Skills, Skills, Skills: The Only Way To Go
Writer’s Reflection
Some years ago a fascinating discovery about the brain was widely reported in the news. Research conducted in England was coming out that appeared to stand previous scientific understandings of the human mind on their head. Stroke victims paralyzed on the right side of their bodies, were regaining use of their previously useless limbs. When their brains were examined with a special kind of xray, doctors found something amazing: the damaged parts of the brain were repairing themselves! And how did this miracle come about? To bring this about, the researchers immobilized the functioning arms of the patients for twelve hours at a time. For these twelve hours patients were expected to feed themselves as well as do all the activities that they would normally do but only with their injured arm. Guess what?! Within hours these previously ‘dead’ arms were back at work! What was previously a permanent disability was no more. Such is the power of determination that it can inspire growth when none was thought possible. And when determination and the skills that you’ll learn about are put together borderline personality won’t stand a chance.
Throughout this book, borderline personality disorder has been described as a group of destructive strategies to deal with very real and highly individual agonies and confusions. Thus in order to leave the most destructive aspects of borderline behind, one must find more effective strategies for dealing with the pain and confusion in living. More than needing a personality transplant, people with borderline personality disorder need ways to cope that respect their sensitivities and celebrate their unique abilities.
And this is what skills training can offer.
This of course was not always the case. For many years well meaning therapists tried to accomplish the worthy goal of healing the person with borderline through reflective therapy. The thinking behind this effort was that a healing supportive relationship could bring about the end of the pain.
Unfortunately, this approach didn’t work. Many patients got worse. They were hospitalized for long periods. Families, mental health professionals, and the patients themselves despaired of ever stopping the cycles of rage, self mutilation, suicidal behaviors and the chaos of borderline personality disorder. In effect, the therapy was undermining patients by making no effort whatsoever at helping them find a way in the world.
In the mid eighties, psychologist Marsha Linehan, bothered by the failure of talk therapy began to reconsider the whole treatment approach. She threw out “the book” so to speak and endeavored to find a new approach that would both help understand the disorder and provide some direction for treatment. Linehan observed that people with borderline personality disorder, more than needing a therapist who passively listened to the horrible complications of their lives, really needed practical assistance in calming their inner turmoil. Due to their exquisite sensitivities they needed real help in making sense of a world that they see as mad. In essence, Dr. Linehan discovered that far from being defective or ‘crazy’, people with borderline personality disorder were deep thinkers, confused by the pain and conflict that exists in the world. While most of us are able to make an uneasy peace such inconsistencies, these people by nature are bothered to no end by them.
Linehan put together a treatment program that taught emotional management skills and offered a sound philosophy for living at peace in their world. This program came to be called dialectical behavioral therapy or DBT. Dialectics refers to a practical philosophical discipline that concretely teaches how to live with the many paradoxes of life. One such paradox includes the desire for change with acceptance of the present moment. Another paradox centers around kindness and personal rights. Without understanding how to thrive in a world of paradox, patients remain stuck in a cloud of confusion that results in impulsive and destructive thinking and action.
Dialectics teaches us that two seemingly two opposed or paradoxical ideas can coexist.
Teaching philosophy however was of course not enough to tame the chaos of borderline personality disorder. Even with a grounded understanding of how the world works, people with borderline still had great difficulties in relationships, solving their problems, and managing their feelings. In response, Dr. Linehan developed a practical curriculum that teaches the skills necessary for positive relationships, solving the real problems of life, and finding joy in life. And because many of the most destructive dimensions of borderline personality disorder become habits with a life of their own such a self mutilation and suicidal behaviors, she developed techniques for creating new alternatives to take the place of the old ones.
The success of Linehan’s program is hard to dispute. People with borderline who have undergone dialectical behavioral therapy engage in far less self mutilation and require less hospitalization than those who receive standard talk therapy. They are more likely to be working and to report satisfaction in their lives.
The skills of DBT focus on the four areas that are the most problematic for people with borderline personality disorder. Without transforming these deficits into strengths, argued Linehan, all of the best intentioned therapies will fail. These skills are designed to empower and guide as people go about the very real business of making a life for themselves.
The skill groups are:
a. Mindfulness Skills
b. Interpersonal Effectiveness Skills
c. Distress Tolerance Skills
d. Emotional Regulation Skills
As detailed in the following chapters, the mastery of these skills will restore control in each of the characteristics of borderline personality disorder.
Monday, December 24, 2007
Focus on: The Difference Between Bipolar Disorder and Borderline Personality Disorder
One of the thorniest issues when it comes to borderline personality disorder is its relationship to depression and bipolar disorder. After all eighty percent of individuals diagnosed with borderline also exhibits symptoms of bipolar disorder. Many people have heard of bipolar disorder, one of the most documented and researched psychiatric disorders. Someone suffering from bipolar disorder is prone to experience frequent, dramatic mood swings. In many ways, it would seem that bipolar disorder and borderline personality disorder are on and the same.
Nothing however could be further from the truth.
Consider these differences:
1. The violent mood swings, rage, hyperactivity, and impulsivity experienced by someone with borderline personality disorder is triggered by inner turmoil. The extreme behaviors are may in fact be strategies to deal with the pain that is felt inside. The moodiness, impulsivity, and hyperactivity of someone suffering from bipolar disorder have a mind of its own. While episodes may be sparked by outside stress, the behaviors of mania and depression have little to do with the inner world.
2. The symptoms of bipolar disorder are usually well controlled with medication. This is usually with some combination of mood stabilizer medication and anti-depressant. The manifestations of borderline personality disorder however are poorly controlled by medication. Some behavioral manifestations of borderline such as depression, impulsivity, self mutilation, and suicidality may be controlled with medication. The inner psychology of the person however remains the same.
3. Whereas dread of abandonment is a hallmark of borderline personality disorder, there is no such parallel among those diagnosed with bipolar disorder.
4. Self mutilatory behaviors are common among those with borderline personality disorder. Similar behaviors are not present among those with bipolar disorder.
Nothing however could be further from the truth.
Consider these differences:
1. The violent mood swings, rage, hyperactivity, and impulsivity experienced by someone with borderline personality disorder is triggered by inner turmoil. The extreme behaviors are may in fact be strategies to deal with the pain that is felt inside. The moodiness, impulsivity, and hyperactivity of someone suffering from bipolar disorder have a mind of its own. While episodes may be sparked by outside stress, the behaviors of mania and depression have little to do with the inner world.
2. The symptoms of bipolar disorder are usually well controlled with medication. This is usually with some combination of mood stabilizer medication and anti-depressant. The manifestations of borderline personality disorder however are poorly controlled by medication. Some behavioral manifestations of borderline such as depression, impulsivity, self mutilation, and suicidality may be controlled with medication. The inner psychology of the person however remains the same.
3. Whereas dread of abandonment is a hallmark of borderline personality disorder, there is no such parallel among those diagnosed with bipolar disorder.
4. Self mutilatory behaviors are common among those with borderline personality disorder. Similar behaviors are not present among those with bipolar disorder.
Saturday, December 8, 2007
Of Lamborghinis and Fords
Of Lamborghinis and Fords
Twenty four year old Brachi and her parents sat with me. Referred by a colleague of mine, they sought guidance on options. Told by a reputable professional that Brachi had borderline personality disorder, they were now focused on the next steps. Which method of treatment would be most appropriate? Should Brachi enter an inpatient program? What about residential treatment?
These were all valid questions. Yet, no matter where Brachi ended up treatment wise, it seemed vital that she and her parents understand some of the vital truths about people borderline personality disorder. A pessimistic outlook of this complex disorder would only mean more and more of the same misery that their beautiful daughter had already been through. So some psychoeducation was in order.
And this education began with Lamborghinis and Fords.
Huh?
Well think of it this way: the Ford Motor Corporation has been making automobiles for many years. Their cars are reliable and not terribly expensive. Ford cars however are not especially flashy or powerful. The rich and famous usually would not be found driving around in a Ford.
In contrast to Ford, the Lamborghini is the opposite. Incredibly expensive, a Lamborghini is extremely powerful. Due to the complexity of its engine it must be serviced quite often. Only special gas may be used. The Lamboghini’s super-powered engined also means that vehicle must be operated with great caution. Otherwise, one may damage the car or, rachama litzlan, injure oneself.
Those who can afford the price and hassle of such a car are in for a unique experience. The price of the Lamborghini however is so high that only few of us can buy one; thus we are limited to driving around in our uninspired, much more affordable Fords.
And this is the same for personalities.
Most of us possess predictable “Ford” type personalities. These personalities serve us adequately when it comes to the day to day work of relationships and accomplishment. While we may rarely consider the deeper meaning of a beautiful blue sky or all the heartbreak in the world, we are content. We don’t think beyond the superficialities of our lives.
And then there are those with a Lamborghini kind of personality. These are people who think beyond the convenient and the superficial. They feel and see in vivid colors and varying intensities. Professor Len Sperry of the University of Wisconsin uses the term Borderline Personality Style to describe this powerful “Lamborghini” person. He lists the following characteristics as the dimensions of such an individual.
He or she tends to experience passionate, focused attachments in all relationships. Nothing in the relationship is taken lightly. He or she usually becomes deeply involved in a romantic relationship with one person.
He or she is emotionally active and reactive. They show their true feelings and put their hearts into everything
He or she tends to be uninhibited, spontaneous, fun loving, and usually undaunted by risk.
He or she is usually creative, lively, busy, and engaging.
He or she usually shows initiative and can stir others to activity with their passion.
He or she is imaginative and curious.
He or she is willing to experience and experiment with other roles, cultures, and value systems.
Such wonderful qualities offer great spiritual advantages. Yet there is great risk that comes with them as well. The sensitivity and deep need for connection can be the cause of great pain. Life after all is difficult. Loved ones leave us. Plans, big and small are frustrated continuously. Whereas the “Ford” types experience the pain with a kind of “nonchalance”, the “Lamborghini” type experiences pain in a most amplified way. And since no one likes to be in pain, such a person, lacking the tools and knowledge specific for their personality, may turn, rachmana litzlan, to quick fixes such as suicidality, drugs and sex that all have long term consequences.
Unfortunately, there is a “no return” policy on the type of personality style that we get. While medical science has figured out how to perform a heart or face transplant and how to generate a new liver from a stem cell, there still is no such thing as a “personality transplant”.
But perhaps that’s just as well. It was after all the pain experienced by Dovid HaMelech and all the other “Lamborghinis” of our people that showed the rest of us what it means to be a Jew.
Twenty four year old Brachi and her parents sat with me. Referred by a colleague of mine, they sought guidance on options. Told by a reputable professional that Brachi had borderline personality disorder, they were now focused on the next steps. Which method of treatment would be most appropriate? Should Brachi enter an inpatient program? What about residential treatment?
These were all valid questions. Yet, no matter where Brachi ended up treatment wise, it seemed vital that she and her parents understand some of the vital truths about people borderline personality disorder. A pessimistic outlook of this complex disorder would only mean more and more of the same misery that their beautiful daughter had already been through. So some psychoeducation was in order.
And this education began with Lamborghinis and Fords.
Huh?
Well think of it this way: the Ford Motor Corporation has been making automobiles for many years. Their cars are reliable and not terribly expensive. Ford cars however are not especially flashy or powerful. The rich and famous usually would not be found driving around in a Ford.
