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:
…………………………………………..

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.

…………………………………………..

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)