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Often, I have had nons say to me that they want their borderlines to be accountable and responsible for their actions. I recently got a 1 star review of “When Hope is Not Enough” that indicated that the reviewer felt that my approach to BPD was a “recipe for walking on eggshells”. It’s clear to me that the reviewer didn’t really understand the content of my book. The reviewer went on to say that: This book doesn’t hold a BPD anywhere close to being responsible for her actions by granting the notion of “emotional dysregulation” a power of grand excuse.
Clearly, the reviewer didn’t understand the idea of emotional dysregulation or the difference between motivation, intent, action and consequence. I attempted to separate and explain each concept in the book, but perhaps I did a poor job.
In “When Hope is Not Enough” I write about the concept of IAAHF (or “It’s all about his/her feelings”). That statement, which is an exploration of the idea “it’s not about you,” is a statement of intent and motivation, not a release from the consequences of someone’s actions. The “all about” statement concerns the motivations of a person with BPD’s actions – that is, rarely does someone with BPD intend to hurt the non-BPD, despite appearances. What the intention of this statement of intent seeks to do is release the non from the paranoia that their loved one with BPD is out to get them. This is typically not the case. Usually, the actions of a person with BPD are intended to reduce their own emotional pain (stemming from emotional dysregulation). Sometimes this emotional pain and emotional dysregulation is triggered by (what I call) perceptions that are “misaligned” with the situation. That is, the “attack” on the borderline is not intended by the non to be an attack at all and through a highly sensitive emotional profile and emotional dysregulation, the borderline will attack back as a way of defending their self from a perceived attack. But the real point here is that the motivation and intention of the borderline’s attack is actually to quell the painful feelings within herself, not to cause interpersonal strife or manipulate the non.
However, as I also say in “When Hope is Not Enough”, the action (or cause) sometimes has unintended consequences (or effects). When a borderline is emotionally dysregulated and overcome with feelings, the action that she takes is likely to be impulsive and the consequences of her actions are not taken into consideration. When behaving this way, the borderline will often behave in an “effect -> cause” way – meaning she will think “I feel bad, so you must have done something to specifically make me feel bad.” If a borderline is to consider the consequences, even the unintended ones, of her actions, she will need to approach the situation in a “cause -> effect” way. Intentions do not provide a free pass for consequences. As I have said on the ATSTP list, just because you didn’t intend to burn down the house while playing with matches, doesn’t bring the house back into existence when you express your intention. One thing that separates the understanding of consequences (that follow from a cause – and in this case the cause is the behavior of the borderline) from blame is that there is an analysis based on observation as opposed to judgment. If you feel that the borderline has done something “wrong,” then you are inserting your judgment, rather than understanding the observed consequences of the behavior. I tried to explain this fully in “When Hope is Not Enough”, but I suppose some people either are so caught up in fault-finding and blame-storming that they can’t separate judgmental thoughts from the understanding of consequences or I have expressed it poorly in the book. If a borderline can begin to understand the consequences of her actions (and especially powerful are those that go against her goals), then, in my mind, the borderline can become responsible for her actions and do so in an effective manner.
 When Hope is Not Enough discounted for the holidays Just in time for the holidays, I am offering a 25% discount on the Publisher’s version of When Hope is Not Enough. You can now buy the book directly from the publisher for only $14.96! That 25% off the retail price and cheaper than buying it at Amazon. This deal will only be valid through the end of the year. To buy the book at this price follow this link:
http://www.lulu.com/product/paperback/when-hope-is-not-enough/2994088
If you need some skills to help you through the holidays, read this post.
This past month – August 2010 – my book “When Hope is Not Enough: a how-to guide for living with and loving someone with Borderline Personality Disorder” enjoyed the best sales of any since it was published over two years ago. I hope it is helping each of you in your relationships with people with BPD. The book’s approach is quite different that that of other well-known and best-selling books about loved ones of people with BPD. I sincerely hope that the book can help you as a loved one of someone with BPD or, if you have BPD, it can help your loved ones as well.
