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Tough Love is not an effective approach to BPD

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?

It's the emotions stupid

In “When Hope is Not Enough” I quote renown Buddhist monk Thich Nhat Hanh about anger. Here is the quote:

Anger is an unpleasant feeling. It is like a blazing flame that burns up our self-control and causes us to say and do things that we regret later. When someone is angry, we can see clearly that he or she is abiding in hell. Anger and hatred are the materials from which hell is made. A mind without anger is cool, fresh and sane.  The absence of anger is the basis of real happiness, the basis of love and compassion.

When we are angry, we are not usually inclined to return to ourselves. We want to think about the person who is making us angry, to think about his hateful aspects – his rudeness, dishonesty, cruelty, maliciousness, and so on. The more we think about him, listen to him, or look at him, the more our anger flares. His dishonesty and hatefulness may be real, imaginary, or exaggerated, but, in fact, the root of the problem is the anger itself, and we have to come back and look first of all inside ourselves. It is best if we do not listen to or look at the person who is the cause of our anger.  Like a fireman, we have to pour water on the blaze first and not waste time looking for the one who set the house on fire..

The thing is that many people, when overcome with emotions, have a tendency to focus on the situation and causes of the anger (who set the fire) vs. the anger itself. This reason is why I try to refocus non-borderlines on the emotions, not the “offense.” People typically defend against the accusations, rather than focus on the anger. Many skills can be applied to cool the anger, but defending is not one of them. Defending just fuels the flames.

Putting out the fire of anger

Putting out the fire of anger

Instead of defending, I encourage non-borderlines to use the I-AM-MAD communication skill. It’s been a while since I elaborated on that skill, so here it is in a nutshell:

I-AM-MAD

1. Identify the emotions.

It’s best to do this with “feeling” words, like “look”, “see”, or “sound”, rather than “know” or “understand”.

Examples: “I see that you are frustrated.”

“You sound aggravated.”

“You look really upset.”

2. Ask a validating question. Immediately – combine with step 1 to be most effective.

This encourages them to share their feelings about whatever triggered them. Do not use “what’s wrong?” If you use “what’s wrong?” they will hear “what’s wrong with YOU?” Also, don’t assume you did anything wrong. Remember, IAAHF (It’s All About His/Her Feelings).

Examples: “What happened?” (most effective because it is open-ended, requires more than yes/no answer)

“Did something go wrong at work [school] today?”

“Want to talk about it?”

3. Make a validating statement about their emotion.

Validate the feelings expressed in step 2. This helps reinforce that it is natural and valid to feel what they are feeling in the situation. Again, remember IAAHF. Don’t defend against blaming or projecting. And don’t apologize at this point, even if you are guilty. (Apologies for things you are actually guilty of can come later… after they have returned to their emotional baseline.)

Examples: “Wow, it must have made you feel awful to have done poorly on that test.”

“Yes, it is frustrating when it seems that someone is taking advantage of you.”

“Yeah, that’s really disappointing.”

4. Make a normalizing statement about their emotion.

By relating the situation as common to all people or “normal” for them, this helps alleviate their stress about feeling judged or unaccepted.

Examples: “I think anyone would feel angry if they had to do that”

“I would feel the same way if that happened to me.”

“I can see why you feel that way.”

5. Analyze the consequences of their behavior.

By examining the consequences of both negative and positive behavior with the person, you help them to separate their emotional reaction from their behavior. The behavior may need to be changed, but the emotions are natural and should not be punished for.

Examples: “When you don’t ask questions about something that confuses you, I don’t realize that you are struggling, so I can’t help you. When you do ask questions though, I can either give you the information you need to solve the problem yourself or we can work together to figure out the best solution to the problem.

“When you yell at me, I feel disrespected and become upset too. However, when you speak calmly to me, I know you have respect for me, so I am able to listen to you better.”

“When you refuse to talk to me, I don’t know what else to do except give you space. When something is bothering you, it’s best to be open and honest with me so I know what’s going on and don’t make the wrong assumptions about what you need.

6. Don’t solve the problem for them.

Solving one’s own problems helps to build self-confidence. Empower the person by getting them to come up with a solution themselves. When given the opportunity in a non-judgmental setting, most people will find that they can come up with solutions to their problems. You can guide them through this process by asking helpful questions to ascertain what they need or want.

Examples: “How would you like to handle this?”

“What would help you make a better choice next time?”

“Is there anything I can do to help?”

