One of the most prevalent examples of emotion dysregulation disorders is Borderline Personality Disorder (BPD). BPD is defined as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins in early adulthood and is present in a variety of contexts” (p. 456) (1). This disorder is characterized by e.g., impulsive aggression, repeated non-suicidal self-injury (NSSI) and chronic suicidal tendencies that are caused by emotion dysregulation (2). Among the personality disorders, BPD has the highest rate of utilization of psychosocial services (3-5). In the Netherlands, it has been estimated that 1 to 2% of the population has BPD (6).
Dialectical Behavior Therapy (DBT) is an empirically supported treatment program developed by Marsha Linehan for individuals with BPD (7, 8). Standard DBT consists of weekly skills training, weekly individual therapy, elective intermittent telephone consultation and regular therapist team consultation. A meta-analysis by Stoffers et al. shows that DBT is especially helpful in the improvement of general functioning and in reducing inappropriate anger and NSSI (9). The DBT model assumes that the disruption of the emotional regulation is the result of a complex and longitudinal transaction between someone with emotional vulnerabilities (the biological component) and their (invalidating) environment (the social component). Examples of the biological component include trait impulsivity (10-13), trait anxiety (14) and emotional sensitivity (15). Normally this would be described as an interaction, but Linehan speaks of transaction because she assumes that a change in the client automatically leads to a change in the environment. In this way, both parties influence and change each other in a continious process that is interactive, mutual and interdependent (16). Chronic and pervasive emotion dysregulation lead to the disruption of a person’s emotional life on both an individual level (identity, behaviour, cognition) and on an interpersonal level (rejection, sensitivity, difficulties in belonging, cooperation, chronic loneliness and negative self-esteem) (17).
Invalidating environments contribute to the enhancement of emotion dysregulation. Linehan defines an invalidating environment as one that does not acknowledgement an individual’s experiences or emotional expressions (17). Invalidation occurs when an individual receives explicit or implicit communication from another indicating that his internal experiences are insignificant, incorrect, inappropriate or that his reaction to a given situation is inappropriate (18). The invalidating environment FGregularly punishes normative expressions of emotion while simultaneously reinforcing more extreme emotional display. As relatives of individuals BPD often show deviations in their emotional regulation abilities (19), it could be hypothesized that they are more likely to forming an invalidating environment. Indeed, family members or partners of people with BPD are directly affected by dysregulating emotional and behavioural phenomena, including repeated (non-suicidal) self-injuries (NSSI). They experience severe impact from the patient’s problem behaviour and are concurrently most likely the ones who affect the patient (20). Since only highly aversive and intensive emotional responses lead to reactions from the invalidating environment, the individual will not learn how to cope with emotions, nor learn to tolerate frustrations. On the contrary, the individual learns to self-invalidate his own experiences and emotion; recognition, labelling and regulation of his own emotions remains poor (7, 8).
Invalidating responses of the environment lead to significant changes in heart rate, skin conductance and affect (21). To reduce this autonomous (bottom up) emotional reactivity (22), studies show that self-destructive behavior is used as an emotional regulation strategy to relieve tension and somatic stress. Although this may temporarily suffice, it leads to misunderstanding, rejection or further invalidation (23). In addition to the aforementioned acute physical consequences of invalidating responses, there are also significant long-term consequences of the self-destructive behaviour including health damage, scars and stigmatization (24-25). Results of Bennett and colleagues (26) shows that adolescents with severe emotion dysregulation problems experience their caregivers to be more invalidating and less supportive than adolescents without these problems. Furthermore other studies show that self-destructive behavior is also more likely to occur in the context of interpersonal problems (27-28). Given this negative spiral of invalidation, increased bottom up reactivity, maladaptive coping strategies and negative environmental responses, it may be concluded that instability in relationships is one of the most stable symptoms in BPD (29-30). Interpersonal disturbances have received significant attention in BPD research. We now know that individuals with BPD are more likely to evaluate social cues in a negative way and to notice criticism or rejection where others would not (31). Since individuals with BPD are prone to feeling rejected or to experiencing criticism, they tend to avoid social relationships which ultimately results in feelings of abandonment or loneliness (32). A negative spiral of emotions and reactions ensues whereby disruption of interpersonal contact leads to increased reactivity to social stressors (33) and to higher rates of perceived criticism, and ultimately to a stronger chance of relapse after treatment (34). In other words, individuals with BPD appear to have less satisfying social interaction and experience less support when they try to cope with their distress, causing further impairment of their emotion regulation abilities (35).
Over the last twenty-five years, therapy programs have been developed to enhance social relationships through reduction of negative social cue evaluation, to reduce invalidation, to minimise drop out and relapse rates and to maximise new skill generalisation. Recently, Kirtley and colleagues (36) suggest that criticism should receive more attention in designated interventions since caretakers of individuals with BPD experience higher levels of burden and criticism than other caretakers. This proposition fits in with the growing tendency to include family members or partners in the treatment of BPD individuals to increase the degree of therapy generalization and to enhance social support. One of these therapy programs is the family network training of DBT (37).
Until now, few studies have focused on the effect of standard DBT - including a network module - on the transaction between individuals with BPD and their network members. While a limited number of studies has shown that residential DBT influences attachment style changes in BPD patients (38), this current study is the first to investigate the added value of the DBT family training with patients and network members on perceived criticism towards each other. In this pilot study, the DBT network training was part of a residential DBT program. Because of the residential character of the program, a network training could help to directly change contingencies since new learned behaviour could easily be incorporated in everyday life. We believe that the combination of analysis, practice and role play to demonstrate learned behaviour, will ultimately change the interaction between network members and result in different perspective taking.
The network training took place every two weeks and was based upon the DBT skills manual. Family members, partners and other important relatives and/or friends of the patients who participated in this residential DBT program received the DBT network training. The total training consisted of eight sessions in which patients and their family/friends (8) studied the DBT theory and learned to apply the DBT skills together.
To assess changes in interpersonal judgment, we measured perceived criticism before and after the family network training. It was hypothesized that after following the DBT network training patients and their family would be less critical of each other.