 When Hope is Not EnoughGet the Non-BPD book that is designed for staying and working on the relationship
You know all, there’s something weird about the sales of “When Hope is Not Enough” – I have tracked sales each day (because I can and because it matters to me) and I have noticed something decidedly weird about those… I sold an average of 2 books a day for the first 12 days of June… and then nothing. Why? I have no idea. I don’t advertise the book much. Yet, if you look at the sales of other competing books – those seem to be going along fine. I have no idea what happened. I mean from 20,000 in sales rank to 200,000+. Strange. Look you all, this book is helpful. It has helped hundreds of people – almost a thousand at this point. I don’t make a living being Bon… yet if you drink the kool-aid – it works! I could quote the readers (and I will soon) but I’m tired. Hey it’s almost 1 AM. I just don’t get how I sell 2 books a day and then nothing in 2 days. Weird.
When Hope is Not EnoughGet the Non-BPD book that is designed for staying and working on the relationship
Ok, after posting about book sales recently and stuff like that, now it’s time for a much more substantive post about BPD. Today, I plan to talk about self-regulation and a new study that points out an intriguing aspect of BPD. There has been much talk in the BPD research and clinical community about the “core” of BPD. Once it was thought to be a personality disorder or even an extreme form of PTSD. Dr. Marsha Linehan (the inventor of DBT) talks about dysregulation in a number of systems, the most important of which (in my interpretation) is the emotional regulation system. People with BPD are extremely emotionally sensitive and subject to emotional “cues” or triggers. They seem to have a less tolerant (in the “controls” sense of the word, meaning more highly sensitive) emotional system. They are triggered more easily and the reactions seem to be more intense and longer-lasting. In “When Hope is Not Enough” I compare this feature to a heat-sensing device and say:
The core problem with BPD is poor emotional regulation. That particular problem can cause other symptoms to arise as the person with BPD becomes emotionally dysregulated. This term emotionally dysregulated (or just dysregulated) is used to denote the state in which a person with BPD is overcome with powerful and, at many times, misaligned emotional reactions. Remember that emotions don’t arise on their own; they are based on cues or triggers from the environment and compared by our “emotional immune system” to the meaning of the cue. For a person with BPD, the meaning can be misjudged or, as is more often the case, the sensitivity to emotional cues is greatly heightened.
An example is a heat-sensing system that helps to detect and suppress fires. Sometimes companies will install heat-sensing equipment in addition to smoke detectors so that they can protect assets that need a certain temperature to operate (e.g. computer equipment which might cease working at a high temperature). The setting at which an alarm goes off might be 80 degrees Fahrenheit. In the case of someone with BPD, the setting (or “tolerance” as it is called in the control community) is naturally set much lower, at say, 50 degrees Fahrenheit. That means that the alarm will be raised much more often and lead to a reaction to the alarm. In other words, people with BPD will experience many, many (what you would consider) false alarms. However, these false alarms seem completely real to them, because their tolerance for emotional triggers is set very low. They are constantly running a fire drill. Unfortunately for you, the BP may drag you along unwillingly and unwittingly for the drill. (Pages 32-33 of WHINE)
As you can see, the position I take in WHINE is that emotional regulation is the “core issue” of BPD. This position is in line with the DBT way of thinking, which is why one of the “modules” of DBT is emotional regulation skills.
The question is today: is emotional regulation at the “core” of BPD? Or does it go deeper than that? Is there a “cause” for emotional regulation? What are the triggers and how does a person with BPD’s internal feelings affect this “systems dysregulation”?
In the American Journal of Psychiatry, Drs. Stanley and Siever recently (January 2010) publish an article entitled “The Interpersonal Dimension of Borderline Personality Disorder: Toward a Neuropeptide Model “ in which they seem to posit (in my interpretation again, since I am a lay person and not a doctor) that this systems dysregulation actually has another cause instead of being a “core cause’ of the disorder. They begin the article like this:
Borderline personality disorder is a complex disorder associated with substantial morbidity, mortality, and public health costs. Prominent symptoms include suicidal behavior, nonsuicidal self-injury, aggressive outbursts, and emotional reactivity, all of which typically manifest in an interpersonal context. For several years, there has been an ongoing discussion about whether impulsive aggression or affective dysregulation is at the core of the disorder. While these factors are important in borderline personality disorder, it is the exquisite interpersonal sensitivity that frequently triggers both dysregulated affect and impulsive behaviors, which suggests that this sensitivity perhaps rests at the core of the disorder and may in turn drive impulsivity and dysregulated affect.
Update to my previous post about “When Hope is Not Enough” being number 10 on the Lulu-published Amazon sales list. Well, today WHINE hit #5 on the June list. Again, thanks all. I appreciate it. It appears that the book is becoming more popular. I have happy about getting the message out!
