13 Reasons Why

I know I've been away for awhile, and have so much to say, but all those snapshots about less essential things will have to wait. 

Because this is really important. 

There is a new show on Netflix, 13 Reasons Why, capturing the attention of teenagers and adults everywhere. When I saw it on the Netflix menu last week I passed without thinking. It seemed so much like work, you know?

But it is at the top of my list now. A therapist has to be informed.

This is a series of 13 shows focused on 13 people, people who in one way or another contributed to a teen's decision to end her life. Hannah Baker has already done the deed, leaves behind 13 audio cassettes implicating others. The screen adaptation is based on teen fiction writer Jay Ashers'  2007 novel of the same name.

Any therapist will tell you that we all, in one way or another, have at some point in our lives, affected the mental health of another person, for better or worse. Indeed, there is a therapy adage, well-understood:

For every suicide, there is someone else who wanted that person dead. 

Yes, that sounds macabre, but it is true. Well, sometimes it is true. Certain personalities are so grating, so annoying, so abusive (whether intentionally or not) so hard on us, so needy and intrusive, that loved ones (loved ones!) wish they were dead. And the one who is the problem picks up on that.

The suicides of patients diagnosed with BPD, Borderline Personality Disorder are often blamed (in notes) on family and friends who could not meet insatiable needs, or who outright rejected them, ended the relationship. The one who took his life likely put impossible demands upon others, expected them to drop everything to help. But it catches up on people, dropping everything else. It takes a toll. It becomes a matter of survival to limit the relationship.

We can't love everyone, and love can hurt. Mostly it is the lack of love that hurts the most, the withdrawal of love.

Borderline Personality Disorder is probably not what 13 Reasons Why is about (remember, I haven't seen it). In Alexa Curtis's article in Rolling Stone (a must read) we learn that Hannah has been raped by a popular boy, and witnessed sexual assault, suffered from bullying and the rejection of friends. She likely didn't have BPD, rather suffered loneliness, hopelessness, low self-worth, and depression.

Alexa Curtis, nineteen years old herself, a survivor of teenage bullying, upon hearing about 13 Reasons had to watch it. She is the founder of Media Impact and Navigation for Teens (M.I.N.T.), an online guide to media, self help. Alexa thought to herself, Had I watched this as a young teen I would have done it! I'd be dead today!  In her Rolling Stone opinion article she suggests that the show does more harm than good, the risk of glamorizing suicide is too great. Her opinion-- Hannah's story lives on forever in the audio tapes, and suicide should be an ending-- that's the point.

Which is not true, unfortunately. It is never an ending, because those who have loved and lost someone carry that person's legacy forever. They never forget the salient details of that person's life, now snuffed out, and will talk about it in therapy, given the opportunity, speak with tears and self-recrimination, of their own guilt, their failure to provide enough help, support, love. The survivors own it, right or wrong, their contribution, and attribute death to their failure.

There is that percentage, one in five of all borderline patients in a clinical population, for whom suicide will be the answer. The act is often to punish the "failures"of other people. The suicide literally says,

It Is Your Fault. 

For others suicide is the choice because they can no longer cope with their depression and need it to stop. Suicidal patients are at the greatest risk when they feel a little better, have the energy to do it. It takes a lot of energy to kill yourself. Depression, abated somewhat, is still close enough to touch. Why not now, is the thinking. It will come back.

And sometimes, with mental illness, even with much, much therapy, the memories of the many reasons not to do it, reasons discussed in therapy, are entirely erased. It is as if, in the throes of an episode, either manic or depressed, the only right thing to do is end it. It is the logical choice of an impaired, illogical mind, a painful choice, sometimes, and always illogical.

And there are other reasons, more than 13 of them, most likely. Complicated reasons.

So we have to have these discussions, talk about them. Make them long discussions.

Teenagers will be watching this new show that depicts fictional Hannah Baker's suicide in one of those episodes, and it looks frighteningly real. And our kids, our friends, the ones who watch, who are vulnerable and depressed, who have been bullied, perhaps, will consider the option. Peers, siblings, children. There will be copycats. Some are videotaping themselves right now.

It is a graphic show, we're warned, one that begs discussion, conversation.

