essential Family Guide to Borderline Personality Disorder: New Tools and Techniques to Stop Walking on Eggshells (2008, Hazelden Publishing). Since I wrote this a decade later, this more accurately states my belief about this:
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Keep these principles in mind as you read this book. These thoughts need to become a permanent part of your mind-set when dealing with someone with BPD.

*********TO HELP YOUR FAMILY MEMBER, YOU MUST HELP YOURSELF FIRST **************

Your intuition may tell you that it should be the other way around—that the health of your relationship is dependent on your family member’s willingness to get help, and your job is to ignore your own needs and concentrate on fixing the other person. Wrong.

People spend years trying to please their borderline family member by twisting themselves into a pretzel to avoid conflict. Even if it works, the price is high. Family members suffer from depression, isolation, helplessness, low self-esteem, sleep deprivation, and even physical illnesses (especially adult children of people with BPD).

Predictably, the relationship begins to degrade, which is exactly what family members are trying to avoid.

This means that paradoxically, the long-term health of your relationship partly depends upon your willingness to look after your own needs, such as taking time away, setting limits with love, and having a hearty life of your own separate from your borderline family member.

This curious paradox is many family members’ undoing. They may hear it but not believe it; they may have lost the ability to take care of themselves (or never had it to begin with), or they may be unwilling to accept that giving, giving, and giving some more is just not helping the situation.

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As you said, “I got a LOT of validation out of SWOE when I first read it 3 years ago.” Validation is the very first step toward family members helping themselves, which is the first step to them helping their BPs.

As I said, your work speaks for itself and is very good. it’s quite likely that your readers will also read something of mine: people want anything that will help. People don’t have to choose between our books. You could just as easily stress the similaries between our approaches as what you see as our differences.

Randi Kreger
Randi @BPDCentral.com
Author, “The Essential Family Guide to Borderline Personality Disorder: New Tips and Tools to Stop Walking on Eggshells”
(Available at http://www.BPDCentral.com)