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WILLINGNESS

• Cultivate a WILLING response to each situation
• Willingness is doing just what is effective in each situation, in an unpretentious way.
• Willingness is listening very carefully to your WISE MIND, acting from your inner self and your deepest core values.
• Willingness is becoming aware of your connection to the universe and to the person you are interacting with.
• Willingness engenders listening and mentalizing.
• Ask yourself, in 5 years from now, will the situation that causes the distress matter?

WILLFULNESS

• Willfulness is like sitting on your hands when action is needed, refusing to make changes that are needed.
• Willfulness is about the desire to be right in a situation, regardless of what is needed to get through effectively.
• Willfulness causes you to fight any suggestions that will improve the distress and thus make it more tolerable.
• Willfulness is being rigid and inflexible.
• It is the opposite of doing what works, of being effective. Willfulness is trying to fix every situation or refusing to tolerate the distressful moment.

That last example in willfulness is particularly important to read and consider. Often, I find the loved ones of borderlines to be “fixers” and try to solve each problem for the borderline. Being willing to listen, and really hear what the other person is feeling and going through is usually more effective, despite the distress it may cause, than telling the other person what to do or giving advice.

Adapted from dbtselfhelp.com, with edits and additions by Bon

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• Psychic Equivalence – when the world is equivalent to the person’s mind. This is the “feelings = facts” mode. “If I feel sad, there must be someone/something that made me sad.”
• Pretend – mental states are not anchored in reality. Pretending “as if” something is true, when external evidence shows the contrary. This is “bullshitting” mode.
• Teleological – mental states can only be expressed in action. “If you loved me, you’d buy me a car.” Only tangible actions count, not words or thoughts.

In addition, there are other ways of thinking that inhibit mentalization such as:

Concrete thinking – “But he said he hated me!” Taking something as gospel and ignoring the underlying mental states and their malleability.

Pseudo-mentalizing – seemingly understanding of mental states, but used in a self-serving fashion.

What do you do when the failure to mentalize happens? When a break in mentalization occurs, you must intervene immediately. You cannot let the break go unnoticed or simply “let it go.” You have to be attentive to the level of mentalization in the conversation and stop the flow of the conversation right away.

Bateman has 3 basic ways of dealing with the break in mentalization, each used for a different intensity of the break. They are:

1. Stop, Listen, Look (for minor cuts, bumps or abrasions).
2. Stop, Rewind, Explore (for breaks, burns and internal injuries).
3. Stop and Stand (for life-and-death struggles and near-fatal injuries)

Huh? What’s up with those?You will notice that “Stop” begins each of these methods. Bateman suggests actually holding up your hand, palm forward in a traffic cop sort of way and saying, “Stop…” (or some variant). This “mentalizing hand” is the “shock to the system” that indicates a hold on further progress to a conversation. It is an indication that you can’t continue the conversation without some sort of clarification of what just happened.

Stop, Listen, Look

This puts the conversation in “pause mode.” It is to remedy a small break in mentalization. It is a reaction to the reaction of the other person. If the person is triggered into an emotion by something that you said, you must stop, listen and look. Some of the ways to do this are:

• “Wait. I’m confused. What I said seemed to have upset you. That wasn’t what I intended. Can you clarify how you feel?”
• “Stop for a minute. You said I was being mean. I didn’t intend for that to be mean, but I guess I was. What do you feel that’s about?”
• “Hold it. You appear to be angry at that. Is that right?”
• “Hang on. I think what I said upset you. Can you help me out here and explain why?”

I know all of this seems rather clunky; however, the purpose of this is two-fold: 1) to get the other person thinking about their thinking (a re-engagement of mentalizing) and 2) to communicate that you are really engaged in the conversation and interested in how the other person is feeling.

Stop, Rewind, Explore

This process is a bit arduous. It requires you to step back through the last few moments of the conversation and explore each, “frame by frame.”

• “Let’s go back and explore what happened just then. It seemed to me we were relating well and then something happened. What do you feel happened?”
• “Something happened just now. Let’s try and rewind a bit to see where the conversation went astray, alright?”
• “Hang on a second. I feel like my intention and the way you felt about what I said are not in synch. Let’s go back and see what happened.”
• “Wait. There appears to have been a misunderstanding a moment or so ago. What do you feel about what I said?”Then, you have to go forward, step-by-step, statement-by-statement and explore each one and see how those made the other person feel.
• “So, I said, ‘maybe he was just tired’ and you felt I was being dismissive of your feelings? Is that right?”
• “You said that you didn’t want to talk about it and I continued. You felt badgered, correct?”
• “When I started talking about our daughter, you felt I wasn’t being attentive to your feelings. Do I have that right?”

Stop and Stand

This process is for the big problems. It is the way that you apply your own personal boundaries to a situation. When the other person is way down the path of emotional dysregulation, stop and stand can be the only option. It is basically your way of either ending the conversation or trying to re-frame it completely.

• “As far as I can tell, we are going around in circles about this. I don’t see any point and continuing to talk about it.”
• “I feel we have reached an impasse. You have your view and I have mine. I don’t think going back and forth will do either of us any good.”
• “I can’t really discuss this anymore right now. Maybe we could discuss it again in the morning.”
• “I can’t listen to you when you’re drunk. Let’s talk about this later.”

Remember: like any application of boundaries, this one is likely to cause an immediate strong reaction, but the “stand” part is that you have to stand your ground.

This content is based solely on my interpretation of mentalization skills.

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Basically, mentalization is the connection of mind to mind in a particular exchange. It is about in-the-moment interaction, not about the past or future. It is about communicating and understanding your and the other person’s explicit and implicit expressions and motivations, feelings, goals, etc. It is about accurately expressing yourself and listening to the other person in a search for meaning. It is about internalizing the other’s viewpoint and having the other internalize your viewpoint. A really good example of mentalizing is an inside joke – both you and the other person completely understand the meaning of the joke and have internalized the meaning.

