The Essential Family Guide to Borderline Personality Disorder Read online

  • DBT is demanding. Each day, patients fill out diary forms, and most patients spend many hours each week in therapeutic activities. To benefit from the therapy, patients must be highly motivated.

  • DBT is not available in all locations. Also, it can be costly (we’ll take a closer look at insurance in the next chapter).

  FINDING A DBT THERAPIST

  DBT therapists come in two flavors:

  1. Those who have completed the official training and work in (or run) a formal DBT program

  2. Those who have taken some DBT training or who use some of Linehan’s patient education materials and techniques. DBT adherents caution that clinicians in this second group may not produce the positive results shown in the studies of DBT.

  The Behavioral Tech Web site (www.behavioraltech.com) has a database of clinicians by state.

  STEPPS Group Treatment Program

  STEPPS stands for Systems Training for Emotional Predictability and Problem Solving. It is popular in the Netherlands and has recently spread to other countries. STEPPS is meant to be used in addition to, not a replacement for, traditional therapy.

  Like DBT, STEPPS is a cognitive-behavioral, skills-training approach. Clients learn specific emotion and behavior management skills. Family members learn how to reinforce and support the newly learned skills by developing a common language to communicate clearly about the disorder and the skills used to manage it. In STEPPS, family members are a crucial part of the team and help their loved one receive help for the disorder.11

  The basic skills program consists of twenty, two-hour weekly meetings that focus on skills such as managing problems, setting goals, and self-care. Clients use a notebook to track the intensity of their thoughts, feelings, and behaviors each day. The program emphasizes personal responsibility, and members of the treatment team are available after hours.12

  Schema Therapy

  Schema therapy is based on the principles of cognitive-behavioral therapy, but also includes techniques and concepts from other psychotherapies. Schema therapy offers patients relief from self-destructive acts while focusing on deeper personality changes. Preliminary research suggests it leads to recovery in about half of all patients with BPD and shows significant improvement in two-thirds.13

  A schema is an entrenched, self-defeating life pattern. A schema mode is the moment-to-moment emotional states and coping responses that we all experience. In this book, we’ve been referring to the abandoned or abused child and the angry and impulsive child. These are schema therapy terms. The punitive parent, who punishes the child for expressing needs and feelings, and the detached protector, who cuts oneself off from needs and feelings, are also part of schema therapy.

  An underlying assumption of schema therapy is that patients were emotionally damaged during childhood and can benefit from reparenting. Schema therapy emphasizes the bond between the therapist and patient. Mutual respect and genuineness is essential. Patients attend intense therapy two times a week for three years. But the therapy’s founder, Jeffrey Young, PhD, of the Cognitive Therapy Center of New York, says that while DBT aims for just changes in behavior, the goal of schema therapy is to help patients feel better, too. “With Schema Therapy, patients are, in addition, breaking free of lives of chaos and misery and making deeper personality changes,” says Dr. Young.14 More information is available at www.schematherapy.com.

  Comparing Individual Treatment Programs

  Comparing therapies isn’t easy because people with BPD experience the disorder in so many different ways. Psychiatrist Dr. Robert Friedel says, “The notion that one can develop any ‘cookbook’ therapy for BPD is contrary to our understanding of the [environmental and biological differences] that place people at risk for the disorder. I know of no study performed to date that takes into account these patient differences. Until we do, discussions [about what treatment is best] will continue.”15

  In the end, the health and happiness of your family member—and your own happiness and sanity—are what are most important. How other people respond to treatment X is not as crucial as how your loved one responds to it. No study can predict how one particular person will respond to one particular type of treatment.

  Keep in mind that treatment takes time—several years, depending on the method. Personality disorders are woven tightly within an individual. A more complicated treatment plan, which can take additional time, may be needed for those who have a co-occurring disorder.

  “Clients with BPD take a long time to realize what they are feeling,” says therapist Andrea Corn in an interview with the author. “They almost always want to say, ‘The other person made me feel that way, it was her fault, or it was his fault—he did it.’ It’s very hard for them to take the ownership. It could take years to tease this stuff out.”16

  Couples Therapy

  In couples therapy, you’re not the patient. Neither is your partner. The “patient” is the relationship itself (although you get to pay the bills). The therapist’s role is not to serve as referee but to improve the relationship in ways that are meaningful to both partners.

  The primary objective is improving the couple’s communication skills. Therapy becomes effective as couples apply their new knowledge to break ineffective communication patterns and develop more useful ones. Other goals include reducing criticism, defensiveness, and derision.

  Many people who have partners with BPD suggest couples therapy after they’ve been unsuccessful in convincing their partners to get help on their own. They usually hope that the therapist will back them up in the face of their partner’s unreasonable demands and irrational behavior. The borderline partner, of course, sees this as an opportunity to do the same in reverse.

  In the face of severe BPD, especially when the BP is unwilling to look at his contribution to marital difficulties, the value of couples therapy is limited. If the therapist doesn’t recognize this limitation—which is not unusual—the therapist may validate the BP’s misperceptions and drive a deeper wedge between the couple.