And there is a media debate about it:

Is this the best way to raise suicide prevention, to get the conversation started?

Yes, because everybody's talking about it.
No, because there will be copycats. Kids will die as a result, will feel empowered. Hannah did it, so can I. 

We have a teenage suicide epidemic going on.

I thought about it and made a note in my calendar to make a few calls, catch up with the adolescents I've seen in the past year who haven't come back, who for one reason or another, dropped out of therapy or terminated therapy. That's one thing I can do.

What can you do?  Well, ask any teenager you know,

Have you seen 13 Reasons Why?

And get a conversation going. You might save a life.
Because for every reason why, you're likely to be able to counter with a good reason Why Not.

therapydoc

Other discussions on this blog about suicide:

Ten Reasons Not to Kill Yourself

How to Save a Life

How to Save a Life, Part 2

How to Save a Life, Part 3

Please Don't Leave Me

He's Just Not That Into You--It's not a new movie, and a lot of people said they were Just Not Into It.

But the topic had me at hello.

The cast is stunning, for one.  I watch chick flicks for many reasons (they're sedating, primarily), but a pleasant looking cast is at the top of the list. You can't talk about deep subjects all the time and not have a really shallow side somewhere deep down inside.

FD didn't bother with it for 30 seconds. He went to bed. But he was tired, is the truth.

Gigi Haim, (Ginnifer Goodwin, above, bottom right below) desperately seeks a boyfriend. It's the desperate part we don't like.  A woman (or a man, this movie could easily have been about a desperate man) should strive for a little more pride, more independence. Hanging on for dear life when someone is pushing you away, stalking restaurants and bars to catch the prey unannounced, feels like high school.  I know it's hard not to do it, and that for many of us, it's hard to have the kind of self-control necessary to go it alone.  But we've got to try.  That said, we can work on this for years in therapy, and we do.

Gigi anxiously waits for telephone calls, checks voicemail a hundred times a day, even when her first dates don't go well, which is always. What she wants, what she needs, is beyond her social intelligence. The social IQ should tell her that a little mystery, a little challenge, is attractive in relationships. And if the attraction isn't mutual, let it go.  But we're made up of much more than social intelligence.  Our emotional lives tend to rule.

She's rejected often, but nothing ventured, nothing gained. And Gigi's obsessive thinking, her compulsive man-chasing, doesn't hurt anyone. She's obsessed, but she would not be diagnosed with OCD, Obsessive Compulsive Disorder. She doesn't want to be alone, and although we might suggest she feels empty, she doesn't have Borderline Personality Disorder, either.  That's the one we think of when we associate fears of abandonment with mental illness.

She's just not getting it, can't read the signs when it's so obvious that it's never going to happen. Men read the neediness in her face instantly. They politely suggest, “Call me," a nice way of saying, "I’m not interested enough to call you, so I won't be calling you, but knock yourself out."

The film is full of examples of these types of metacommunications, communications about communications. It is worth seeing for that alone. But remember, the epiphanies of a chick flick aren't usually rocket science.

Gigi's social disconnect, her persistence in knocking when the doors are all closed, is a remez (rhymes with them-pez, Hebrew for hint, but hint just doesn't quite say it as well) to the drive that makes some people successful in this world. They know what they want and get it, don't take no for an answer.

When it comes to relationships and love, unfortunately, that kind of persistence and drive doesn't usually pay off. Forcing ourselves upon others only makes us less attractive, less likable. Gigi's manhunt turns out to be the exception to the rule. It's romantic comedy, after all.

Contrast this to Pink, and her violent music video, Please Don't Leave Me. I can't even link to it for you, it's so violent. Pink bloodies her boyfriend, beats him senseless so that he can't get out of the apartment. She's a sociopath, clearly, a violent, antisocial individual. I mean, rock star.  Not that rock stars are violent.

When I first heard the song, the lyrics isolated from the video screamed Borderline Personality Disorder. So I checked out the video at YouTube to see if it would work as a teaching tool for high school kids learning about abandonment anxiety. (They teach kids about that, right, in your high schools?)

