She was crying like I had never seen anyone cry before. As she sat with her head in her hands, the large, clear tears rushed down her cheek and dripped on the floor. Her husband had just informed her that he would be leaving her and taking their six-year-old daughter with him, with the parting words “until you can change.”
The look on her face in that moment is forever engrained in my memory as the pain and anguish which this woman was experiencing was like nothing I had seen before. She leaned towards me and it took every single ounce of energy left for her to attempt to speak to me, but no words could even make it to the surface. But the look said it all; “Do something! Help me! What is happening to me?”
“All I want to do is lie down and go to bed,” she finally muttered. I knew that there was an implied “forever” at the end of her statement. She was experiencing pain in the form of shame. She had been repeatedly told that she was not OK, she is sick, and she needs to change. Now, everything she has ever loved was going to be taken away from her due to her “illness.”
“Sammy, just look at me,” I said with a sincere tone, “there is nothing wrong with you.”
She lifted her face, the tears had stopped, hands and chin ceased to tremble anymore, and I had her attention. She glared at me with a mixed look of confusion and hope. It was apparent she had never been told this her entire life.
Sammy had been diagnosed with what is deemed the most difficult personality disorder to treat, and also the most difficult to bear –Borderline Personality Disorder (BPD), as per Mayo Clinic.
But the question is – is this really a disorder?
What is Borderline Personality Disorder?
The Diagnostic and Statistical Manual for Mental Disorders (DSM) defines BPD as a pervasive pattern of instability of interpersonal relationships, self-image, and affects. It also includes problems regulating emotions and thoughts and can include impulsive and reckless behaviour.
Clinicians refer to this illness as being “addicted to drama.”
We are told that those with this illness depend completely on the external environment for clues as to what emotion to feel. Symptoms may include behaviour that is manipulative, gamey, attention-seeking, dramatic, self-damaging, and emotionally unstable.
The term borderline was first used in 1938 by psychiatrists to describe people who they thought to be on the border of diagnoses of neurosis and psychosis.
However this term is outdated as neurosis is no longer recognised in any diagnostic material and BPD is no longer believed to be a psychotic disorder.
In Western medicine and society all mental illnesses focus on what is broken in the person and what needs to be fixed. In the East and ancient cultures, shamans view mental illness as the birth of a healer and good news from the outer world.
From a shamanistic perspective, the symptoms of BPD include feeling intensely connected to everything; and therefore, highly affected by everyone and everything.
The person is seen as not bad, but having a spiritual gift. They can sense the emotions of others instinctively and feel things that we cannot.
They know how to make people feel as if they are reading your soul.
Dr. Marsha Linehan, the founder of Dialectical Behavioral Therapy (DBT) and leading expert in the understanding and treating of BPD, explains patients with BPD are like third degree burn victims. Just by walking by them, you may hurt them.
Linehan had her own personal struggle with BPD and was and hospitalised for 26 months in 1963. In her discharge summary it states, “Miss Linehan was for a considerable part of this time, one of the most disturbed patients in the hospital.”
It is reported that she had attempted suicide multiple times because she could not close the gap between the person she was and the person she wanted to be. The gap was insurmountable which left her desperate, hopeless, and homesick for a life she would never see.
Living with BPD is like the earth beneath your feet is constantly shifting and changing which keeps you off balance, scared, and defensive. It is a roller coaster of moods, thoughts, emotions, relationships, self-image, goals, and even likes and dislikes can come at such frequent intervals it is overwhelming and confusing.
Understanding Interconnection
The greatest sages, philosophers, and spiritual masters have understood the interconnection of the universe. People with BPD also have this sense of connection.
The Big Bang Theory is one theory for the beginning of the universe which states that we all came from the same source – hence, we were once connected, and therefore, are always connected. Yet those who have this innate sense of connection we label as overly emotional and difficult.
Causes of Borderline Personality Disorder
The experts are still in the infancy stages of determining the roots of BPD, but it does include variations in biological temperament, social invalidation, suppressed feelings, psychological trauma, stigma and judgements, and a yearning to escape the suffering of the phony existence in which we reside.
