Anything to Stop the Pain - BPD and Non-BPs

In my Google Group, I recently responded to a member about boundaries and the term “non”. In this message the word SWOE refers to the book “Stop Walking on Eggshells” and WTO refers to the “Welcome to Oz” Yahoo mailing group (which is the largest Non group on the Internet). As you can see by my message I am not over enthusiastic about either:

– snip

The WTO site is all about the “non” and
setting “boundaries” does this come from SWOE???

The non label does come from SWOE as far as I’ve been able to tell. It is in common usage now throuhgout the Internet and the BPD community in general. I know some in the DBT trade that are extremely upset about the use of the term non. A reponse from one of these people: “Would you call someone living with a cancer victim a ‘non’?” (as in non-cancer-patient). The belief that BPD is a medical condition (rather than, say, a purely behavioral one) is very strong in that community. Part of that is because most of the people I have met are parents of BPD daughters (all of them, no sons). I think they don’t want to feel that they have contributed in any way to their child’s condition. I can understnd this - it is painful enough to have a child with BPD, it is even more painful to think that you caused it.

At WTO we went round and round about nature vs. nuture. I think there is a combo of each involved. Most of the “non” community thinks that sexual or physical abuse is the ONLY cause of BPD. Clearly, that is not true. My wife was sexually abused, but my daughter (who shows signs of emotional regulation problems and impulsivity) has not been. As for parenting “style” - we have many times told my daughter to “cut it out” when she was acting particularly emotional - and that is invalidating. The completely weird thing is I always thought I’d treat all my children the same way, but now I know it won’t work. They are all different and all need different treatment of their emotional needs.

As for boundaries, I’m not sure why that seems to be the focus of the people that read SWOE. I hadn’t read it in a while, but I looked over the workbook and found the following:

1) It has a very validating message toward the nons, but a very “us vs. them” message to the BPs. I can understand this since the audience is the nons. We feel confused and upset and those feelings need validating as much as the BP’s feelings. Most BPs that have read the book think it is brutal toward them. Why? Because it paints them in a fairly manipulative light. I don’t think they find themselves to be manipulative. I no longer see my wife as manipulative, she just doesn’t have the self esteem or social skills to be that way. What is true is that her feelings are all about HER - so it feels like there is a selfishness in it, even when she hates herself.

A note from a borderline’s site on SWOE:

Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder

This is written primarily for those who care about someone with BPD rather than for BPs themselves. However, I have read it (I need to know what they’re writing about us) and can’t say I was over-impressed. I don’t think it presented BPD in a favourable light at all and it was written very much in an ‘us versus them’ style (a very provocative stance to present to a borderline!). It may provide important validation for those suffering at the hands of their BP’s confusing behaviour and help to explain where some of the ‘odd’ behaviour comes from, but I found it hard to evaluate the ’self-help’ section as I found it very patronising. I believe there is a second edition of this out now, so who knows, maybe some of these problems have been ironed out. As far as I know it’s still the only book on BPD specifically for the friends and family of BPs so you may have no choice…

2) Boundaries DO play a large part in SWOE, but I think most people mis-understand them. Boundaries are for yourself. The idea that “control” of the BP can be affected by boundaries is clearly not the case. I think that what happens with boundaries is that nons have such anger and are feeling that their partners are doing all these crazy “out of control” things, that they are very empowered by the idea of boundaries. Usually the nons are co-dependant and either allow the behavior to happen or blow up and get angry with the BP. The boundaries provide them with a new sense of control over their life - so they’re like “whohoo!” Also, the boundaries provide nons with something that they can do without having to understand the BP at all. Meaning, it says, “all of the crazy behavior is the BP’s fault, they have no boundaries, they are manipulative, they are evil, etc.” so the nons latch on to that idea without having to take any responsibility for their own invalidating behvaior and without having to “look at the problem through the BP’s eyes” (being empathetic) and without having to show unconditional love to some one who is emotionally ill (compassion).