Here are the lyrics:

Da da da da, da da da da
Da da da, da da
Da da da, da da

I don't know if I can yell any louder
How many time I've kicked you outta here?
Or said something insulting?
Da da da, da da

I can be so mean when I wanna be
I am capable of really anything
I can cut you into pieces
But my heart is broken
Da da da, da da

Please don't leave me
Please don't leave me
I always say how I don't need you
But it's always gonna come right back to this
Please, don't leave me

How did I become so obnoxious?
What is it with you that makes me act like this?
I've never been this nasty
Da da da, da da

Can't you tell that this is all just a contest?
The one that wins will be the one that hits the hardest
But baby I don't mean it
I mean it, I promise
Da da da, da da

Please don't leave me
Oh please don't leave me
I always say how I don't need you
But it's always gonna come right back to this
Please, don't leave me

I forgot to say out loud how beautiful you really are to me
I cannot be without, you're my perfect little punching bag
And I need you, I'm sorry
Da da da, da da

You say I don't need you
But it's always gonna come right back
It's gonna come right back to this
Please, don't leave me

Please don't leave me, oh no no no.

What's interesting to me is that both women, Gigi and Pink, are desperately in need of a relationship, both concentrate all of their energy to keep a relationship, even go to extreme measures. But they are such different women.

Engaging Gigi in therapy would be a snap. Teaching her rubberband theory, exploring her insecurities about being alone, she'd grow leaps and bounds in a single visit. Well, not a single visit, but a few for sure.  It's hard to let go, and managing neediness in relationships can take a lot of therapy, it's true.  Yet Gigi's not that dysfunctional. She hurts only herself.

Whereas someone like Pink would be self-mutilating in my office and throwing rocks at home.  I'd call in a team to work with her.

The differences in the two women, both so needy, underscores the importance of not diagnosing based upon a single symptom, not even an extreme symptom, although the no sleep thing in Bi-polar Disorder, and the hallucinations or delusions in Schizophrenia are fairly robust indicators of disease.  But even then, there are things to rule out before making a diagnosis. Like speed, acid, other physical disease, brain tumors. Things.

I looked already. Nothing's on tonight.

therapydoc

Judging Mother

The trend in psychotherapy in the first half of the twentieth century was to blame the mother for whatever the symptoms expressed by anyone else in the family. 

Then in the fifties it became fashionable to blame mom and dad.  Father took blame for supporting mother's pathological influence, be it abuse or neglect, and sometimes for behaving poorly himself.  He was given a pass, however, on neglect, didn't have to participate in family life because: (a) he worked, and (b) guys aren't supposed to talk about feelings or ask about them. Certainly not when they're tired at the end of the day. 

Then in the sixties, seventies and eighties, family therapists caught on to the transgenerational system.  We noted that pathological behavioral and belief patterns are passed down, consciously or not, from parents to children.

So we searched the transgenerational family tree, blamed grandparents, great-grandparents, great-great-great grandparents, even uncles and aunts and distant cousins, way up to the top branches-- the ganztza mishpacha (Yiddish, sounds like fonts-ah- dish-puck-ah) --  the whole family.  We blamed the family system for awhile then finally decreed: No one is to blame. It is the family system that is to blame, family dynamics, patterns that repeat, unchallenged, year after year after year.

At some point we came to realize that no family system is an island, and if we're going to blame anyone, anything, we might have to blame the entire universe; for even people and events in the news affect our thoughts and behavior, as do our teachers and co-workers, the people in the grocery store.  So we added "search" to the ecosystem to find a systems diagnosis, and used that for system change.

But sometimes it is just so obvious.  It's Mom.  We really can blame her, although the tree, those teachers, the neighbors, might be culpable, too; and Dad could get best supporting actor.  But Mom has a corner on emotional power, that power to make us feel happy, or to make us feel sad, and sometimes she knows it, can't help but wield it. And it hurts all the more because, rightly or not, we expect more from women.  When our woman doesn't deliver, it is the unkindest cut of all.

We'll put aside our wide-angle lens when father does it, too.  We stop looking for patterns when one parent or another is consistently hurtful, is negligent or abusive consistently throughout the "child's" life.  We stop looking because the patient, no longer a child, is really, really sick and needs treatment, understanding and empathy, may be cutting or suicidal.

A narrative points to a story of disappointment, pain, insults and drama, a relationship that never healed properly, one that didn't turn out nice, not like parent-child relationships should.  No fairy tale here.