In contrast to Ford, the Lamborghini is the opposite. Incredibly expensive, a Lamborghini is extremely powerful. Due to the complexity of its engine it must be serviced quite often. Only special gas may be used. The Lamboghini’s super-powered engined also means that vehicle must be operated with great caution. Otherwise, one may damage the car or, rachama litzlan, injure oneself.
Those who can afford the price and hassle of such a car are in for a unique experience. The price of the Lamborghini however is so high that only few of us can buy one; thus we are limited to driving around in our uninspired, much more affordable Fords.
And this is the same for personalities.
Most of us possess predictable “Ford” type personalities. These personalities serve us adequately when it comes to the day to day work of relationships and accomplishment. While we may rarely consider the deeper meaning of a beautiful blue sky or all the heartbreak in the world, we are content. We don’t think beyond the superficialities of our lives.
And then there are those with a Lamborghini kind of personality. These are people who think beyond the convenient and the superficial. They feel and see in vivid colors and varying intensities. Professor Len Sperry of the University of Wisconsin uses the term Borderline Personality Style to describe this powerful “Lamborghini” person. He lists the following characteristics as the dimensions of such an individual.
He or she tends to experience passionate, focused attachments in all relationships. Nothing in the relationship is taken lightly. He or she usually becomes deeply involved in a romantic relationship with one person.
He or she is emotionally active and reactive. They show their true feelings and put their hearts into everything
He or she tends to be uninhibited, spontaneous, fun loving, and usually undaunted by risk.
He or she is usually creative, lively, busy, and engaging.
He or she usually shows initiative and can stir others to activity with their passion.
He or she is imaginative and curious.
He or she is willing to experience and experiment with other roles, cultures, and value systems.
Such wonderful qualities offer great spiritual advantages. Yet there is great risk that comes with them as well. The sensitivity and deep need for connection can be the cause of great pain. Life after all is difficult. Loved ones leave us. Plans, big and small are frustrated continuously. Whereas the “Ford” types experience the pain with a kind of “nonchalance”, the “Lamborghini” type experiences pain in a most amplified way. And since no one likes to be in pain, such a person, lacking the tools and knowledge specific for their personality, may turn, rachmana litzlan, to quick fixes such as suicidality, drugs and sex that all have long term consequences.
Unfortunately, there is a “no return” policy on the type of personality style that we get. While medical science has figured out how to perform a heart or face transplant and how to generate a new liver from a stem cell, there still is no such thing as a “personality transplant”.
But perhaps that’s just as well. It was after all the pain experienced by Dovid HaMelech and all the other “Lamborghinis” of our people that showed the rest of us what it means to be a Jew.
What Is Borderline Personality Disorder?
What Is Borderline Personality Disorder?
Consider the following:
Tammy, 19, is calmly sitting in a chair in the exam room of an emergency room. A nurse is putting the final touches on a bandage that covers a three inch long cut on her left forearm. A doctor has already put in eight stitches. The nurse, caring about this young beautiful woman, tries to strike up a dialogue.
“So Tammy. Did you really cut your arm on the door of your apartment?”
“Why? Is that what my dorm counselor said when she brought me in?”
“That’s exactly what she said. Why? Was it something else?”
“Yeah. I was really upset about some problems at school so I cut myself. It feels so good when I do that.”
Seffy closes the door as she leaves Dr. Cohen’s office. Dr Cohen, a psychiatrist, pulls over Seffy’s chart as she begins to write her session notes. She reads over what has been written before. Seffy has been depressed since her fourteenth birthday. She has been expelled from six different schools because of her extreme behaviors. The five psychiatrists and eight psychologists that Seffy has seen have not made any real progress. Seffy has taken over twenty different psychiatric medications in all kinds of combinations. Still, seven years later, at the age of 21, Seffy remains stuck in her misery with no friends and a baffled family. Dr Cohen feels sad and despairing. What can she do to help Seffy?
Thirty year old Meir rocks gently with the subway as it makes its way through the tunnel. Meir however doesn’t really notice it. His mind is rehashing a conversation that he had with his father earlier that afternoon. Actually, it was not much of a conversation since his father did most of the talking. ‘Why aren’t you calling that shadchan back?! What was wrong with that girl?! Haven’t your mother and I tried enough for you? All of your friends are married with kids already! What is wrong with you?!’ As Meir reflected on his father’s words he became confused. What was wrong with him? Even he didn’t understand the thoughts that crisscrossed his mind. Sometimes he got so frustrated with himself, he felt that he and his family would be better off if he were dead.
These three vignettes describe three different experiences of borderline personality disorder. Borderline Personality Disorder is one of the eleven personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV). The DSM IV contains a listing of all the psychiatric disorders that have been identified by the American Psychiatric Association. So authoritative is the DSM IV, that only those disorders listed in it are considered official medical conditions by the United States government.
The DSM describes borderline personality disorder as
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.
In other words, a person with borderline personality disorder has:
Difficulties maintaining positive relationships with others.
Has great difficulty developing an effective sense of identity.
Frequently experiences extreme moods.
Often acts without adequate regard to the consequences.
The DSM offers specific ways that these difficulties are manifest. They are (a separate chapter will be devoted to each of these manifestations):
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 and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two 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
In order to be diagnosed with borderline personality disorder, an individual must display five out of these nine characteristics. Should he or she manifest less than five, they can be described as having borderline traits. Individuals displaying more characteristics have worse personalities than those with less.
Beyond the level of severity, people with borderline personality disorder are often described as exhibiting one of three subtypes of the disorder. These subtypes are:
Dependent type borderline personality disorder
Histrionic type borderline personality disorder
Narcissistic type personality disorder
Someone with dependent type borderline personality disorder lives in a state of terrible fear of aloneness. Every action and thought is deeply involved in preventing their abandonment by others. They will often undermine their own self interests and future in order to prevent such abandonment. The manifestions of borderline personality disorder are often organized around the feared loss of a relationship.
Tamara, an eighteen year old seminary student, was referred to me by one of her teachers. Over the course of the ninety minute initial consultation a picture of a highly anxious and fragile young person emerges. This is Tamara’s first time away from home and she is adjusting with great difficulty. Her major worried preoccupation is that her best friend, Michal, will abandon her. Because of this worry, Tamara has literally become Michal’s servant and financier. While Tamara recognizes that the relationship is lopsided, she cannot take the risk of abandonment. The anxiety has become so bad that she finds herself feeling more and more desperate. The only thing that seems to relieve the terror is by distracting herself with cutting. Then calmness comes over her.
Someone with histrionic type borderline personality disorder desperately seeks the attention of others. The preoccupation with others’ attention often leads them to act in inappropriate ways so as to become the center of attention. The manifestations of borderline personality disorder are in response to the failures of others to give them the attention so seek.
Menachem was sent for an evaluation by the mashgiach of his yeshiva after a violently angry eruption over a recent in-house Shabbos. From what the mashgiach had shared with me, Menachem had become enraged when his friends had grown tired of his attempts at monopolizing a late night schmooze. Menachem later explained to me that he craved being the center of attention because it was only then that he felt alive. Otherwise, he felt dead. It was at such times that he thought about death.
Someone with narcissistic type borderline personality disorder believe him or herself to be so uniquely special as to deserve to be associated only with others viewed as also uniquely special. The manifestations of borderline personality disorder are in response to the frustration of their attempts to viewed in the manner that they wish.
It was only with great difficulty that Moshe was persuaded to seek treatment. Until the rosh yeshiva intervened, Moshe had rejected the recommendation of both his rebbe and his mashgiach. As he later explained to me, he did not accept the feedback anyone but the rosh yeshiva. His arrogance manner throughout our session belied the emptiness underneath. Moshe was miserably depressed, irritable, and easily enraged. He spoke of feeling empty inside.
Regardless of the exact form that it takes, borderline personality disorder levies a heavy price. The difficult moods and frightening behaviors get in the way of joyful relationships and personal accomplishment. Many people with borderline personality disorder have lives littered with failure and hurt. Feelings of utter despair are not uncommon, rachmana litzlan.
Yet there is good news. Treatment really can help. But first a complete understanding of borderline is needed. The next chapters will explain the concept of personality disorder and the inner psychological world of someone with borderline disorder.
Consider the following:
Tammy, 19, is calmly sitting in a chair in the exam room of an emergency room. A nurse is putting the final touches on a bandage that covers a three inch long cut on her left forearm. A doctor has already put in eight stitches. The nurse, caring about this young beautiful woman, tries to strike up a dialogue.
“So Tammy. Did you really cut your arm on the door of your apartment?”
“Why? Is that what my dorm counselor said when she brought me in?”
“That’s exactly what she said. Why? Was it something else?”
“Yeah. I was really upset about some problems at school so I cut myself. It feels so good when I do that.”
Seffy closes the door as she leaves Dr. Cohen’s office. Dr Cohen, a psychiatrist, pulls over Seffy’s chart as she begins to write her session notes. She reads over what has been written before. Seffy has been depressed since her fourteenth birthday. She has been expelled from six different schools because of her extreme behaviors. The five psychiatrists and eight psychologists that Seffy has seen have not made any real progress. Seffy has taken over twenty different psychiatric medications in all kinds of combinations. Still, seven years later, at the age of 21, Seffy remains stuck in her misery with no friends and a baffled family. Dr Cohen feels sad and despairing. What can she do to help Seffy?
Thirty year old Meir rocks gently with the subway as it makes its way through the tunnel. Meir however doesn’t really notice it. His mind is rehashing a conversation that he had with his father earlier that afternoon. Actually, it was not much of a conversation since his father did most of the talking. ‘Why aren’t you calling that shadchan back?! What was wrong with that girl?! Haven’t your mother and I tried enough for you? All of your friends are married with kids already! What is wrong with you?!’ As Meir reflected on his father’s words he became confused. What was wrong with him? Even he didn’t understand the thoughts that crisscrossed his mind. Sometimes he got so frustrated with himself, he felt that he and his family would be better off if he were dead.
These three vignettes describe three different experiences of borderline personality disorder. Borderline Personality Disorder is one of the eleven personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV). The DSM IV contains a listing of all the psychiatric disorders that have been identified by the American Psychiatric Association. So authoritative is the DSM IV, that only those disorders listed in it are considered official medical conditions by the United States government.
The DSM describes borderline personality disorder as
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.
In other words, a person with borderline personality disorder has:
Difficulties maintaining positive relationships with others.
Has great difficulty developing an effective sense of identity.
Frequently experiences extreme moods.
Often acts without adequate regard to the consequences.
The DSM offers specific ways that these difficulties are manifest. They are (a separate chapter will be devoted to each of these manifestations):
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 and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two 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
In order to be diagnosed with borderline personality disorder, an individual must display five out of these nine characteristics. Should he or she manifest less than five, they can be described as having borderline traits. Individuals displaying more characteristics have worse personalities than those with less.
Beyond the level of severity, people with borderline personality disorder are often described as exhibiting one of three subtypes of the disorder. These subtypes are:
Dependent type borderline personality disorder
Histrionic type borderline personality disorder
Narcissistic type personality disorder
Someone with dependent type borderline personality disorder lives in a state of terrible fear of aloneness. Every action and thought is deeply involved in preventing their abandonment by others. They will often undermine their own self interests and future in order to prevent such abandonment. The manifestions of borderline personality disorder are often organized around the feared loss of a relationship.