  Some therapists are aware of the BP’s deeper pathology; however, they may discourage the non-BP from bringing up sensitive issues out of fear that the BP may bolt. Non-BPs end up feeling invalidated, and therapy can actually make the situation worse. For this reason, if you do choose couples therapy for yourself and your partner, proceed with the utmost caution.

  Another problem with couples therapy, according to therapist James Holifield, is that many people only enter therapy when there’s a crisis and they’re forced to do something different. A good example is when one partner threatens to end the relationship unless the other person changes. A BP partner may agree to therapy, but then find an excuse to drop out once the immediate threat is over and the non-BP is hooked back into the relationship. At this point, typically, their behavior goes back to what it was before.

  “That’s something very different than real therapy,” Holifield says. “So usually one of my first goals is to establish a motivation for engagement in the process, a sort of a contract between us that the purpose of therapy is not what they thought they came in for, but to consider other ways of relating to each other that is beyond their comfort level, but more beneficial to the relationship. Otherwise it just doesn’t work very well. You never get past a certain level if someone feels coerced into the process.”17

  Couples counseling may not change the fundamental relationship, but it can provide a safer place to try out the new communication and limit-setting skills you’ll learn in the second half of this book. Sometimes a structured setting and the presence of a third person can make a big, positive difference.

  Hospitalization

  Hospitalization may be necessary if your family member is a danger to others; has a co-occurring disorder that requires intensive treatment; feels suicidal; has made suicide attempts; is becoming psychotic; or has severe symptoms that aren’t getting better with outpatient therapy. Lower-functioning conventional BPs often enter the hospital from the emergency depar
tment, where they are rushed after a suicide attempt.

  Insurance companies are not eager to pay for hospitalization, and some clinicians believe that hospitalization should be a last resort for borderline patients because it can encourage dependence.

  Once a patient has been admitted, her psychiatrist controls what happens next: the appropriate number of days in the hospital, the medications the patient will be taking, whether the patient can leave the unit to go to the cafeteria, what activities the patient will participate in, when she can be discharged, and so on.

  When the patient is admitted, she may be asked to fill out a form that assesses her level of safety. Expect your family member’s belongings to be briefly searched for any contraband objects (such as pills or sharp objects). You and other visitors may be searched as well.

  What happens on the treatment unit varies from hospital to hospital. There may be individual counseling sessions, educational sessions about coping skills, and art or music therapy. The best environment is one that is highly structured.

  Get to know the nurses. One on each shift will probably be the primary nurse for your family member. Most important, talk with the admitting psychiatrist, who will visit your family member each day to assess her condition, talk to her about her concerns, and change any medical orders, if necessary.

  In general, patients aren’t discharged until they fill out the level-of-safety form again and indicate that they’re no longer a danger to themselves or others. There should be an aftercare plan that specifies what professionals the patient will see after discharge, what medications they will take, and so forth.

  Partial hospitalization, also called day treatment, is when your family member attends educational/support sessions during the day and then returns home in the evening. Typically, inpatient hospitalization is followed by a week or so of day treatment, which provides support, structure, and education without the costs and more confined environment of a hospital.

  All this may sound intimidating at first. But it is also a respite for you. Your family member’s need for hospitalization is not your fault; you have not failed, and neither has your family member. Remind yourself that your family member is getting cared for by professionals.

  BPD Patients Do Get Better!

  I don’t think that we do people a service by saying that there’s only one treatment, and if you can’t get it then [your family member] won’t get well. People who come to my DBT treatment program say, “This is my last chance, and if I don’t get better here I’m not going to ever get better.”

  We tell them right away that is absolutely not true. We hope our treatment will help you, but we’re not your last chance. Sometimes the timing is wrong, or sometimes the mix with the therapist isn’t the right match, but that doesn’t mean they won’t be helped somewhere else. People need to know that there’s hope and that people do get better.

  Perry Hoffman, president of the National Education Alliance for Borderline Personality Disorder18

  Chapter 6

  Finding Professional Help

  Finding a therapist you can work with can be tough and can take a few trials and errors before you find the right person. Therapists are basically human critters like everybody else and come in all shapes and sizes. Like other people, they sometimes make mistakes, give off attitude, or can at times just seem worthless. Like other people, some are smarter than others, and some are smarter at one set of things than they are about another.

  • Glenn Johnson, PhD •

  By far, Welcome to Oz community members’ number one complaint is that finding effective treatment for their borderline family member is frustrating, expensive, and emotionally trying. The demand for clinicians experienced with borderline personality disorder—and who are willing to add someone with this disorder to their client roster—greatly outstrips the supply.

  In an ideal world, someone would give you a few names of possible therapists so you could look them up, find out that they have much experience treating people with BPD, and hear that they would be delighted to take on another one—yes, of course they take your insurance—and give you an appointment for tomorrow, if not yesterday.

