Now research suggests that, beneath all the screams and kicking and shouting, lies a phenomenon that is entirely amenable to scientific dissection. Tantrums turn out to have a pattern and rhythm to them. Once understood, researchers say, this pattern can help parents, teachers and even hapless bystanders respond more effectively to temper tantrums — and help clinicians tell the difference between ordinary tantrums, which are a normal part of a child’s development, and those that may be warning signals of an underlying disorder.

Read the entire story or hear the audio

What I found illustrative of this story was the first comment… An excerpt:

This was the worst piece of parenting psycho-babble I’ve ever heard. Explain to me what the child has learned from this besides how to manipulate his or her parents into getting his or her own way? It’s all well and good to study and understand the dynamics of a temper tantrum, but as parents, our responsibility is to help our children become civilized human beings. In our household, tantrums were an automatic “no” for whatever the child was asking for and, if one of my kids had slammed a chair against a wall, that child would have been in his room. Amazingly, my children had very few tantrums and none of them escalated to this level. Not only did they learn that this behavior is unacceptable, they also learned how to ask for what they wanted in a respectful and polite manner and how to negotiate if they really, really wanted something.

I’m sure it’s wonderful to have judgmental atttitudes about others’ kids behavior, but what it illustrates to me is that most people, especially parents, don’t understand the basic mechanics of emotions. And don’t know how to properly react to emotional outbursts. To me, this comment just describes an “invalidating environment”. Kids are not trying to manipulate the parents during a truly emotional outburst. No, their reacting just like their emotions inform them (anger/sadness) and behaving in a perfectly natural way. If you deal with the emotions properly, this behavior will not occur.

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latimes.com/health/la-he-child-temper-20111010,0,3234089.story

latimes.com

Child mental disorders: New diagnosis or another dilemma?

A proposed new diagnosis for outbursts and tantrums sparks debate in the psychiatric community. Would it help parents desperate for answers, or just add to the confusion?

By Shari Roan, Los Angeles Times

October 10, 2011

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The final straw for Carolyn Alves came last fall when she tried to help her daughter Cecelia dress for kindergarten.

The volatile 6-year-old had worked herself into a frenzy as she tried on outfit after outfit, rejecting each as unacceptable. The tantrum at full bore, she scooped up a pile of clothes and hurled them at the front door of the family’s Spanish-style bungalow in Glendale.

The clock ticked past the school’s 8 a.m. bell. Alves pulled her wailing child into her arms and held her on the couch. After several minutes, Cecelia stopped, took a breath and announced that she was ready to go to school.

“It was like watching someone who was having a mental breakdown,” Alves said. Then “a switch went off and she went back to being normal.”

Alves and her husband, Marcos, have consulted five doctors and therapists in the last four years. Cecelia has been diagnosed with a smorgasbord of psychiatric disorders — including the controversial diagnosis of child bipolar disorder — in addition to being called a normal kid.

Experts in pediatric mental health readily acknowledge that their failure to pinpoint the problem with children like Cecelia makes a difficult situation worse. And some of them are pressing for an unconventional solution: a new diagnostic category called disruptive mood dysregulation disorder, or DMDD.

Creating a diagnosis is considered a radical step in mental health circles, and the proposal has sparked much debate. The controversy underscores the fact that therapists simply don’t know what to make of the estimated 3% of children in the U.S. who suffer from severe irritability and emotional outbursts.

“Everyone wishes we could have a genetic test or a blood test” to determine which disorder a child has, said Erik Parens, senior research scholar at the Hastings Center, a bioethics think tank in Garrison, N.Y. “Unfortunately, nature doesn’t work the way we wish.”

As a result, parents may be told their children have conduct disorder, oppositional defiant disorder, attention deficit hyperactive disorder, depression or bipolar disorder — if they get a diagnosis at all.

Adding disruptive mood dysregulation disorder to the list of ailments doctors may consider would reduce the number of children misdiagnosed with bipolar disorder and treated with powerful psychiatric medications, proponents say. And, they add, improving treatment for children who have problems with mood and temper would reduce the number of children at risk of falling through the cracks in school and society.

But critics counter there is no scientific evidence to warrant recognition of a new mental disorder.

As doctors quarrel, parents like Alves struggle with the lack of medical options.

“I feel in limbo right now,” Alves said one afternoon, cuddling her painfully shy daughter. “Having a diagnosis would help me know what direction to take.”

Psychiatrists sharpened their interest in child mood problems several years ago in response to criticism over the number of children diagnosed with bipolar disorder — a debilitating condition in which periods of depression alternate with euphoria or elevated moods. It is considered incurable, although symptoms may be treated with drugs that carry serious side effects.