The therapist sees cause and effect and doesn't like it.  The patient has shopped, priced, and compared, knows that many, if not most people have mothers (fine, fathers, too) who are not insistent upon the child's independence, who care for them when they are sick, who praise, rather than criticize, who don't withhold love, don't slap.  The adult patient is thinking that at some point a human being should stop, should shape up, should become someone who knows how to give.  Parental.

In this process, while talking through the narrative, neither the doctor nor the patient wants to label anyone bad.We tiptoe around the word bad, play with deficient, unknowing, mentally ill, a product of his or her parents. Mama didn't know any better; she is an improvement upon her mama.

Mother's culpability only becomes an issue when reality steps up and delivers.A call from her, maybe, asking for money, or time. Maybe new information from a sibling or a cousin.  Someone posts an old family video, or a picture. Facebook.  Anything and everything can be a trigger.  The patient is going along, doing fine, minding her own business, feeling fairly protected, when suddenly anxiety is off the charts, defenses shot to hell.  Like a broken child, she voices it in therapy:  I'm alone.   I was used to it.  But it is so clear, so painful, how she never loved anyone but herself.  What does she want from my life?  Why can't she just leave me alone? I'm alone either way.

That existential dilemma.

Those of us who have healthy parents have tucked inside healthy introjects, representations of the good mom, the good dad, home and goodness, an identity that gets us through tough times.  When a parent has been grossly negligent, absent, deficient, or terrifying, the child has no positive introject, no soothing representation of family.  When there's nothing inside to lean upon, that existential dilemma, loneliness, becomes a crisis.  Save me, they say, silently.

Sometimes I think I see abandonment everywhere, in every relationship, or its dear cousin, narcissism, selfishness. None of us are perfect parents.  We can't always be there for our children, and sometimes we are all about us.  It's true.  But we try to keep that to a minimum, try to be there for our kids, and we express our love, our undying love.  True narcissists, and people who are sick, sometimes people with addictions, might not want to but they abandon their children.  They are the only ones in the room, the only ones with feelings that matter, and their children miss out, suffer a slow emotional starvation.

In a good therapy we do look for the love, try to find what's below the surface, forgotten good vibes.  We spend hours seeking love in the history, giving people the benefit of the doubt, and we may find splashes of it.  Or not. Or the pickings are just so slim we might look at one another and sigh, agree to abandon the search. 

When we do that, it's okay, it really is. A person can do very well without parents, can find others as mentors, can be loved, protected by someone else. We think we need parents to be secure, but we don't.  So much more goes into being secure.

It's very hard to get to that place, to let go, emotionally, to stop hoping for what might never happen. When there is a cut off, miraculously, the world does not stop spinning.  It even feels safer.  It might be inevitable if a parent isn't amenable to therapy, or won't work on the relationship, maybe has no resources.  Or family therapy didn't work.  Most therapists don't bother trying to work with older parents.  Instead, they become highly adept at engineering sturdier umbrellas for surviving adult children.

The triggers are what make the umbrella something to keep in the car because there seems to be some kind of direct neurological pathway between the Mother event in real time and cutting and thoughts of suicide.  The cutting is to leech the pain or to send the therapist, the good mom, a message. Save me.

I bring this up because it begs an ecosystem solution.  Because I don't want to do the saving, not by myself. We talked about this a little in How to Save a Life.

The modest proposal,  a solution to the problem of judging mother is empathizing with son and daughter.  Since they are unidentifiable, since we don't know who they are and there may be thousands of them, we must empathize with everyone in every social context.  This may seem like an impossible solution, for so many of us simply haven't got the chip, but we know that empathy can be learned, like we all learn a new skill, like stopping at stop signs while driving. Those who don't stop at stop signs will be harder sells on empathy.

I'm thinking people should throw it into conversation, should ask one another, Do you think I'm an empathetic person?  Responses are likely to be honest.   It's a relief, honesty.  Expect to feel defensive but good, for this is a teaching moment.

Empathy works like this in a therapeutic context:
1. Someone complains about Mother.
2. The good therapist only cares about that complaint and how it affects the individual.  It is all about feeling this person's experience, the therapist feeling the patient's pain.
3. Questions apply; answers do not. We ask in order to better experience the pain of the patient.
4. We ask more.  We want to know all about it. Empathy is not about giving answers or suggestions; it is all about questions.

