Thursday, October 15, 2009

Borderline Personality Disorder

Dr. William (Bill) Hay on borderline personality disorder – October 14, 2009

When I graduated psychiatry it had been said that if you wanted to be a great psychiatrist you should study schizophrenia as a human condition. However about the time of my graduation schizophrenia was rather well understood, was responding to medications and what wasn't, was often being called Borderline Personality Disorder. Borderline Personality Disorder was further a kind of garbage bag diagnosis that increasingly would act as a refugee camp for a variety of diagnosis including schizoaffective disorder, atypical bipolar disorder, multiple personality disorder and post traumatic stress disorder. So I read all there was to read about it academically at the time, mostly Kernberg, Kohut and Masterson. Also Karen Horney had some to contribute as did the Jungians but they didn't quite use the same terminology or get closer to the internal workings of the beast than Kohut or Kernberg. Transactional analysis had some very useful insights and mostly my work as a family therapist back then brought me fully into the developmental issues that underline borderline. In my private practice, in contrast to the adage that one should never accept any more than one borderline at a time i sometimes had 10 to 20 and probably have a lifetime aggregate of borderline personality disorder patients in the hundreds maybe even a thousand, maybe more. I was once a supervisor in the psychiatric emergency and in charge of the suicide wards in asylums which are two favourite vacation spots for borderline personality disorders.

First for the Monday morning armchair quarterbacks and professional critics but non doers, I fully believe that insanity is a insane way of coping with an insane situation. Therefore, but for the grace of God there go I. However, how I got to be something doesn't dictate how I need to change it, how long it takes to change it and whether it can be changed. Studying with the Palo Alto school psychiatrist Dr. Watsowaylic who wrote the book, Change, I learned that if I think the problem is a very big problem that's lasted a very long time them I'm likely to think a solution will have to be a very big solution that takes a long time. I was delighted to see the Berlin Wall come down in my time proving the truth of the Palo Alto school in a personal way for me. The key note of learning for me however was that the 'reformer is the enemy of anyone who would benefit from the status quo.' This systemically was tied in with the individual internal learning of reinforcement and 'secondary gain'. Often it was not apparent what a benefit a borderline personality disorder would achieve by their bizarre and apparently self destructive tendencies. Well, it was obvious they were getting attention, distracting the group from something else, and often winning the American Idol prize for the best bad guy or gal. They got respect and distance in an odd way.

In DSMIV Personality disorders, following on Dr. Carl Jung's work, are arranged in three groups, cluster A or odd, cluster B or extrovert and cluster c, introvert. The extrovert group has 4 personality disorders, one of which is borderline. The two which are predominantly male are the narcissistic and antisocial while the predominantly female are the histrionic and borderline. I've described these as the criminal and the criminal lawyer and the movie star and the pornography B movie star. Narcissistic and histrionic refer to white collar crime where as antisocial and histrionic refer to blue collar crime. One's uptown while the other is down town.

Borderline personality disorder is externally delayed adolescence, a 13 yo emotionally in a 35 year old body. Their principle 'defence' or coping mechanism is 'splitting' which is divide and conquer. They are out of control and yet careening at high speed they refuse to give up the steering wheel because they have that death grip on the wheel while playing the " I did it my way" song on the stereo. That's the 2 year oppositional disorder 'mine, me' cry that drowns out easy and clearly obvious solutions. They are impulsive, prone to multiple relationships, rarely can keep a long term relationship unless the other person is vying for sainthood or martyrdom or much older, and have serious difficulties holding jobs. They are 'blamers' and the 'locus of control' for their lives is outside themselves. They are often self destructive, and much of their lives are highly sexualized. Control is a key word in their vocabulary and they are at high risk for drug and alcohol problems Indeed they are often the back bone of 12 step recovery programs since the capacity to say 'no' to themselves ironically gives them the freedom that never came with doing what they 'felt' like doing. They're the 60's caricature of freedom and fundamentally lack empathy while they're very sympathetic and lack wisdom while they're often extremely intelligent. Sometimes called 'emotional terrorists' , it's often hard to remember that their behaviour is their disease.