The idea that bipolar illness can begin in childhood caught hold in the last decade. The number of outpatient visits for children diagnosed with bipolar disorder mushroomed from fewer than 200,000 a year in 1995 to 800,000 in 2003, according to a 2007 study in Archives of General Psychiatry.

The study reinforced the notion that childhood bipolar disorder had become a fad diagnosis.

“The diagnosis means exposure to pretty potent medications,” said Dr. Jan Fawcett, a psychiatrist at the University of New Mexico School of Medicine in Albuquerque. “And, if the diagnosis holds, it means lifetime exposure to these medications.”

Such children often receive drugs like lithium or Depakote, which can cause severe weight gain, sedation and involuntary muscle contractions. They aren’t prescribed antidepressants or stimulants, which could worsen the condition in children who are truly bipolar. If the diagnosis is incorrect, however, children are deprived of drugs that could alleviate their anxiety or depression.

“We had to do something about it,” said Dr. David Shaffer, a child psychiatrist at Columbia University in New York and member of an American Psychiatric Assn. work group that proposed adding disruptive mood dysregulation disorder to the Diagnostic and Statistical Manual of Mental Disorders, the book that forms the bedrock of psychiatry. That would allow doctors to reclassify a significant portion of children who are considered bipolar, he said.

According to the definition under consideration, DMDD would be characterized by severe, recurrent temper outbursts in response to common stressors that are not developmentally appropriate and are out of proportion to the situation. Between tantrums, the child’s mood is nearly always negative, irritable, angry or sad. Such children are not like 3-year-olds who have fits if they don’t get cookies before dinner.

Symptoms would be apparent not just to parents but to teachers and others, and they would be present for at least 12 months before a diagnosis was made in a child under 10. It’s unclear how the condition would be treated, although proponents of the diagnosis say they are trying to reduce the use of antipsychotic medications.

But some of the symptoms can also be found in children with bipolar disorder or other conditions, said Dr. David A. Axelson, who argued against the proposed diagnosis this year in the Journal of Clinical Psychiatry. He and other experts say there is insufficient evidence that a distinct disorder exists.

“The scientific backing for it is quite lacking,” he said. “It doesn’t mean this shouldn’t be a diagnosis in the future, but we need solid scientific studies.”

David Miklowitz, a professor of psychology at UCLA, said he feared that many doctors who were reluctant to label children as having bipolar illness or conduct disorder would adopt DMDD as a default diagnosis.

“I think they are actually solving one problem but creating another,” he said. “The risk, with a diagnosis like this, is that clinicians who are strapped for time will slap on this diagnosis and say, ‘I’ve got it figured out.’ ”

The debate has been polarizing and uncharacteristically bitter for the mental health community. In his recent paper, Axelson and his colleagues charged that the proposal was “a step backward for the progression of psychiatry as a rational scientific discipline.”

And a past editor of the Diagnostic and Statistical Manual of Mental Disorders, Dr. Allen Frances, has written several critiques of the proposal, including one last summer that accused the scientific review group that endorsed DMDD of running a “sham review process.”

“New diagnoses are as potentially dangerous as new drugs, and we need a much tighter regulatory mechanism to ensure that they are both necessary and safe,” Frances said in an interview.

Fawcett acknowledged that more scientific evidence was typically needed to justify a move like this.

“Creating a new disorder should require much more evidence than we have,” he said. “But, on the other hand, there is a much bigger problem here.”

Alves doesn’t care what doctors decide to call her daughter’s condition, but she wants them to come up with a firm diagnosis. She wants strategic help for the child who, at 9 months, was having long bouts of screaming and uncontrollable crying and who, at age 3, would bang her head against the floor if something upset her.

Alves remembers the sunny day in June when the family attended Cecelia’s kindergarten performance at school. Cecelia didn’t want to go on stage and erupted in a 20-minute meltdown before reluctantly joining her classmates.

“It’s more apparent all the time that this is not just a tantrum,” Alves said.