3) There are some nuggets of good information in SWOE (such as the DEAR and PUVAS techniques), but much of that good info is ignored by the nons that read it for the above reasons.

I can certainly see why nons would feel that it has not been about their feelings for so long that they need someone to say “Take care of YOURSELF and set up boundaries to do so”. It is a simple message and seems to be the only one that is tauted in most non boards.

Unfortnately, it is a recipe for divorce, if that’s the ONLY thing you do. It sucks to be a non, but I expect it sucks even worse to be a BP. If you want to help your BP, compassion is the key, not boundaries. You can’t save them, but you can deal with them in such a way that they will not go directly to Oz.

Of course, they have responsibilties too - like working to get better (and if you follow DBT, accepting themselves the way they are), but that is a decision they have to make. You can’t make it for them.

– snip

If you want to join my Non-BP-Bashing-”Non”-Email-List, go here:

http://groups.google.com/group/ATSTPGroup.

bon :: Jun.23.2006 :: Boundaries, Borderline Personality Disorder :: No Comments »

I made another realization recently. When I am depressed, I don’t know what makes me sad, but I feel sad (it’s worse than “sad” but that’s the general family). I imagine that when people get panic disorder they fear fear for “no reason”. So, I was thinking - perhaps depression is when sadness goes haywire, panic when fear goes haywire and BPD (or ERD, or whatever the disorder is called) is when shame goes haywire. It’s not like there is a “valid external reason” to feel shame. They just DO. But often they look for external reasons. It’s a theory anyway…

bon :: Jun.07.2006 :: Shame :: No Comments »

Here’s an article published in JAMA journal the Archives of
General Psychiatry (http://archpsyc.ama-assn.org/) on June 5th, 2006:

Recovery possible for Borderline Patients

Dutch investigators prove effectiveness of new treatment.

For the first time in history it has been proven that Borderline
Personality Disorder can be effectively treated in its full range.
Investigators of Maastricht University, Vrije Universiteit Amsterdam, and Leiden University published in the June 2006 issue of the JAMA journal the Archives of General Psychiatry a study into the effectiveness of two psychotherapies for borderline patients. The study demonstrates that Schema focused therapy leads to complete recovery in about 50% of the patients, and in two-thirds to a significant improvement. The success of the therapies is strongly related to their duration and intensity (two sessions a week for three years). The results clearly contradict common ideas that borderline personality disorder cannot be fully cured, and that prolonged psychotherapy is useless.

Borderline Personality Disorder is generally known as “untreatable” and is quite common in the general population: 1 to 2.5 % of the population suffers from it. Characteristics are chronic instability, emotional dysregulation, self-mutilation, suicidal behaviour, impulsivity, abandonment fears, anger attacks, identity problems, and low stress tolerance. The medical and societal costs are high, and many of these people cannot participate in the labour process, or don’t function at levels that could be expected given their intellectual capacities. Usual care is limited in effectiveness, and even the best treatments so far can only successfully address a minority of the borderline problems.

Dr. Josephine Giesen-Bloo, Dr. Arnoud Arntz (projectleader), Dr. Philip Spinhoven, Dr. Richard van Dyck and other investigators of the universities mentioned above compared in the study two treatments for borderline personality disorder: Schema focused therapy (SFT) and
Transference focused psychotherapy (TFP). 86 patients recruited in 4 mental health institutes in the Netherlands (Maastricht, Amsterdam, The Hague, and Leiden) received two sessions SFT or TFP a week for 3 years. The effects of the treatments were assessed with 4 criteria:
borderline-symptoms (BPDSI-IV-score), general psychopathological symptoms, personality characteristics, and quality of life. During the 3 years assessments were conducted every 3 months. In 24% (TFP) and 46% (SFT) of the patients treatment led to full recovery. One year later the percentages even increased to 52% (SFT) and 29% (TFP). In the SFT condition two-thirds of the patients improved to a significant degree. On the other 3 criteria effects were also positive and in favour of SFT.

