Clinical Handbook of Mindfulness (70 page)

Williams, J. M. G., Teasdale, J. D., Segal, Z. V., & Soulsby, J. (2000). Mindfulness-

based cognitive therapy reduces overgeneral autobiographical memory in formerly

depressed patients.
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, 150–155.

Williams, J. M. G., Van der Does, A. J. W., Barnhofer, T., Crane, C., & Segal, Z. V.

(in press). Cognitive reactivity, suicidal ideation and future fluency: preliminary

investigation of a differential activation theory of hopelessness/suicidality.
Cogni-

tive Therapy and Research
.

13

Mindfulness and Borderline

Personality Disorder

Shireen L. Rizvi, Stacy Shaw Welch, and Sona Dimidjian

Borderline personality disorder (BPD) is a severe personality disorder

characterized by prominent and pervasive dysregulation of emotion, behav-

ior, and cognition. Current diagnostic criteria for BPD include difficulties

with interpersonal relationships, affective instability, problems with anger,

destructive impulsive behaviors, frantic efforts to avoid abandonment, prob-

lems with self-identity, chronic feelings of emptiness, transient dissociative

symptoms and/or paranoid ideation, and suicidal behaviors (American Psy-

chiatric Association,
2000).
In order for a diagnosis to be made, at least five of these nine criteria must be present beginning in early adulthood and lasting for several years.

Of all psychiatric disorders, BPD represents one of the more challenging

to manage and treat within the mental health system for several reasons.

First, individuals with BPD utilize mental health treatment at highly dispro-

portionate rates. Although prevalence rates indicate that 1–2% of the general

population meet criteria for BPD, it is estimated that between 9 and 40% of

high inpatient services utilizers have a diagnosis of BPD
(Surber et al., 1987;

Swigar, Astrachan, Levine, Mayfield, & Radovich, 1991).
Second, a diagnosis of BPD is associated with a number of “therapy interfering behaviors” which

makes administration of consistent treatment difficult. High dropout rates

of up to 60% are not uncommon in treatment studies for BPD and usually

occur within the first three to six months of treatment regardless of actual

planned treatment length
(Kelly et al., 1992; Skodol, Buckley, & Charles,

1983; Waldinger and Gunderson, 1984).
Other behaviors that interfere with therapy and may lead to therapist burn-out are storming out of sessions early

or not leaving when the session is over, throwing objects, not showing up for

appointments or showing up extremely late, not paying for therapy, or not

doing assigned tasks
(Linehan, 1993a; Stone, 2000).
Third, individuals with BPD often carry diagnoses for several disorders at the same time. Mood disorders, especially major depression, are most commonly observed, but rates

of other Axis I disorders, including eating disorders, substance use disorders,

and PTSD are also quite high
(Lieb, Schmahl, Linehan, & Bohus, 2004;
Skodol et al.,
2002).
Finally, BPD is associated with high risk of lethality. BPD is the only DSM-IV diagnosis for which chronic attempts to harm or kill oneself is

a criterion and studies have demonstrated up to 8% of individuals with BPD

ultimately commit suicide
(Linehan, Rizvi, Shaw Welch, & Page, 2000).

245

246

Shireen L. Rizvi, Stacy Shaw Welch, and Sona Dimidjian

Fortunately, recent advances in the field have led to promising treatments

for BPD. Dialectical Behavior Therapy (DBT), originally developed by Line-

han for suicidal individuals with BPD (Linehan, 1993a, b), has received the

most empirical support thus far, with nine randomized clinical trials demon-

strating its efficacy (see
Linehan & Dexter-Mazza, 2007,
for a review). DBT is also one of the first psychosocial treatments for any disorder to incorporate

mindfulness as a core component.

Overview of DBT for BPD

DBT is a cognitive-behavioral therapy infused with acceptance strategies.

The central “dialectic” in DBT exists in the tension between accepting the

client exactly as he/she is in that moment and simultaneously pushing toward

change and creating a life worth living. Change is achieved through standard

cognitive-behavioral strategies, such as functional analyses, contingency man-

agement, cognitive restructuring, exposure, and skills training. Acceptance

is an active process, demonstrated through the use of validation strategies

(Linehan, 1997).

In its standard form, four components comprise the treatment: weekly

individual psychotherapy, weekly group skills training sessions, as-needed

telephone consultation, and weekly consultation team meetings involving all

DBT therapists. Guidelines for conducting individual sessions specify that

treatment should address clearly prioritized targets. These targets include, in

order of priority: life threatening behaviors including suicidal/self-harm and

homicidal urges and actions, behaviors that interfere with or threaten ther-

apy, severe Axis I disorders, and patterns that preclude a reasonable quality

of life. In addition, sessions are structured to begin with a review of the diary

card, which is a monitoring form that the client completes daily to record

urges, behavior, skills use, and emotional experiences that arose in week

since the preceding session. Skills training sessions function similar to a class

and follow a particular agenda each week designed to enhance skills capa-

bilities in four domains: mindfulness, interpersonal effectiveness, emotion

regulation, and distress tolerance
(Linehan, 1993b).

Biosocial Theory and the Development and Maintenance

of BPD Symptomatology

Linehan’s biosocial theory of BPD posits that the disorder is primarily a dys-

function of the emotion regulation system. From this perspective, BPD crite-

rion behaviors can be seen as either attempts to regulate negative emotions

or inexorable consequences of dysregulated emotions. Furthermore, the

theory states that this emotion regulation dysfunction develops over time.

