Although Loving Someone with Borderline Personality Disorder was published in 2011, I have only recently learned about its existence. I am very grateful to the therapist who is trained and certified in DBT and who recommended the book to me. Each time I review sections, I find more insights and will probably update this post as I do.
The author is Shari Y. Manning, PhD, who has been focusing on the treatment of people diagnosed with BPD since 1993. The book is available in paperback [Guilford Press, 2011] and includes a foreword by Marsha M. Linehan, PhD, who created Dialectical Behavioral Therapy (DBT) and who revealed in the New York Times in June 2011 that she fought BPD, too. I felt compelled to read the book with the goal of improving my understanding of this diagnosis as well as relating more effectively to a person with the diagnosis.
As with other posts, I've highlighted some of the things I gained from reading the book. This isn't a true book review.
Synopsis: Shari Manning provides us - parents, family members, partners, and therapists - with the tools to help us stay grounded as well as
coach our loved ones away from distressing thoughts and harmful behaviors towards living a
more productive and serene life.
The book's underlying premise - one that I had not heard before and that provides a very different view of what's going on - is found
on p.3 of the introduction, and that is,
"....The truth as you'll learn
in this book, is that your loved one is not a terrible person, as much
as he or she may have a pattern of some pretty terrible behavior. It's
not that your partner or family member wants to create chaos or make
anyone miserable. It's that your loved one can't do the right thing,
get along with others, or make the choices that seem so plainly correct
to everyone else - because he or she doesn't know how.
That may seem awfully hard to grasp. Doesn't everyone just have a
feel for what it takes to keep a job or a friend, how much is too much
to ask of those who care about us, and how to exercise a little
self-control! Wasn't your loved one born with the same instincts and
the same opportunities to learn how to navigate the world as the rest of
us? As difficult as it is to believe, the answer is no. People with
BPD were born with an invisible, innate difference that profoundly
changed the landscape for them when they were growing up......."
The author cites research that sounds very familiar to
those of us who have believed all along that something "else" is going
on for those of our loved ones who develop an eating disorder, the reason I began this blog.
Even if the BPD diagnosis is still unclear, the techniques Manning shares are useful and echo
in many ways those provided by Dr. Xavier Amador who I have quoted many
times from his book, I am Not Sick, I Don't Need Help and from his
theory of communication - LEAP - that is summarized here.
Manning explains the disorder, introduces the reader to dialectical behavioral therapy, provides extensive examples of how to respond - not react!! - to our loved ones through validation, describes the varying behaviors of people diagnosed with BPD, and (as does Amador's) offers important information on how to deal with crises as well as get help (both for us and for our loved one). I will touch on these topics below.
As readers of my blog know, I don't like the DSM's terminology Borderline Personality Disorder. Francis Mark Mondimore, MD, and Patrick Kelly, MD, helped me understand and articulate why not on pages 229-231 of their book, Borderline Personality Disorder: New Reasons for Hope. The terminology can cause one to think the condition is permanent and this isn't necessarily true. The terminology also can undermine the person's view of himself/herself. Two strikes before treatment has even begun!! For some time I've been calling BPD emotional dysregulation disorder because the person with the diagnosis cannot regulate their emotions and the behaviors that evolve from those emotions. I also want to move away from this terminology because it conjures up what was thought to be an uncurable condition to the point that many therapists won't accept people with this diagnosis as patients. Better yet, there are more therapists classically trained in this technique (in my opinion critical if someone with this disorder is to be treated well). I am grateful that this situation has changed.
Recently, I read and provided my impression of Borderline Personality Disorder: New Reasons for Hope by Francis Mark Mondimore, MD, and Patrick Kelly, MD. I want to repeat their distillation (as they term it) (p. 251) of this complicated disorder because this paragraph summarizes background that Manning also provides in great detail:
"Borderline personality disorder develops when a child born with extremes of
temperament and a biologically
rooted difficulty managing emotions encounters a mismatched childhood
environment. This mismatch may be quite subtle or quite pathological but is
experienced by the child as inconsistent and unpredictable, leading her to
develop a damaged sense of self and the expectation that others will continue to
be inconsistent, unpredictable, and ultimately unreliable and abandoning. This
in turn causes profound emptiness and hopelessness to dominate her emotional
life. To cope with her emotional extremes, and her desperate and painful
unhappiness, she develops self-destructive coping behaviors like addictions,
eating disorders, and self-mutilation. Frequently, these individuals also
suffer from biologically based mental illnesses that exacerbate all their other
problems and prevent behavioral and psychological treatments from helping
them.