Jerry Holmes, a researcher that works with Anthony Bateman (a co-creator of mentalization therapy), calls mentalization the process of “seeing yourself from the outside and others from the inside.”

Why mentalize?

We mentalize for several reasons. The main one is that mentalization is a “meeting of the minds” in which a personal connection is made. Mentalization encourages the integration of thoughts, desires, feelings, motivations, intentions, goals and all other internal mental elements and the communication and understanding of the same in others. When we mentalize, we are out of “lizard brain” thinking and into the prefrontal cortex. That requires the reflection upon meaning and discourages emotional dysregulation, concrete thinking, bullshitting, dismissive attitudes, blaming and IAAHF.

Mentalization serves to:

• Improve trust – others feel that you “get them.”
• Improves communication between two people – the meaning is exchanged.
• Builds empathy and compassion – you can see the world through the other’s eyes.
• Help work on a relationship – people take responsibility for feelings, words, and mental processes.
• Decrease misunderstanding and resentment – understanding other person’s intent.
• Change viewpoints and assumptions – when alternative meaning is applied to situations, beliefs and assumptions can change.

How does one mentalize?

It is important to remember that mentalization is about NOW. It is not about any other moment than now. Therefore, if you are dragging old issues or future worries into the conversation (or if the other person is) then you are experiencing a “failure to mentalize.”

You mentalize by continually monitoring the progress and state of a conversation. You mentalize by asking questions about the current conversation, the feelings and intention of the other person and monitoring your own feelings and understanding of the current conversation. It is a natural skill and is built into the human mind; however, it is also a difficult skill, because we are often not mindful of the current moment when having a conversation. We are often distracted by our own thoughts and feelings, assumptions and automatic thoughts, history and attachment to the other person. If your mind meanders into these things, you are experiencing a failure to mentalize.

Mentalization is done from a “stance,” which is summarized as follows:

• Compassionate for yourself and the other person
• Focus on the other person’s mind
• Humble about your viewpoint and not bullying
• Curious and interested, an authentic desire to see the other person’s point of view
• Validating for additional information about inner mental states (before offering alternative perspectives)
• Normalizing and generalizing – “everyone makes sense (to themselves) at all times”

Mentalization is the true essence of love, compassion and understanding, because it allows you to internalize the authentic “image” of the other person’s mind (and they can yours as well).

Mentalization is essentially done through asking questions, but not leading questions. One cannot ASSUME the other person’s thoughts and feelings are what you think they are. You have to start with a blank slate each time. You can “read” momentary feelings (such as recognizing micro-expressions) but the MEANING of those feelings is not always clear.

If you don’t know, you have to ask.

You ask by being “dumb” and not assuming. For example:

• “I’m not sure I understand. Can you help me out and explain how you feel?”
• “Why do you think he said that?”
• “What happened?”
• “How did you feel about that?”
• “That’d make me feel sad. Do you feel sad about it too?”
• “What do you think was up with that?”
• “Could you tell me more about that?”
• “Really? That wasn’t my intention. Perhaps we could talk about that more?”
• “I wonder if…” statements

The purpose is to probe the other person’s mind and to get as close to a full understanding of the other person’s internal mental processes as possible. It is impossible without a true interest in the other person. It is impossible if you judge the other person, or if you get in your own way, entangled in your own mental processes.

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An article from psychcentral about a study indicating that social problems in teens can lead to personality disorders:

Social Problems in Teens Can Lead to Personality Disorders

By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on September 29, 2011

A new research study looks at how adolescents think, how disordered thinking can take root, and how this thought pattern can ultimately lead to an adult personality disorder.

The study examines the relationship between borderline personality disorder (BPD) traits and “hypermentalizing” in adolescents. Mentalizing is the social intelligence that refers to the ability to infer and attribute thoughts and feelings to understand and predict another person’s behavior.

Dr. Carla Sharp, psychologist at the University of Houston (UH) and lead researcher, believes the results of the data can be used for early intervention, treatment, and identification, of borderline personality disorder (BPD) in adolescents.

This includes improved treatment strategies — such as putting the brakes on “hypermentalizing” — and encouraging a BPD patient to stick to the facts.

“Why does someone with borderline personality disorder key a car, if doing so will not lead to good consequences? What compels her to make that decision?” Sharp said.

“I am trying to understand the development of the disorder and what happens in the brain, and what happens in the minds of these children as they develop to put them on a different trajectory compared to their peers.

“Borderline personality disorder is a condition in which people have long-term patterns of unstable or turbulent emotions about themselves and others. These inner experiences often cause them to take impulsive actions and have chaotic relationships.

“The criteria for BPD includes: excessive anger, affective instability, a clear pattern of self-harm over two years – burning, cutting, suicide attempts, abandonment fears, relationship problems, significant impulsivity – drinking alcohol, drug abuse, eating, anorexia, overeating and illegal activities.

“Clinicians have been reluctant to diagnose BPD in adolescence because there is the notion that personality is not fully developed in childhood and adolescence. We know that the brain is only fully developed by age 25, so how can we diagnose a personality disorder in someone if they don’t have a fully developed brain yet?” said Sharp.

“On the one hand, we are finding in our research that kids do have a stable pattern of interaction with others. Parents will describe their kids to you in terms that remain stable over time.

“Therefore, personality researchers have highlighted the point that teens do not wake up at 19 and have a personality disorder on the first day of their 19th year, so there must be some precursors to the disorders. There’s been a group of people, including myself, advocating that we not necessarily diagnose borderline personality disorder in adolescence, but that we assess for it to make sure that we don’t miss these children.”

