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CASE STUDY
"Sister Maria" •  Emotional Dysregulation

R. Dario Pulido, Ph.D., is a Licensed Psychologist and a therapist in the women's program at SLI.

Sr. Maria is thirty-five years old and has struggled with both her emotions and her relationships for years. She has suffered from intense feelings of depression, despair, and emptiness, often losing control and acting impulsively and in harmful ways to herself and others. Her community is struggling with how to help her and how to keep her chronic distress from negatively impacting the other sisters. Both Sr. Maria and her community have been unsuccessful in helping her cope with her sudden outbursts, emotional reactivity, clinging behavior, and helplessness. Most recently, sisters reported that Sr. Maria has been cutting herself when upset.

When Sr. Maria is feeling her best, she is caring, compassionate, generous and sensitive. In her work, she is considered competent and capable, and she has had noteworthy success in her ministry. Internally, however, Sr. Maria struggles with intense insecurity and emotional instability. She doesn't view herself positively and has difficulty even knowing what she wants for herself. She is prone to feeling depressed and suffers intensely when she perceives that things are not going her way. When she enters such a state of despair, she remains there for extended periods of time and seems to be unable to find adaptive ways to cope. The intensity of her distress and her lack of effective coping skills result in behaviors (wrist cutting) that initially seem to provide emotional release but in reality are self-destructive and can lead to greater risk of self-harm.

Interpersonally, Sr. Maria also faces significant problems, primarily around trust. She experiences repeated instances of getting very close to someone and then feeling betrayed or abandoned, and devastated. She in turn lashes out in anger. Not surprisingly, her sisters in community feel baffled by her behavior. They feel they are walking on eggshells and have learned that at any moment, and for apparently minor reasons, Sr. Maria might become enraged and explosive. This keeps members of the community from feeling comfortable around her and many even avoid her.

Emotional Dysregulation
Sr. Maria is experiencing difficulty with emotional regulation, the ability to be aware of one's emotions, think in ways that contain the emotions, and effectively manage behaviors flowing from these emotions. Sr. Maria is experiencing dysregulation, characterized by a low threshold for activation (e.g., minor things and comments set her off), intense reactions (e.g., "severe despair") and a slow return to baseline (e.g., Sr. Maria's difficulty with calming herself effectively after conflict).

Marsha Linehan, Ph.D., a leading researcher and developer of Dialectical Behavior Therapy, a treatment approach for Borderline Personality Disorder, identifies emotional dysregulation as a central feature of persons with a Borderline Personality Disorder. Emotional dysregulation represents a true struggle with one's emotions in which emotions appear to steamroll over one's more logical self. Sr. Maria is often described as "overly emotional." While it may not be true that she is more emotional than anyone else, it is true that she is less able to reign in her emotions when it would benefit her to do so. When she is most distraught, her emotions are securely in the driver's seat.

There are several possible reasons why someone might develop problems regulating their emotions: biological predispositions, neuropsychological problems, or traumas. An environmental condition that appears to have clear links to emotional dysregulation is growing up in an emotionally invalidating environment, in contrast to one in which a person is consistently heard, understood, responded to accurately, and affirmed. Humans learn from one another. Childhood, in part, consists of a process whereby children experience themselves in relationship with caregivers and through this learn to soothe themselves, value themselves, and tolerate frustrations. For many, skills for understanding their emotional state and managing it effectively were never integrated or learned.

Sr. Maria was raised in an invalidating environment. Both of her parents suffered from alcoholism. In addition, her father was often cruel and physically abusive, while her mother was primarily focused on herself and did not attend to Sr. Maria's basic needs. Her parents were controlling, usually disregarding her wishes. Maria learned to put on a brave public face and did not tell anyone of the difficulties at home.

Just as relationships play a significant role in the development of emotional dysregulation, they also play a role in the development of effective emotion management. Following an evaluation, Sr. Maria entered residential treatment to help her learn to better cope with her feelings. In therapy groups she experienced a sense of camaraderie and connection that allowed her to test out fears about what would happen if she trusted. In addition, she eventually felt valued, cared for, trusted and safe with her therapist.

Gradually, important shifts occurred in Sr. Maria's manner of thinking about herself and others. She became more aware of her behaviors as separate from who she is and her worth as a person. This shift extended to her community as they became better able to see behaviors as problematic rather than Maria as problematic. Sr. Maria learned to be more accepting of her present reality rather than solely shamed by it. This facilitated her acceptance of responsibility for making positive changes in her life. Over time, Sr. Maria became more empowered and aware of her impact on others, which challenged her previous view of herself as acted upon and having no real say in how others treat her.

Consistent with Dr. Linehan's skills training for Borderline Personality Disorders, Sr. Maria learned skills related to self-awareness (e.g., mindfulness), relating to others, understanding emotions, and dealing with stressors. These specific skills provided her with an increased ability to assess her current emotional state, to be aware of how emotions affect and influence her, and to appropriately assert herself and cope with crises.

Sr. Maria returned to community with a clearer understanding of herself that was not wrought with shame and which allowed her to relate more effectively to others in her community. She still experiences anger, frustration and other emotions, at times quite intensely. However, she is able to name her feelings, acknowledge what she needs, and behave in ways that are consistent with her ultimate goals. She reports increased ability to enjoy her life, and her community experiences her as less emotionally needy. Although wary at first, Sr. Maria's community has become gradually more able to relate to her. When occasional blowups occur, community members have greater empathy for Sr. Maria, and together they are usually able to work through conflicts. Over time, and with the support of ongoing therapy, Sr. Maria has become increasingly more adept at managing her emotions and behaviors.

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Permission to use these materials must be requested in writing by contacting
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SLI EDUCATION DEPARTMENT
Saint Luke Institute
8901 New Hampshire Ave.
Silver Spring, MD 20903
(301) 422-5499 • (301) 422-5519 (fax)

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