Tamara, an eighteen year old seminary student, was referred to me by one of her teachers. Over the course of the ninety minute initial consultation a picture of a highly anxious and fragile young person emerges. This is Tamara’s first time away from home and she is adjusting with great difficulty. Her major worried preoccupation is that her best friend, Michal, will abandon her. Because of this worry, Tamara has literally become Michal’s servant and financier. While Tamara recognizes that the relationship is lopsided, she cannot take the risk of abandonment. The anxiety has become so bad that she finds herself feeling more and more desperate. The only thing that seems to relieve the terror is by distracting herself with cutting. Then calmness comes over her.
Someone with histrionic type borderline personality disorder desperately seeks the attention of others. The preoccupation with others’ attention often leads them to act in inappropriate ways so as to become the center of attention. The manifestations of borderline personality disorder are in response to the failures of others to give them the attention so seek.
Menachem was sent for an evaluation by the mashgiach of his yeshiva after a violently angry eruption over a recent in-house Shabbos. From what the mashgiach had shared with me, Menachem had become enraged when his friends had grown tired of his attempts at monopolizing a late night schmooze. Menachem later explained to me that he craved being the center of attention because it was only then that he felt alive. Otherwise, he felt dead. It was at such times that he thought about death.
Someone with narcissistic type borderline personality disorder believe him or herself to be so uniquely special as to deserve to be associated only with others viewed as also uniquely special. The manifestations of borderline personality disorder are in response to the frustration of their attempts to viewed in the manner that they wish.
It was only with great difficulty that Moshe was persuaded to seek treatment. Until the rosh yeshiva intervened, Moshe had rejected the recommendation of both his rebbe and his mashgiach. As he later explained to me, he did not accept the feedback anyone but the rosh yeshiva. His arrogance manner throughout our session belied the emptiness underneath. Moshe was miserably depressed, irritable, and easily enraged. He spoke of feeling empty inside.
Regardless of the exact form that it takes, borderline personality disorder levies a heavy price. The difficult moods and frightening behaviors get in the way of joyful relationships and personal accomplishment. Many people with borderline personality disorder have lives littered with failure and hurt. Feelings of utter despair are not uncommon, rachmana litzlan.
Yet there is good news. Treatment really can help. But first a complete understanding of borderline is needed. The next chapters will explain the concept of personality disorder and the inner psychological world of someone with borderline disorder.
Saturday, November 10, 2007
Chapter III Recipe For Agony
The Why: The Making Of Borderline Personality Disorder
Writer’s Reflection: The Rabbis tell us that when a tzaddik is shown what their yetzer hara looks like, it will appear as a gigantic mountain of Everest proportions. The tzaddik will exclaim, “how did I ever win in my war with such a behemoth?!”. The rasha is also shown his yetzer hara. To him it will appear as a small, inconsequential mound of dirt. The rasha will exclaim, “Oy!!! Why could I not conquer such a puny adversary”. The baalay Mussar explain that whereas the rasha is overwhelmed by the enormity of the task, the tzaddik goes forward one step at a time. The rasha’s point of view leaves him so immobilized that even a mound of dirt is too much. The tzaddik’s approach allows him to climb even the mighty Everest.
When I educate patients, families, and lay people about the ‘ingredients’ of borderline personality disorder, I always share the deep words of the sainted Rabbis with them. My wish is to reassure everyone that despite the seemingly overwhelming deficits and factors that cause so much suffering there is hope for healing. This hope is grounded in the reality that if, like the tzaddik, we focus on putting one foot in front of the other we can scale mountains.
Is it brain chemicals?
Is it bad parenting?
Is it society’s fault?
The most often question asked about borderline personality disorder is what causes it. And it’s good a question. After all, if we knew the cause, we could take steps to prevent it. By understanding the causes, we can devise strategies to lessen the symptoms.
The fact of the matter however is that borderline personality disorder is not caused by one thing any more than cancer or asthma is caused by only one thing. Borderline personality disorder is the end point of a group of converging vulnerabilities. These vulnerabilities include family tensions, psychological predispositions, neurological sensitivities, social gaps, genetics, and life experiences. Like some sort of horrible recipe, only when brought together does one end up with the pain and agony of borderline.
Throughout the psychological literature, scientists refer to deficits or vulnerabilities that lay the groundwork for the formation of borderline. Taken separately, each of these deficits could be quite disabling. When two or three of more factors come together though a devastating synergy is created. The result is often borderline personality disorder. In order to better understand this horrible recipe, let’s consider each of these vulnerabilities separately:
Neurological Deficits
Since borderline personality disorder is considered a psychiatric disorder, few of us consider the fact that there are also physical dimensions to it as well. Indeed, without adequately considering these physical qualities, all of the well intentioned psychological and psychiatric interventions will have little or not effect. Scientists however have long noticed that people with borderline personality disorder have characteristic somatic attributes. Brain and nervous system irregularities are the most documented of these somatic attributes.
Scientific literature speaks of two types of such irregularities. The first kind involves subtle, minor deviations in the frontal lobe region of the brain. This region is one of the systems that closely evaluate responses to the demands of daily living. Even slight, minimal damage to this region can result in distortions in thinking such as inflexibility and impulsive decision making.
The second type of neurological irregularity frequently discussed in scientific literature focuses on the limbic system in the brain. The limbic system is one of the brain systems in charge of the control of emotions. Specifically, it is tasked with modulating the intensity of feelings. Researchers have found that many individuals with borderline personality disorder have limbic systems that are limited in their ability to calm raging feelings.
The consequence of these seemingly trivial brain and neurological deficits can be devastating sensory hypersensitivity that begin in infancy. As the baby grows into childhood, adolescence, and adulthood, this sensitivity results in an individual who is easily overwhelmed by even changes. Because of this reactivity they often develop strategies of avoidance so that the ‘apple cart’ so to speak is not upset. Parents, friends, and teachers usually support these avoidant strategies out of sympathy for the distress that would otherwise occur.
Such excessive neurological reactivity can easily set the stage for adjustment difficulties in adulthood. While avoidant strategies may be indulged by parents during childhood, it is much harder to cover up such sensitivity in adulthood. Roommates, bosses, spouses, and teachers will have far less tolerance for sensory avoidance. As a result, the young adult may choose either to remain at home or to make choices that serve to protect them from sensory overload but come with “negative side effects”. Examples include self mutilation, addictions, and involvement with destructive individuals.
So Tachlis, what can be done about these neurological deficits? Isn’t one’s neurological system and brain hard wired? What kind of positive changes can be reasonably expected if biology is so stacked in favor of borderline personality disorder?
The answer to these questions is both sobering and hopeful. Indeed, the biology of many individuals with borderline does make living in peace and in joy more difficult. On the other hand the miraculous complexity of the human mind and nervous system have many ‘back up systems’ that permit us to live, learn, and grow even when one or two parts are impaired.
Furthermore, neuroscientists continue to discover the elasticity of the brain. In other words the notion that are minds are fixed and hardened is simply not true. We know now that given the right approach even the most damaged mind can grow again. Effective treatment for borderline personality disorder such as dialectical behavioral therapy offers many strategies for taming these neurological irregularities.
Family Related Deficits
Few aspects of borderline personality disorder have been as hotly debated as the influence of family. On one extreme are those theorists who insist that the parents and family life are the sole contributing factors to the development of the disorder. On the other extreme are those who say that family has nothing to do with the borderline. Biology, social forces, and individual psychology are the real culprits according to this view.
Like every other aspect of borderline personality disorder, it is most likely that the truth lies somewhere in between these extremes. For some adults with borderline personality disorder family dysfunction in the form of child abuse, neglect, and abandonment have a great deal to do with the evolution of their disorder. For others however factors unrelated to the family are clearly to blame. In fact, they may come from wonderfully warm, high functioning families.
Instead of focusing on specific actions of parents as the cause of borderline symptomology, contemporary researchers speak of deficit of validation in the parent-child environment. Validation refers to the unconditional acceptance of someone else’s feelings, thoughts, needs, and experiences. All children have a sense of self that is profoundly dependent on their parents. In a psychological sense, children know only what they are told by their parents. Any feeling, thought, event, or opinion that is experienced by the child is not fully accepted by the child unless his or her parent validates it.
In the absence of a parent’s validation the child remains confused as to whether he really feels or thinks the way he does. When such validation is consistently missing the child may very well live with a great deal of confusion about his or her feelings, wants, dislikes and needs. This gap in validation is in fact responsible for the chronic feelings of identity confusion and emptiness that are experienced by the adult with borderline personality disorder.
One thing is clear however: a mind set, often supported by even the most well meaning professional, that locks the patient in a blaming, fault-finding, vengeful relationship with his or her family is almost always counterproductive. Blaming is always self destructive because it focuses our attention away from where it is most needed: taking responsibility for ourselves, our lives, and our own sanity.
So instead of blaming, an attitude of personal responsibility is the way to go. Adults with borderline personality disorder have legitimate needs, just like everybody else. They need respect. They need others to believe in them, their efforts, and their dreams. Most importantly, they must learn to understand and respect their feelings and their needs. Because they need these experiences like a fish needs water, they are responsible to see to it that they get them. Much of the work of effective psychotherapy for borderline personality disorder is helping the patient get their legitimate needs met in their relationships.
Learning Disability Related Factors
It often comes as a surprise that learning disabilities are a significant factor in the development of borderline personality disorder. Neuroscientists however continue to discover the influence that learning disabilities have over mental heath and contentment.
The two most well understood learning disabilities that influence the development of borderline are inability to generalize and poor ability to problem solve. When scientists speak of the ability to generalize, they are referring to the individual’s ability to use skills that are effective in one setting in a different one. A common example is a woman who can easily handle the complex stresses of the workplace. Home life however is a different story. Despite its similarities to work, she is overwhelmed by her children’s many demands. She is unable to take the skills that she uses so well at work and deploy them at home.
Deficits in problem solving abilities are also common to individuals with borderline personality disorder. Problem solving refers to a group of strategies that are used to choose the best course of action when one must choose between two or more competing demands. A common example is when a yeshiva bochur must decide whether to study one chavrusa or another. One chavrusa is a close friend. The other chavrusa is quite gifted. Who should he learn with? What if his friend’s feelings will be hurt? A good set of problem solving skills are necessary to navigate this difficult situation.
Such learning difficulties compromise the individual’s success in so many different ways. It is not hard to understand that learning disabilities undermine school success which leads to further difficulties. But more than the impact on learning is the impact on social adjustment. Poor ability to generalize knowledge and to solve problems puts one at great disadvantage.
Effective treatment for psychotherapy must therefore address these and other learning disabilities. Dialectical behavioral therapy for instance has components devoted to teaching patients how to generalize and to problem solve.
Trauma Factors
Psychological trauma among individuals with borderline personality is quite common. Researchers claim that more than sixty percent of individuals with borderline have experienced significant psychological trauma. Many of these people also have post traumatic stress disorder.
Psychological trauma traditionally refers to exposure to an event in which the person was afraid for his or her life. In the last twenty years, as deeper understanding of how we handle traumatic events, scientists have begun to claim that even non life threatening traumatic events that are not life threatening can have the same effect. This is especially the case when the traumatic events occur again and again. Common examples of such events are frequent family arguments, family illness, and living in violent, unstable environments.
While these may not be as seemingly traumatic as being in a near fatal car crash, these events have create a cumulative trauma. Such traumatization reduces the child to focus on basic survival. School and friends become much less important than getting the most simple physical needs met. They have no one to bond with, to talk with, no one to find loving reassurance, rachmana litzlan. And because the child is preoccupied with basic survival, he or she misses out on all the other activities that he or she would otherwise be involved with.