(Note: Sometimes you have to go back and forth to help them find the most effective solution. They may say, “I don’t know” or “I don’t care.” This can be tough. Go back to step one to deal with any additional emotions that become apparent.)

Tough Love Reconsidered with BPD

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.

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

Tough Love is NOT the Answer with BPD

I often peruse the web for articles and posts about dealing with people with Borderline Personality Disorder and what I usually find is incorrect and misguided. I recently stumbled upon a post that can be found here:

http://www.helium.com/tm/339437/individuals-suffering-borderline-personality

In which the author gives some insight and advice about “dealing with” someone with Borderline Personality Disorder. I’d like to look at her advice by excerpting some of her text and then offer a little commentary.

First of all, she says this:

Individuals suffering from borderline personality disorder are very self-destructive and they have great difficulty forming any good relationships. A deep-seeded fear of abandonment is behind every wayward action and prolonged mood swing. It’s [sic] victims are mainly women who show frequent displays of inappropriate anger and who exhibit forms of self-mutilation. They also act on impulse, without regards to consequences and than [sic] hold others responsible for their actions. They are sexually permissive and may indulge in binge eating and drug abuse. Victims of this disorder may shop lift. Hell bent on harming themselves, they live with no discipline or boundary.

While this characterization is generally true, it suffers from what wikipedia calls “weasel words”. Basically, the words that are used slant the information toward being extremely judgmental. What I mean is the use of the words “great difficulty forming any good relationships,” “every wayward action and prolonged mood swing,” “show frequent displays of inappropriate anger,” and “they live with no discipline or boundary” all show us that the author is judgmental toward the sufferer. The idea of “prolonged mood swing” is incorrect as well, since the “moods” of a person with BPD generally last only hours. Also, the idea that “they are sexually permissive” MAY be true for some of the sufferers, but not for all. The idea that a “fear of abandonment is behind EVERY wayward action” is also incorrect. Much of the “actions” are motivated by pain relief and/or shame. Use of the words “no discipline” betrays the authors true feelings about people with the disorder and tells me she doesn’t understand the disorder very well (see below on “Tough Love”).

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

The author goes on to say:

Group therapy can resolve self-destructive behaviors. These individuals learn better from their peers because of their resistance to authority. Impulse behavior can be curtailed in this same setting.

Which is basically wrong. Group therapy does work (especially in the context of DBT), but not for the reasons that the author suggests. It is not a “resistance to authority” that drives the effectiveness of group therapy. Instead, seeing that one is not the only sufferer and having the ability to support one another normalizes the disorder. You are not just the broken, shameful person that you feel you are. Interestingly, many people with BPD will criticize others in the group and report that they are not as “crazy” as those people are.

The thing I have the most problem with is this:

Tough love may be needed from family members and loved ones before the person asks for assistance.

This statement is completely false and possibly harmful. Here is the text of a post of mine in the ATSTP group which addresses Tough Love:

Depending on the actual problem with your son(s) the idea of “tough love” might be the worst thing for him (them). While it seems to work for substance abuse, tough love can be an awful mixture for those with ERD-like issues. The problem comes down to the “invalidating environment” as Marsha Linehan puts it. Tough love will invalidate a person’s basic feelings and lead to shame and the feeling of “brokenness”. I have seen this first-hand with one of my daughter’s friends. This friend is 16 now and is a classic BPD/ERD case. She has been kicked out of several “lock down” facilities. Recently her mother sent her to a “tough love”/boot camp. It was a total disaster for the kid and for the family.

A better approach IMO, is emotional validation + a sense of personal responsibility. This combination is built through letting the person know that feelings are not wrong or right, they just ARE. The second half comes through building mastery over their behavior associated with feelings. Bad feelings just exist. This is important because often a person with such issues will use behaviors (like drug abuse or cutting or raging) to make the bad feelings go away as quickly as possible. They need to learn to tolerate the distress and behave in an effective manner. Once this new behavior/reaction to feelings is practiced, they can eventually build mastery over the behaviors. This works backward to help quell the feelings.

It seems that most parents believe that emotional validation = “giving in” (or agreeing with the child or “poor discipline” or whatever). This is NOT the case. It’s difficult for me to express this more firmly. Remember the word “emotional” is important. If you validate invalid behavior, you are enabling. It is important to separate in your mind the emotions (which are natural) from the behavior (which can be painful to all involved). If that separation can be communicated to the person with ERD, it can be worked with. It is difficult, but possible.

Unfortunately, tough love is not the answer.