When a person is triggered, distressed, it is safe to say that anyone can be therapeutic by staying with this person, this friend in need. And best is to let the friend go ahead and judge. There might be a few rules to keep in mind.

This is not the time to say,

Give the benefit of the doubt. 
There must have been a good reason for. . .
You might have done the same if you were in that situation.

Not therapeutic, and for a person who has been abandoned many, many times over, the benefit of the doubt is hollow, reasons shallow. And you're likely to hear:
No, I would not have done this, no matter the circumstances.With attitude.

This is not the time to say,

You have to let go of your anger.  Forget about it.

Or worse,

You should confront her. Let her know how you feel.

Send the sheep to the wolf, why don't you.

This is not the time to say,

Forgiveness is divine.

Forgiveness is a process, for some, a lifelong process.

This is certainly not the time to say,

What you should do is . . .What you should have done was . . .

It is a good time to say,

Tell me, tell me about your anger.
You have a right to your feelings.

It is safe to believe that these feelings don't come out of nowhere.

There is a proverb, maybe a mishna (Google it) that says,

Don't speak to a man when he is angry.

The cutting, the suicidal behavior, this comes from a very angry, sad place.

Once the anger and sadness has lifted and healing is palpable, in therapy we talk about alternative narratives. We might rewrite the script, employ visual imagery, all kinds of cognitive behavioral interventions.

Wouldn't it have been great if you could have said. . .?
Why don't you put her in the chair and talk to her, tell her how you feel?

You can do that too, after the anger is gone. Timing is everything. Just be sure not to trigger your buddy again. Less said, seriously.

For it really is okay to judge someone, and it's more than okay, it is therapeutic to let another person judge. Even if it is the very same person who brought him into the world.

therapydoc

PS:  If you judge someone's mother, you're taking a huge risk.  I can say whatever I want about my mother, but you better well not.  That's my mother you're talking about.

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

Borderline Personality Disorder and the DSM

Almost 30 years ago, when I started my master's degree program, if we discussed borderline, that meant we were discussing psychosis. A "borderline" was a person on the "border" of psychosis.

In those days we were taught that psychopathology either manifested as

(1) a neurotic disorder, people were depressed or they worried endlessly over problems stemming from unresolved childhood guilt; we called them the Woody Allens;

(2) a psychotic disorder, accompanied with hallucinations and/or delusions; the patient being out of touch "times three," meaning he didn't know his name (person), where he lived (place) or the day of the week (time) ;

or

(3) a borderline disorder, essentially No-Man's Land, neither neurotic or psychotic, but definitely leaning towards the latter.

Borderline meant having such poor boundaries that the patient felt blended with others psychologically, did not see where his or her perception of others' thoughts or intentions could be wrong. The condition would manifest as severe abandonment anxiety, anger or depression, and certainly suicidality, ala that movie, Girl Interrupted. Perhaps the behavior was manipulative, but who knew for sure?

Disturbed, that we recognized. Depression didn't have to enter the equation (but it usually did).

Merging was thought the natural consequence of not having separated properly from parents, not having individuated or developed into an independent person, secure all on one's own. And to individuate well, one needed psychologically healthy parents who encouraged that differentiation and confidence.

You see why I push it, some thirty years later.

The first Diagnostic Statistical Manual (DSM, 1952), the Big Book of psychiatric diagnosis, included an etiological component that subsequent versions for the most part phased out in favor of statistics. Empirically-based medicine had evolved.

But ideas of merging and family dysfunction had a place in the first manual, as did other etiological explanations of pathology, such as the stress of combat contributing to substance abuse in the military. Not surprisingly, the American Psychiatric Association (APA) released the first DSM to meet the needs of the military— soldiers had returned from war alcoholic and traumatized.

This was also about the time that psychiatrists recognized the association between self-medicating with alcohol, and the manic component of bi-polar disorder.

The need to mesh psychiatric diagnosis with numeric coding consistent with the International Statistical Classification of Diseases and Related Health Problems [(ICD), the World Health Organization] followed soon thereafter. Then the mission of the DSM officially shifted from the explanation of psychiatric disorders to descriptions.