The study spanned a two-year period and included 111 adolescent inpatients between the ages of 12 to 17.

A key component was the use of a new tool to assess social cognition in children. The tool is called the Movie for the Assessment of Cognition (MASC) and is used alongside self-report measures of emotion regulation and psychopathology.

In the study, research subjects were presented with actual movie scenes. They were introduced to the characters in the movie: Sandra, Michael, Betty and Cliff, by showing a photo of each. They were instructed to watch the 15-minute film carefully to understand what the characters are feeling and thinking.

They are then asked what the character in the movie might be feeling or thinking, with four options to choose from, forcing a single response prompt for one of the following categories: no mentalizing, less mentalizing, hypermentalizing or accurate mentalization.

Researchers found that 23 percent of the adolescents in the inpatient setting met the criteria for BPD. The young adults who met criteria for BPD had a higher frequency of these overmentalizing responses.

The study also found hypermentalizing interacted with emotional regulation. The individuals with BPD misread people’s thoughts, upsetting the adolescent and disrupting emotional regulation which can lead to an increase in borderline personality disorder symptoms.

“This research study is groundbreaking in that it’s the first to provide empirical evidence of the link between BPD and mentalizing in adolescents. By identifying precursors and treating BPD early in adolescence, we can use validated treatments to help these children,” Sharp said.

“The danger of not recognizing precursors of BPD in adolescents is that it can lead to years of confusion and pain for family members and the individual with misdiagnosis and lack of appropriate treatment. These families often go through years of assessment, and people might think it’s bipolar disorder, depression, conduct disorder or comorbidity.”

They are often relieved when they get to their mid-’20s and get to the right treatment facility that can actually diagnosis them and give a name to the cluster of symptoms they’ve been experiencing for so long, Sharp said.

“The next step is to try to do this work while neuroimaging the teen’s brain, so that we can look at the biological correlates of this. Such research could potentially lead to pharmacological intervention in addition to the talk therapy,” she said.

Source: University of Houston

APA Reference
Nauert PhD, R. (2011). Social Problems in Teens Can Lead to Personality Disorders. Psych Central. Retrieved on October 4, 2011, from http://psychcentral.com/news/2011/09/29/social-problems-in-teens-can-lead-to-personality-disorders/29893.html

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Lemonsky had to wait until her late twenties even to be given a name for the condition that left every aspect of her life in disarray. Then, after one of her suicide attempts came perilously close to succeeding, a concerned doctor got her an appointment with Anthony Bateman at St Ann’s Hospital in London.

Bateman’s unit specialises in treating personality disorders, but Lemonsky didn’t realise that until, sitting in his office, she pleaded for an explanation of her problems. “He said: ‘It’s borderline personality disorder.’ I said: ‘Is it treatable?’ He said: ‘Yes.’”

This simple yet optimistic exchange will surprise many people who have been given the same diagnosis. It may even surprise some psychiatrists. Personality disorders revolve around difficulties interacting with other people. They can be extremely debilitating to those with the condition and those around them, and have been thought to be lifelong afflictions. Borderline personality disorder, in particular, has a terrible reputation, summed up on a cover of Time magazine as “The disorder that doctors fear most.” Even the current edition of psychiatry’s handbook, the Diagnostic and Statistical Manual of Mental Disorders (DSM), perpetuates the gloom by describing personality disorders as “stable and enduring”.

“It turns out that it’s not true,” says John Oldham, a specialist in personality disorders at Baylor College of Medicine in Houston, Texas, and president of the American Psychiatric Association, which publishes the DSM. For despairing families, the encouraging news is that the problems of people with borderline personality disorder subside with age. Recent clinical trials have also shown that specialised psychotherapy can significantly improve their lives. Still, a lingering “untreatable” stigma, combined with the difficulty of securing funding for therapy, means that relatively few people with the condition get the help they need.

The encouraging results for borderline personality have kindled hope that other forms of personality disorder? – which are collectively more common but poorly studied? – might also be less ingrained and more amenable to treatment than thought.

Psychiatrists currently recognise 10 personality disorders, classified into three “clusters”? – though the constellation of conditions is mired in diagnostic confusion (see “What’s in a name?”, page 48 ). The disorders manifest in diverse ways, from the callous disregard of others typical of those with antisocial personality disorder?- many of whom pursue a life of crime?- to the extreme social anxiety of people with avoidant personality disorder. Problems interacting with others are the common thread. “You can’t have a personality disorder on a desert island,” observes Conor Duggan, a forensic psychiatrist at the University of Nottingham in the UK.

Borderline personality disorder, which is characterised by extreme emotional instability, is the best studied because the people that have it are aware something is badly wrong and tend to seek help. Anyone familiar with the condition knows that “borderline” doesn’t mean that people with this diagnosis are close to the boundary between mental health and mental illness. Far from it: the disorder got its name because it seemed to combine the distress of neurosis with some of the delusions of psychosis.

At the core of the disorder lies an inability to form stable relationships. People with borderline personality have an almost paranoid fear of abandonment, which often becomes a self-fulfilling prophecy. Friends may be idolised one day only to be despised the next after a perceived slight. Angry outbursts are frequent, and people who try to help often bear the brunt.

“These are patients who don’t trust you. They are highly vigilant and quick to misinterpret things,” says Oldham. “A lot of healthcare workers don’t understand that it’s part of the pathology and take it personally.”

Road to recovery

The first study, led by Mary Zanarini of the McLean Hospital in Belmont, Massachusetts, reported last year that 86 per cent of 249 patients had improved to the point that they no longer met diagnostic criteria for borderline personality for at least four years within the 10 years of follow up (American Journal of Psychiatry, vol 167, p 663).

