Monday, January 12, 2009

Borderline Personality Disorder Uncovered

In my years of study, each time I have come across any article or book about borderline Personality Disorder, I have been left with a feeling incompleteness and an almost disgust at the medical community. When looking at the diagnostic criteria, borderlines come across as something like pathological whiners. As a strong advocate for those suffering from mental illness, I was upset by this limited view of what is one of the most complicated disorders in psychiatry. Yet, knowing there must be more to the borderline, it wasn’t until just recently that I finally encountered a piece of literature that describes in great detail what exactly a borderline person is. Marsha Linehan is well known in the psychiatric community for her development of dialectical behavioural therapy and her book, Cognitive Behavioral Treatment of Borderline Personality Disorder, finally filled in the many empty spaces in other descriptions of BPD.


I do not want to be a promoter of selling anything, but this is a book that should be read by everyone practising therapy. Since that is unlikely to happen, I also strongly encourage people suffering from BPD to read the book themselves. Borderlines are among the most difficult people to treat requiring a lot of skill and energy on the side of the practitioner, as well as with the patient whom is constantly struggling to make sense of themselves and their environment. There is a lot of great language used to describe the struggle of borderlines and for the patient this may help you communicate more clearly to your therapist.


The umbrella problem of borderlines is that they live in a world composed of opposites with little in between. Attempts at reconciliation of these two poles leads to confusion, depression, withdrawal, anxiety, and anger (often directed towards the self). It is easy for a therapist to misinterpret any of a borderline’s behaviours in these attempts at reconciliation, which has the negative impact of invalidating their emotions and further perpetuating the negative perception of the self of the borderline in relation to others.


The borderline person feels everything with an exaggerated affect. Simple tasks can quickly escalate into crises with the precipitating event lost in the confusion. Furthermore, the borderline person is always feeling; they have no ‘off’ switch, so to speak of, and this constant state of crises is what eventually leads to more dramatic behaviours, including suicidal acts, as a means of communicating and reconciling their own feelings with the perceived expectations of the environment with the additional belief that they deserve to be punished . As such, treatment needs to be more focused on behavioural skills rather than crisis intervention. However, notice must be taken when the situation has progressed into the suicidal realm, but without over-emphasising the behaviour or precipitating event.


“borderline individuals are the psychological equivalent of third-degree burn patient. They simply have…no emotional skin. Even the slightest touch or movement can create immense suffering. Yet, on the other hand, life is movement. Therapy, at its best, requires both movement and touch. Thus, both the therapist and … therapy…cannot fail to cause intensely painful emotional experiences…Both the therapist and the patient must have the courage to encounter the pain that arises.”


“…borderline individuals tend at times to appear to others, including their therapists, deceptively less emotionally vulnerable than they are. One consequence of this state of affairs is that the sensitivity of borderline patient’s is far more difficult to comprehend and keep in mind… We can imagine not having physical skin; it is much harder for most of us to imagine what life would be like if we were always emotionally vulnerable or did not have psychological skin ourselves. That is the life of borderline patients.”


“Rarely have I seen such vengeance as that of borderline individuals’ hatred towards themselves.”


The therapist needs to understand that the demeanour of the borderline may not at all be indicative of what they are actually experiencing in the moment or of what they experience outside of session. It is easy for the therapist to discredit the patient’s descriptions of extreme emotional distress when such descriptions are made calmly on the part of the patient. However, it is essential to understand that the patient is trying to communicate as best they can and that what they are describing is in fact true, not an act of manipulation. It is also important for the therapist to remember that the patient “believes that she has communicated clearly [and] that a simple description of how she feels…is sufficient. She may not be aware that the nonverbal message is discordant…Yet when others fail to pick up the message, the individual is usually quite distressed. This failure is understandable, however, since most individuals faced with discrepant verbal and nonverbal affect cues will trust the nonverbal over the verbal cues.” This discrepancy between what is said and what is seen can lead to the many other negative assumptions of a borderline’s motivations including manipulation and laziness.


LISTEN TO THE PATIENT. LISTEN TO THEIR WORDS AND BELIEVE THEM.


While this article details the difficulties in treating BPD, I do not mean to discourage. On the contrary, BPD can be overcome. However this requires commitment and patience of both the caregiver and the borderline. Both therapist and patient need to validate each other. If you are a borderline and in treatment, make sure to tell your therapist every once in a while that you understand the difficulties in overcoming the disorder and you appreciate their efforts. Outside of therapy, also ensure to tell others in your long-term support network that you appreciate them as well. If you are a therapist or a support person, make sure you do the same for the person you are caring for, and do so frequently. Knowing that their efforts are being noticed and validated is essential for treatment.


I could go on with this, and I will come back to the topic, but for now I will refer the reader to Linehan’s book CBT of BPD. If money is an issue, copies are available at many libraries. Or, buy the book from a store and read it without damaging it, then return it.


Links:


http://www.sciencedaily.com/releases/2007/10/071018095733.htm

- an article that says mental health professionals believe care for BPD’d patients is inadequate


http://kconxepts.blogspot.com/2008/12/borderline-personality-disordernotes.html

- one psychiatrist’s notes about BPD


http://psychiatrist-blog.blogspot.com/2007/05/darth-vader-had-borderline-personality.html

- Darth Vader and BPD


http://mentalhealthhumor.today.com/2008/06/10/mental-health-humor-bearing-borderline-personality-disorder/

- another person irritated with the ignorance surrounding BPD and a funny comic


There are so many resources and blogs about BPD. Search around for what motivates and interests you the most. If you have BPD, you may find other’s personal journals to be of help in knowing you are not crazy and you are not alone.

* all quotes are from Linehan's CBT of BPD

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