After 10 years of psychotherapy with borderlines I learned that those who had drug and alcohol problems could not be treated successfully with individual psychotherapy but both patient and therapist would commonly collude for years in these relationships which were a kind of abuse, lucrative and beneficial to the therapist while 'enabling' and perpetuating the borderline personality disorders failure in life. I also agreed with colleagues who felt that borderline personality disorders were one group that benefitted most from group or family therapy since individually they tended to only stay in therapy as long as the therapist stroked them and leave the minute it was asked of them to do some work. Confrontation was a key and necessary component of therapy with borderlines but a number of social factors interfered with therapists being able to use 'confrontation' most significantly 'political correctness' which indeed recruited borderlines as activists against others feeding into the borderlines immature and often downright paranoid division of the world, then later dumping them when their usefulness ran out or their personal demands over rode the organizations 'agenda'.

While I recognised that borderline personality disorders were post traumatic stress disorders until proven otherwise, getting to working with the dissociation associated with often early trauma was rarely possible because of the various defensive mechanisms which kept them from addressing core issues. Mostly they were liars. They wanted to be in control of the pain they created themselves fearing the perhaps greater pain that would come with objective truth versus their 'subjective truth' which was also highly 'selective truth'. They were ripe for being co-opted for various social movements most of which were organized by sociopaths. So political correctness "protected" borderlines for their own purposes. Only in a group therapy could the group collectively present the 'confrontation' then. Limit setting was essential to working with borderlines yet limit setting and things like tough love were increasingly 'politically incorrect'. Nothing beat a borderline for identifying the systemic problems.

I stopped working with borderlines and trained in addiction medicine because I found the politically correct crowd weren't co-opting crack addicts and drunks. They're like the cuddly animal lovers who never rally to the plight of lizards or frogs. Many of these addicts and alcoholics were borderline personality disorders and the 12 step programs of AA and NA were ideal for socializing borderline personality disorders.

It was said that personality disorders got under your skin while neurotics got under their skin. Having married a borderline personality disorder I was fascinated to watch them leave their social network and move into mine where they used up the resources and discarded me then moved back to their previous hunting ground. Borderlines are the original emotional hunter gathers and fundamentally gypsy tribal in the sense that emotionally they use up their hinterlands and then move on till eventually their neighbours box them into some corner where geographical solutions aren't possible and they are finally forced to face themselves. Unfortunately for families this is usually when the borderline personality disorder returns not as a 'prodigal son' with humility but rather with arrogance and mayhem and an intent to finally battle the parents to the death. Increasing parental abuse is at the hands of borderlines who have grown strong on the 'therapy' that allowed them to 'blame' their parents and 'society' without asking them to look at their part in the equation. The state and all it's agencies helped the borderline personality disorder all along until one day despite their false promise of unconditional love, welfare, health care etc, they make something conditional and dump the borderline who quite enraged turns back to the family, the last refuge.

Their rage, the rage of a 2 year old or 13 year old in an adult body now fluctuates between homicide and suicide. Thanks to the state and it's 'feel good' resources that are so self serving, and a constant stream of social workers, untrained junior counsellors drunk on Carl Rogers and superficial tunnel visioned bureaucrats , the borderline personality disorder appears before the loved one asking not what it can do for them but demanding more what they will do for her or him.

Omnipotent Child was a brilliant book written by a West Vancouver Psychiatrist and it's one of the best practical resources for reflecting on how to do it right and where it may have gone wrong. That said borderline personality disorders can begin in childhood and adolescent but are also seen as a consequence of head injury, trauma and drug and alcohol abuse.

In Al Anon they have a key phrase, detach with love. In Christianity they say, 'love the sinner, not the sin.' The borderline personality disorder wants you to love them with all their negative behaviours and the state is keen to help a few for their particular ideology of the month but never are willing to take on the life long commitments that their brand of therapy demands. The key to the borderline perosnality disorder is less not more and specific not general. One shoe never fits all with the borderline and yet beaurocracies want everyone to fit their odd size. It's important to maintain the contact and not allow oneself or them to burn bridges. Borderlines so commonly set up the scenario of rejection when they prove that you too, like everyone else, will fail them. The tricky part is to be there but not get caught up in this 'fixed' game of theirs. When you can do that together you go onto a higher level of functioning with new learning and less drama.

