Thursday, September 24, 2009

Borderline Personality Disorder and The Fake


Originally I just wanted to tell the story about the stand underneath my fish tank, how I found it at Bed Bath and Beyond while shopping for a gift for a shower (yes, I had the coupon), shlepped it to the office myself, borrowed a screwdriver, for mine is never where it's supposed to be, and put it together in little under two hours. Of course I knew the secret about the cam screws. Put them in, tighten them up, last.

I see this sort of behavior as fairly normal, if a little impulsive, sure, because ordinarily I'd ask FD to put it together for me. But doing something physical and challenging is a nice way to distract a person from thinking, and sometimes we just think too much. So I'm always telling people to do something. You feel better if you can distract.

And the computer desk that supported the tank just didn't cut it.

Then I found myself talking about Borderline Personality Disorder, BPD. This disorder is very much about impulsivity, which substantiates the rule that things that are thought to be pathological can be perfectly normal in a different context.

Impulsively buying a bookcase that matches your furniture, even if it weighs more than you do, and putting it together yourself, even if your best tools are a hole puncher and a nail file, beats impulsively getting drunk to feel less edgy (a "borderline" thing to do), impulsively cutting one's self (another "borderline" thing to do), or impulsively whacking someone across the face because you're jealous or in a bad mood. You get the idea.

And if the impulsive act also functions to build your self-esteem, as opposed to, say, lowering it, then it's a good thing to be impulsive, right?

But people who suffer from BPD have a helluva time trying to reign in their impulsivity, and the folks who try to love them, who want to help them, get worn out by the drama.

It's easy enough to start to write something, quite another to finish, and that's what happened to this post. Then then something cool happened. Retriever wrote to me to ask what I thought about something going on at Dr. Helen's Blog and Dr. Bliss's blog over at Maggie's Farm. Both docs are writing about BPD, and lo and behold, Doc Helen has a video interview with my new favorite self-help guru, Randi Kreger.

Randi Kreger (Walking on Eggshells) has a fairly new book, The Essential Family Guide to Borderline Personality Disorder. I read it cover to cover in a night only a few weeks ago, found it a terrific resource, funny, easy to read, and full of information that everyone should know. Especially if you have someone in your family who is "impossible", who can't regulate his or her emotions, who acts impulsively to dampen heightened negative arousal, like anger.

And she has a great section called Tools in the back of the book.

I'll throw one at you right now, a favorite I've suggested many times to people in therapy. Randi would call this intervention an incompatible behavior. I've always called it The Fake.

The idea is that a person can't be obsessing and angry about something if something else is a more attractive option. It's no different than distracting a whining three year old with a shiny yo-yo. All of a sudden the icecream he wants isn't important anymore.

With kids it's always,
Outsmart them. You're older. You can do it.
With older people who simply can't let something go, who are stuck on abusing you or raging about something or someone, who really will not stop to listen to anyone else's point of view or entertain other positions, it has to be,
Did you hear the one about. . .
Or
Did you hear what happened to So and So?
Good gossip is sheer genius. Gets 'em every time.*

My favorite fake is laughter. You laughing at your tormentor.

This person is tormenting you, criticizing you, ranting, and you break into hysterics, literal belly-bending, on the floor, doubled over with laughter hysterics. You do it respectfully, though, for you are complimenting the person who is clearly trying to upset you. But now the abuser sees himself, herself, as a good person, someone who can make you laugh, not just laugh, but laugh hard, and that fleeting self-esteem returns with your praise. Now we're all comedians, should work stand-up.

If you throw someone off like this, anger and blame are impossible.

And the truth is, most people with this disorder are smart, and they can really be very funny.

Traditionally with people who have Borderline Personality Disorder, once they're flying, meaning angry, there's no stopping them. The anger is a manifestation of pain. If you can't see that, then there's no helping your spouse, your child, your friend, your mother, whoever it is who is unable to regulate emotion. When the plate needs shattering, it will shatter. When they need love, they'll find someone to sleep with. When a car needs to be keyed, it will be keyed.