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1. Physical sensitivity to the sensory input. This sensitivity may include the inability to tolerate loud environments, to wear “scratchy” clothing or expressions of disgust with smells that others are not sensitive to.
2. Inconsolable as a baby or toddler. The “borderline” child is more likely to exhibit more distress than his/her siblings and have long crying jags and/or temper tantrums.
3. Migraine headaches and/or other physical, chronic pain. Pain is a common feature of BPD. This pain may show up in childhood as a migraine or some other form of physical pain.
4. Inability to integrate the meaning emotional experiences. This represents at some level a “failure to mentalize” on the part of the child. He/she may exhibit an inability to understand the emotions of others as displayed in their faces and/or through their actions.
5. Intense personalization of events. The belief that all things are “about them” or “about their feelings,” particularly social events and situations.
6. Anxiety leading to avoidant behavior. This can represent itself through avoiding social situations (e.g. “because those people are mean”) and or avoiding academic tasks.
7. Intense emotional reactions to frustration. Temper tantrums and the inability to tolerate frustrating emotional situations, particular social ones. This can manifest itself in violence or in bridge-burning.
8. Shame. The feeling that he/she is not a worthy person and “deserves” to get hurt. He/she may also “run away” from friendships or social situations that are shame-inducing.
9. Not feeling “normal”. Young people with BPD seem to feel at some level “something is wrong with me” or “I’m not normal”.  The feeling of “strangeness” seems to be a theme in young people with BPD.
10. Expectations of doom. The concern that at any time the world is going to come down around their ears, especially socially. Sometimes there is paranoia around this subject, as if their friends are really “fooling” them into believing they’re liked. At any time, the borderline child could be rejected and ostracized.

While this is probably not a completely exhaustive list of the traits of the borderline child, these are the common traits I’ve experienced and been told. It is important for parents to identify an “emotionally vulnerable” child as early as possible. The road of an adolescent and young adult borderline can be dangerous, painful and even deadly. Borderlines are 400 times more likely to commit suicide than the general population. Based on the non-scientific polls conducted on my website, 70-75% of borderlines abuse substances, engage in self-injury and attempt suicide at least once in their lives.

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Potty training provides an excellent example of positive reinforcement and the ignoring of “backsliding.” That is the essence of this tool. When you teach a child to use the potty, you make a BIG positive deal about it when it is successful. The first time you see the poop in the potty, what happens? Typically, the parent praises the child, positively reinforcing the behavior in a way that is out-of-proportion with the accomplishment. You may say, “Yeah! You did it! That’s fantastic! Good Job!” and clap your hands and cheer. You also will tend to do it within seconds of the completed behavior. That is where positive reinforcement differs with general praise. Praise can be given much after the fact and can be bestowed for a number of reasons, including character traits. That is, you could say, “Wow, you are so smart” after your child receives a 100% grade on a math test. That is praise. (Although I’m not sure it is effective, but that is not the topic at hand). Positive reinforcement is for behaviors and should occur right when the behavior is completed. That is how animals are trained. The positive reinforcement (feeding, for example) occurs within seconds of the completed behavior so that the two can be connected in the mind of the animal.

If I return to potty training, you will notice that you also naturally ignore and don’t punish behaviors that don’t match the desired behavior. That is, if the child has an accident and poops in his/her pants (while not wearing a diaper) you don’t say, “You are a naughty little boy/girl!” No, that would be damaging to your child’s self-image. No, instead, you say, “Everyone has accidents at first. You can try again next time. It’s OK.” This is an accurate corollary to emotional regulation and reinforcement and punishment. Since the BP naturally has difficulties regulating her emotions, the idea of her “messing up” or “backsliding” is analogous to child pooping in her pants (even if this is more the “rule” than the “exception” in the BP’s life). It is not effective to punish her for behaviors that (at first) she can’t control. The behaviors are conditioned and the purpose of this tool is to help recondition a BP to behaviors that are more desired and effective. After conditioning, the child is able to control (or at least sense) when she has to go potty. After conditioning a BP is able to control (or at least sense) when she is becoming dysregulated.

- An excerpt from When Hope is Not Enough: a how-to guide for living with and loving someone with Borderline Personality Disorder. Available online in Print, eBook and Kindle
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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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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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Lindsay Lohan and BPD?