My particular interest to day is 'focal therapy' where I take only one thing and work to achieve that limited goal knowing that if I can 'win' that 'struggle for control' I can build on my "d day beach". Slowly but surely I socialize borderlines into groups. I do the initial street fighting and get the key cooperation. In drug and alcohol work the 12 step programs are there to support this. The Government agencies often live off borderlines much like the criminal services depend upon the 'clients' or 'prisoner's' to perpetuate their own form of oft-time diabolical services.

Increasingly I've seen borderlines linked with sociopaths and see them as this sadomasochistic collusion that disrupts the rest of society from getting on with maturity. I'm helped by believing that Jesus, Buddha and their friends are waiting like I am till the last borderline and sociopaths gets to heaven before the rest of us can pass through the doors. I'm sure I want to get to heaven and I'm pretty sure Jesus does but I know the borderlines and sociopaths are having a pretty good time here despite their claims to the contrary. And as a therapist I was taught by an old therapist that if I feel like I'm doing more work than the patient I probably am and that is just one of the indications of borderline traits in the patient.. Mostly you observe your own behaviour. Understanding things like projection and projective identification are essential to working with borderline personality disorders.

Robert Hare's "Snakes in Suits' talked about sociopaths in high places and mostly referred to men since by gender sociopaths have been male and use force or threat to extort, female sociopaths are usually called borderlines and use sexual manipulation (now threat of sexual harassment as much as sleeping with men in power or getting their girlfriends by sleeping with their husbands was done in the past). I'm fascinated by “high function borderlines” or what could best be called “borderlines in suits' because corporations, governments, beurocracies and modern politics which supported sociopaths seem to equally support these female sociopaths or high functioning borderlines. Maybe Hare will one day favour us with a book on borderlines in power, how to recognize them and how to avoid the damage they so often leave in their trail of personal angst.

That said I'm continuously successful in treating addicts and alcoholics and personality disorders these days but am only mildly amused that the system doesn't care about 'success' since it's more interested in self perpetuations of lucrative and outdated psychologies and philosophies. I was once asked to assess a community mental health department and pointed to the fact that 80% of personnel and resources were devoted to this one borderline with political connections. I recommended they cut off services and see what happened as the borderlines addiction was more resources and more attention, (external solutions to internal problems ) and as long as they threw manpower and programs at this person they'd not get better. God forbid a community health program would want to work with the community as opposed to this individual. The borderline gave them 'raison d'etre' and the illusion of doing mental health work. By that time the borderline had had dozens of attempted suicides. Borderlines die of suicide but mostly accidental suicidal (if you attempt enough you'll probably die by happenstance more than actual intent )because they have an increasing demand for more and more drama.

When I was in charge of a suicide ward I reduced the suicides from 5 a year on the ward to nil and the attempts from 30 a year to 10. Those results lasted several years because I trained the nurses in 'limit setting' and such ideas of negative reinforcement (ignore negative behaviours) and reward positive behaviours and how to identify the drug addict or alcoholic enabler in the treatment team thereby avoiding 'splitting'.

Like my favourite teachers, I am now very knowledgeable and effective but politically incorrect as a result and enjoying being yet another voice in the dessert. Abstinence and the via negativa are indeed the roads to success for all in this borderline world.

And yes, I just was rejected by another borderline in these last months. One I'd helped get sober for over 6 month got them into treatment and watched them become increasingly furious with me and the rest of the treatment team because we collectively confronted their acting out with ‘lower companions’ sexually as a means to create drama and chaos as a precursor for relapse. They claimed to have met a counselor who could really help them. We all knew this meant that the counselor was someone they could manipulate and ‘split’. The sad part was that the family had paid a fortune for the treatment to date and again it was being sabotaged when the treatment centre, drug and alcohol counselor, family and myself sought accountability. In the end I felt sad and tired and rather beat up after working more than the patient and again having that emotional experience all too familiar to those of us who work with borderlines that somehow as a therapist I could have done better.