When it's all over, it's What's for Dinner? As if nothing happened. So in therapy we're forever working on strategies that will work, that will distract, end an episode.

If you think of this as an episode of true psychopathology and pain, then it's a lot easier to swallow the negative behavior.

And you have to see them as capable of seeing life differently, seeing themselves as their greatest allies, capable of rational, laudable behavior. Good lives.

I work dialectically with suicidal, self-destructive people who have BPD , for you have to do this, dialogue in an empathic way, one that reaches them, meets that place in the ego that wants to live. Typical questions from me include:
(1) Would you want your niece to cut herself? No? Then why are you setting an example? You think she doesn't respect you, look to you as a role model?

(2) Do people deserve to have quality lives?

(3) Aren't you a person?
People tend to agree. They deserve better. They are capable of better. They want more out of life. They want quality lives.

Then the question becomes how to get it.

And it isn't an impossible quest, an impossible, reprehensible therapy. I've referred to ACT, Acceptance and Commitment Therapy here in this blog, and it helps to know DBT, Dialectical Behavioral Therapy, and Schema Therapy. There is progress and people do get better, so I'm a little miffed, frankly, at all the negativity I read on the Internet about BPD, avoiding BPD patients.

Yes, people can be difficult. They can be high maintenance, and yes, group therapy surely helps, and for sure, without a team it is so, so hard to work a successful therapy. I get it that people with Borderline Personality Disorder can be more than difficult, that they can and will make your life a living hell without help. And yes, therapists try to avoid treating the disorder, need help for ourselves to cope with all the drama.

But with help? With time? (lots of this, endurance is the essence)

There's no greater therapy, no greater pleasure, no greater success than helping someone with this disorder get well.

That's all I'm gonna' say. I have some algae to scrape off my tank here at home, and spilled some sugar behind a cabinet. There's a lot to do, basically.

therapydoc

*Okay, not every time. Go ahead, talk about it.
See the Second Road on Self-Pity.
Other posts by me about BPD

21 comments:

Cat said...

Ah damn. You have helped me get to some kind of an aha moment about my 17 year old son - I finally called and asked for a determination - some testing on him becuase he is much more than difficult and I am unsure how much more I can manage...

I suspect he is borderline personality disorder... at least this is a good place to begin right?

therapydoc said...

I don't know. You have to read the DSM guides to the disorder. I feel it is often over-diagnosed, especially in young people who are still developing a sense of self and really have no idea what they should be, who they should be at any one moment. The indecisiveness, too, is hallmark.

Many adolescents and young adults seem to have the disorder at some point or another. Little kids are labeled just that, little kids.

So big kids could be labeled big little kids and it wouldn't sound so pathological.

-T- said...

I guess I have been doing "the fake" with my 16 yo daughter without even realizing it. "hey, let's go out for some fresh air and check on the calves" in the middle of the intense drama and crying and blaming worked wonders last night for both me and her. 10 months in a residential treatment facility with lots of therapy has eased the drama and given her some better coping skills I guess. Still lots of work to do though.

I'm definitely going to check out these links.

Jack said...

I remember trying the laugh at my tormentor bit in school. I laughed and he hit me in the head. Not sure that this guy was borderline or not.

But I haven't forgotten him.

Syd said...

I think that a lot of these disorders seem to have some overlapping symptoms--BPD, ODD, ADD to name a few. I suppose a person could have all of these and be really a mess???

lynette said...

i actually have a problem with this approach. when my kids are worked up about something, i work with them to get it into words so we can talk about what is distressing them, why they are so angry. it works miracles. if i were to laugh at them or make light of them, then i am completely dismissing the emotions underlying the behavior and setting them up to learn to repress, not express.

my husband, who becomes enraged and verbally abusive, would likely escalate into physical anger if i tried this. it is all i can do to get out of the same room as him without him following me in a rant.

again, my goal is to set a good example for my kids and to protect myself and them.

not laugh at someone's pain? just thinking.