I read an article today about Lindsay Lohan from Fox News’ Dr. Keith Albow entitled “What Lindsay Lohan’s Parents Stole From Her”. While I can certainly understand Dr. Albow’s point at some level (although mostly I believe it was to attract readers to Fox with a catchy title about Lindsay Lohan’s situation), I have a problem with Dr. Albow’s analysis of Ms. Lohan’s parents. My problem has several facets to it, so you’ll have to bear with me as I go through them. The first part of my problem has to do with the “blaming the parents” aspect of mental health care and the attitude of mental health care professionals. When you take a child with possible BPD or with behavioral issues like Ms. Lohan has reportedly experienced (those include possible theft, substance abuse, sexual orientation confusion, impulsive actions, self-injury, depression, anxiety and the like), the first thing that is assumed about you is that the child has experienced trauma, neglect or abuse by the parents (that is, YOU). Oftentimes this is NOT the case. I have two daughters (fraternal twins) and one of them has emotional regulation issues, the other does not. The environment in which they were raised was essential the same. The thing is, the children are not the same. I know of another individual who has two daughters, two years apart in age, one of which is a drug addict who never attended college and the other has a ph. d. They were also seemingly raised in the same environment. Granted, neither my children nor the daughters of my friend are child stars as Ms. Lohan was. Yet, my problem #1 is blaming the parents. It doesn’t do anything to help Ms. Lohan. In DBT there’s a couple of rules that you learn at the beginning. One of these “rules” (or guidelines) goes something like this: Even though I didn’t cause some of my problems, I still have to be responsible for solving those problems. In other words, even if you lay the cause and responsibly solely at the feet of Ms. Lohan’s parents and what they “stole” from her, it doesn’t function to make Ms. Lohan behave more effectively or feel any better. Instead, now that she is an adult, she will be required to take responsibility for her behavior and learn the skills necessary to function in a more effective manner, regardless of who caused her problems. I want you all to understand though, if she DOES indeed have a mental illness, these problems might be more difficult for her to overcome. That is because IMO (and in the recent opinions of many scientists) there is a biological component to most mental illnesses (including BPD) and, whereas many people with BPD also have comorbid PTSD from trauma and/or abuse/neglect, many do not. I believe that in order to have BPD the biological component must be present. Dr. Marsha Linehan’s bio-social model seems to reflect this. In other words, in the case of my twins and my friend’s daughters, what is different about each of them is their biological system, not the environment. The kids are different biologically. In the case of Ms. Lohan, perhaps she also has a biological feature that would increase the likelihood of impulsive behavior (among other features).

Now this brings me to point #2 which has to do with boundaries and the fuzzy understanding of what boundaries are. Dr. Albow says:

If she’s guilty, she did it for the same reason she illegally used drugs and drove under the influence and—maybe—assaulted an employee at The Betty Ford Center: She had so much stolen from her as a young person, had her boundaries violated so feloniously, that she considers the boundaries of others irrelevant.

Ahh, boundaries! Anytime I mention BPD to anyone who is not steeped in the world of BPD/non-BPD, including and especially therapists, one of the first things out of their mouths is boundaries (after trauma/abuse). This doctor doesn’t understand boundaries and the way that they function. A person like Lindsay Lohan doesn’t have a boundary problem, she has an emotional problem. You could rewrite the first sentence like this:

If she’s guilty, she did it for the same reason she illegally used drugs and drove under the influence and—maybe—assaulted an employee at The Betty Ford Center: she is in a great deal of emotional pain, has issues regulating her emotions, is impulsive and will behave in an “anything to stop the pain” manner. She acts on her emotions and action impulses before she thinks of the consequences.

Her problem is dysphoria and a poor sense of well-being, which in turn leads to impulsive behavior like shoplifting a necklace when you could just afford to buy one.

I don’t want to go into a long discussion of boundaries here. I‘ve talk about boundaries so many times, it gets old. If you understand my view of boundaries and rules and consequences and intent and the differentiation between these important behavioral and mental concepts, you’ll immediately see why I object to the “boundary violation” explanation of  Ms. Lohan’s make-up and behavior. No, the problem with Lindsay Lohan is (IMO) dysphoria, poor impulse control, emotional dysregulation and a large amount of emotional pain. That is why she does the drugs, steals things (allegedly), engages in risky behavior, cuts herself, etc. It’s not because she “considers the boundaries of others irrelevant”. That statement just shows me that you, doctor, don’t understand boundaries, despite your status as a mental health professional and a Fox News guy. In fact, it has NOTHING to do with the other’s boundaries or feelings at all. It’s all about her feelings.

My last problem with the article has to do with this statement:

Assault and theft. Lindsay Lohan, I would venture, knows all about those things, very deep inside. And not just because of what she did. No, no. Don’t believe that for a moment. Mostly, this is a story about what was done to her.

No, it’s not a story about what was done to her. I’m sorry, but the problem for Ms. Lohan is two-fold. Firstly, if she does indeed have mental health issues, emotional issues, substance abuse issues, and behavioral issues, it is her responsibility as an adult to address those effectively. The question is not “what was done to her by whom?” – it’s “what does she do about it now?” She’s no longer a child. She must address her behavioral issues with the help of a mental health, substance abuse and/or behavioral health specialist. If she continues to play out the approach that Dr. Albow espouses here – the “I had a f*cked up childhood” approach, she’s going to continue to behave ineffectively. What she’s doing is anything to stop the pain, yet, ironically, it is causing MORE pain for her because she’s behaving in an ineffective manner.