And as clusters of features and symptoms emerged for each new edition, psychological disorders became medical disorders, handily recognizable sets of features and symptomatology.

Our latest edition, the DSM IV-TR has refined the process, adding cultural diversity to the mix and some general psycho-social history that is associated with certain disorders. There is also an occasional reference to how genetics steer the course for others.

But to diagnose, we focus upon what we see and hear in our offices.

And borderline no longer necessarily implies having "poor boundaries." The disorder is now neatly cataloged as an Axis II personality disorder with easy to recognize socially dysfunctional features (see below). But those of us who remember what it means to people to feel less than whole, to have a need to own or merge with someone else's ego, body, or personality, are more likely to empathize with that particular pain, even though it isn't on the list.

Lucky for us, the DSM modifies, adds, and removes diagnoses with each edition.* So I look forward to seeing what the next one (2012) will do with borderline.

As it stands, anyone with or without a college vocabulary can take a stab at reading and understanding the DSM IV-TR to diagnose family and friends. Anyone can look up a diagnosis like "Borderline Personality Disorder," find the features, and label others. I started this post because a patient wanted me to list the features so that she could do that. You, too, might become rather good at psychiatric diagnosis with a working knowledge of the DSM IV-TR, assuming memory and retention serve.

It is a free country. Go buy a copy. (But pop for the full edition if you do, not the condensed spiral). It will teach you little about how a person develops a disorder or what to do about it, but at least you won't be caught using terms like "split personality" or "multiple personality disorder" anymore.

We'll get to the Dissociative Disorders another day.

But you wanted to know about Borderline Personality Disorder. So here you go. Here's what it says in the book:

Diagnostic criteria for 301.83 Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization or devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

Well, on the re-read, perhaps one might need a dictionary, if not a graduate school education, to really get this.

You can see why it's considered a VERY painful condition. Painful to have, painful to treat, painful to live with, all around painful. The disorder always calls me to task, forces my patience, and ultimately brings out my compassion. It's difficult, emotional work and I've heard time and again from peers that working with too many patients suffering from borderline personality disorder contributes significantly to burn-out.

But there are those who burn-out working with people who suffer from depression, too.

Notice my use of language. SUFFER FROM. You'll read on the Web that people think of themselves as borderlines, or bi-polars, obsessive-compulsives, depressives, or schizophrenics.

The better way to refer to someone with a disorder is:

a person who suffers from schizophrenia

or a person suffering from borderline personality disorder.

And so on. We don't say, "She's schizophrenic." Or, "He's bi-polar."

That minimizes a person. The process does that already. We don't need to add to it.

Copyright 2007, therapydoc

*Homosexuality, for example, is no longer considered a disorder, and it is likely that in the fifth edition of the DSM we will see Adult Asperger's and Adult Attention Deficit Disorder, currently two disorders of childhood.

Borderline and Jealous

Switch the biological sexes and relationship labels to make them politically correct.
Like "wife" can be "partner" or "spouse."

"Man can be woman." "Woman", "man". That sort of thing.

Sometimes a guy will bring a woman to marital therapy because he's jealous and angry, ready to leave the relationship. She just wants to go out with her friends. And chutzpah of chutzpah, doesn't necessarily answer the phone. The argument is on-going.

She's very responsible when she goes out, hardly even drinks, really. She doesn't use cocaine. She comes home in a great mood, albeit late, and she might even feel sort of loving. But inevitably, he's angry.

Why? He's done this many times, comes home really drunk. She's not even coming home drunk. She's the designated driver.

While she's gone he tries hard not to picture guys hitting on her, but it's REALLY hard to do that. Worse, because she's naïve about men (at least he thinks so) he thinks she'll put herself in an uncompromising position. She's out late, very late.

What kind of a girl stays out so late, anyway?

Let me tell you. All kinds of people are out at all kinds of hours. Some people actually work midnight or late shifts, and when they're finished with their jobs it's hard for them to go right home and go to sleep. They need a life, too.

So they aren't all loose women and men closing the bars early in the morning.

Ah, he tells me. His wife doesn't work a late shift.