On a deeper level however the damage goes deeper than a lost childhood. Trauma profoundly reshapes the brain and nervous system. Each traumatic event, even those seemingly minor, releases all of the stress hormones associated with the fight or flight response. After so many activations, the nervous system gets stuck in an activated state.
A common consequence of such a state is a high degree of physiological reactivity. They are easily enraged since there nervous system are already Furthermore, it becomes extremely hard for such traumatized individuals to relax their bodies. Unfortunately, drugs, alcohol, and addictive behaviors are often turned to because of their seeming ability to calm these chronically terrified people. In addition, due to their state of chronic stress, these people may have a host of physical illnesses and weaknesses.
Because of the high prevalence of post traumatic stress disorder among individuals with borderline personality disorder, effective psychotherapy includes components to address trauma related symptoms. Aside from physiological stress activation, patients may also experience intrusive flash back memories that may be quite disabling. Techniques such as eye movement desensitization and reprogramming, exposure therapy, and various body-centered techniques can help patients regain physiological peace and reduce psychological distress.
Psychological Deficits
The psychological factors of borderline personality disorder are discussed throughout the psychological literature. There are in fact many theories that attempt to explain how this personality disorder comes to be. Some theories have been rejected by scientists as lacking validity. Others theories are still debated and studied.
Despite this vast debate about psychological causes, one universally accepted psychological factor has been advanced by cognitive therapists, Aaron Beck and Albert Ellis. In their view the strongest cause for borderline is a cognitive bias known as dichotomous thinking. Simply put, people with borderline personality disorder automatically process the events in their lives as either wonderful or absolutely horrible.
The result of such “either-or” thinking is to respond to life’s ups and downs with exaggerated joy or exaggerated misery and anger. Because of this inability to question their black and white assessments, people with borderline cannot take effective action to solve problems and make their lives better. Their dichotomous thinking forces them into passivity, despair, or aggressive acting out.
A second psychological factor in the development of borderline personality disorder focuses on emotional memory. Every single event that we experience is contained within our memory. The people who love us, our favorite foods, music, names of people that we have met, and a myriad of other data are stored within the memory’s recesses.
Just as important as these facts are the emotions associated with them. A parent who looks at a photo of his child, automatically feels love and tenderness for that child. A child, having a rough day in school, recalls the safety of her bedroom, easily feels a sense of peace. These are manifestations of the emotional memory. In both cases the positive feelings serve to blunt any negative feelings that are experienced at the same time.
Psychologists have found that individuals with borderline personality disorder lack emotional memory. They have cannot summon up feelings that would counter their current feelings of distress. Without these warm, fuzzy memories, people with borderline must deal head on with the emotional distress of the moment.
Interpersonal Deficits
Despite their strong desire for deep, meaningful relationships, individuals with borderline personality disorder often have great difficulty in their relationships with others. They may often be excessively demanding of the attention and resources of others. Conversely, they may also become overly forgiving of still others who have caused them harm in the past.
The consequences of these interpersonal skill deficits are often quite devastating. The ability to form healthy, satisfying relationships with others is the most important psychological skill that one can possess. Our relationships make us or break us. Since individuals with borderline have few relationships that pull them towards joy, they sink lower and lower into their own misery, rachmana litzlan. Effective psychotherapy for borderline personality disorder therefore must focus on strengthening the patient’s ability to form positive relationships.
Considering the impact of these different deficits, despair would seem the most rational response to borderline personality disorder. The truth of the matter however is that such despair is unwarranted. While each of these deficits would seem to deliver a lasting blow to personal success, the human spirit is so much stronger than all of the eminent psychologists could ever predict. With love, patience, effective treatment, and siyata d’shmaya, even the most intractable cases can find hope, peace, and power.
Writer’s Reflection: The Rabbis tell us that when a tzaddik is shown what their yetzer hara looks like, it will appear as a gigantic mountain of Everest proportions. The tzaddik will exclaim, “how did I ever win in my war with such a behemoth?!”. The rasha is also shown his yetzer hara. To him it will appear as a small, inconsequential mound of dirt. The rasha will exclaim, “Oy!!! Why could I not conquer such a puny adversary”. The baalay Mussar explain that whereas the rasha is overwhelmed by the enormity of the task, the tzaddik goes forward one step at a time. The rasha’s point of view leaves him so immobilized that even a mound of dirt is too much. The tzaddik’s approach allows him to climb even the mighty Everest.
When I educate patients, families, and lay people about the ‘ingredients’ of borderline personality disorder, I always share the deep words of the sainted Rabbis with them. My wish is to reassure everyone that despite the seemingly overwhelming deficits and factors that cause so much suffering there is hope for healing. This hope is grounded in the reality that if, like the tzaddik, we focus on putting one foot in front of the other we can scale mountains.
Is it brain chemicals?
Is it bad parenting?
Is it society’s fault?
The most often question asked about borderline personality disorder is what causes it. And it’s good a question. After all, if we knew the cause, we could take steps to prevent it. By understanding the causes, we can devise strategies to lessen the symptoms.
The fact of the matter however is that borderline personality disorder is not caused by one thing any more than cancer or asthma is caused by only one thing. Borderline personality disorder is the end point of a group of converging vulnerabilities. These vulnerabilities include family tensions, psychological predispositions, neurological sensitivities, social gaps, genetics, and life experiences. Like some sort of horrible recipe, only when brought together does one end up with the pain and agony of borderline.
Throughout the psychological literature, scientists refer to deficits or vulnerabilities that lay the groundwork for the formation of borderline. Taken separately, each of these deficits could be quite disabling. When two or three of more factors come together though a devastating synergy is created. The result is often borderline personality disorder. In order to better understand this horrible recipe, let’s consider each of these vulnerabilities separately:
Neurological Deficits
Since borderline personality disorder is considered a psychiatric disorder, few of us consider the fact that there are also physical dimensions to it as well. Indeed, without adequately considering these physical qualities, all of the well intentioned psychological and psychiatric interventions will have little or not effect. Scientists however have long noticed that people with borderline personality disorder have characteristic somatic attributes. Brain and nervous system irregularities are the most documented of these somatic attributes.
Scientific literature speaks of two types of such irregularities. The first kind involves subtle, minor deviations in the frontal lobe region of the brain. This region is one of the systems that closely evaluate responses to the demands of daily living. Even slight, minimal damage to this region can result in distortions in thinking such as inflexibility and impulsive decision making.
The second type of neurological irregularity frequently discussed in scientific literature focuses on the limbic system in the brain. The limbic system is one of the brain systems in charge of the control of emotions. Specifically, it is tasked with modulating the intensity of feelings. Researchers have found that many individuals with borderline personality disorder have limbic systems that are limited in their ability to calm raging feelings.
The consequence of these seemingly trivial brain and neurological deficits can be devastating sensory hypersensitivity that begin in infancy. As the baby grows into childhood, adolescence, and adulthood, this sensitivity results in an individual who is easily overwhelmed by even changes. Because of this reactivity they often develop strategies of avoidance so that the ‘apple cart’ so to speak is not upset. Parents, friends, and teachers usually support these avoidant strategies out of sympathy for the distress that would otherwise occur.
Such excessive neurological reactivity can easily set the stage for adjustment difficulties in adulthood. While avoidant strategies may be indulged by parents during childhood, it is much harder to cover up such sensitivity in adulthood. Roommates, bosses, spouses, and teachers will have far less tolerance for sensory avoidance. As a result, the young adult may choose either to remain at home or to make choices that serve to protect them from sensory overload but come with “negative side effects”. Examples include self mutilation, addictions, and involvement with destructive individuals.
So Tachlis, what can be done about these neurological deficits? Isn’t one’s neurological system and brain hard wired? What kind of positive changes can be reasonably expected if biology is so stacked in favor of borderline personality disorder?
The answer to these questions is both sobering and hopeful. Indeed, the biology of many individuals with borderline does make living in peace and in joy more difficult. On the other hand the miraculous complexity of the human mind and nervous system have many ‘back up systems’ that permit us to live, learn, and grow even when one or two parts are impaired.
Furthermore, neuroscientists continue to discover the elasticity of the brain. In other words the notion that are minds are fixed and hardened is simply not true. We know now that given the right approach even the most damaged mind can grow again. Effective treatment for borderline personality disorder such as dialectical behavioral therapy offers many strategies for taming these neurological irregularities.
Family Related Deficits
Few aspects of borderline personality disorder have been as hotly debated as the influence of family. On one extreme are those theorists who insist that the parents and family life are the sole contributing factors to the development of the disorder. On the other extreme are those who say that family has nothing to do with the borderline. Biology, social forces, and individual psychology are the real culprits according to this view.
Like every other aspect of borderline personality disorder, it is most likely that the truth lies somewhere in between these extremes. For some adults with borderline personality disorder family dysfunction in the form of child abuse, neglect, and abandonment have a great deal to do with the evolution of their disorder. For others however factors unrelated to the family are clearly to blame. In fact, they may come from wonderfully warm, high functioning families.
Instead of focusing on specific actions of parents as the cause of borderline symptomology, contemporary researchers speak of deficit of validation in the parent-child environment. Validation refers to the unconditional acceptance of someone else’s feelings, thoughts, needs, and experiences. All children have a sense of self that is profoundly dependent on their parents. In a psychological sense, children know only what they are told by their parents. Any feeling, thought, event, or opinion that is experienced by the child is not fully accepted by the child unless his or her parent validates it.
In the absence of a parent’s validation the child remains confused as to whether he really feels or thinks the way he does. When such validation is consistently missing the child may very well live with a great deal of confusion about his or her feelings, wants, dislikes and needs. This gap in validation is in fact responsible for the chronic feelings of identity confusion and emptiness that are experienced by the adult with borderline personality disorder.
One thing is clear however: a mind set, often supported by even the most well meaning professional, that locks the patient in a blaming, fault-finding, vengeful relationship with his or her family is almost always counterproductive. Blaming is always self destructive because it focuses our attention away from where it is most needed: taking responsibility for ourselves, our lives, and our own sanity.
So instead of blaming, an attitude of personal responsibility is the way to go. Adults with borderline personality disorder have legitimate needs, just like everybody else. They need respect. They need others to believe in them, their efforts, and their dreams. Most importantly, they must learn to understand and respect their feelings and their needs. Because they need these experiences like a fish needs water, they are responsible to see to it that they get them. Much of the work of effective psychotherapy for borderline personality disorder is helping the patient get their legitimate needs met in their relationships.
Learning Disability Related Factors
It often comes as a surprise that learning disabilities are a significant factor in the development of borderline personality disorder. Neuroscientists however continue to discover the influence that learning disabilities have over mental heath and contentment.
The two most well understood learning disabilities that influence the development of borderline are inability to generalize and poor ability to problem solve. When scientists speak of the ability to generalize, they are referring to the individual’s ability to use skills that are effective in one setting in a different one. A common example is a woman who can easily handle the complex stresses of the workplace. Home life however is a different story. Despite its similarities to work, she is overwhelmed by her children’s many demands. She is unable to take the skills that she uses so well at work and deploy them at home.