The theory posits that there is a transaction between a biological tendency

toward intense emotionality and an “invalidating environment” (see
Linehan,

1993a),
which often punishes, corrects, or ignores behavior independent of its actual validity. Through interactions with this environment, the individual

learns to discount the validity of their own emotional responses and often

looks to external cues for information on how to respond. In addition, the

individual learns to form unrealistic goals and expectations for themselves

Chapter 13 Mindfulness and Borderline Personality Disorder

247

and others. As a consequence of this learning over time, a person with BPD

tends to oscillate between emotional inhibition (shutting down emotional

responses) and extreme emotional styles. Furthermore, Linehan theorized

that a central problem in individuals with BPD is that their experience of

emotions is different than individuals without BPD in three specific domains.

First, individuals with BPD have lower thresholds to emotional cues. Second,

BPD individuals have higher reactivity to emotional cues, meaning that their

responses are more extreme more quickly than other individuals. Third, in

BPD, a slower return to baseline following an emotion episode is theorized

to be evident. These three characteristics are a result of both the biological

deficit and the invalidating environment, proposed in the biosocial theory,

and inevitably lead to a life filled with intense emotions, interpersonal diffi-

culties, coping problems, and dysfunctional behaviors, which often function

(no matter how short-lived) to ease the pain and suffering of such intolerable

emotional states.

Addressing Emotion Dysregulation Through

Mindfulness in DBT

The core mindfulness skills in DBT are designed to help individuals focus

more on the present moment, letting go of memories of the past and worry

about the future. The seven concrete skills also target the difficulties that are

inevitable consequences of the pervasive emotion dysregulation described

above. These difficulties include problems that occur under highly aroused

states with processing new information vital to learning, longstanding pat-

terns of self-invalidation, and impulsive behavior that occurs in the context

of emotional arousal and that functions to decrease emotional suffering in

the short-term. Mindfulness skills, described below, are taught routinely in

group skills training.

In addition to the teaching of mindfulness in skills groups, the individual

therapist also frequently incorporates mindfulness into individual therapy.

Therapy is an opportunity (though often an unwelcome one!) during which

individuals with BPD are put into direct contact with emotional cues that

they generally try to avoid. Being asked to describe a recent negative inter-

action with a partner or recount their latest self-injurious act about which

they feel intense shame can cause highly dysregulated states. A goal of DBT

is to have the individual learn to be skillful in all relevant contexts, including

during times of difficulty. Mindfulness skills are used within sessions, then,

to help the individual begin to regulate his or her emotions in an effective

manner. Mindfulness practice helps a client with BPD in four overlapping

ways: (1) increasing attentional control, (2) increasing awareness of private

experience, (3) decreasing impulsive action, and (4) increasing self-validation

(Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).

Increased attentional control occurs through an emphasis on full partici-

pation in each moment. This focus on the current moment initially requires

constant effort as most individuals report that they very infrequently do this.

Clients in distress might be asked to focus on their breath as it comes in and

out of their nostrils as a way of drawing awareness to this one moment. This

focus of attention also allows for a client to begin to practice experiencing

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Shireen L. Rizvi, Stacy Shaw Welch, and Sona Dimidjian

and attending to their own states (emotions/urges/thoughts) without doing

anything to eliminate them. By doing so, clients become more aware of their

private experience and can begin to label a thought as a thought, a feeling

as a feeling without judgment. An added benefit of these skills is an increase

in insight of possible precipitants and consequences of maladaptive behav-

ior (e.g., “I realize that the thought ‘I’m a horrible person’ went through

my mind before I had the urge to harm myself” or “I noticed a decrease in

anger immediately after I injured myself”). This insight helps in contributing

to comprehensive behavioral assessment of maladaptive behavior, which is

the foundation of all cognitive-behavioral treatment.

Furthermore, this greater awareness also leads to more effective solutions

in that the individual learns to “ride out” impulsive urges. By just noticing

physiological sensations or thoughts without doing anything to try to overtly

change them, individuals learn to accept and tolerate them through mind-

fulness. The behavioral conceptualization of destructive behaviors charac-

teristic of BPD (e.g., substance use, suicidal behavior) specifies that such

behaviors are frequently negatively reinforced due to the immediate reduc-

tion in emotional distress that follows such behavior. Because individuals

have learned to engage in such behaviors over time, they have typically
not

learned that emotional distress will dissipate on its own.

Finally, mindfulness targets the self-invalidating behavior so common to

clients with BPD. According to the biosocial theory, individuals with BPD

have often grown up in environments that consistently modeled invalidation.

Thus, many have learned to self-invalidate over time. Such self-invalidation

typically presents in treatment through the often repeated words of “I can’t”

and “I shouldn’t” as they apply to what clients think, what they feel, and who

they are. The ubiquity of self-invalidation among clients with BPD is particu-

larly troubling given the research on the effects of thought suppression and

avoidance. These studies demonstrate a clear pattern in which thought sup-

pression and avoidance have the paradoxical consequence of
increasing
the

very thoughts and feelings one attempts to decrease
(Gross & John, 2003;

Wegner, 1994).
One of the functions of mindfulness interventions in DBT

is to target explicitly self-invalidation among clients with BPD. Mindfulness

teaches clients to approach experience with a nonjudgmental and accepting

stance. Through practice, clients learn to apply these skills to thoughts and

feelings that they may have learned through past experience to invalidate

automatically. In these ways, mindfulness strategies can help to interrupt the

cycle of intense emotion and the paradoxical effects of invalidation.