Secondly, like everyone in society, Ms. Lohan has to learn that her behavior has consequences, even unintended ones. Sure, she might have a disorder like BPD in which she would find it difficult NOT to behave impulsively and in a pain-killing way, yet when all that is done, she has to face the consequences of her behavior like everyone else. As I have said in the past, just because you didn’t mean to burn down the house while playing with matches, doesn’t mean the house magically comes back from the ashes. No, the house is still in ashes whether your parents abused/neglected you or you were just trying to stop the pain inside your head. Ms. Lohan’s behavior has consequences and sometimes those consequences are going to jail. The judge is not going to accept the argument, “my parents made me do this by taking away my childhood.”

And all of that brings me back to the serenity prayer, which (as I have said in “When Hope is Not Enough”) I always thought was a stupid cliche, yet, Lindsay Lohan is an excellent example of those words at work. (And BTW, I am not a support of A.A., despite my reference to the prayer). Ms. Lohan has no ability to change what her parents did to her. That is something she must accept. Trying to change those things will  cause frustration and, in her case, maybe incarceration. What she CAN change is her future by learning to behave more effectively and manage her emotions more effectively. If she doesn’t do that, she’s going to end up helpless (“my parents made me this way and there’s nothing I can do about it”), in jail or on the wrong side of the grass.

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Tough Love and BPD

Tough Love is not an effective approach with children and teenagers with Borderline Personality Disorder. Although some therapists and self-help authors recommend tough love as what should be done with BPD, it is ultimately detrimental to the borderline and to your relationship with the borderline. The problem comes in regarding the nature of the disorder. While behavioral therapies can work, those based on reinforcement and shaping, those therapies usually include acceptance strategies and non-judgmental approaches. The nature of BPD is that the individual with the disorder is in deep emotional pain because of the dysregulation of the emotional system. They are exquisitely sensitive to emotional experiences and many of these experiences are physical in nature, especially with children. There is intense physical pain and social rejection (to which borderlines are also intensely aware) causes more pain. The borderline will then seek to end the pain in any way they can, including substance abuse, casual sex, thrill-seeking and other dangerous methods. While these methods will stop the pain temporarily, the pain always comes back.

OK, now back to why tough love doesn’t work. A person with borderline personality disorder wants more than anything to communicate his/her pain with those with whom he/she has an attachment relationship. Understand that BPD is not just a case of the person “behaving badly”. The behavior has a function and generally that function is to either stop the pain or to communicate the pain. If you try to deal with behavior with tough love (rules, contracts, boundaries, punishments, etc.), the person with BPD will feel more rejected, more abandoned and unable to communicate the pain. This causes MORE pain and requires more pain-quelling behavior. It causes more of what made you start using tough love to begin with.

A little while ago, I was speaking with someone about a friend of my daughter’s. This girl probably has BPD. Her behavior was totally off the charts – drugs, turning tricks, running away, cutting herself, suicide attempts, etc. When the person I was speaking with expressed sympathy for the girl’s mother, I responded like this: “I think what happened with [girl’s name] was that she was in a lot of pain and didn’t know why. All she really wanted was for her mother to see her pain. All she ever wanted was for her mother to understand her and her pain. But her mother only saw bad behavior and tried to deal with that. So, the girl tried anything and everything to stop her pain.”

The word compassion actually means “to suffer alongside” (or co-suffering). If you’re a parent of a person with BPD, are you seeing and understanding their pain? Or are you fed-up with their “bad behavior”? Developing non-reactive compassion is the answer, not tough love. Tough love sends a message that the borderline can’t communicate their pain. Are you co-suffering? Or are you punishing the borderline for doing anything to stop the pain?

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Courtney Love in wake of losing custody of Frances Bean: ‘terrible influences, pure evil’
By Vicki Hyman/The Star-Ledger
December 15, 2009, 10:29AM

Courtney and Frances Bean

Courtney Love has left a string of only occasionally coherent messages on her Facebook page in the wake of a Los Angeles court decision to give temporary custody of Frances Bean Cobain to the girl’s paternal grandmother: “cruelty to children and people too young to understand that under that rock isnt gold its only,.,,,,, utah on steroids” and “terrible influences, pure evil. and a poor baby caught inside a trap”.

That clears things up.

Love’s lawyer tells People that Frances Bean, Love’s daughter with dead rock icon Kurt Cobain, wanted to live with her grandmother, and the judge’s decision should not be taken as confirmation that Love has had a drug relapse.

“Courtney’s been clean for years and is perfectly fine,” Keith A. Fink says. “Frances is 17 and a strong-willed child, and this is a decision she made on her own. No matter what, Courtney loves her daughter more than anything in the world.”