Deficits in problem solving abilities are also common to individuals with borderline personality disorder. Problem solving refers to a group of strategies that are used to choose the best course of action when one must choose between two or more competing demands. A common example is when a yeshiva bochur must decide whether to study one chavrusa or another. One chavrusa is a close friend. The other chavrusa is quite gifted. Who should he learn with? What if his friend’s feelings will be hurt? A good set of problem solving skills are necessary to navigate this difficult situation.
Such learning difficulties compromise the individual’s success in so many different ways. It is not hard to understand that learning disabilities undermine school success which leads to further difficulties. But more than the impact on learning is the impact on social adjustment. Poor ability to generalize knowledge and to solve problems puts one at great disadvantage.
Effective treatment for psychotherapy must therefore address these and other learning disabilities. Dialectical behavioral therapy for instance has components devoted to teaching patients how to generalize and to problem solve.
Trauma Factors
Psychological trauma among individuals with borderline personality is quite common. Researchers claim that more than sixty percent of individuals with borderline have experienced significant psychological trauma. Many of these people also have post traumatic stress disorder.
Psychological trauma traditionally refers to exposure to an event in which the person was afraid for his or her life. In the last twenty years, as deeper understanding of how we handle traumatic events, scientists have begun to claim that even non life threatening traumatic events that are not life threatening can have the same effect. This is especially the case when the traumatic events occur again and again. Common examples of such events are frequent family arguments, family illness, and living in violent, unstable environments.
While these may not be as seemingly traumatic as being in a near fatal car crash, these events have create a cumulative trauma. Such traumatization reduces the child to focus on basic survival. School and friends become much less important than getting the most simple physical needs met. They have no one to bond with, to talk with, no one to find loving reassurance, rachmana litzlan. And because the child is preoccupied with basic survival, he or she misses out on all the other activities that he or she would otherwise be involved with.
On a deeper level however the damage goes deeper than a lost childhood. Trauma profoundly reshapes the brain and nervous system. Each traumatic event, even those seemingly minor, releases all of the stress hormones associated with the fight or flight response. After so many activations, the nervous system gets stuck in an activated state.
A common consequence of such a state is a high degree of physiological reactivity. They are easily enraged since there nervous system are already Furthermore, it becomes extremely hard for such traumatized individuals to relax their bodies. Unfortunately, drugs, alcohol, and addictive behaviors are often turned to because of their seeming ability to calm these chronically terrified people. In addition, due to their state of chronic stress, these people may have a host of physical illnesses and weaknesses.
Because of the high prevalence of post traumatic stress disorder among individuals with borderline personality disorder, effective psychotherapy includes components to address trauma related symptoms. Aside from physiological stress activation, patients may also experience intrusive flash back memories that may be quite disabling. Techniques such as eye movement desensitization and reprogramming, exposure therapy, and various body-centered techniques can help patients regain physiological peace and reduce psychological distress.
Psychological Deficits
The psychological factors of borderline personality disorder are discussed throughout the psychological literature. There are in fact many theories that attempt to explain how this personality disorder comes to be. Some theories have been rejected by scientists as lacking validity. Others theories are still debated and studied.
Despite this vast debate about psychological causes, one universally accepted psychological factor has been advanced by cognitive therapists, Aaron Beck and Albert Ellis. In their view the strongest cause for borderline is a cognitive bias known as dichotomous thinking. Simply put, people with borderline personality disorder automatically process the events in their lives as either wonderful or absolutely horrible.
The result of such “either-or” thinking is to respond to life’s ups and downs with exaggerated joy or exaggerated misery and anger. Because of this inability to question their black and white assessments, people with borderline cannot take effective action to solve problems and make their lives better. Their dichotomous thinking forces them into passivity, despair, or aggressive acting out.
A second psychological factor in the development of borderline personality disorder focuses on emotional memory. Every single event that we experience is contained within our memory. The people who love us, our favorite foods, music, names of people that we have met, and a myriad of other data are stored within the memory’s recesses.
Just as important as these facts are the emotions associated with them. A parent who looks at a photo of his child, automatically feels love and tenderness for that child. A child, having a rough day in school, recalls the safety of her bedroom, easily feels a sense of peace. These are manifestations of the emotional memory. In both cases the positive feelings serve to blunt any negative feelings that are experienced at the same time.
Psychologists have found that individuals with borderline personality disorder lack emotional memory. They have cannot summon up feelings that would counter their current feelings of distress. Without these warm, fuzzy memories, people with borderline must deal head on with the emotional distress of the moment.
Interpersonal Deficits
Despite their strong desire for deep, meaningful relationships, individuals with borderline personality disorder often have great difficulty in their relationships with others. They may often be excessively demanding of the attention and resources of others. Conversely, they may also become overly forgiving of still others who have caused them harm in the past.
The consequences of these interpersonal skill deficits are often quite devastating. The ability to form healthy, satisfying relationships with others is the most important psychological skill that one can possess. Our relationships make us or break us. Since individuals with borderline have few relationships that pull them towards joy, they sink lower and lower into their own misery, rachmana litzlan. Effective psychotherapy for borderline personality disorder therefore must focus on strengthening the patient’s ability to form positive relationships.
Considering the impact of these different deficits, despair would seem the most rational response to borderline personality disorder. The truth of the matter however is that such despair is unwarranted. While each of these deficits would seem to deliver a lasting blow to personal success, the human spirit is so much stronger than all of the eminent psychologists could ever predict. With love, patience, effective treatment, and siyata d’shmaya, even the most intractable cases can find hope, peace, and power.
Sunday, September 30, 2007
Chapter II Personality And Its Disorders
Chapter II Personality And Its Disorders
Few things are as debated in the field of modern psychology as the concept of personality. Indeed the existence of personality is itself the subject to debate. Scientists have debated the role of genetics, health, social class, gender and many other dimensions in human behavior. Perhaps what we think of as personality is nothing more than how we behave in a given circumstance. Since circumstances vary, such thinking goes, there is no consistent personality.
Nevertheless, there is enough consensus however to offer the following description of personality:
Personality is a group of consistent ways that an individual interacts with himself and with others. It is a collection of expectations and habits of action that each of us develops in order to deal meet individual needs.
From this perspective, a personality disorder may be thought of as ineffective personal expectations and behavioral habits. In other words it is a group of habits that fail to help us get what we want in life. This chapter will briefly describe the evolution of personality and explain what is meant by personality disorder.
The Evolution Of Personality
Central to any model of personality is that all human behavior is purpose driven. The forward urge of life is constant from the moment of conception through death. From the perspective of biology, such purpose driven behavior is directed towards the imperative of survival at all costs. Even self destructive behaviors such as suicide or drug use at a deep level is intended to protect the individual from seemingly greater threats such as pain or abandonment.
The evolution of human personality is sequential in nature. Completion of one developmental stage leads to the next stage. This process begins with birth and continues into young adulthood when our personality reaches a plateau.
Of most relevance to borderline personality disorder are two fundamental factors in personality development: temperament and parenting. These two factors alone account for most of the personality related habits that either make us or break us.
The Influence Of Temperament
Fundamental to our survival in the world is the ability to make sense of what is happening in the world around us. Raw data is taken in through the sensory organs, the eyes, tongue, ears, skin, and nose. Impulses are sent along nerves to the brain where they are identified and processed. The brain then responds as it sees fit based on the circumstances.
Linking the mind and the sensory organs is the central nervous system. Much more than passive conduits of electrochemical information, the structures of the central nervous system add their own twist to the information flowing back and forth between the outside world and the mind. Like the strings of a piano that the shape the impulses of the pianist and the listener, the CNS either amplifies or curtail the impulses. This influence is often referred to temperament.
Temperament refers to how our nervous system interacts with the environment. Neuroscientists think of temperament as a ‘hard-wired’ facet of who we are. For the most part, the temperament that we are born with, is the temperament that we will live with for the remainder of our days. Without much consciousness or thought, many of us possess nervous systems that smoothly flow with the give and take of the environment around us. The process that begins with nervous system activation by outside stimuli and then ending with relaxation runs smoothly and efficiently.
Some of us however have a more difficult time. Even as newborns, the interface between temperament and environment is uneven. Infants with such temperaments may be easily “upended” by even slight changes in their environment. Their nervous systems may become so excited that the process of attaining equilibrium is much more protracted than a less excitable infant.
Built upon temperament are the first skills and expectations of the growing infant. Skills such as the ability to grasp for a desired object or to persevere in the face of frustration are first manifest in the first year of life. With time and experience, new skills and expectations are laid upon the previous layer. This process continues throughout childhood, adolescence, and early adulthood.
For the child with an easy going temperament, skills acquisition is fairly easy. There are ups and downs and difficult moments but overall, the child becomes adept at getting his many physical and social needs met. The world for this child is an inviting place filled with ever widening vistas. He or she develops a repertoire of skills and expectations that allow full participation in this world. The child’s easy going temperament allows him or her to concentrate on the tasks of growth without becoming distracted by the comings and goings of the world.
Such is not the case for the child with a difficult temperament. Even as infants, life was difficult. As they grow they continue to feel disjointed in the world. The skills and expectations that they develop are more often intended to be protective of the fragile peace that they can carve out for themselves. While their more easy going friends are comfortably exploring and mastering their world, these kids are retreating into a cocoon of safety and predictability. This cocoon often becomes a significant part of their personality. Children with such high maintenance temperaments spend a great deal of effort in warding off distress that they have little energy left to explore and conquer the world.
Parenting And Personality Development
While temperament provides the first foundation of personality development, the most influential factors lie outside the child. Chief among them is the relationship between the parent and child. It is even no exaggeration to say that parenting style has the capacity to shape the child’s future.
When a child emerges into the world, it knows nothing. Philosophers (including the Rabbis in Pirkay Avos) have long described the mind of the new-born child as resembling a ‘blank slate’. While the neonate certainly experiences sensations of distress and pleasure, it lacks the understanding to make any sense of them. It is only the input of those in the outside world that can help make sense of such confusion.
At first, it is the parents’ responses to the child that provide direction. Holding, diaper changing, feeding, singing, and so forth offer some coherence. The parent and baby together learn which inner sensation goes with which response. With the leaps and bounds of brain and language development during the first years of life, the child is able to use verbal and non-verbal language to label his or her own inner sensations.
Their extraordinary role in early development makes the parent into the center of the child’s world. The parent is the most important and powerful determinant of how things are and how they should be. Philosophers and psychologists alike describe the parent as a god-like figure in the mind of the child. Whatever a child learns from observing the parent will remain a dominant part of the child’s awareness for rest of his or her days. Such knowledge includes everything from how to tie one’s shoes to how to deal with social rejection.
Beyond the how-to knowledge imparted by the parent is who-am-I knowledge that shapes the child’s expectations and behavior. The core beliefs about who we are and what we can do originate with how parents interact with us. By the time a child enters school, he or she has already developed some rudimentary curiosity about his or her place in their expanding world.
While the child’s curiosity is motivates learning about the world, it naturally leads to confusion about themselves. Examples of confusion include whether the child is lovable, smart, talented, forgivable, and capable. This confusion is quite distressing. The child automatically looks to his or her parents, as they are the ones who have always made the world understandable.
The answers that the parent offers will become the unquestioned truth for the child. The desperation with which the child seeks answers means that whatever the parent answers will be accepted deeply into the child’s psyche. If the parents communicates through his or her words and actions that the child is lovable, likable, smart, capable, and so on then the child will believe that that to be the case even in the face of difficulties. And if, rachaman litzlan, the parent communicates with his or her actions that the child doesn’t measure up, then the child will accept that to be the case even when he or she succeeds in school or in career. The consequence of this will be a child who lacks the confidence necessary to take the risks of personal growth. Such lack of confidence leaves the child deeply confused and unable to adapt to the changing terrain of his or her social and physical development.