One Angry Daughter said...

I'm reading Stop Walking on Eggshells now and I wish I had started with this book. It gave me the coping startegies I was searching for before the fallout. I had been focusing my reading on NPD because it seemed to fit my mom. No doubt she her behavior fits NPD, but now I'm learning her behavior fits BPD very very closely! Both being Cluster B personality disorder, I can see why the overlap.

What ifs are dangerous, but lately I've been wondering what if I know about BPD sooner and tried some of these coping strategies with my mom and sister --- would I have withdrawn sooner? Watching my family drown without accepting help while all I can do is watch from the shoreline is the most difficult thing I've ever done.

Thanks for this post! A lot to think about!

SocialWrkr24/7 said...

"Many adolescents and young adults seem to have the disorder at some point or another. Little kids are labeled just that, little kids.

So big kids could be labeled big little kids and it wouldn't sound so pathological."

Genius. Seriously. :)

Isle Dance said...

I tend to see it as abusive personality...if they don't get help. And if we try to help them, but they still refuse to get help, I have to stay away. I feel sad, I can see their pain, but their rage is always popping up. And then they don't understand why I can't hug them just because they're ready to eat now. No resolution. No reparation. I just can't live like that.

blogbehave said...

Not familliar with ACT, will check out that post.

I am a big fan and believer of DBT, having read Linehan's book and having a copy of her workbook on my shelf. I frequently refer to DBT groups. As Linehan says, one therapist in the room is sometimes not enough.

I can understand the reluctance to work with individuals with BPD. Being the victim of angry acting out can hurt, can lead to fear and avoidance. Some therapists are burnt more than others or don't have an adequate skill set. Linehan's book is a good starting point, as I said, she advocates that 1:1 therapy may not be enough.

therapydoc said...

T, there's tons of stuff on the web. I love the cow stuff.

Jack, I should have made it clear that I hate diagnosing people with virtually anything, cuz as soon as people read about a disorder they have it. It's amazing how many disorders a person can have in the space of an hour if we work at it hard enough.

Syd, ditto. Best to look at what's wrong and work on fixing it, not get caught up in the DX.

Lynette, of course you can't laugh at a kid. It works best with a sister, is the truth, or a brother. When I make a suggestion it isn't a prescription, just an example of one type of intervention that works some of the time. And no. You wouldn't laugh at someone who will punish you for it.

One Angry, personality disorders can take years, even when you know what's going on. One of the problems is that we used to think that environment, primarily, caused them. Seeing there's wiring (genetics) and that we have to work against this surely helps. But yeah. You might have distanced sooner.

Thanks, Social Worker 24/7

Isle Dance, you got it. It's very hard.

blogbehave, she's right, probably. Family therapists bring others in, but groups and teams trained in DBT are the best solution. Finding one's the problem.

hiro said...

Nice to meet you.

I was going to paste the link without permission because I had very felt the interest for your blog.

Please link me with the blog if it is good.

URL:http://hiro-anniversary.blogspot.com/

E-mail:h-mori@ibs-office.com

ilanadavita said...

Thanks for the reference. I'll go and check if I can find the book via Amazon.fr (which might be quicker) or have to rely on the American website.
L'shanah tovah.

porcini66 said...

There's no greater therapy, no greater pleasure, no greater success than helping someone with this disorder get well.

And this, I think, is why you must be so very good at what you do. My own T has said so often that he feels privileged to help people like me get better. I'm not borderline, but came to him because of my husband and ended up staying for myself. With him, I finally addressed my childhood abuse issues. I finally acknowledged my alcoholism and am solidly in recovery. I have chosen to give up smoking. Not because he is a magician, but because he had the patience to stay with me and showed me tolerance as I learned how to live without crutches. I have grown exponentially in his care and continue to visit him when I need guidance and outside perspective, yet he maintains that HE is the one that got the better end of the deal.