Frances Bean has reportedly always been close with her grandmother, who had custody during a particularly messy period (and that’s saying something) of Love’s life in 2003 and 2004.

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Are you and your BP on the same team?

When someone is highly emotional, they need to know that they have an advocate and that someone is on “their side.” I often ask my consulting clients (especially partners of people with emotional regulation issues) if they feel that their partner and they are “on the same team.” Many times the answer is no. Why does someone have a desire to have someone on their side, even when the “sides” are not desired, intended or even clearly delineated? The answer in my mind comes down to shame and rejection sensitivity.

If a person has shame (or even low self-worth, which is similar), then the person is likely to have a high level of rejection sensitivity. Being rejected by others is painful, especially for emotional people. Having an advocate of their “side” of the issue, which is essentially answering, “I am on your side no matter what the situation,” is tantamount in these highly emotional, social interactions that involve rejection. One can be “on their side” emotionally without condoning whatever behavior that one doesn’t agree with.

There are teaching moments and there are times that one doesn’t teach. If you try and teach, punish or impart values during a period of emotional dysregulation, the relationship will be damaged and nothing effective will be accomplished. Instead, emotional validation and support can be used to cool the bonfire. Once it is cool, then a teaching moment can present itself.

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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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The reason I am posting this message though is because both of them seem to have a craving for affection, attachment and love. It appears to me that each had all these children such that they could be unconditionally loved by as many people as possible. I wonder what happened in their childhood (or if anything happened) that would drive this strong desire to have as many children as they have had.

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Tough Love

Not too long ago I wrote an article on why tough love is not the answer for BPD. I still believe that ONLY tough love is not the answer; however, I have come to reconsider tough love and BPD.One of the reasons was that the TIME article said that DBT is a combination of emotional validation and tough love.

One of my list members has moved from the techniques that I provide in “When Hope is Not Enough” – which is basically a non-judgmental attitude plus validation and normalization – to a combination of those techniques plus “tough love.” What is tough love? In my opinion, tough love is the application of PERSONAL boundaries on a relationship. These personal boundaries need to be understood. Often, people don’t understand personal boundaries. Even popular books about BPD for Non-BPs (such as SWOE) get this concept wrong. In fact, even books that are ABOUT boundaries get this concept wrong. The other day I posted a link to a video of a part of the film “The Basketball Diaries” in which Jim Carroll’s mother (Jim Carroll is played by Leonardo DiCaprio BTW and the film is based on the book by Jim Carroll and is true) denies her son money for drugs (he is a heroin addict). She enforces her own boundary (I will not give my son money to buy drugs). She does not enforce a “rule” which is the way that someone tries to control the behavior of another person. Rules and boundaries differ significantly. With a rule, you try and control another person’s behavior – such as telling a child “you have to go to bed at 8:30 PM.” That is a rule, not a boundary, because it has to be enforced. Rules have to be enforced, boundaries do not (except on yourself).

Back to tough love… how does one use tough love with BPD? Well, first of all I have to say you can’t START with tough love, because first emotional trust has to be established. If you start with tough love and use ONLY tough love, that is a recipe for disaster with someone with BPD. The problem is that tough love hurts too much for them. They feel “different” and “broken” and tough love reinforces these feelings. However, tough love can be used once the trust is established. Tough love is something you can use FOR YOU to establish your own boundaries with someone with BPD. But you have to make sure that it’s your boundaries that are being applied and not rules for another person’s behavior.

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

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Enjoy! (ok, if you’re a kid of a BP you might not be enjoying, but hopefully it will help).

UPDATE: www.kobies.org seems to not longer be available. I don’t know why as of yet.

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1. I haven’t bought/read it yet, but here’s a children’s book for kids with a BP mom

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I also found an article called “Spiritual Glasses to Understand the Difficult Child” which was described with the question: When you get frustrated with your child, what is the most effective discipline? I was intrigued and decided to read the article.

I have to say, I was surprised by the wisdom in some of her comments. I find it interesting that what she says about children can be applied directly to people with BPD. Consider the following:

If your child is a chronic liar, parents worry and panic. The spiritual glasses allow you to see a very insecure child with poor self concept or image. Are your expectations of him too high? Why does he feel worthless? Is he bullied around by friends or older siblings?