Psychologists refer to the feedback loop between parent and child as validation. Through the psychological process of validation the child is able to form a personal identity. Personality development is highly influenced by the quality of the parent’s validation of the child. This influence is reflected in the beautiful words of the poet and educator, Dorothy Law Holte:
If a child lives with criticism, he learns to condemn.
If a child lives with hostility, he learns to fight.
If a child lives with ridicule, he learns to be shy.
If a child lives with shame, he learns to feel guilty.
If a child lives with tolerance, he learns to be patient.
If a child lives with encouragement, he learns confidence.
If a child lives with praise, he learns to appreciate.
If a child lives with fairness, he learns justice.
If a child lives with security, he learns to have faith.
If a child lives with approval, he learns to like himself.
If a child lives with acceptance and friendship, he learns to find love in the world.
Without continuous and consistent validation of the child’s feelings, fears, struggles, weaknesses, capacities, and dreams the child will grow into adulthood full of self doubt. No amount of intellect, easy-going temperament, health or any other “lucky break” can make up for the consequences of such self doubt.
From Personality To Personality Disorder
Until now the discussion has focused on normal, healthy personality development. While it may seem that possessing a difficult temperament and having been parented in a poorly validating environment would be a recipe for disaster, the fact is that most with such backgrounds live very satisfying lives. This is because there are many forces in our social environment positive circumstances that make up for any deficits. Such forces may include a helpful teacher or a good friend who comes into our lives at the right time. Whatever it is, most of us are given the chance to develop into people who can thrive in our adulthood even when our childhoods have been difficult.
People who develop borderline personality disorder and other personality disorders don’t get these lucky breaks. Sometimes their temperament and degree of parental invalidation are so extreme that their development is interrupted. The developing child remains stuck in earlier levels of growth, afraid and unable to develop new skills so that he or she can keep up with others and with the world. Consider these examples:
Devora, Aged 24
Devora returned home from a job interview in a foul mood. Her mother, distressed by Devora’s anger tried to comfort her. This set Devora off even more. She screamed at her mother and demanded that she leave her alone. Later on, when it seemed that Devora had calmed down, her mother inquired about the interview, Devora related that it had gone poorly. When Devora’s mother confronted her daughter about the earlier outburst, Devora stated that the mother was “bugging me”.
Discussion
Disappointment is difficult for everybody, including young children. It is not uncommon for an eight or nine year old to storm into the house of apartment after a difficult day and yell at his or her family members. Aggression in this age group is to be expected as it allows a child, who lacks the problem solving and self soothing skills of an adult, to regain a sense of mastery. In a young adult however aggression is no longer an acceptable way to deal with frustration. By the time one reaches adulthood, it is expected that one can manage the feelings that come with frustration without lashing out at others.
Alex, aged 24
Alex was due for his six month performance review at the accounting firm where he worked. He was quite nervous since he felt that his supervisor didn’t like him. That the supervisor was cold and standoffish to everyone in the department was lost on Alex. He just assumed that the supervisor was planning on firing him from his probationary employment. Alex was therefore quite surprised when the supervisor told him that he was eligible for permanent employment.
Discussion
Young children relate to the world through their own inner experience. In the vast majority of children, the ability to recognize that others may think and feel different than he or she does, only comes with further cognitive development. They automatically assume that what they feel or think is true for others. This tendency is referred to as projection. If he or she is scared then the other child is scared. If he or she is angry then the other child is angry.
While projection in a child is perfectly normal, in a young adult however projection is highly limiting. Projection leads people to interact with others in ways that are inaccurate. A husband who projects his own happiness onto his wife, won’t notice that she is sad and in need of his reassurance. By the time one reaches adulthood, it is expected that one can separate out his or her own thoughts from those of others.
In essence, a personality disorder can be thought of as a repertoire of problem solving kills and expectations that fail to meet the individual’s current needs. While these skills and expectations may have been useful or developmental understandable in earlier stages, they no longer are. The failure to “upgrade” the skill set is the consequence of avoidance to learning new skills and the deep confusion caused by parental validation.
The discrepancies between the skills acquisition of psychological development and physical maturation are manifest in many ways. In fact, almost all of us to some minor degree fail to be fully “grown up” at different times in our lives. It is only when such immaturity or lack of skills is manifest often and significantly gets in the way of an enjoyable life that it is considered a personality disorder.
The DSM-IV lists nine different personality disorders. They are:
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizoptypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive Compulsive Personality Disorder
Each of these personality disorders is organized around a central theme. For example, someone with dependent personality disorder exhibits excessive dependency on others; he or she cannot seem to act independently. Someone with obsessive compulsive personality disorder (NOT obsessive compulsive disorder or OCD) is excessively obsessed with order as well as collecting things even when doing so undermines other dimensions of his or her own life such as social relationships or career. Someone with antisocial personality disorder has little regard for the feelings and rights of others.
It is important to note that borderline personality disorder is different from other personality disorders in four ways. First of all, individuals with borderline personality disorder often suffer from other, highly treatable, psychiatric disorders. Such disorders are clinical depression, any of the bipolar disorders such a bipolar I or bipolar II, and post-traumatic stress disorder (P.T.S.D.).
Furthermore individuals with borderline personality disorder often exhibit characteristics of other personality disorders. This is especially the case with antisocial personality disorder, histrionic personality disorder, dependent personality disorder, and narcissistic personality disorder.
The third difference between those with borderline and those with other personality disorders is that individuals with borderline live in a great amount of inner pain. People with personality disorders are usually quite untroubled by their habits and idiosyncracies. It is other who are frustrated by them. People with borderline however usually live in an unremitting state of fear, rejection, chaos, and misery.
Finally, unlike those with other personality disorder, individuals with borderline personality disorder are significantly more likely to improve with treatment.
There are many, many resources that explain each of these personality disorders. For those looking for the authoritative book on the subject, The Diagnosis and Treatment of DSM-IV Personality Disorders, by Len Sperry, M.D., Ph.D. is an excellent place to start.
How One Is Diagnosed With A Personality Disorder
Fewer aspects of professional psychology and psychiatry are fraught with more inconsistency than personality disorders. Have ten clinicians evaluate someone for a personality disorder and there may very well be ten different opinions. Yet as surprising as such confusion may seem, psychological diagnosis is very difficult. After all, objective tests such as a biopsies and x-rays have not been developed for psychological diagnosis.
Instead, clinicians must draw upon highly subjective exams of psychological and social functioning to accurately diagnosis any psychological disorder. Still, diagnosis is part of the process of repair and healing. Accurate diagnosis can point the way towards a much brighter future.
In the best case diagnostic scenarios a large amount of data is first collected about the person seeking assistance. Data collection begins with a complete medical evaluation to determine how the person’s health may be contributing to his or her psychological difficulties. The person is then tested for difficulties with memory, attention, and perception processing since deficits in these areas can understandably undermine psychological and social adjustment.
Exhaustive psychological interviews are conducted with the person. These inventories evaluate how he or she interacts with others, manages stress and fears, and how they self comfort. Self-report questionnaires that assess personality traits such as hostility, depression, impulsivity, and anxiety are administered. Family members and others are interviewed for their experiences with the person and his or her difficulties. This mass of data is then analyzed to determine the factors that cause the difficulties in question.
Such an exhaustive diagnostic process is always helpful. Yet it is often not practical for a number of reasons. For one thing, the expense is often not covered by insurance (although ironically far more expensive diagnostic tests such as MRI’s are commonly covered). Furthermore, patients and their families often do not know to ask for psychological assessment when seeking assistance. When exhaustive diagnostics cannot be performed, a competent professional should be sought for consultation. Such a professional will most likely advanced training and supervised work experience in the treatment of individuals with personality disorders. They must also be willing to invest the time of understanding the patient and his or her social background.
Regrettably, these procedures are only rarely performed. Poorly trained and confused professionals often give many people a seat-of-the-pants diagnosis. Such diagnoses often are inaccurate to the extent that time, money, and hope is squandered on the wrong treatments. That such diagnoses are made in such cavalier ways shows a fundamental lack of respect for the patient, his or her family, and ultimately for the clinician himself.
Few things are as debated in the field of modern psychology as the concept of personality. Indeed the existence of personality is itself the subject to debate. Scientists have debated the role of genetics, health, social class, gender and many other dimensions in human behavior. Perhaps what we think of as personality is nothing more than how we behave in a given circumstance. Since circumstances vary, such thinking goes, there is no consistent personality.
Nevertheless, there is enough consensus however to offer the following description of personality:
Personality is a group of consistent ways that an individual interacts with himself and with others. It is a collection of expectations and habits of action that each of us develops in order to deal meet individual needs.
From this perspective, a personality disorder may be thought of as ineffective personal expectations and behavioral habits. In other words it is a group of habits that fail to help us get what we want in life. This chapter will briefly describe the evolution of personality and explain what is meant by personality disorder.
The Evolution Of Personality
Central to any model of personality is that all human behavior is purpose driven. The forward urge of life is constant from the moment of conception through death. From the perspective of biology, such purpose driven behavior is directed towards the imperative of survival at all costs. Even self destructive behaviors such as suicide or drug use at a deep level is intended to protect the individual from seemingly greater threats such as pain or abandonment.
The evolution of human personality is sequential in nature. Completion of one developmental stage leads to the next stage. This process begins with birth and continues into young adulthood when our personality reaches a plateau.
Of most relevance to borderline personality disorder are two fundamental factors in personality development: temperament and parenting. These two factors alone account for most of the personality related habits that either make us or break us.
The Influence Of Temperament
Fundamental to our survival in the world is the ability to make sense of what is happening in the world around us. Raw data is taken in through the sensory organs, the eyes, tongue, ears, skin, and nose. Impulses are sent along nerves to the brain where they are identified and processed. The brain then responds as it sees fit based on the circumstances.
Linking the mind and the sensory organs is the central nervous system. Much more than passive conduits of electrochemical information, the structures of the central nervous system add their own twist to the information flowing back and forth between the outside world and the mind. Like the strings of a piano that the shape the impulses of the pianist and the listener, the CNS either amplifies or curtail the impulses. This influence is often referred to temperament.
Temperament refers to how our nervous system interacts with the environment. Neuroscientists think of temperament as a ‘hard-wired’ facet of who we are. For the most part, the temperament that we are born with, is the temperament that we will live with for the remainder of our days. Without much consciousness or thought, many of us possess nervous systems that smoothly flow with the give and take of the environment around us. The process that begins with nervous system activation by outside stimuli and then ending with relaxation runs smoothly and efficiently.
Some of us however have a more difficult time. Even as newborns, the interface between temperament and environment is uneven. Infants with such temperaments may be easily “upended” by even slight changes in their environment. Their nervous systems may become so excited that the process of attaining equilibrium is much more protracted than a less excitable infant.
Built upon temperament are the first skills and expectations of the growing infant. Skills such as the ability to grasp for a desired object or to persevere in the face of frustration are first manifest in the first year of life. With time and experience, new skills and expectations are laid upon the previous layer. This process continues throughout childhood, adolescence, and early adulthood.