Positive effects became apparent after one year, with continuing
improvement in years 2-4. The investigators conclude that both
treatments have positive effects, with a clearly higher effectivity of SFT. Moreover, the lower dropout rate indicates that SFT induces a higher treatment allegiance in the patients than TFP.

SFT is a cognitive-behavioral therapy, in which patients acquire
insights in the patterns that underlie their problems. For borderline personality disorders these are classified into 4 standardized patterns, called schemas. By means of behavioural, cognitive and experiential techniques the disorder is treated. The treatment focuses on the relationship with the therapist, on daily life outside of therapy, and on traumatic childhood experiences (which are very common in this disorder).

TFP is a psychodynamic therapy. At start, a treatment contract is agreed upon, which remains at the centre during treatment. By continuous analysis and interpretation of the mutual relationship a structural change in personality of the patient is brought about.

Thus, both treatments address the problems at the level of the personality, whereas most common treatments are restricted to the reduction of specific symptoms of the disorder (i.e., self-destructive
behaviors).

The investigators plead for the recognition of SFT as an evidenced based treatment of borderline personality disorder. Despite the high number of sessions and the long duration, they observed that the treatment is cost-effective, as it leads to an immediate cost-reduction for society of 4500 Euros per patient per year, already during treatment. The common idea that prolonged psychotherapy is unjustified is, at least in the case of SFT for borderline personality disorder, incorrect.

bon :: Jun.06.2006 :: Treatment, Borderline Personality Disorder :: No Comments »

Validation and DBT:

Validation in DBT involves five different levels. This first two are similar to other psychotherapies and involve unbiased listening and observing, and eliciting and accurately reflecting the patient’s thoughts, feelings, and assumptions. The third step of validation is to articulate for the patient unverbalized emotions, thoughts, or behavior patterns. The idea is to accurately “read their minds” and help them learn to accurately label internal states. The fourth step is for the therapist to validate the person’s present behavior based on their past learning history. In other words, from the DBT perspective, any human given the same biological makeup and learning history would end up responding in exactly the same way given the same context. Fifth, the therapist looks for and articulates the part of the patient’s response that is valid and / or wise. The idea is that even dysfunctional behavior, to some degree, makes absolute sense at the time the patient engaged in the behavior (e.g., served to reduce pain) and that if the patient could have done anything different (i.e., more adaptive), he or she would have done so. Thus, the therapist validates the grain of truth in any given response, while at the same time he or she works with the patient to change that very same response

bon :: Jun.06.2006 :: Validation, DBT :: No Comments »

Schema-focused therapy is a form of BPD treatment that Gunderson uses.
It is CBT, but focuses on schemas and deeply-entrenced “cognitions”.
Unlike DBT, which focuses on emotions (mainly) and cognitive
distortions, SFT takes a page from the personality people and tries to
rebuild the schemas that make up the personality. DBT is usually not
too concerned with “what you learned from your parents” more “what you
think about things and how can we change that”. Now, with respect to a Jospeh Campbell thing - I could say quite a
bit. What I'd like to say is this (hopefully briefly, because I'm busy
today - I have read all the messages from yesterday and before and
there seems to be a bunch of stuff going on in everyone's lives. I also
want to post another message about my daughter who is having some
serious emotional issues):