I get more searches on this blog for “lying,” “liars,” “chronic liars,” etc. than about anything else. (Actually to be honest the most searches I get are about “celebrities with BPD” or some variant of that, but lying-related searches come in a close second.) I’d like to take her words and apply them to BPD and replace the words “spiritual glasses” with “emotional glasses.” I think if you look at a chronic liar, which many people with BPD are, you will find that one motivation for lying is a poor self image, feeling worthless or insecurity. These concepts are interrelated and spring from shame. People with BPD do have a poor self-image. Even though many nons report that their loved one with BPD is selfish or narcissistic, in reality people with BPD actually hate themselves. This feeling arises from shame as well, but the shame also arises from emotional invalidation. Mrs. Treasures doesn’t really provide a prescription for dealing with a liar, other than not to label (judge) the child as a “difficult child” right away and try to understand them and set proper expectations. The same can be said of a non’s relationship with a BP. Judging their behavior as “difficult” right away or setting expectations too high can invalidate the BP’s emotional responses. This sets up an “invalidating environment” for the child’s emotions and the effects of an invalidating environment are summarized by Dr. Marsha Linehan:

[The] effect of an invalidating environment, especially when basic emotions such as fear, anger, and sadness are invalidated, is that a person in such an environment does not learn when to trust her own emotional responses as valid reflections of individual and situational events. Thus, she is unable to validate and trust herself… If communication of negative emotions is punished, as it often is in invalidating environment, then a response of shame follows experiencing the intense emotion in the first place and expressing it publicly in the second.[i]

If a person is unable to trust herself, she can not validate herself and a “response of shame follows” emotional experiences. That is one pathway to BPD. If you punish a child for feeling inadequate, for example, if the child is lying to you because he wants to make himself feel better about himself, then you are invalidating his emotional responses.

Mrs. Treasures also say this about temper tantrums:

For your younger children showing tantrums and hitting other siblings, the spiritual glasses permit you to see a child struggling to deal with his immature emotions. The child’s frustration is his inability to communicate his feelings and needs to his siblings.

Again, if we substitute “emotional glasses” for “spiritual glasses” and “BP” for “child,” I believe she is accurately describing the state of someone with BPD. People with BPD are emotionally immature. It’s not their fault; it’s just that they were not raised in an emotionally supportive environment. They feel that by feeling emotions intensely, they are wrong and should be punished. Again, the shame comes into play. They do have an “inability to communicate [their] feelings.” Because of the invalidating environment, the BP becomes unable to trust her own emotions and becomes frustrated and angry. THAT is what fuels rage more than anything.

OK, now what do you do to counter-act an invalidating environment (with both children and BPs)? You learn to validate their emotional responses. I have quite a few examples of validation techniques on this site and if you follow this link, you can read about validation.

[i] Linehan, Marsha, Cognitive-Behavioral Treatment of Borderline Personality Disorder, pg 72

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My wife can be very validating and understand at times (even more than me); however, she also takes the “life is hard” and “get over it/suck it up” route with our children at times. I don’t know if you other nons have experienced the same thing, but I see a lot of that in my Google Email Group. If you’d like to discuss this further, you can leave a comment here or, better, request to join the Anything to Stop the Pain Google Email Group by going here:

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

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This was my response on WTO to a woman who was very angry with her daughter for lying to her and for having friends over to her (the mother’s) house all night when the mother specifically prohibited it. The mother felt very manipulated and angry – she felt the daughter was disobeying her to hurt her. FYI, the daughter is 23 and was diagnosed with BPD when she was about 16.

Hi. Yes, I thought that your daughter was in a situation like that – around 21-25, diagnosed with BPD and once in a residential facility. The reason I asked those specific questions is that I have seen other young women in the exact situation as your daughter and acting exactly the same way. I could further speculate that your daughter has trouble keeping a job (even a very menial one), has difficulty getting up in the morning, smokes (or once did) or does (or did) rely on drugs or alcohol, etc. – typical BP behavior for young women her age.

I think I can help explain the motivation behind her actions. After you read this you can choose to believe me or not, but these comments are based on my experience with several BPs from a support group (a physical one) that I attended. I met many parents of BP daughters and spoke with them about their daughters behaviors and, after several weeks, their feelings. It took some time to see through the behaviors to the feelings. What I am giving you here is sort of a “short cut” to the underlying feelings of your BP daughter. It may be hard to believe at first, but I would encourage you to consider it carefully.

First of all, it totally stinks to have your daughter not heed your requests. It’s got to be extrememly frustrating to have a daughter who seems to sepcifically disobey you and lie to you on a daily basis. It also must be infuriating to see her “buffalo” the doctors that she goes to see.