 When Hope is Not Enough Hits #5 on Lulu/Amazon List When Hope is Not EnoughGet the Non-BPD book that is designed for staying and working on the relationship
Apparently, “When Hope is Not Enough” is available for the iPad now. I don’t have one, so I can’t share it or whatever you do with those things. But this week, I got an unexpected boon from Lulu regarding my sales from last month. I sold 13 copies of my book in the iPad format.
Today, my book When Hope is Not Enough cracked the top ten (at #10) on the Amazon sales list for books published through Lulu. Thanks all! I “hope” the book will help each of you.
 When Hope is Not Enough reaches number 10 for May sales Lulu books
 Books for a Non-BPD I decided today to re-do my recommended reading list and use my Amazon store in its place. I felt it was getting kind of hard to maintain, and a bit stale. The new version has more good books on Borderline Personality Disorder, emotional skills and other such things. I arraigned it in categories now. Those categories are:
- Best Non-BPD books (self-help and informational books)
- Research on BPD (current and past research – mainly for therapists)
- Emotional Skills books (I particularly like Ekman’s books)
- Other books (Miscellaneous books on training, mindfulness and decision-making)
- And, my new favorite:
- ATSTP List Member Books (recommended by members of the ATSTP email list)
Check them out and enjoy. One feature I really like of Amazon’s is the provision of similar items and lists by other members of Amazon. While I might not recommend their suggestions, sometimes they are still quite helpful.
 Where are you on the tree? When I talk to Nons, either in person or virtually, I find that they have the biggest problems with the behaviors of their loved ones with BPD. In When Hope is Not Enough, I outline a way to work on behavior modification and help the person with BPD change problem behaviors. The tool of reinforcement is number eight out of a tool of eleven tools. It rests on the foundation built through the application of other tools (mostly emotional ones) and attitudes presented in When Hope is Not Enough. In other words, behavior modification through reinforcement, which is usually called “shaping,” is not possible without first understanding, implementing and mastering the tools and attitudes presented before the eighth tool. That said, today I’d like to talk about another problem with using behavior modification techniques with someone with BPD: that problem is the scale at which many nons try to make the change. I have come up with a brief “model” that can help you figure out if you are operating at the right scale. This model uses a tree as a metaphor. The largest scale is presented first, with me gradually winnowing it down to the smallest and most effective scale.
In the sky:
- She is selfish.
- She is lazy.
- She’s a chicken.
- He’s a bully.
- She’s a liar.
- He’s too rigid.
- He’s closed-minded.
- She’s so dramatic.
- She’s immature.
- He always has to be right.
In the leaves:
- Her up-bringing made her that way, so she can never change.
- He doesn’t care about anyone.
- She needs to be more rational and not freak out all the time.
- She was spoiled by her dad.
- She was abused.
- He thinks he’s better than everyone else.
- She doesn’t care about my feelings.
In the branches:
- He lacks empathy.
- She doesn’t know how to communicate.
- He’s got to listen more.
- She screws up all the time.
- He doesn’t spend enough time with the kids.
- He rages at me for nothing.
- She needs to learn to cope.
On the trunk:
- He needs to come home earlier.
- She needs to learn how to do it herself.
- He should be on time more.
- She has to stop making so many commitments.
- He has to be more polite to my friends.
- She has to stop finishing things halfway through.
- He has to be less critical of my family.
On the ground:
- I’d like for him to spend Saturday afternoons with the kids.
- I’d like for her to pay the phone bill.
- I’d like for her to send a thank you note to my mother.
- I’d like for him to say hello to my friend when she comes over.
- I’d like for her to work on the kitchen project we agreed to do.
- I’d like for him to arrive home at 6PM on Tuesdays.
What I have found is that many nons come to support forums with a basket full of problems at various scales along the tree. Some are character traits, some are psychological explanations, some are wide behavior patterns, etc. The problem with this approach is that a non can’t solve (or work with the BPD to solve) all the problems at once. Secondly, large, general problems are not solvable in a support forum. One has to solve, through behavior modification (and the use of the other tools in When Hope is Not Enough) specific problems with specific outcomes. Once you are at ground level, you can actually get something worked out, because if the specific positive behavior is observed, you can reinforce that specific behavior. That is the “one small step at a time” approach to behavioral change. It is the only one that actually works.
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