This result was no fluke: in April this year a second study, which set a higher bar for judging remission, reported that 85 per cent of 111 patients had remitted for at least a year over a 10-year period (Archives of General Psychiatry, vol 68, p 827).

“I’ve been immersed with these patients and I didn’t anticipate it,” says John Gunderson, also at the McLean Hospital and one of the leaders of the second study. He says that psychiatrists simply failed to realise that many people who stopped turning up for therapy were actually getting better.

Given the suffering of people with borderline personality and their families, finding ways to accelerate recovery is a top priority. Although some progress has been made in understanding the condition’s biological basis (see Inside the borderline mind, page 47), the pharmacological revolution that dominates modern psychiatry has stalled in the case of borderline personality. Antipsychotic drugs or mood stabilisers can help lessen some symptoms, but last year a systematic review of clinical trials concluded that such drugs make little difference to the disorder’s overall severity.

Another successful approach is mentalisation-based treatment, pioneered by Bateman and Peter Fonagy at University College London. MBT comes from the tradition of psychoanalysis, and concentrates on getting people with borderline personality to better understand their own and others’ mental states. It has been less widely studied, but seems to reduce suicide attempts and the use of psychiatric services, while increasing people’s ability to hold down a job.

For Lemonsky, who had found previous therapists dismissive of what seemed to them trivial issues, the last aspect was a revelation. “Whatever I said was treated with the utmost importance,” she says of her experience in Bateman’s clinic.

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A: Unless your borderline loved one is a minor or you have a court order, you can’t force anyone into therapy. Therapy must be a choice of the person that needs it. It will probably be much more effective if the person with BPD chooses to go to therapy. Yet, therapy is not like sending your car in for repairs. It’s not as if you send the person in to therapy, he/she gets a new part and comes out fixed. That’s not the way therapy works.

For BPD, the “gold standard” of therapy is Dialectic Behavior Therapy (DBT). It is an “evidence-based” treatment – meaning the therapy has been researched against “therapy as usual” (TAU) and been shown to be more effective than TAU. However, DBT is generally measured on reducing suicidal impulses and self-harm. DBT has been criticized for being most effective with the “lowest functioning” people with BPD. I personally like DBT in that it provides the borderline with essential skills that can make their lives more effective. DBT usually takes at least a year. It took my daughter two years to complete. For more on DBT from this blog, click here. It is also important to note that, in many circumstances, the family members can be more effective if they participate in the DBT treatment by learning the necessary skills to support the treatment.

Recently, a new treatment called Mentalization-Based Treatment (MBT) has come on to the scene – particularly in the UK. I only know of two places in the US that MBT is available. Mentalization-based therapy focusing on the skill of “mentalizing” and is an interactive therapy in which the moment-to-moment relationship between the client and the therapist helps encourage critical, integrative thinking. Mentalizing is a process and it requires participation of each person in a particular conversation. One must try to see the world through the other’s eyes and clearly express one’s own mental aspects including intent, desire, motivation, feelings and aspirations. For more on MBT on this blog, click here.

There are other therapies that can be effective with BPD including schema-focused therapy, STEPPS and transference-focused therapy.

Both DBT and MBT are quite expensive at this time.

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“…BPD is present in about 6% of primary care patients and persons in community-based samples and in 15 to 20% of patients in psychiatric hospitals and outpatient clinics,” writes John G. Gunderson, MD, from the Psychosocial and Personality Research Program, McLean Hospital in Belmont, Massachusetts. “Patients with BPD usually enter treatment facilities after suicide attempts or after episodes of deliberate self-injury. Such episodes result in an average hospital stay of 6.3 days per year and nearly 1 emergency room visit every 2 years, rates that are 6 to 12 times those among patients with a major depressive disorder.”

As you can see BPD has a major financial impact on the health care system, not to mention the distress for the patients and their families.

When reviewing the various treatment options, the author says this about mentalization therapy:

Mentalization-based therapy is a cognitive or psychodynamic therapy including individual as well as group therapy. While assuming a “not-knowing” stance, the therapist insists that the patient “mentalize,” or examine and label his or her own experiences and those of others. This emphasis on thinking before reacting may be a process central to all effective therapies.

That “not-knowing” stance is what I tell the nons that I know: Be a detective, not a judge.

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IATROGENESIS, PSYCHOTHERAPY AND BORDERLINE PERSONALITY DISORDER

Pharmacological studies routinely explore the potential harm that a well-intentioned treatment may cause. In the case of psychosocial treatments we all too readily assume that at worst such treatments are inert. However, there may be particular disorders where psychotherapy represents a significant risk to the patient. Whatever the mechanisms of therapeutic change might be, traditional psychotherapeutic approaches depend for their effectiveness on the capacity of the individual to consider their experience of their own mental state alongside its re-presentation by the psychotherapist. The appreciation of the difference between one’s own experience of one’s mind and that presented by another person is key. It is the integration of one’s current experience of mind with the alternative view presented by the psychotherapist that must be at the foundation of a change process. The capacity to understand behaviour in terms of the associated mental states in self and other (the capacity to mentalise) is essential for the achievement of this integration.

Most individuals with no major psychological problems are in a relatively strong position to make productive use of an alternative perspective presented by the psychotherapist. However, those who have a very poor appreciation of their own and others’ perception of mind are unlikely to be able to benefit from traditional (particularly insight-oriented) psychological therapies. We have argued that persons with borderline personality disorder have an impoverished model of their own and others’ mental function (Bateman & Fonagy, 2004). Their schematic, rigid, sometimes extreme ideas about their own and others’ states of mind make them vulnerable to powerful emotional storms and apparently impulsive actions, and create profound problems of behavioural and affect regulation. The weaker an individual’s sense of their own subjectivity, the harder it is for them to compare the validity of their own perceptions of the way their mind works with that which a ‘mind expert’ presents. When presented with a coherent view of mental function in the context of psychotherapy, they are not able to compare the picture offered to them with a self-generated model and may all too often accept alternative perspectives uncritically or reject them wholesale.