For the child with an easy going temperament, skills acquisition is fairly easy. There are ups and downs and difficult moments but overall, the child becomes adept at getting his many physical and social needs met. The world for this child is an inviting place filled with ever widening vistas. He or she develops a repertoire of skills and expectations that allow full participation in this world. The child’s easy going temperament allows him or her to concentrate on the tasks of growth without becoming distracted by the comings and goings of the world.
Such is not the case for the child with a difficult temperament. Even as infants, life was difficult. As they grow they continue to feel disjointed in the world. The skills and expectations that they develop are more often intended to be protective of the fragile peace that they can carve out for themselves. While their more easy going friends are comfortably exploring and mastering their world, these kids are retreating into a cocoon of safety and predictability. This cocoon often becomes a significant part of their personality. Children with such high maintenance temperaments spend a great deal of effort in warding off distress that they have little energy left to explore and conquer the world.
Parenting And Personality Development
While temperament provides the first foundation of personality development, the most influential factors lie outside the child. Chief among them is the relationship between the parent and child. It is even no exaggeration to say that parenting style has the capacity to shape the child’s future.
When a child emerges into the world, it knows nothing. Philosophers (including the Rabbis in Pirkay Avos) have long described the mind of the new-born child as resembling a ‘blank slate’. While the neonate certainly experiences sensations of distress and pleasure, it lacks the understanding to make any sense of them. It is only the input of those in the outside world that can help make sense of such confusion.
At first, it is the parents’ responses to the child that provide direction. Holding, diaper changing, feeding, singing, and so forth offer some coherence. The parent and baby together learn which inner sensation goes with which response. With the leaps and bounds of brain and language development during the first years of life, the child is able to use verbal and non-verbal language to label his or her own inner sensations.
Their extraordinary role in early development makes the parent into the center of the child’s world. The parent is the most important and powerful determinant of how things are and how they should be. Philosophers and psychologists alike describe the parent as a god-like figure in the mind of the child. Whatever a child learns from observing the parent will remain a dominant part of the child’s awareness for rest of his or her days. Such knowledge includes everything from how to tie one’s shoes to how to deal with social rejection.
Beyond the how-to knowledge imparted by the parent is who-am-I knowledge that shapes the child’s expectations and behavior. The core beliefs about who we are and what we can do originate with how parents interact with us. By the time a child enters school, he or she has already developed some rudimentary curiosity about his or her place in their expanding world.
While the child’s curiosity is motivates learning about the world, it naturally leads to confusion about themselves. Examples of confusion include whether the child is lovable, smart, talented, forgivable, and capable. This confusion is quite distressing. The child automatically looks to his or her parents, as they are the ones who have always made the world understandable.
The answers that the parent offers will become the unquestioned truth for the child. The desperation with which the child seeks answers means that whatever the parent answers will be accepted deeply into the child’s psyche. If the parents communicates through his or her words and actions that the child is lovable, likable, smart, capable, and so on then the child will believe that that to be the case even in the face of difficulties. And if, rachaman litzlan, the parent communicates with his or her actions that the child doesn’t measure up, then the child will accept that to be the case even when he or she succeeds in school or in career. The consequence of this will be a child who lacks the confidence necessary to take the risks of personal growth. Such lack of confidence leaves the child deeply confused and unable to adapt to the changing terrain of his or her social and physical development.
Psychologists refer to the feedback loop between parent and child as validation. Through the psychological process of validation the child is able to form a personal identity. Personality development is highly influenced by the quality of the parent’s validation of the child. This influence is reflected in the beautiful words of the poet and educator, Dorothy Law Holte:
If a child lives with criticism, he learns to condemn.
If a child lives with hostility, he learns to fight.
If a child lives with ridicule, he learns to be shy.
If a child lives with shame, he learns to feel guilty.
If a child lives with tolerance, he learns to be patient.
If a child lives with encouragement, he learns confidence.
If a child lives with praise, he learns to appreciate.
If a child lives with fairness, he learns justice.
If a child lives with security, he learns to have faith.
If a child lives with approval, he learns to like himself.
If a child lives with acceptance and friendship, he learns to find love in the world.
Without continuous and consistent validation of the child’s feelings, fears, struggles, weaknesses, capacities, and dreams the child will grow into adulthood full of self doubt. No amount of intellect, easy-going temperament, health or any other “lucky break” can make up for the consequences of such self doubt.
From Personality To Personality Disorder
Until now the discussion has focused on normal, healthy personality development. While it may seem that possessing a difficult temperament and having been parented in a poorly validating environment would be a recipe for disaster, the fact is that most with such backgrounds live very satisfying lives. This is because there are many forces in our social environment positive circumstances that make up for any deficits. Such forces may include a helpful teacher or a good friend who comes into our lives at the right time. Whatever it is, most of us are given the chance to develop into people who can thrive in our adulthood even when our childhoods have been difficult.
People who develop borderline personality disorder and other personality disorders don’t get these lucky breaks. Sometimes their temperament and degree of parental invalidation are so extreme that their development is interrupted. The developing child remains stuck in earlier levels of growth, afraid and unable to develop new skills so that he or she can keep up with others and with the world. Consider these examples:
Devora, Aged 24
Devora returned home from a job interview in a foul mood. Her mother, distressed by Devora’s anger tried to comfort her. This set Devora off even more. She screamed at her mother and demanded that she leave her alone. Later on, when it seemed that Devora had calmed down, her mother inquired about the interview, Devora related that it had gone poorly. When Devora’s mother confronted her daughter about the earlier outburst, Devora stated that the mother was “bugging me”.
Discussion
Disappointment is difficult for everybody, including young children. It is not uncommon for an eight or nine year old to storm into the house of apartment after a difficult day and yell at his or her family members. Aggression in this age group is to be expected as it allows a child, who lacks the problem solving and self soothing skills of an adult, to regain a sense of mastery. In a young adult however aggression is no longer an acceptable way to deal with frustration. By the time one reaches adulthood, it is expected that one can manage the feelings that come with frustration without lashing out at others.
Alex, aged 24
Alex was due for his six month performance review at the accounting firm where he worked. He was quite nervous since he felt that his supervisor didn’t like him. That the supervisor was cold and standoffish to everyone in the department was lost on Alex. He just assumed that the supervisor was planning on firing him from his probationary employment. Alex was therefore quite surprised when the supervisor told him that he was eligible for permanent employment.
Discussion
Young children relate to the world through their own inner experience. In the vast majority of children, the ability to recognize that others may think and feel different than he or she does, only comes with further cognitive development. They automatically assume that what they feel or think is true for others. This tendency is referred to as projection. If he or she is scared then the other child is scared. If he or she is angry then the other child is angry.
While projection in a child is perfectly normal, in a young adult however projection is highly limiting. Projection leads people to interact with others in ways that are inaccurate. A husband who projects his own happiness onto his wife, won’t notice that she is sad and in need of his reassurance. By the time one reaches adulthood, it is expected that one can separate out his or her own thoughts from those of others.
In essence, a personality disorder can be thought of as a repertoire of problem solving kills and expectations that fail to meet the individual’s current needs. While these skills and expectations may have been useful or developmental understandable in earlier stages, they no longer are. The failure to “upgrade” the skill set is the consequence of avoidance to learning new skills and the deep confusion caused by parental validation.
The discrepancies between the skills acquisition of psychological development and physical maturation are manifest in many ways. In fact, almost all of us to some minor degree fail to be fully “grown up” at different times in our lives. It is only when such immaturity or lack of skills is manifest often and significantly gets in the way of an enjoyable life that it is considered a personality disorder.
The DSM-IV lists nine different personality disorders. They are:
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizoptypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive Compulsive Personality Disorder
Each of these personality disorders is organized around a central theme. For example, someone with dependent personality disorder exhibits excessive dependency on others; he or she cannot seem to act independently. Someone with obsessive compulsive personality disorder (NOT obsessive compulsive disorder or OCD) is excessively obsessed with order as well as collecting things even when doing so undermines other dimensions of his or her own life such as social relationships or career. Someone with antisocial personality disorder has little regard for the feelings and rights of others.
It is important to note that borderline personality disorder is different from other personality disorders in four ways. First of all, individuals with borderline personality disorder often suffer from other, highly treatable, psychiatric disorders. Such disorders are clinical depression, any of the bipolar disorders such a bipolar I or bipolar II, and post-traumatic stress disorder (P.T.S.D.).
Furthermore individuals with borderline personality disorder often exhibit characteristics of other personality disorders. This is especially the case with antisocial personality disorder, histrionic personality disorder, dependent personality disorder, and narcissistic personality disorder.
The third difference between those with borderline and those with other personality disorders is that individuals with borderline live in a great amount of inner pain. People with personality disorders are usually quite untroubled by their habits and idiosyncracies. It is other who are frustrated by them. People with borderline however usually live in an unremitting state of fear, rejection, chaos, and misery.
Finally, unlike those with other personality disorder, individuals with borderline personality disorder are significantly more likely to improve with treatment.
There are many, many resources that explain each of these personality disorders. For those looking for the authoritative book on the subject, The Diagnosis and Treatment of DSM-IV Personality Disorders, by Len Sperry, M.D., Ph.D. is an excellent place to start.
How One Is Diagnosed With A Personality Disorder
Fewer aspects of professional psychology and psychiatry are fraught with more inconsistency than personality disorders. Have ten clinicians evaluate someone for a personality disorder and there may very well be ten different opinions. Yet as surprising as such confusion may seem, psychological diagnosis is very difficult. After all, objective tests such as a biopsies and x-rays have not been developed for psychological diagnosis.
Instead, clinicians must draw upon highly subjective exams of psychological and social functioning to accurately diagnosis any psychological disorder. Still, diagnosis is part of the process of repair and healing. Accurate diagnosis can point the way towards a much brighter future.
In the best case diagnostic scenarios a large amount of data is first collected about the person seeking assistance. Data collection begins with a complete medical evaluation to determine how the person’s health may be contributing to his or her psychological difficulties. The person is then tested for difficulties with memory, attention, and perception processing since deficits in these areas can understandably undermine psychological and social adjustment.
Exhaustive psychological interviews are conducted with the person. These inventories evaluate how he or she interacts with others, manages stress and fears, and how they self comfort. Self-report questionnaires that assess personality traits such as hostility, depression, impulsivity, and anxiety are administered. Family members and others are interviewed for their experiences with the person and his or her difficulties. This mass of data is then analyzed to determine the factors that cause the difficulties in question.
Such an exhaustive diagnostic process is always helpful. Yet it is often not practical for a number of reasons. For one thing, the expense is often not covered by insurance (although ironically far more expensive diagnostic tests such as MRI’s are commonly covered). Furthermore, patients and their families often do not know to ask for psychological assessment when seeking assistance. When exhaustive diagnostics cannot be performed, a competent professional should be sought for consultation. Such a professional will most likely advanced training and supervised work experience in the treatment of individuals with personality disorders. They must also be willing to invest the time of understanding the patient and his or her social background.
Regrettably, these procedures are only rarely performed. Poorly trained and confused professionals often give many people a seat-of-the-pants diagnosis. Such diagnoses often are inaccurate to the extent that time, money, and hope is squandered on the wrong treatments. That such diagnoses are made in such cavalier ways shows a fundamental lack of respect for the patient, his or her family, and ultimately for the clinician himself.
Thursday, September 27, 2007
Returning To Peace: Some Introductory Thoughts
Borderline Personality Disorder.
Incurable.
Untreatable.
Impossible.