However, I think I can explain all of that. I have found that BPs pretty much all feel the same way inside. So, I am going to speculate that the reason that your daughter lies to you and disobeys you to have her friends over is twofold (but inter-related):

1) She is too ashamed of herself to say “no” to her friends. She doesn’t want them to know that she’s “crazy”. She feels that the consequences with her friends to say “no” to them are greater than the consequences she will incur by lying to you. Meaning, her lying is not specifically to hurt you (although it DOES hurt you a lot, as I can see); instead, her lying is about her feelings of shame and her inability to say “no” to her friends because of it. It is VERY common for BPs to overcommit themselves to other people because they are desperately seeking approval from their peers. They feel that to be a good friend (and, for them, a good person), they have to give everything to their friends (at first). When this doesn’t make them feel any better inside, they withdrawl suddenly from friendships in anger – they split the friends black. But ultimately this behavior of valuation and devaluation is rooted in their inner shame about who they are. Why do they feel that way? Well, that could lead to a much longer discussion, but let’s just say that they ALL DO.

2) At 23, she is desperate to be “normal” and not be “crazy”. The stint in the in patient facility and the diagnosis of BPD has put a big red “C” (for crazy) across her chest. She’s terribly afraid that her friends will see that she is crazy and will run away from her (fear of abandonment). This fear is also rooted in shame. She is ashamed that she is not just a normal young woman like all of her peers. She’s 23, so she thinks “isn’t it ‘normal’ to be able to have friends over to your house all night?” The problem is she doesn’t know how it actually feels to be normal. And that she is not normal enough to have her own place yet (that probably also deeply embarrasses her). She has always (I suspect from when she was a little girl) felt uneasy about her feelings – she has always felt weird and broken inside. She is ashamed of that feeling, because it is not normal. She probably constantly worries about not being normal, about being broken. And then she worries about worrying too much and on and on. They (the BPs) all feel this way too. So she is fighting not really against you specifically, but against her own feelings of being not normal, of being crazy.

Anyway, I understand why you would feel that her actions are specifically designed to hurt you. She “buffalos” the doctors for the same reason. She is ashamed to admit to herself that she’s “crazy” in any way – although deep down she’s always known that she is “different” or “weird inside”. I have verfied these feelings with many different borderline teens, young adults and adults (including my wife and my “pre-BPD” daughter). I used to think that there was malice involved in their actions, but now I believe their actions are sad attempts to try and fill that deep sense of emptiness that they have inside them. They really don’t consider how their actions effect you at all. It takes time and learning before they can see that.

OK, I don’t know if I’m right on the money as far as the daughter is concerned. But feel free to comment if you think I am or am not.

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Seeking to clarify some of these issues, my colleagues and I followed up a group of adolescents who had been referred for assessment to an adolescent unit in Sydney, Australia (Rey and others). Follow-up consisted of a lengthy interview during which a variety of diagnostic instruments and questionnaires was administered. These included the Personality Disorders Examination (Loranger). At the time of initial assessment, the average age was 14 years, while at follow-up it was 20 years. Of the 205 subjects who were located, 145 were fully interviewed. About half of these (44 percent) were female. During the ensuing six years, four of the subjects had died. One female, initially diagnosed as having attention-deficit disorder with hyperactivity, died of a heroin overdose following a period of severe disturbance during which she probably met criteria for conduct disorder. Two males suffered from conduct disorder. One committed suicide; the other died of multiple organ failure caused by hepatitis one day after being released from prison. One male had an adjustment disorder with disturbance of conduct. Reports from relatives at the time of follow-up suggest he was well-adjusted. He died in a car accident. There were 114 (56 percent) individuals with a disruptive disorder diagnosis among the 205 subjects located. Although numbers are too small to draw conclusions, these findings suggest that mortality (3.5 percent) among adolescents with these conditions is likely to be high.

Putting the mortality rate aside, we find that 56% were diagnosed with a disruptive disorder as children. The point here is that there was something wrong with them as children, although it was not labeled a “personality disorder.” If up to 10% of people with BPD take their own life, then it would seem to me that identifying the candidates for BPD as children would be paramount. If there is a constellation of childhood illnesses – childhood bipolar, ADHD, ODD, CD, etc. – then these children can be monitored to help them develop emotional skills to handle their labile emotional states. Here is a quote from a personal interview with a Borderline:

At about the age of 13. I kept feeling like something was missing in me, like I was “”defective”". My social skills were bad, and there was a growing feeling of a void inside me. I went to the school counselor, but as I could not yet identify what was wrong, was not really helped. At 14 I started to suffer from suicidal thoughts. It has never gone since. It’s always there, like some undercurrent. My parents are emotionally crippled in many ways and they could not help or understand, they would tell me to stop being so sensitive.

http://www.borderlinepersonalitytoday.com/main/interviewc.htm

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