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A few days I got a comment on my post “How mentalization and attachment might explain ‘high functioning’ Borderline”. The comment was from a self-proclaimed “quiet borderline”. I have gone back and forth on this blog, through posts and comments alike, on whether the term “high functioning” or “invisible borderline” is a myth, a reality or a made-up category. As I said in “The Myth of the High Functioning Borderline,” I have yet to discover a researcher or clinician using these terms. Until now. Dr. Margaret Cochran guest-blogged on Randi Krieger’s “Stop Walking on Eggshells” blog and used both terms (invisible and high-functioning). I really don’t know what her familiarity with BPD is, but that really doesn’t matter. The combination of the comment I received and her post made me think about how mentalization failures translate into ineffective behavior and how the type of mentalization failures that are prevalent might explain the different “categories” (or levels of functioning) of someone with BPD.
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.
Continue reading Does the mode of “failure to mentalize” determine the ineffective behavior of the borderline? →
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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.
 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.
I have written quite a bit about the reason that people with BPD behave in a certain fashion. Much of the impulsive behavior is to stop the pain. Yet, the behavior can still be destructive to relationships, even when it is not the intention of the person with BPD to hurt the other person. Intention is often misread with BPD. Here is one message about that from the ATSTP list (written by me):
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.
Recently, in the ATSTP group we discussed the power of saying “when you do [whatever], I feel [whatever else].” This formulation of words is very powerful when dealing with an emotional person. It does a couple of things that are important. First, it lets the other person know that you have feelings as well. Sometimes someone with BPD will feel that they are the only one in the world with feelings to be hurt. DBT actually “encourages” this way of thinking IMO. Since DBT is all about the client’s emotions and behaviors, the “other’s” (the therapist) feelings and behaviors are not often taken into account. This situation is not really ideal for a family member. Saying: “When you did [this], I felt [that]” often does the trick. It’s basically the “inserting your feelings” tool from When Hope is Not Enough. However, you need to make sure that you are communicating your feelings, not your judgments about the behavior. That is, use feeling words (sad, angry, afraid, etc.) and not judgment words (manipulated, disrespected, etc.). If you use feelings words, you can’t be argued with.
Is it even possible? The short answer is: yes. I see many nons hopelessly entangled with their borderlines. I don’t use the word “hopelessly” lightly. It is a difficult situation to be in and, unfortunately, in the world of human relationships, it is a natural situation to be in. One of the main issues as I see it is that we get our emotions engaged in the mix. When someone (anyone) is emotional, it is natural to “circle the wagons” so to speak. When we get emotional, other people’s intent, feelings and motivations disappear from our mind. This situation is particularly acute for borderlines. Their emotions become engaged rather quickly and intensely (see “BPD, self-regulation and others” for more detail). Additionally, we, as just regular people, have our own emotional triggers. One way that we get entangled is through assumptions of other’s mental states. We assume what the motivation of others is without ever asking ourselves (or them) what they are feeling or thinking. We rarely ask about intent. Instead, we assume that the other person is “out to hurt/manipulate/disrespect” us.
The most effective way to combat entanglement is a process:
- Don’t assume what the intent/motivation of the other person’s actions is. Ask. Be a detective, not a judge.
- Be honest and clear with yourself about which issues are yours and which are theirs.
- Understand that most people (particularly borderlines) are most often motivated by their feelings. This is why I say in “When Hope is Not Enough”: It’s all about his/her feelings (IAAHF). What that means is that the motivation of his/her actions is typically a reaction to his/her emotions and, for the most part, your mental states are not considered. In other words, you are not even on the radar screen, even though it feels (your emotions) like you’re being “hurt/manipulated/disrespected.
- Don’t focus so much on content – instead, look to emotional context. Think about what you’d feel if you were them in a given situation. Ask about intent. Ask about feelings. Validate feelings in order to get a clearer picture of the other person’s mind-set.
- Don’t defend. This is quite difficult to do. It takes time and practice. When people are attacked (or feel attacked), the natural reaction is to defend, deny (“That’s not what I meant!”) or to avoid. Instead, engage the other person’s mental states.
- Help get thinking back on track by asking for information. You can’t be a mind-reader. If you assume the other person’s mental states, you could be far off. You could assume the worst. If thinking (rather than reacting) can get back on the rails, then a true interaction can take place.
- Stay in the moment. Don’t plug in past problems, childhood issues (yours or theirs), history (“she always does this!”) or future fears (“he’ll never get a job!”). The conversation is about now.
An abstract on MBT:
Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder
Anthony Bateman, M.A., F.R.C.Psych., and Peter Fonagy, Ph.D., F.B.A.
Objective: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.
Method: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables.
Results: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.
Conclusions: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.
http://focus.psychiatryonline.org/cgi/content/abstract/8/1/55
 New "Beyond Boundaries" eBook I published a new eBook called Beyond Boundaries: the advanced guide for loved ones of people with BPD. This 72 page eBook is packed with information and tools for you to gain a more effective and calmer relationship with someone with BPD. It is the culmination of what I have done in When Hope is Not Enough as well as what I have been working on since. It explains (rather tersely) what you can do and how you can get your relationship to be more of a trusting, loving relationship. It also explains when boundaries are helpful and when they are not.
The cost of the new eBook is $18.00. I think you will find that it is worth it. People in NY will have to pay sales tax. Sorry, blame the NY State legislature.
The eBook is available through Google Checkout below:
Beyond Boundaries
 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
From the Menninger Clinic… about mentalizing.:
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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