Temperament
We are all born with a fundamental personality type. There are a number of different temperament traits including adaptability, approach/withdrawal, distractibility, intensity of reaction, quality of mood, and sensory threshold. Then, of course, each of these can have a wide range of levels of intensity. Some of us are born at the lower end of the spectrum of not being emotional at all, and others on the high end of being extremely emotional.
About fifteen to twenty percent of children are born as highly sensitive with a nervous system that is more aware and quick to react to everything. They are also easily overwhelmed at high levels of stimulation, sudden changes, and emotional distress of others.
Temperament alone will not cause Borderline Personality Disorder.
Social Invalidation
This happens all the time at a young age. Parents (functional or dysfunctional) will invalidate children who are feeling a way in which they do not understand. A young child who is crying over losing a balloon may be having a very emotional experience. The parents may view this as an extreme over-reaction in which they tell the child to “stop over-reacting” or “stop being a baby” or “stop crying, because they are embarrassing them.”
The implicit message to the child is it is not OK to feel that way.
Over a long period of continuous invalidations the child begins to believe that something is wrong with him/her and that they should not be feeling this way and they look to the external environment to see how they should feel. They learn to not trust themselves or their feelings.
This is the beginning of the formation of the mask. The intense feelings are still there, they are just hidden, which makes them even more difficult.
This is also referred to as our ‘shadow’ or repressed emotions.
Suppressed Emotions
Over time, these suppressed emotions continue to build up and start to give our shadow great power over our wellbeing. The more we try to resist this part of ourselves, the stronger it becomes. This can lead to compulsive risk-taking behaviour such as gambling, alcohol, taking drugs, cutting, burning, eating disorders, excessive spending, reckless driving, or hypersexual behaviour to mask the feelings.
Which is why, according to the NIMH , about 85-percent of people with BPD also have another mental illness. This is typically depression, substance abuse, eating disorder, bipolar, self-injury, narcissism, or they are anti-social.
Trauma
Prolonged and severe trauma, especially early in life, tends to result in a chronic inability to modulate emotions.
When this occurs, people develop a large range of behaviour to self-soothe such as the ones listed above.
Only each individual can determine what is traumatic for them, again it has to do with individual temperaments. If you are standing on the top step of the ladder (extremely emotional) and fall down, it is going to hurt a lot more than someone who fell from the first step (not emotional at all).
With regard to BPD, it is likely the person suffered from some type of attachment trauma when they were young. It is when we are infants and toddlers that we first learn how the world responds to us. If our caregivers are cold, inconsistent, or highly anxious, then we do not learn to care for ourselves and we internalise that we deserve to be treated poorly because there is something wrong with us.
Stigma and Judgement
To add to the mix is if behaviour is highly criticised and unfairly judged which only adds to the shame and guilt of the person who is already suffering.
The person attempts to fake it in the world in which they do not wish to reside until eventually it blows up in some sort of self-destructive behaviour. Some books refer to this as an “unrelenting crisis”, and which I refer to as blaming the victim.
Someone with these symptoms has already been through hell. We do not understand their struggle so to say that they are attention-seeking and addicted to drama only makes the problem worse and is the next level of invalidation.
This can then lead to self-harm behaviour and suicide attempts because the person is being reinforced by loved ones.
This reinforcement becomes the only time they are supported ie. when their behaviour is extreme. So the person comes alive with this newfound feeling, hence the addiction to drama.
Inside clinics, staff don’t want to work with BPD people. Before they even walk in the door if they have that diagnosis, the staff is instantly on edge and wary of the person which negatively affects the treatment they receive.
Even the clinicians who are supposed to be providing care cannot “deal with them” because they are too “high maintenance.” (I find it odd that people enter a field because they want to help people, but then don’t want to work with those who need the help …)
When I was first told about BPD it frightened me. I was trained to think that it is all just “attention-seeking and manipulative behaviour.” I believed the way I was trained and that it was all fake and I didn’t want to “deal with it” either.
I was taught that these people were “bad” and that we were “good” for the services we provided by ignoring and avoiding them. Yet now I see that these are the people that have endured some of the greatest pain. And with this pain, often comes the greatest moments of clarity. As Rumi states:
“The wound is where the light enters.”
But instead of trying to help them through their pain to experience that light, we are adding to their suffering.