These are the typical reactions of many mental health professionals to the condition known as borderline personality disorder. People with borderline are considered the most difficult to treat. Their seemingly unpredictable mood swings, frequent intense outbursts, and fragile sense of self can cause many otherwise competent professionals to throw up their hands.
Of course, the individuals with the disorder are just as baffled as the professionals. So many precious lives are controlled by inscrutable inner forces. Therapy, medication, hospitalization after hospitalization, folk healing. Nothing seems to help.
Some find temporary relief in self destructive behaviors such as drug use, behavioral addictions like sex and shopping. Others find self mutilation able to calm their inner turmoil. Obviously the toll on family life, work, career, social relationships, and spirituality is heavy. It is little wonder that people with borderline personality will try anything to stop their intense suffering.
In the last fifteen years however the situation has improved. With the publication of Cognitive Therapy Of Borderline Personality Disorder, psychologist Marsha Linehan ushered in a significant, new perspective on borderline. Dialectical Behavioral Therapy, a system of treatment for people with borderline that Linehan developed, created hope that people a system of treatment for people with borderline that Linehan developed, created hope that people could live without all the agony.
Furthermore, developments in psychopharmacology (the use of medication to treat psychological conditions), psychotherapy, and educational psychology have given sufferers of borderline and their families reason for real optimism. As a psychotherapist trained in the DBT method and having thousands of hours of experience treating adults with borderline personality disorder, I have witnessed the dramatic turning around of wounded lives. The time for hope has arrived.
Returning To Peace is intended to get the good news about borderline personality disorder out. Returning To Peace brings together the latest scientific understanding of borderline personality disorder with tried and true techniques for finding a way through the chaos. Most importantly, readers will find reason for a new optimism about a disorder that for too long has been shrouded in shame and confusion.
Why A Special Book For Torah Observant Jewry?
When it comes to recovery from borderline, the Torah observant Jew has some unfair advantages.
Allow me to explain:
For many years, religion was viewed with contempt by many of the greats of psychology. Understandably, religion responded with distrust of professional psychology. The result were two "sides" who despite their many common aspirations, would not learn from each other.
Over the years however this feud thawed. This has been especially the case among Torah observant Jewry. More and more frum people and communities have turned to the mental health community. It is no longer difficult to find superbly trained, compassionate b'nay Torah for the gamut of mental health problems. This should be a source of great pride to us all.
Just as the religious have turned to psychology, psychology has taken a fresh look at religion. In the last fifteen years, psychological researchers have flocked to the religious to understand the many psychological benefits of religious faith and practice. The most well known of these scientists are Martin Seligman and the late M. Scott Peck.
Most ironic however is the integration of religious spiritual practices into psychology. Prayer, loving kindness, faith, and spirit are all accepted parts of this new psychology. What was once rejected is now embraced. Go figure!
Thus I was hardly surprised when I began learning about cognitive therapy or reading Dr. Linehan's Cognitive Therapy Of Borderline Personality Disorder. In fact the more I integrated their techniques into my clinical practice the more I realized how close many of the most basic dimensions of Yiddishkeit were being 'copied' in these scientifically validated treatments. Davening and chessed were examples of 'opposite actions'. The mitzva of tochacha and other interpersonal mitzvos paralled the 'DEAR MAN' technique. The many brachos that we say throughout the day makes mindfulness practice come like a snap. In fact, it began to dawn on me that a spirited Torah observant lifestyle offers a kind of unfair advantage. And when it comes to borderline personality disorder one needs every advantage.
About The Title
Over the last fifteen years, I've worked with hundreds of adults with borderline. When I include the children, parents, spouses, teachers, and coworkers of people with borderline, it is safe to say that I have encountered thousands. Through individual psychotherapy, group therapy, and family treatment I've become intimately familiar with borderline. The more I sit with people and listen to them, the more I learn about the disorder and the real people who suffer with it. And while I would never misrepresent myself as a true insider, I've been able to form a most personal view of borderline personality disorder.
So what have I learned about this disorder? What have I learned about the very real people who intensely suffer as a result of borderline? Perhaps the most significant realization is that people with borderline want more than anything to live in peace. The person with borderline often lives conflict with their world. Harmony and comfort are states so rarely experienced!
Hence, the title of the book that you hold in your hands. Returning To Peace flows from my heart directly to your heart with one goal in mind: to help you find a measure of peace.
Incurable.
Untreatable.
Impossible.
These are the typical reactions of many mental health professionals to the condition known as borderline personality disorder. People with borderline are considered the most difficult to treat. Their seemingly unpredictable mood swings, frequent intense outbursts, and fragile sense of self can cause many otherwise competent professionals to throw up their hands.
Of course, the individuals with the disorder are just as baffled as the professionals. So many precious lives are controlled by inscrutable inner forces. Therapy, medication, hospitalization after hospitalization, folk healing. Nothing seems to help.
Some find temporary relief in self destructive behaviors such as drug use, behavioral addictions like sex and shopping. Others find self mutilation able to calm their inner turmoil. Obviously the toll on family life, work, career, social relationships, and spirituality is heavy. It is little wonder that people with borderline personality will try anything to stop their intense suffering.
In the last fifteen years however the situation has improved. With the publication of Cognitive Therapy Of Borderline Personality Disorder, psychologist Marsha Linehan ushered in a significant, new perspective on borderline. Dialectical Behavioral Therapy, a system of treatment for people with borderline that Linehan developed, created hope that people a system of treatment for people with borderline that Linehan developed, created hope that people could live without all the agony.
Furthermore, developments in psychopharmacology (the use of medication to treat psychological conditions), psychotherapy, and educational psychology have given sufferers of borderline and their families reason for real optimism. As a psychotherapist trained in the DBT method and having thousands of hours of experience treating adults with borderline personality disorder, I have witnessed the dramatic turning around of wounded lives. The time for hope has arrived.
Returning To Peace is intended to get the good news about borderline personality disorder out. Returning To Peace brings together the latest scientific understanding of borderline personality disorder with tried and true techniques for finding a way through the chaos. Most importantly, readers will find reason for a new optimism about a disorder that for too long has been shrouded in shame and confusion.
Why A Special Book For Torah Observant Jewry?
When it comes to recovery from borderline, the Torah observant Jew has some unfair advantages.
Allow me to explain:
For many years, religion was viewed with contempt by many of the greats of psychology. Understandably, religion responded with distrust of professional psychology. The result were two "sides" who despite their many common aspirations, would not learn from each other.
Over the years however this feud thawed. This has been especially the case among Torah observant Jewry. More and more frum people and communities have turned to the mental health community. It is no longer difficult to find superbly trained, compassionate b'nay Torah for the gamut of mental health problems. This should be a source of great pride to us all.
Just as the religious have turned to psychology, psychology has taken a fresh look at religion. In the last fifteen years, psychological researchers have flocked to the religious to understand the many psychological benefits of religious faith and practice. The most well known of these scientists are Martin Seligman and the late M. Scott Peck.
Most ironic however is the integration of religious spiritual practices into psychology. Prayer, loving kindness, faith, and spirit are all accepted parts of this new psychology. What was once rejected is now embraced. Go figure!
Thus I was hardly surprised when I began learning about cognitive therapy or reading Dr. Linehan's Cognitive Therapy Of Borderline Personality Disorder. In fact the more I integrated their techniques into my clinical practice the more I realized how close many of the most basic dimensions of Yiddishkeit were being 'copied' in these scientifically validated treatments. Davening and chessed were examples of 'opposite actions'. The mitzva of tochacha and other interpersonal mitzvos paralled the 'DEAR MAN' technique. The many brachos that we say throughout the day makes mindfulness practice come like a snap. In fact, it began to dawn on me that a spirited Torah observant lifestyle offers a kind of unfair advantage. And when it comes to borderline personality disorder one needs every advantage.
About The Title
Over the last fifteen years, I've worked with hundreds of adults with borderline. When I include the children, parents, spouses, teachers, and coworkers of people with borderline, it is safe to say that I have encountered thousands. Through individual psychotherapy, group therapy, and family treatment I've become intimately familiar with borderline. The more I sit with people and listen to them, the more I learn about the disorder and the real people who suffer with it. And while I would never misrepresent myself as a true insider, I've been able to form a most personal view of borderline personality disorder.
So what have I learned about this disorder? What have I learned about the very real people who intensely suffer as a result of borderline? Perhaps the most significant realization is that people with borderline want more than anything to live in peace. The person with borderline often lives conflict with their world. Harmony and comfort are states so rarely experienced!
Hence, the title of the book that you hold in your hands. Returning To Peace flows from my heart directly to your heart with one goal in mind: to help you find a measure of peace.
What FrummyDBT is all about
Hey there people. About a year ago, a mentor of mine encouraged me to write a book about borderline personality disorder (BPD). It seems that in this age of blogging, it made sense to publish my thoughts and writings on this “gigantic” topic as they are come to mind. While it is my plan to ultimately publish my ideas as book, frummydbt will serve as a first draft.
BPD has been a professional and personal interest of mine for many years. As a young therapist in the early nineties, I worked at a facility that was one of the first on the east coast of the United States to have fully integrated dialectical behavioral therapy (DBT) into the services offered there. DBT is a treatment system designed by Marsha Linehan based on her fascinating understanding of borderline. The DBT system worked for many of our patients and I’ve been hooked on it ever since.
As a personal interest, borderline has fascinated me ever since I learned about it in my university days. Borderline has certainly shaped the lives of many people who I know and love. What’s more is that I’ve made peace with the very real possibility that I’ve exhibited some borderline traits over the years. Good therapy, loving relationships, and mazal have for the most part helped me stay in the land of the living even when my self destructive personality traits have wanted to undo me.
On a deeper level in fact, I’ve come to believe in fact that it is my borderline traits that are my most prized possessions. As a trained hypnotherapist and as a committed Jew, I’ve learned that “symptoms” and “problems” are often invitations to creativity and deeper spiritual connection. When I saw how DBT and other disciplines could transform the liabilities of personality disorders, I realized that my unstable moods, my seeming endless identity confusion, suicidal fantasies, and other painful aspects of who I am were in fact potential assets! My life is filled, thank God, with great joy and power now, which I believe is connected to my own BPD.
BPD has been a professional and personal interest of mine for many years. As a young therapist in the early nineties, I worked at a facility that was one of the first on the east coast of the United States to have fully integrated dialectical behavioral therapy (DBT) into the services offered there. DBT is a treatment system designed by Marsha Linehan based on her fascinating understanding of borderline. The DBT system worked for many of our patients and I’ve been hooked on it ever since.
As a personal interest, borderline has fascinated me ever since I learned about it in my university days. Borderline has certainly shaped the lives of many people who I know and love. What’s more is that I’ve made peace with the very real possibility that I’ve exhibited some borderline traits over the years. Good therapy, loving relationships, and mazal have for the most part helped me stay in the land of the living even when my self destructive personality traits have wanted to undo me.
On a deeper level in fact, I’ve come to believe in fact that it is my borderline traits that are my most prized possessions. As a trained hypnotherapist and as a committed Jew, I’ve learned that “symptoms” and “problems” are often invitations to creativity and deeper spiritual connection. When I saw how DBT and other disciplines could transform the liabilities of personality disorders, I realized that my unstable moods, my seeming endless identity confusion, suicidal fantasies, and other painful aspects of who I am were in fact potential assets! My life is filled, thank God, with great joy and power now, which I believe is connected to my own BPD.
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