Any psychological therapy can generate these divergent responses. Both cognitively based and dynamically orientated therapies offer causal explanations for underlying mental states. These can give ready-made answers and provide illusory stability by inducing a process of pseudo-mentalisation in which the patient takes on the explanations without question and makes them his/her own. Conversely, both types of perspective can be summarily and angrily dismissed as overly simplistic and patronising, which in turn fuels a sense of abandonment, feelings of isolation and desperation. Even focusing on how the patient feels can have its dangers. A person who has little capacity to discern the subjective state associated with anger cannot benefit from being told both that they are feeling angry and the underlying cause of that anger. Such an assertion addresses nothing that is known or can be integrated. It can only be accepted as true or rejected outright, but in neither case is it helpful. The dissonance between the patient’s inner experience and the perspective given by the therapist, in the context of feelings of attachment to the therapist, leads to bewilderment which in turn leads to instability as the patient attempts to integrate the different views and experiences. Unsurprisingly, this results in more rather than less mental and behavioural disturbance.

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Before I go into this, however, I would like to note something about my (unscientific) polls. I have been told that by certain “experts” in the non-BPD area that this “quiet”, “invisible” or “high functioning” borderline is much MORE common than the (presumably) “loud”, “visible” or “low functioning” borderline. Except… my poll numbers don’t bear that out. I really assumed that these poll numbers would reflect that the “invisible” borderline was more common. However, what my numbers show is that around 75% of borderlines report suicide attempts, substance abuse and self-injury. There seems to be an assumption that there are many, many invisible borderlines, suffering in quiet desperation and known only to their loved ones (and themselves – maybe). I’m not even going to bother to go into the assumption that there are also a large percentage of borderlines with NPD too. Personally, I think this is a fallacy (that there is a large %) and, although there are some for sure (even though my comments reflect that the borderlines feel that these ways of thinking are at opposite spectrums), the skills to effectively interact with someone with BPD and someone with NPD are not the same. I focus on what I think are the vast majority of borderlines – those without NPD.

Now back to the mentalization failures:

Pretend Mode – I believe that this mode is the one in which my commenter was operating often. In pretend mode, you have a sense that you are “faking your way through it” and that you’re pretending “as if” things are ok. This is also the nature of bull-shitting and with BPD, people seem to be able to bullshit their way through about anything, including therapy, relationships, and careers. This mode seems to be the “default state” of the quiet/invisible/high-functioning borderline. However, as evidenced by my commenter, that view of the borderline is from the outside only. From the inside, they feel fake, alien and on the verge of a breakdown and as she says: “I should say the appearance of ‘all is well’ has been going on since then [her in-patient stint]”. It’s all about appearances. For me this can cause the non-BPD to lack compassion for the borderline, because the non-BPD feels that the borderline can “turn it on and off”. What’s missing in the understanding of the non-BPD is the inner view of the borderline which is why in When Hope is Not Enough, I focus on internal features of the disorder (shame, emotional dysregulation and impulsivity).

Psychic Equivalence – this is the “feelings = facts” mode, in which the contents of the borderline’s mind are equivalent with the outside world, other’s thoughts and reality in general. It seems to cause the raging, the paranoid thoughts, the “you’re being mean to me” (on purpose) behavior, and the suspicious behavior, such as stalking, badgering and accusation of affairs, accusations of evilness and “black splitting”. The borderlines that spend a lot of time in psychic equivalence are the aggressive ones (to others). It seems to be the “what if” (in a very negative, “waiting for the other shoe to drop” variety) way of thinking.

Teleological – this is when only physical manifestations of support and soothing matter. Teleological modes seems to manifest in cutting and other forms of self-injury (I bleed so I can stop the hurt), over-deserving behavior (like over-spending, “I deserve a new dress even though I can’t afford it”), and demanding of physical examples of being soothed, such as sex, moving to a new place (“if only I lived in X place, I’d feel better”) and demanding of new things (“if you really loved me, you’d buy me a car”). It causes a very concrete and inflexible way of thinking in which only physical demonstration of self-worth matter.

While each borderline is different and probably spend time in each of these modes, the “default” mode (or conditioned mode) of thinking seems to affect the behavior of the borderline. At least this is what I am postulating regarding the question of “invisible” versus “visible” borderlines. Comments are welcome. For more on modes of thinking (according to me) click here.

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1. How mentalization and attachment might explain “high-functioning” BPD
2. The great tree of behavior modification
3. Book Review: Overcoming Borderline Personality Disorder

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See larger image Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change (Paperback) By (author) Valerie Porr List Price: $24.95 USD New From: $15.03 In Stock Used from: $11.49 In Stock

Overcoming Borderline Personality Disorder by Valerie Porr is perhaps the most up-to-date and complete book for family members of people with BPD published to date. When I read the book, I couldn’t help but think that Ms. Porr had the therapists and mental health professional more in mind than the family members. It appears as though she is trying to dispel many myths about BPD that exist not only in the family environment but also in the mental health community. This book is steeped in scientific research, including research involving the biological under-pinnings of BPD. It includes many skills for family members from both DBT and mentalization based therapy (MBT). Clearly Ms. Porr is highly respected by the clinical community since many of the leading experts in research and practice in BPD treatment have written blurbs for this book. The book is quite dense and a must read for family members of those with BPD. Yet it might not be the best book to start with because of the complexity of the scientific research, the psychoeducational aspects and the technical details about the various therapies for those with BPD. Still, I highly recommend Overcoming Borderline Personality Disorder.