With this pain and suffering, these people know the truth. They are the ones who understand life and the connections at a deeper level. But instead of validating them for who they are, we place a stronger mask on them to ensure they are never allowed to use the gift we don’t understand.
Sammy’s Story
Over the last few hundred years, the psychiatric industry has consistently been wrong about how to treat patients. They have killed and tortured patients in asylums, sterilised them in the 1900s, performed lobotomies to remove any life from their mind, and now give them chemical lobotomies with medications that render them to less than human. Treatments inside psychiatric units has not changed much today. If the general public knew what went on behind closed doors, there would be an uproar and outcry for the mistreatment of the mentally ill. But the facilities are locked in order to “protect the patients’ rights,” when in fact they are protecting themselves from the abuse they carry out.
Sammy was one of those patients that endured the abuse both outside and inside the psychiatric unit. She sat there trembling in fear as her husband was about to take away her children because she was sick and “refused to change.”
“What do you need to change?” I asked her.
“I don’t know,” she cried uncontrollably, “I don’t know.”
“There is nothing wrong with you,” I told her again.
I would like to tell you that there is a happy storybook ending here, but that is not the case. I didn’t save her life. She committed suicide a few months later.
However, for that one day, she felt she was OK and for the first time in her life she did not think that there was anything wrong with her. I could sense this as she was brighter, happier, and carrying herself differently.
That is all we can do. Embrace every moment with each other and make it the best moment possible – radical acceptance. In that room, for that day, she accepted herself in all her perfect imperfections. This is part of Dr. Linehan’s groundbreaking DBT treatment which features two opposing principles:
(1) acceptance of life as it is, not as it is supposed to be and
(2) the need to change, despite that reality and because of it.
But Sammy did not kill herself. Society and the psychiatric profession killed her.
We will never change the problems of the world until we start embracing diversity and gifts.
We have these intuitive, special people and they are invalidated and abused. We continue to abuse and punish them. We need to stop punishing them. I agree, yes, the behaviour is tough to deal with. But there is truth in their behaviour. There is a truth that sometimes we do not want to deal with.
We have to simply change or reframe the way we see things. See beyond the mask.
To do this, sometimes we have to forget all the knowledge we think we think we have.
Sammy, there was nothing wrong with you, there is something wrong with us.
—————————————————————————————————————————————————-
Borderline Personality Disorder: Understanding the Intersection with PTSD and the Role of Dialectical Behaviour Therapy
Borderline Personality Disorder (BPD) is a complex and often misunderstood mental health condition that affects approximately 1.6% of the adult population. Characterised by pervasive patterns of instability in interpersonal relationships, self-image, and emotions, as well as marked impulsivity, BPD can lead to significant distress and impairment in functioning. This article aims to provide a comprehensive understanding of BPD, its relationship with Post Traumatic Stress Disorder (PTSD), and the therapeutic interventions, particularly Dialectical Behaviour Therapy (DBT), that have been developed to treat it.
Understanding Borderline Personality Disorder
BPD is a mental health disorder that is included in the Cluster B group of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Individuals with BPD often experience intense episodes of anger, depression, and anxiety that can last from a few hours to days. They may also have difficulty regulating their emotions and thoughts, engage in impulsive and often destructive behaviour, and have a chronic fear of abandonment.
The symptoms of BPD can be grouped into four main areas:
1. Emotional Instability:
People with BPD may experience intense and rapidly fluctuating emotions, including feelings of emptiness and difficulty tolerating being alone.
2. Disturbed Patterns of Thinking or Perception:
This can include dissociative states under stress and paranoid thoughts.
3. Impulsive Behaviour:
This may manifest in self-damaging activities such as substance abuse, binge eating, and reckless driving.
4. Intense but Unstable Relationships:
Individuals with BPD may idealise others initially but quickly switch to devaluing them, experiencing intense and unstable relationships.
The Etiology of BPD and the Link with Trauma
The causes of BPD are not fully understood, but research suggests that a combination of genetic, neurological, environmental, and social factors may contribute to its development. Trauma, particularly during early childhood, is one of the key risk factors associated with BPD. Many individuals with BPD report a history of abuse, neglect, or prolonged exposure to adverse conditions during their formative years.