I think that you are probably as good as he is, and that is a high compliment. Thanks for sharing this.

Retriever said...

Another wonderful post, TD! :) Thanks for the link, and for writing about this so well.

Lou said...

My son got a dx of BPD. The big problem for me is he was a heroin addict at the time. That is the PRIMARY problem. He has been to many county/prison therapists and gotten many different dx's. He has also been diagnosed with bipolar & affective schizophrenia, in addition to BPD. I know it is difficult to diagnose him because he says things to get drugs. He is a drug addict, and these other "conditions" just give him another excuse to not work on himself or to look for legal ways to medicate himself. I have given up trying to figure out what, if any, underlying problems he has until he has some significant sobriety.
I'm sure you hear the frustration in my comment.

After years of dealing with the addiction, the drs, the rainbow of psych meds, I feel very ambivalent about the real prevalence of these conditions.

nashbabe said...

My psych says that yes, my mother more than likely has BPD. I liken it to someone frozen at the emotional age of a five or six year old--it's always seemingly someone else's fault, not theirs; they throw a fit if they don't get their way; they have explosive, mercurial moods. But with this infantile thinking comes all the power and vocabulary of an adult.

I am surprised at your willingness to work with BPD patients. Hanging out at one of Randi Kreger's support groups for people who deal with BPDs, the prognosis is usually very dim. David Celani is the only guy I've read about that really seems to take them on. The joke is that the BPD won't pay the therapist... ;-)

The only solution for me was to break contact completely. I know you advise against that, but as my sister says, "mom is really mad that you don't talk to her any more, but she's like someone trying to shoot you...why would you stay around to let someone try to kill you?"

I know your mileage varies. Sorry to be the wet blanket. The toxicity, combined with a landslide of other stressors, was too much to handle. I decided getting abused by her was completely optional.

Health wise, I imagine the other shoe will drop at some point. At this point, I am insulating myself. The fake doesn't work with her. You can see the storm rising, we call it "the turn". Sometimes I wonder if she's bipolar as well.

Sarah said...

New here. I wish all psychiatrists would read your posts, along with the insightful comments! I was once given a diagnosis of BPD as punishment for disagreeing with my egomaniac of a doctor. (He was insisting that i was bipolar. When i pointed out that i have never experienced mania, he responded that he didn't believe me. This was as an inpatient, so the man had known me for about ten minutes. I can think of no other basis for the BPD diagnosis, except that i used to be a cutter, and so i have a small history with being tossed into that "trash can".)

Not only did that not help me, but it was also an insult to everyone who suffers from the disorder to condense their experiences down to "difficult, disagreeable patient." (And this was a well-respected doctor!) I have never personally known anyone with BPD, but i can imagine how hard it can be to get help when encountering this kind of discrimination within the mental health field.

therapydoc said...

I hate the very thought of "snap" diagnosis. Thanks for sharing.

Kellen said...

Thanks for a great article on BPD. It's hard to find empathic, yet useful information about this disorder. And "The Fake" is absolutely brilliant.

The Blue Morpho said...

Hey therapydoc - You continue to write a great and thought provoking blog.

Like nashbabe, I chose to cut contact with my mother, who we suspect is both BPD and Narcissistic. It was an important step for me, since it was only outside of her influence that I was able to deal with the chronic PTSD and more stemming from the abusive childhood she and my father provided. Allowing the abuse to continue into adulthood was nothing more than self-punishment and continuing self-victimization. I feel bad for her, knowing her life was and is filled with pain. But I strongly felt, for me, that I could not save someone drowning when I was already going down for the third time, myself. And I'm afraid she has to make that same choice - the choice to save herself. No one can do that for you.

So we all need to make our own choices about if we stay in contact with abusive family, or not. For some it is more important and healing to continue a relationship of some sort. But for me, cutting that tie was a critical turning point in my own healing.

The Blue Morpho
www.anxietyland.blogspot.com