....Borderline personality disorder results from an interaction of
genetic and other biological factors, inborn temperament, and childhood
experiences and is usually complicated by the development of abnormal behaviors
and psychiatric illnesses. All these factors require therapeutic attention,
often by different professionals using different approaches."
To help other therapists effectively understand and address what Mondimore and Kelly describe above, Dr. Linehan created a five-part reclassification/subdivision of dysregulation:
- emotional dysregulation
- interpersonal chaos
- behavioral dysregulation
- loss of sense of self
- cognitive dysregulation
Most of these are self-explanatory and Manning provides excellent and clear examples; however, the one that I struggled to understand was the loss of sense of self. Manning defines this by saying (p. 22-23)
"....People with BPD often don't have a sense of what they like, what their values are, or who they are....In the moment, they are unable to identify what their experience is -- what they feel in their bodies, what their thoughts and emotions are. They often judge themselves very harshly and struggle to develop realistic goals for the future.....Not knowing who you are is a byproduct of the extreme emotionality of people with BPD.... They feel lost and empty."
Very simple - perhaps too simple because the issue is much more complicated - examples of how this sense of self can be lost [when compounded] are hearing, as a child, a person tell them that of course they aren't scared (when they are scared to death in that situation); that brussel sprouts taste good (I sure didn't think so as a kid); to quit crying (as though emotions can be turned on and off on a dime); to stop telling lies (the information is not a lie but because the behaviors they are reporting are unbelievable - such as abuse from another family member - the family member squelches the child's need for support), etc., etc. Manning provides a much more comprehensive discussion of the development of this aspect of the disorder.
It's important to remember here that the term used by Mondimore and Kelly - mismatched environment - is a very important piece of the puzzle. Who really knows how this happens in some and not others or why? And, as time goes on, we may learn that the emphasis falls more distinctly on inherited traits and less on environment. The fact remains, though, that studied interaction is very important.
I've discussed in another post about communication (with links to previous posts) why family therapy really helps parents in particular understand that each of their children is unique. These are my remarks and not those specifically found in Manning's book but the reader certainly finds similar examples. If, for example, your family isn't as demonstratively affectionate (or less so) as your individual child may need it to be because of his/her own temperament, those who take the time to connect with their child(ren) may find unexpected rewards. Of if your family's culture is to keep a stiff upper lip in times of terrible sadness such as when a family member or even a beloved pet dies, yet the son's or daughter's sensitivity to such events is profound, how do they reconcile - or can they - their feelings with their family's seeming insensitivity. One might ask, what's wrong with me or think, I do not belong in this family.
The bottom line, once this disorder takes hold, is that people struggle with varying states of this dysregulation every single day.
Their solutions to deal with the fall-out of this disorder range from cutting to impulse buying or even shoplifting to alcohol and/or drug abuse to running away to shattering a beloved relationship to suicide attempts. These behaviors can help the person release the pain they are feeling but the release, even though it may feel "good" in the moment, provides negative reinforcement, meaning that it is rewarding in a negative way.
What we all want to happen instead is for the person with this diagnosis to learn to substitute other positive behavior so they can get on with a happy, productive life.
Marsha Linehan came up with the "how". She developed dialectical behavioral therapy (DBT) to (p. 27)
"....provide an alternative in the form of specific skills that help them maintain good relationships, tolerate distress and survive crises, and learn to use their emotions as the important resource they were designed to be [emphasis mine.]"
Emotions are part of what makes us human. Manning distinguishes three emotional tendencies of those with emotional dysregulation:
- extreme emotional sensitivity
- emotional reactivity (no pausing; just acting)
- slow return to baseline - perseveration
Imagine the physical and psychological energy this must consume!