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1. Princess Di and Borderline Personality Disorder
2. A Review of WHINE by someone with BPD
3. Understanding Major Depression With Borderline Personality Disorder?

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Genetics in Borderline Personality Disorder

I was reading an article called “Social cognition in borderline personality disorder: evidence for disturbed recognition of the emotions, thoughts, and intentions of others” and noticed a line in the article that said this: “Thus, in addition to high heritability of BPD (Torgersen et al., 2008), these results argue that environmental factors (e.g., trauma) contribute to disturbed social cognition in BPD. In sum­mary, for the current study we expected PTSD to be a negative predictor of social cognition.” That intrigued me on two levels. One was the “high heritability” part, because often I see comments about BPD and how many people believe that it is mainly caused by childhood trauma (and/or invalidation). In WHINE I state this: As I said earlier, one of the causes of BPD is the “invalidating environment.” Now, it could be that it is not an actual “cause” (and that all the real causes of BPD are biological), but more a reinforcer of BPD. So, the second part of the article that intrigued me was the idea that “we expected PTSD to be a negative predictor of social cognition” – and the discussion and methodology of comorbid PTSD with BPD. What they found was that people with BPD (with or without comorbid PTSD) are less able to understand the intent, thoughts and motivations of social interactions in others – in other words, people with BPD can’t mentalize as well as controls. They also found that this lack of ability is more marked in people with BPD who also have comorbid PTSD. The fact that they mention comorbid PTSD at all is something of a revelation – or perhaps should be to us nons. Many people come to support lists and do research on the Internet and begin their “introduction” of their BPD person with a long list of childhood traumas that explains why the person has BPD. This current research would indicate that PTSD and BPD are clearly two separate disorders and that, while PTSD is a contributor to poorer functioning that BPD alone, BPD is in itself a highly inheritable disorder and biological in nature, yet “reinforced” or made more severe (especially in a social functioning sense) when PTSD is present.

Anyway, this research led me to another scientific study called “Familial Resemblance of Borderline Personality Disorder Features: Genetic or Cultural Transmission?” In which the researchers studied twins, siblings and parents of borderlines to determine the genetic underpinning of BPD or whether the environment and/or cultural influences could have more of an influence on the development of BPD. They found this: “In the present study an extended twin-family design was applied to self-report data of twins (N = 5,017) and their siblings (N = 1,266), parents (N = 3,064) and spouses (N = 939) from 4,015 families, to estimate the effects of additive and non-additive genetic and environmental factors, cultural transmission and non-random mating on individual differences in borderline personality features. Results showed that resemblance among biological relatives could completely be attributed to genetic effects.” and this: “There was no effect of cultural transmission from parents to offspring.”

Recently, in the ATSTP group, we have been discussing the idea that shame/honor-based cultures  and whether that environment could be explanatory in some sense of the development of BPD. It appears (at least based on this 2009 study) that the development and transmission of BPD is NOT cultural. It is essentially genetic (mainly “additive”, meaning it is more than one gene involved) and the environment has an effect, yet cultural transmission was not apparent.

They do go on to say this: “Gene by environment interaction implies that genes determine the degree to which an individual is sensitive to an environment. In the presence of gene-environment interaction, individuals with a ‘sensitive’ genotype will be at greater risk of developing BPD if an undesirable environment is present, than individuals with an ‘insensitive’ genotype.” So, basically, although this interaction has not been fully studied, it appears that some sort of “sensitive” genotype is required to develop BPD.

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1. Bellman’s Syndrome – BPD and Chronic Pain
2. Possible Genetic link in BPD?

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MANY times emotionally sensitive people will read intentions and states of mind into the other that are not aligned with reality. They might say that you’re being mean or trying to ruin their life. Clearing up intention can be a way to mentalize the interaction. That is, if my wife were to say that I did something to ruin her life I can come back with “it is not my intention to ruin your life. I’m not sure why that would be my intention. Can you help me understand how you thought that was my intention?” The purpose is to get a person to start thinking about the mental states of the other person more accurately. Consequence of BEHAVIOR is important. Intention, motivation, goals, desires, etc. of mental states is also important when you’re talking interpersonal relationships. As a friend of mine said about her BPD child: “people with BPD don’t read minds, they read INTO minds” – and because BPD is configured the way that it is (threat awareness, mistrust, fear of shame discovery and intense personalization) it is likely that the intention being read into by a person with BPD will be malevolent.

The flip-side of that idea (that malevolent intentions are misread), is the idea that if it is not your intention to hurt the other person, the other person has no “right” to feel hurt. However:

One must also remember  that INTENTION DOES NOT NEGATE CONSEQUENCE, Just because you didn’t MEAN to hurt someone with a lie, just because you felt bad about yourself and lied (or bullshitted), it still can hurt the other person and their sense of trust. Just because you didn’t MEAN to burn down the house when you were playing with matches, doesn’t bring the house back.

All people, with BPD or not, need to know that, despite intention, behavior has consequences.

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1. BPD: What’s in a Name and How does it feel to be that person?

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Sometimes the holidays can be stressful

Hey all, I haven’t posted much in the way of skills lately, but today, as the holidays are upon us, I think it is helpful to go over some emotional skills and other tools that can help us non-BPD people get through the holidays reasonably unscathed. The holidays are a tough emotional time for everyone. There are expectations that the holidays be “jolly and happy” when, sometimes, the holidays are anything but. The get-together with relatives – many who don’t understand the actions, feelings and behaviors of someone with BPD – can cause huge stress for those with BPD and for the loved ones. Expectations of a low conflict Christmas (or other holiday) are typical, but not often “delivered upon”. Stress and the feeling of being “on-stage” or “good enough” for the family can cause emotional dysregulation and distress. Sometimes an invalidating family can compare the person with BPD with other, less emotional family members. You know, “why can’t you be like your cousin?”