There are at least three ways of looking at the universe (and it’s
interaction with our minds). They are basically this:
1) The western way (or the “clockwork universe”). Because rationality,
science and technology is so ingrained in our way of thinking the model
of the universe is that of a giant mechanism. We (or bodies) are also
mechanisms. The mind/spirit/soul/self is some kind of “ghost in the
machine” - living inside it’s machine skin and going on after death to
another realm.
2) The Indian way (or “all the world’s a stage”). Every person and
thing is a hiding place for god - he (or the ultimate spirit - the pure
brahma - ok my spelling will be crappy and I don’t have time to look it
up) is reflected in you (in “your” ultimate spirit called “atman” in
sanskrit). God wears a “you” mask and a “me” mask. Basically, (in
computer terms) we are all particular instances of a class called
“spirit”. That is the “true” reality, the rest is illusion (maya). This
grew out of the society (which, with it’s caste system is very
role-based). However, Buddhist thought shattered that world-view (more
on that later).
3) The Chinese way. (or “organic systems” - in Chinese I think it’s
called Wu-Li). The universe and you are a tightly integrated organic
engery system. You are a natural extension of the world and the world
is a natural extenion of you. You can not exist without the world, it
can not exist without you. Think of the Yin-Yang and that symbol sort
of summarizes this position.

As Buddhism integrated Chinese concepts #2 and #3 sort of merged and
mixed. Buddha, however, pretty much dismissed “atman” (or essential
essence, see below).

OK, on the Buddhist thing. Buddha expoused three core concepts (called
the 3 “marks of existence” - he BTW had a lot of lists of ideas. Why?
because these ideas were not written down for hundreds of years, so the
monk had to remember them.) - they are:
1) Dukkha - suffering. Suffering exists and it exists because of a
basic inability of the mind to accept the state that it is actually in.
We thrist for “other” and cling to what we think we “have” (including,
paradoxically, our own mind).
2) Anicca - impermance. Every thing is in a state of flux, passing in
and out of existence, including ourselves and our minds. There is a
really interesting related concept called “Dependent Arising” (although
there are a number of translations of it). I don’t have time to talk
about that, but it is facisnating (and implies there is no creator of
the universe or beginning at all, BTW).
3) (OK here is the biggy in the Joseph Campbell sense) Anatta means
“no-self”. Buddha didn’t believe that we had a “core”
personality/mind/identity. This concept is that the mind (or self) is
made up of five “bundles”. A quote from the buddhism scripture (written
long after buddha died BTW):

“A chariot is neither asserted to be other than its parts, nor to be
non-other. It does not possess them. It does not depend on the parts,
and the parts do not depend on it. It is neither the mere collection of
the parts, nor it is their shape.:

Basically, we created the “charriot” in our minds and call it “me”. But
it is made up of parts that, on their own, can’t be called a charriot.
It is a concept that we label something with wheels and a seat and a
place for horses to pull (or race in like “Ben-hur”). But it is nothing
more than a label we slap on that concept. Buddha was suggesting that
our identity is the same way. There is no “you” there. Instead there is
a flux of feelings, thoughts, memories, sensory perceptions (or
“cognitions” - mental floral and fauna) that you throw together, slap
your name on it and say “hey that’s me!” However, are you the same you
as you were at 9 years old?

What does any of this have to do with BPD? Actually, probably a LOT. If
they feel that they have no core - they, according to the Buddha
anyway, might be experiencing reality as is really is. But it scares
the living sh*t out of them. Like doing acid? I think
it is probably a whole lot like doing acid. Nothing to stand on,
nothing to build on. You can’t build a castle on top of a river.

So, DBT borrowed more from Buddhism than mindfulness - it also borrowed
the concept of radical acceptance - deep acceptance and knowing of the
way things REALLY are. If you can’t accept it, if you cling to that
illusion, if you feel that your mental afflictions are real, then you
are in for a whole lot of suffering (see “mark of existence #1″). But
the interesting things is: what if our BP’s are actually MORE sensitive
to the “actual” reality than we are? Sure, it’s scary, but it might be
more “real”? That, of course, only applies to their sense of “self”,
not the impulsiveness and the emotional dysregulation. I think there
was a psychologist that called schizophrenics “the hyper-sane” (but I
think he became a Scientologist and disavowed psychiatric meds and
stuff). Something to think about.

Anyway, that was fun. As you know I find Buddhist thought/philosophy
very interesting.

bon :: Jun.03.2006 :: Mindfulness, DBT :: No Comments »