The Relationship between BPD and PTSD
The relationship between BPD and PTSD is complex and multifaceted. PTSD is a mental health condition that can develop after a person has been exposed to a traumatic event. Symptoms of PTSD include re-experiencing the traumatic event, avoidance of stimuli associated with the trauma, negative alterations in cognition and mood, and hyperarousal.
Individuals with BPD are more likely to have experienced trauma, and a significant number also meet the criteria for PTSD. The co-occurrence of BPD and PTSD can exacerbate the symptoms of both disorders, making it more challenging to treat and manage. The overlapping symptoms, such as emotional dysregulation, impulsivity, and interpersonal difficulties, highlight the importance of addressing both conditions in treatment.
Dialectical Behaviour Therapy (DBT)
One of the most effective treatments for BPD is Dialectical Behaviour Therapy (DBT), a form of cognitive-behavioral therapy developed by Dr. Marsha Linehan in the late 1980s. DBT was specifically designed to treat individuals with BPD and has since been adapted for other complex disorders. The core philosophy of DBT is the synthesis of acceptance and change, which are seen as dialectical opposites. This approach helps patients balance the need to accept themselves with the recognition that certain behaviors need to change.
DBT is structured around four main components:
- Mindfulness: The practice of being fully aware and present in the moment.
- Distress Tolerance: Increasing the ability to tolerate pain in difficult situations, rather than trying to escape it.
- Emotion Regulation: Learning to manage and change intense emotions that are causing problems in a person’s life.
- Interpersonal Effectiveness: Techniques that enable individuals to communicate with others in a way that is assertive, maintains self-respect, and strengthens relationships.
DBT is typically delivered through individual therapy, group skills training, phone coaching, and therapist consultation teams. The comprehensive nature of DBT, with its emphasis on skill-building and support, makes it well-suited for individuals with BPD, particularly those who also suffer from PTSD.
Dr. Marsha Linehan’s Contribution to BPD Treatment
Dr. Marsha Linehan’s development of DBT marked a significant milestone in the treatment of BPD. Before DBT, there were few effective treatments for BPD, and the disorder was often considered untreatable. Dr. Linehan’s own experiences with mental health struggles informed her compassionate and pragmatic approach to therapy. Her work has provided hope for countless individuals and has fundamentally changed the way BPD is understood and treated.
The Impact of DBT on BPD and PTSD
Research has consistently shown that DBT is effective in reducing the symptoms of BPD, including self-harm, suicidal behaviour, and hospitalisations. DBT also helps improve emotional regulation, reduce relationship conflicts, and increase overall functioning. For individuals with co-occurring BPD and PTSD, DBT can be adapted to address trauma-related symptoms, providing a more integrated approach to treatment.
DBT has been shown to be particularly effective in reducing the symptoms of PTSD, such as avoidance, intrusive thoughts, and hyper-arousal. The skills taught in DBT, such as mindfulness and distress tolerance, can help individuals with PTSD cope with and process traumatic memories in a safe and controlled manner.
Conclusion
Borderline Personality Disorder is a complex and challenging condition that often co-occurs with PTSD, compounding the difficulties faced by those who suffer from these disorders. The development of Dialectical Behaviour Therapy by Dr. Marsha Linehan has revolutionised the treatment of BPD and has shown promise in treating co-occurring PTSD. Through the core strategies of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, DBT provides individuals with the skills needed to manage their symptoms, improve their relationships, and build a life worth living.
As our understanding of BPD and PTSD continues to evolve, so too will the treatments available. It is crucial for mental health professionals to remain informed about the latest research and developments in the field to provide the best possible care for their clients. For those living with BPD and PTSD, DBT offers a path to recovery and the hope for a more stable and fulfilling life.
If you need help, reach out to someone, and below are also some organisations who can provide a more immediate response.
HELPLINES IN AUSTRALIA
Emergency: 000
Lifeline: 13 11 14
Beyond Blue: 1300 22 46 36
Mensline Australia: 1300 78 99
Sane Australia: 1800 187 263
*This is an edited version of an article originally written by Cortland Pferrer & Irwin Ozborne.