  Yet, for most people, finding an effective clinician is a process of trial and error. It’s not like picking up the phone and ordering a shirt from a catalog in a certain color and size. It’s more like finding a job that meets your specific requirements. The good news, though, is that at least this time you’re the one who’s doing the hiring.

  Why It’s So Hard to Find a Therapist

  If you want to hear a lively and revealing conversation, listen in to a group of mental health professionals talk about patients with BPD. June Peoples, a producer of the Infinite Mind radio show, did just that. It happened at a cocktail party attended by social workers, psychologists, and psychiatrists—“smart people and concerned, caring therapists,” Peoples says.

  Over hummus and veggies, the group started to talk about patients who, it seemed, were a therapist’s worst nightmare. One therapist said that she was careful to make sure she wasn’t treating more than one of them at any given time. “I won’t treat them at all,” said another, and a heated discussion ensued about the importance of a rapid and correct diagnosis of these patients—not for therapeutic reasons, but to make sure you don’t get stuck with them.1

  Therapists develop this negative mind-set for two general reasons. First, BPs are one of the most challenging types of patients to treat—if not the most challenging. Second, treating borderline patients can be emotionally draining for the therapist. Each of these factors feeds into the other.

  Borderline Patients Are Professionally Challenging

  Personality disorders are more tightly woven into the fabric of a person’s being than other types of brain disorders. BPD alters the process by which a person thinks, feels, and acts. You can’t get any more fundamental than that.

  Lower-functioning conventional BPs often come to therapy with a defeatist attitude—understandably, after all the time they’ve spent in the mental health system without feeling better. Psychiatrist Richard Moskovitz says, “Even during the first therapy sessions, patients make remarks like, ‘You can’t help me,’ ‘Why should you be any different from the people in my past who betrayed me,’ and ‘I am too defective to ever be repaired.’”2

  What all this comes down to is that borderline patients are probably the toughest clients a clinician will ever treat. They test the skills of even the most experienced and well-trained therapists. One common dilemma is finding time to explore deeper issues when the BP is always in crisis. Another is that some therapists (especially those inexperienced in treating borderline clients) have difficulty observing their own limits, such as keeping after-hours phone calls to a reasonable number. Once problems begin, it’s tough for the therapist to reverse course without seeming overly critical or abandoning. In situations like these, an untrained therapist can be worse than none at all.

  Borderline Patients Are Emotionally Challenging

  Mental health professionals are human beings. As such, they have many of the same gut reactions that you do when they’re faced with rage and blame—even though they know intellectually it’s not personal. “Borderline patients can be hostile or attack,” says Marsha M. Linehan. “Therapists can feel so scared, angry, frustrated, or helpless that they pull back. And that is harmful to the patient.”3

  Kathleen, a woman with BPD, agrees. “A lot of the therapists I saw were frightened by my rage and my inability to engage or form an alliance with them. I didn’t want really to get better. I just wanted to express rage. I always felt that the people who were treating me were disgusted by me.”4

  On the other side of the spectrum, it can be scary if borderline patients go overboard in the other direction: idealizing their therapists, fantasizing about having a relationship with them, and making them the focus of their lives.

  Mental health professionals go into the field because they want to help people. When a client
doesn’t get better despite the therapist’s best efforts, it’s tempting to blame the client for the lack of progress and to view their attempts at trying to get what they need as manipulation, rather than to question whether the treatment they’re providing is effective.

  Of course, all of this is only a problem if your family member is willing to walk through a clinician’s door.

  How Do I Motivate My Family Member to Seek Help?

  Nearly everyone in the WTO community has made numerous attempts to compel their family member to see a therapist. Common methods include

  • manipulation

  • bribes

  • crying

  • pointing out the person’s flaws

  • logic and reasoning

  • begging and pleading

  • leaving self-help books around the house

  What happens next is as predictable as the change of seasons.

  Stage 1: The BP says it’s the non-BP who needs therapy, not the BP. If the non-BP has unwisely put forth BPD as an explanation for their BP’s behavior, the BP accuses the non-BP of being the one with BPD. For good measure, the BP also accuses the non-BP of being abusive, unreasonable, and controlling.

  Stage 2: In desperation, often during a crisis, the non-BP finally resorts to an ultimatum such as “Go to a therapist or I’m leaving you,” or some other consequence. The non-BP hopes that once the BP is in therapy, the clinician will force their family member to see the light.

  Stage 3: Apprehensive that his loved one might actually carry out his threat, the BP agrees to see a therapist, perhaps with the partner or other family members. Therapy, however, goes nowhere. That’s because even the best BPD clinicians can’t help a patient who doesn’t want to be helped.

  Stage 4: Once the immediate threat dissipates, the BP finds some reason to drop out of therapy. This is especially true if the therapist is a good one, skilled at bringing the focus to the BP’s core issues instead of reinforcing the BP’s feelings of victimhood. However, if the therapist takes everything the BP says at face value without probing further—and this is not uncommon—the therapist may inadvertently reinforce the BP’s twisted thinking, making things worse.