So, in order to skillfully approach the holidays, I’d like to remind non-BPD people and people with BPD alike of the following skills that can help all of us get through. Here we go:

1.    Frustration Tolerance. Sometimes we are overcome with frustration. We feel like we “can’t stand it” or “can’t take it anymore.” When you feel that way, I would encourage you to ask yourself some questions that can help build frustration tolerance. Some questions are:

a.    Can I really not stand it?
b.    Am I really going to explode?
c.    How does exploding/raging help me in my relationships?
d.    What can I do to decrease the frustration?

2.   Mentalizing with yourself in a search for meaning within other people’s actions. Often people jump to conclusions or assume the intent and motivation of others. Sometimes these motivations are assumed to be malevolent, invalidating or uncaring. You can ask yourself the following questions to help understand the intent within yourself:

a.    Do I really believe that he/she is being mean?
b.    Is there another explanation as to his/her motivations?
c.    What would he/she be feeling that could explain this action?

3.    Mentalizing with others to understand others’ internal mental states. Be curious. Ask questions. Don’t “load” these questions. That is, ask “can you clarify what you meant, I’m not sure I understand you intention?” vs. “Why are you being so mean to me?”

4.   Be validating toward yourself and others. Remember that emotions are a major influence on people’s behavior. Listen to others and validate the emotions. Validation does not equal agreement with behavior. It shows that you have heard the other person’s emotions and that it is ok to feel however one feels. Normalization can also be helpful here.

5.    Don’t label people, label events. In other words, rather than saying “he’s an asshole”, say “he did something that bothered me.” This can be used on your own actions as well. Rather than telling yourself you’re a “failure,” you can say “I didn’t do that as I would have liked.”

6.    Be mindful of the moment. Monitor interactions actively and in a way that is non-judgmental. Don’t get caught up in past reactions or fear of future reactions.

7.    Cheerlead yourself and others. This is not “positive mental attitude” statements. This is encouraging others to be brave and effective. The essence of this skill is “you can do/face hard/difficult things.”

8.    Consider the consequences of mind-altering substances. Too much alcohol and/or drugs can create impulsive situations and ones that you may regret later. Think before you drink.

Here’s wishing you all an effective holiday season!

Take good care,
Bon

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2. Lindsay Lohan and possible BPD (more detail this time)
3. Holiday Discount of Publisher’s version of When Hope is Not Enough

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Mentalizing conference call with Drs. Peter Fonagy & Efrain Bleiberg
At the request of participants and the positive response to this November 2009 presentation on the interactive conference call, we are making this tape availalble.

Download conference call

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1. New Free “White Paper”: 5 Common Mistakes by Non-BPs
2. Shared my First Presentation on Slide Share
3. Ask Bon: How do I get my borderline loved one in therapy? What’s the best kind of therapy? How long will it take to cure them?

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Mindblindness

A little while ago, I was reading through “Mentalizing in Clinical Practice” (a dense read, but worth it IMO) and I was reading the section on Mindblindness. This is a concept that was originally developed with respect to autism. It means that you have the inability to accurately read the intentions, motivations or emotions of another person, based on their behavior. We each develop (around 3-4 years old) the ability to read others motivations based on their behavior. The example they give in the book is a “mind reading” (in the sense of accurately understanding another person’s motivations – internal states – based on behavior) test – it is as follows:

Maxi is helping his mother unload the groceries. He takes the chocolate chips out of the bag and places it in the GREEN cabinet, remembering where he put it with the intention of coming back later and eating some. He goes out to play. While he is outside, his mother opens the GREEN cabinet and takes out the chocolate and uses some for cookies. She places the bag back in the BLUE cabinet and goes down to grab the laundry. While she is gone Maxi returns to get the chocolate. Which cabinet does Maxi open to try to find the chocolate chips?

Most of us would say GREEN, right? People with mindblindness and little children (less than 3-4) say BLUE. Why? Because they already know the chocolate is in the BLUE cabinet – they can’t put their minds in the mindset of MAXI, who doesn’t know the chocolate has been moved.

Why do I bring this up?

Because both people with BPD and Nons do this sort of thing all the time. We attribute motivations to others based on information in OUR minds and not on information in THEIRS. Next time you attribute a motivation to your BP (i.e. “she’s trying to control me!” or “she’s out to get me” or “she’s just trying to get attention”) stop and think about this post. Instead of assuming, ask.

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1. Turning the Mind around Social Situations

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DBT calls this “apparent competence,” which makes sense with respect to the dialectical model (the dialectic side of apparent competence is “active passivity” BTW). The one thing that never made a whole lot of sense to me was how the behavior can generally be “reined in” when with certain people. Most non-borderlines think, “Well, if she can control her behavior with [whomever], this must be completely under her control. So, she needs to start behaving better with me.” Sometimes, it seems as though a person with BPD can turn it on and off at will. However, this is not really the case.

Instead, mentalization explains this through attachment relationships: The closer the attachment, the more at stake for a person with BPD. This is why there is a fear of abandonment in BPD. When it comes to close relationships (such as partner or parent), the attachment is more important to the person with BPD and the fear of losing that attachment, the fear that the other person will judge him/her as wrong or bad (shame), is much larger. Unfortunately, the method of coping with this fear is usually maladaptive and functions to push the other person further away. Sadly, that can lead to a self-fulfilling prophecy of abandonment.