So, you might ask, where do I come in? What can I do without trying to take on the role of a therapist for which I am not qualified? How can I avoid
fragilizing my loved one
[Manning's term and a descriptive word!]. As family members, we want to encourage and
praise our loved one's growing competence as they employ the principles of DBT. Believe and remember that this competence
can develop. And we also need to understand, according to Manning, where our loved one is in the process so we can provide appropriate support as needed. She provides tools to help us accomplish this, too.
Your task is to (p. 48)
"Understand the tasks of emotional regulation that your loved one [and you!] needs to be able to perform."
Think about the above statement for a moment. How helpful can you be if you, too, are emotionally reacting to whatever it is your loved one has said or done.
How do you help your loved one [and you] (p. 48):
- reorient attention
- Up-regulate or down-regulate our physiological arousal
- Stop ourselves from doing whatever it is our emotion and mood tell us to do
- Have a life with goals in it that are independent of emotion
To cope with the ups and downs of living, everyone needs to put these four points into action. Throwing temper tantrums as a two-year-old or losing one's temper as an adult are not effective ways (well, maybe they can be but at what cost in the long run if the person perpetuates this behavior) to get what one wants.
As the person who wants to maintain a relationship with your loved one, you can take the steps provided in this book that are the basis for an
extensive discussion, especially about validation, and Manning provides exercises and examples to help you do this. To elaborate on the concept of validation, Manning incorporates
Linehan's six levels of validation and I've provided a link to an article about the levels that also appeared in
Psychology Today. As I've said, I encountered some of these in Amador's book. I also learned aspects of this in a mediation course. Dispute resolution includes some of this as well.
Here are the suggested steps for you to take to help your loved one:
(p. 51)
- Assess: ask [objectively] what has happened.
- Listen actively; don't contradict, judge, or say your loved one is overreacting.
- Validate: find something in what happened that makes sense and is understandable, that you can related to; say what that is.
- Ask if you can help, not to solve the problem, but to get through the moment.
- If your loved ones says no, give him or her space and remember the emotions of emotionally vulnerable people last longer.
Having gotten through the first three of these steps [the first three because I had not been coached in steps 4 and 5], I had asked (so as to put the responsibility onto the person needing to solve the problem), "what are you going to do about it?"
Thanks to Manning, I've come to understand - going back to the five areas of dysregulation - that those with BPD may
not know what to do about it. This can be shocking. Accept that just maybe your loved one needs a complete retraining or even an introduction to problem-solving skills in a variety of settings that are applied to many aspects of life to make a successful go of it. If you wonder about the veracity of this possibility, you can arrange for neuropsychological testing that will identify deficits that need attention.
So, what are effective problem-solving steps? Manning reviews seven suggested steps and also enhances the discussion on Active-Passivity (getting someone else to solve the problem). (p. 138):
- Define the problem: What are you trying to solve here? What are your goals?
- Analyze the problem: What are the facts about the problem and/or the problem situation?
- Generate solutions: Purely brainstorm. Don't exclude any ideas because they are ridiculous or unrealistic.
- Choose a solution: Narrow down the solutions to the one you think will best get you to your goal, will solve the problem, and is the most realistic to implement. [Even this can be quite a bit of work for your loved one.]
- Troubleshoot the solution: What could get in the way of achieving the goal? How will you overcome these obstacles?
- Put the solution into action: Try the solution.
- Evaluate the solution: Did it work? If not, choose another solution from the "generate solutions" list and implement it.
In addition to problem solving and Active-Passivity, the second section of the book addresses
other
faces -- the
experiences --
of BPD; for example, self-invalidation, conflicting
feelings, shame, and apparent confidence.
There's a wrinkle that Manning defines as she examines the concept of apparent confidence. The easiest and simplest way to describe this is to think of a dog learning to sit. In your home or with you in your backyard, your pet doesn't have many distractions and after some practice (with treats), sits when asked. So, off you go to the pet store with your companion on a leash only to find that your pet doesn't listen to your sit command -- doesn't seem to listen at all -- when other dogs and people are present in what to your pet is a new -- and often noisy -- environment.