I'm left feeling the same old borderline blues, I gave you my all and you shat on me, which obviously meant they got under my skin. It still happens and I recognise that having become 'attached' rather than remaining 'detached' I'd become less truly 'loving' and was probably going through the motions of caring rather than really caring, because it's hard to be caring when the world is so uncaring in this economic crisis, but the borderlines are the ones most sensitive to the world fear and quickest to experience a sense of rejection by you when you’re not a 100% on the game. Nothing like a borderline to keep you on your toes therapeutically. Emotionally being around them is often likened to walking on eggshells emotionally.

And yes I forgot to say that borderlines don't respond to high dose medications but respond to low dose medications. Often these days they're diagnosed 'bipolar II" so that the psychopharmacologist psychiatrist with only a hammer can make them a nail. The truth is that more medication disinhibits and they don't need this. Since working with brain injury as much as I do I often wonder if they didn't have a mild brain injury with healing and some mild miswiring. Certainly my last borderline had had a head injury and that's when their problems began but I think most would not have noticed it. Chemical addictions cause a reversible brain injury too. The brain injured are very sensitive to low dose meds and get worse with high dose which is why I wondered about this.

I should look up the neuroimaging data again on borderlines and see if they've learned anything more than the last time I checked this out. The principal difficulty with the claims in this so called ‘hard science’ areas is that the ‘labelling’ is such a disparate group and it will take a long time before they tease out clinically useful data that can be extrapolated to the group as a whole. The small case studies look good on paper but when you look more closely at the research it’s been commonly fudged or manipulated in someway to make a point much stronger than it really is. So far very little of this basic research has contributed to an major change or improvement in what is available in terms of clinical treatments. Meanwhile our government will fund millions of security guards in brown shirts but won't buy a local MRI or fund the private companies that responded to the increasing 'death by waitlist' of the government's latest 'proto euthanasia' program.

Group therapy, and individual therapy are what I combine with low dose medication (atypical antipsychotic, tranquilizers and antidepressants mostly ie prozac 10 mg or zoloft 25 or zyprexia 5 mg or rispiridone 1 mg). Not uncommonly I work with a mind body psychologist or do the beginning work to get a patient settled down to where they can actually begin to do the advanced psychoanalytic type work that can get at their core issues without them trashing the therapist or themselves the minute these anxiety provoking uncovering therapies are engaged.

All that said, when I look back over the decades I’ve seen so many successful resolutions for borderlines with most going on to highly successful careers and many establishing long term relationships. They’re extremely creative people commonly and when their negative behaviours can be harnessed to creative outlets their contributions to society are truly amazing. That said, I literally had no success when I didn’t address drug and alcohol issues first.

Beautiful people have beautiful problems and looking back working with borderlines has been some of the most challenging insightful learning experiences of my career and the successes have been so rewarding. Dozens of the borderlines I worked with turned out to be geniuses and they went from being expelled from high schools and universities to post graduate students and later professionals. One of my early borderline patients became a famous singer who came to me sexually abused by everyone and the dog with multiple suicide attempts and slash marks all over her bodies. At the time I was using a Kleinian approach and had another therapist I was discussing sessions with on an ongoing basis to avoid being ‘enmeshed’.

Today hearing her songs of hope and survival on the radio still touches me when I remember the struggle she had learning to trust again and rejoining the human race that had earlier so failed her. I can’t help but think her songs today must have helped thousands who had been lost in the dark places she eventually found her way out of.

When I’m faced with the cut backs and gross insensitivity and arrogance of the beaurocrats and live with the stigma and abuse that the mentally ill and those who treat them experience daily I like to remember one of her songs. Then for a while it all seems worth it.

1 comment:

Anonymous said...

Thank you for letting me stand in your world, for a moment, and observe from the other side of the curtain this stage upon which we all play.
Some of us didn't wittingly choose the turbulent, chaotic roles we find ourselves in. Nice to know someone is rooting for our team and successfully recruiting us to play for the larger world.
Well done.