When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

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2. A failure to mentalize – Mentalization Information Part 2
3. Mentalization Information Part 1

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Implicit and Explicit

In a Non-BP/BPD relationship, this connection is generally broken. There are too many assumptions, too much focus on the content (rather than the meaning/function), too much personalization and too much “baggage” that prevents fully mentalizing. Some of the ways that one can fully mentalize is to approach each conversation from a particular “framework,” the characteristics of which are not a complete list, but a nice first attempt):

• Being curious about the other person’s implicit situation. Ask them how they feel. (“How did you feel when he said that?”)
• Validation for the purpose of understanding implicit understandings. (“Wow, that must have made you feel awful! Why do you think he said that?”)
• Being humble and admitting “fault” where “fault” is warranted. (“Yes, I can see that when I said that it hurt your feelings. That wasn’t my intention.”)
• Being compassionate for the other person’s suffering. (“You seem to be in a lot of pain right now. What do you think would help you feel better?”)
• Seeing the situation through the other person’s eyes.
• Starting afresh in each conversation, without grievances, relationship failures, victimhood, or assumptions that this is the “same” conversation over and over again. (NOT: “Here we go again.”)
• Being fully engaged in the conversation.
• Noticing words, actions and body language that break down engagement. (“When I said that, you seem to have gotten upset. What happened there?”)
• Listen for meaning, rather than just hearing the words.

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1. Shame and BPD
2. Mentalization Information Part 1
3. A failure to mentalize – Mentalization Information Part 2

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Event -> Interpretation -> Emotional/Physical Feelings -> Action Impulses -> Expression and Behavior

DBT-FST seems to me to operate at the Action Impulses to Expression and Behavior link, while validating the Emotional/Physical Feelings link. Don’t get me wrong, the DBT-FST skills are extremely powerful in communicating with someone with BPD. Yet, the change that is requested is at the end of the chain. I have heard that Marsha Linehan is quoted as saying something like, “Just because you feel like a crazy person, doesn’t mean you have to behave like one.” The point here is that DBT is a behavioral therapy and by modifying behavior, that works backwards toward regulating emotion and tolerating distress. In other words, DBT trains you to behave differently based on your feelings. When you gradually learn that your new behavior is more effective than the previous behavior, you break the conditioned chain between Action Impulses and Expression and Behavior. That is the essence of the DBT skill “Opposite Action.” An interesting side note is that by practicing Opposite Action (that is, doing the exact opposite of what your feelings implore you to do – such as engaging when you feel sad, rather than hiding under the covers all day), you actually feel better, because the action does work backward. Dr. Paul Ekman found that configuring one’s face to mimic a certain feeling actually causes that feeling to be experienced. That is the theory behind DBT’s “Half Smile” skill. Ultimately though, by working at that link in the chain, the person still feels the emotion, yet he or she just behaves differently than the emotion originally informed him/her to behave.

MBT on the other hand takes on the on the problem at the Interpretation link. By asking questions and being open to alternative interpretations, the person with BPD is more likely to have a broader view of other people’s behavior and the events in life. DBT never asks about the intent or motivation of the other person and just takes the interpretation as a given in a person with BPD. If a person with BPD says something happens and that something means X, then in DBT it means X. There is very little questioning of the validity of the interpretation X. In MBT, however, the interpretation X can be questioned and alternative interpretations (such as Y or Z) can be examined. The nice thing about this is that when the person with BPD is faced with a similar situation, he/she is less likely to jump to conclusion X and might consider Y or Z.

An example of the differences in the two approaches is as follows:

My daughter comes home from school after being teased by a boy on the playground. My daughter ends up throwing a thermos at the boy’s head.

With DBT, I would validate her anger and ask her how she could behave more effectively the next time this teasing occurs. So next time she will behave more effectively and not throw the thermos.

With MBT, I would validate her feelings and begin to probe with curious and straight-forward questions as to the intent of the boy. Perhaps he actually likes my daughter and that is why he is teasing. Perhaps he is showing off to his friends. If this approach is taken, my daughter is more likely to consider the boy’s motivation for the teasing. If she understands the motivation, she can actually never get angry and risk throwing the thermos.

All of that being said, I believe these skills have to be learned as a “ladder” to effectiveness. You can’t start at point E without going through points A-D. DBT-FST provide the foundation for more advanced skills, like those in MBT.

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Modes of Thinking

“If only”

If only is a way of thinking in which the person says to themselves “I would be happy or content, if only a certain thing occurred or if only I had a certain thing.” It is a way of objecting to the unfairness of the world. It is a form of projective, delusional thinking… Like, “if only I won the lottery I would be happy” or “if only my partner would have sex with me more, I’d be happy”… Etc. It is equivalent to asking oneself “If I could have one thing/state, I’d be ok”

“What if”

What if is different than “if only” because “what if” can be either positive or negative. What if can stimulate alternate views on the future and it can also be a substitute for “if only”. If used as an iterative testing framework, “what if” can help a person understand the possible outcome of variable changes. However, one must not assume the outcome of a “what if” – sometimes, because of the complexity of variable conditions, changing one variable could lead to unexpected outcomes.

“As if”

“As if” is an engagement of pretend mode in which some pretends as if they know something or something exists when they have no insight into the subject matter – they don’t get it – they merely bullshit their way through “as if” they get it.

“As is”

“As is” is a way of accepting reality as is and not struggling against that over which you have no control or that which you can not change. As is accepts that which is as it is and changes that which can be changed.

One piece of advice that I would provide to partners of people with BPD is that if you can’t accept the person “as is” and love them for what they are, it is most likely never going to work out in the long run. If you can’t accept them “as is” and consider any changes in the relationship or in their behavior as a bonus, then you are actually engaging in “if only” thinking.

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http://www.ucl.ac.uk/psychoanalysis/unit-staff/anthony.htm

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1. Mentalization Based Therapy Shows Promise with BPD
2. How mentalization and attachment might explain “high-functioning” BPD
3. Mentalization-Based Treatment Versus Structured Clinical Management for BPD

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