But, she tells him, not everyone is out to hit on her or anyone else's wife. Most people, at 2 or 3 a.m. are getting quietly sloshed.

So I talk to her and learn that indeed, she does adore her guy, and has no interest in other men or other women, for that matter. (She is out with the girls, after all).

Our guy understands that. He gets it. His rational brain tells him exactly why she's out with her friends at this hour. She didn't get to act out at all as a kid, always wanted to socialize but couldn't, and now she's all grown up and, insert expletive here, she's going to do what she wants as an adult.

You go, girl, I believe is the expression.

He tells me that he flips between loving her more than anything in the whole world and trusting her, following our visits, usually, to over the top, unstoppable, painful jealousy and rage, not caring what happens to her, wishing she'd drop dead, or at least leave him, put him out of his misery.

And all over a coupla' beers.

He himself makes the connection that it is because he loves and trusts her, because he knows that she's the one he wants for partner, mother of his children, lover, and friend, that he becomes wildly anxious when he fears she may be in the process of abandoning him, cheating on him.

What we have here is psychotic anxiety and rage that is triggered by a fear of abandonment. These fears have to be worked on, you know. You can't let them fester forever.

Anxiety that's to the point of psychotic inhibits rational thinking. One's thoughts have no basis in reality but they feel very real.

What to do?

Well, marital therapy, obviously. She has to reassure him and to develop some kind of behavioral strategy that will chill him out. And he has to work on his abandonment issues, and his impulse control, rationally go over a few of the symptoms of Borderline Personality Disorder, see if they fit. And if they do, get to work on them.

If she doesn't want to make the proverbial call to him from the bar, always had to call her mommy and can't do it anymore, she can plant a note or two in the apartment that tells him that she's looking forward to coming home late at night.

That would be CODE for something nice.

He would get it.

If she's the romantic type, then she can be obvious about it, tell him how she loves his 4 a.m. shadow, stuff like that.

In a relationship therapy I'd have her be the one to reassure him, to hold him more. It's hard, I know, to hold someone who is angry.

He has to learn, clearly, to contain that anxiety and never to display anger (we err on the exaggeration here).

For those of you who like to see the feedback loops, how behaviors and messages in marriage reinforce problems rather than "correct" them, take a look at this one.

Guy and his girl are doing fine, he loves her, they're not fighting. → She wants to go out with her friends to have fun and he's okay with it, not real okay, but okay. →

She goes out, has a great time, but her phone is on vibrate and she doesn't want to call him. She's talking with friends. Those of you who know how intimate friendship can be know that answering the phone can be a REAL pain if someone's in the middle of something→

His natural anxiety and insecurity begin to rise→ His thoughts go to places that reinforce his natural anxiety and insecurity, i.e., she could be hurt, raped, at that moment someone could be holding a gun to her head or touching her in places that he feels are off limits to everyone but himself→

He begins to call her every ten minutes, entertains the notion of going out to find her → His anxiety is unbearable and morphs into anger. After all, anger and anxiety use the same arousal system, the Central Nervous System. We all have one. →

His thoughts go to angry thoughts, What do I need this bitch for in my life, she's nothing but trouble, she has no respect for herself, none for our marriage, she doesn't deserve me →

He goes from that to thinking that marrying her was a really bad idea, that she isn't the one for him, that he would rather be alone than feel the way he feels, think the thoughts he's thinking →

And oh, by the way, another girl would appreciate him more in every way→ Maybe, he thinks, he should give her some of her own medicine, cheat on her, or simply not come home→

His wife comes home, he's exhausted himself with his thoughts, sleeps on the couch, doesn't even say hello to her →

He sees me the next day, tells me all of it, still really angry, by the way, ready to end the marriage→

In therapy we keep it rational, go with what's real, the fact that she adores him, it is he who can't handle the separation when she goes out, and his thoughts and emotions →

Oh, and by the way, it's not as if he doesn't give her grief. He hasn't been the perfect mate at the end of the day. →

We arrange for him to work it out with her, he leaves calm→ the whole thing starts all over again. They do fine for awhile, love each other, don't fight. →

Then she goes out and it starts all over again.

So it makes sense to look at more than the behavior, obviously, to force the psychology, the why, here.

therapydoc

Copyright 2006