The same disruption can occur for those with BPD. In a one-on-one conversation or exercises, what comes next having taken these steps appears to be simple and easy for the person to tackle. But add many more people, some of whom might be viewed as being judgmental, noise, the stress of believing that the "right" decision needs to be arrived at, and so forth and suddenly everything seems impossible.
Manning writes, (p. 150)
People with BPD seem to have more trouble generalizing behaviors than others largely because, as with so many of their other problems, emotions interfere with learning....If your loved one seems unable to do something in one context that she can do in another, it's not that she isn't trying hard enough, it's that the behaviors literally are not in her repertoire of behaviors for that specific environment.
As you might imagine, shame figures hugely in all of this, too. Going along day after day under these circumstances is incredibly difficult.
Once you are aware of and have accepted all this information, the next
step is to take action or depending on your relationship or energy
level, to find a trained/certified life skills coach.
Absorbing and putting into practice the information that Manning includes in her book takes time, hard work, practice and thoughtful communication on the reader's part. I'm participating in some training sessions, too.
Manning provides the reader with lists, examples and exercises to
help you respond effectively. In fact, she suggests that you xerox
pages and have them handy. One table is on p. 72 and lists the
Five
Steps to Responding Effectively to Borderline Behavior:
- Regulate your own emotion.
- Validate [yourself] (do this at every step).
- Ask/assess.
- Brainstorm/troubleshoot.
- Get information on your role (if any) and what you can plan on hearing about the outcome.
Taking care of oneself is important, too. Manning provides suggestions in another short but effective table about identifying and communicating limits.
Boundaries often is another term people use to describe limits. All these points need practice.
Hopefully, your loved one is also working at least one hour or even two hours a week with a
competent certified DBT therapist. Expect this therapy to last at least six months, possibly a year, and to eventually include group work with others who are motivated to change. What I mean by competent is someone who has taken the training and applies the training completely rather than inserting aspects of it into another form of therapy and who recertifies often, possibly once a year. Your role is to support the work that your loved one is doing as he/she applies his/her learning to the real world. Again, your role is NOT to be the therapist.
If your loved one also has an eating disorder, find a therapist who is willing to work with the DBT therapist to enhance the value of ongoing treatment.
Addition here: remember, that some with BPD will deliberately create the idea of good therapist/bad therapist and interfere with his/her own recovery as a result. This manipulation often is subconscious so if another therapist is added to the equation, s/he and the BPD therapist MUST work together and inform their patient that they are working together. In addition, ask the DBT therapist if s/he seeks regular guidance from another DBT therapist in order to stay grounded and not drawn into the whirlwind that someone with BPD can create.
Part III of the book focuses on the practicalities of dealing with crises and getting help. Here Manning thoughtfully helps the reader reflect on his/her feelings, experiences and actions -- fear, guilt, despair -- leading up to this point. She provides an in-depth section on your loved one's potential for self-harm as well as suicide and in addition examines the pros and cons of inpatient versus outpatient treatment. Finally she provides the names of other resources including organizations developed to provide help to families and those diagnosed with BPD.
In summary and to close, here's a quote from the "Praise for" section of the book by the parents of an adult child with BPD. Jim and Diane Hall who are also family educators for the National Alliance on Mental Illness (NAMI) and the National Education Alliance for Borderline Personality Disorder (NEA-BPD) state:
The title says it all! Dr. Manning explains what she has learned about the true nature of BPD from the experts themselves -- those who have the disorder. She shows family and friends how our instinctive responses to the crises associated with BPD are frequently ineffective or even harmful, and illuminates what we can do differently, providing practical, incisive, step-by-step guidance. The book helps readers understand their complicated relationship with a person with severe emotion dysregulation. It provides valuable tools for dealing with self-harm, suicidality, and hospitalization decisions. Of crucial importance, Dr. Manning clearly affirms that BPD -- and the pain experienced by those who suffer -- is real. We highly recommend this book.
