The Essential Family Guide to Borderline Personality Disorder

by Randi Kreger

  In therapy, the first thing I do is assess how well clients can manage their emotions. Otherwise, we can’t go anywhere. If they’re unable to do so, I teach them to use relaxation CDs until their medication kicks in. I give them mindfulness exercises and other homework and talk to them about experiences that are really throwing things off. We walk through every step of how this happened and how they might intervene with themselves the next time it happens.

  I have had many high-functioning borderline clients who are not suicidal; for some reason they’re able to moderate their emotions. It may be that they’ve found a good psychiatrist and their medications are working well. It may be that they have a lot of intellectual resources and a career that makes them feel good about themselves, or a partner who is reliable and consistent. All those things help. But even these patients may call several times a day, sobbing and in crisis.

  It’s essential for therapists to have good communication with their client’s psychiatrist. That can be hard because psychiatrists are very, very busy. Typically, I send them a letter that explains the client’s symptoms and gives them my diagnosis and treatment plan. On occasion, they will reply. Some will leave me a voice mail with lots of information about their perception of the client, how they’re going to intervene, what meds they’re going to put him on, and what their plan is. It’s ideal when we’re on the same page in the beginning.

  I take a lot of time to accentuate the client’s strengths and successes. With one patient, I emphasized a lot of her skills in nurturing and loving instead of talking about the night she fell apart during the week. I will talk with her about the six nights that she kept it together instead of the one night she fell apart. I’ll ask, “How did you do that while staying in a good relationship with your husband?” When I do this, clients walk out the door feeling more successful, happier, optimistic, and confident.

  I have a lot of compassion for most of my clients, especially those who are willing to work and those who are emotionally vulnerable. When a patient calls me several times a day, I do get frustrated and tired, especially when that call comes at eleven o’clock at night—or later. I think most therapists who treat borderline clients are very compassionate, in particular if the client can put her guard down.

  Blaise Aguirre, MD, on Diagnosing Minors with BPD

  What follows is an interview with Dr. Blaise Aguirre, medical director of the Adolescent Dialectical Behavioral Therapy Center at McLean Hospital, Belmont, Massachusetts.23

  Kreger: How does one go about diagnosing a child? Are there any tests?

  Dr. Aguirre: Right now, the diagnosis is made using the DSM, although, increasingly, clinicians look for a series of problems in dealing with emotions—especially anger. The adolescents may have chaotic relationships, be confused about their identity and values, practice self-harm, be overly impulsive, or feel empty. They may also present cognitive impairments such as irrational beliefs, paranoia, and dissociation. I don’t know of any childhood conditions, other than BPD, where all these symptoms are likely to occur.

  Parents often say that their child was diagnosed with another disorder that just doesn’t seem to fit and that the medications they were given didn’t work.

  Also, we know that, in some cases, BPD runs in families. We plan to include genetic testing in our future research. We also want to study the question as to which criteria best help in making the diagnosis of BPD in adolescents. We hope to eventually develop a standardized interview that will help clinicians distinguish BPD from normal adolescent behavior. We also hope advanced imaging techniques can help identify brain differences in these children in the future.

  Kreger: How should parents work with clinicians to obtain a diagnosis?

  Dr. Aguirre: As with any specific diagnosis, the more a clinician is familiar with the symptoms, the better he or she can recognize the condition. Because kids can’t drive or might not be sexually active, I include other impulsive and disruptive behavior such as skipping school, so-called hooking up, and sneaking out at night.

  Adolescents who have had more than a year of symptoms often come to us with chronic thoughts of suicide, marked self-loathing, self-injury, relationships characterized with overidealization/devaluation, and stark black-and-white, all-or-nothing-type thinking.

  Their abandonment fears are profound. Many recognize that they test their loved ones endlessly to get them to prove their love, although they know these tests can be very destructive to their relationships.

  Kreger: How do you tell the difference between BPD and other disorders?

  Dr. Aguirre: The main differences lie in the degree of self-destructive behavior, the degree of self-loathing, and the unremitting thoughts of suicide.

  Self-loathing is pretty unique to BPD. Self-injury is very rare in oppositional defiant disorder or conduct disorder, although it may be seen in clinical depression. The impulsivity in attention-deficit/hyperactivity disorder is sometimes similar to the impulsivity in BPD.

  Although adolescents with BPD can be aggressive, this is not a common presenting symptom at our unit. Often, when BP adolescents are aggressive, they feel ashamed or remorseful after the event. Children with conduct disorder generally do not care at all (or at least do not appear to care) if they have hurt someone.

  Two things are absolutely clear. First, adults with BPD almost always recognize that their symptoms and suffering started in childhood or adolescence. Second, adolescents have symptoms that are so consistent with BPD that it would be unethical not to make this diagnosis and treat them accordingly.

  • Part 2 •

  POWER TOOLS

  About Power Tools

  In the first half of this book, you learned just how BPD impairs an individual’s thoughts and feelings, which in turn triggers behaviors such as raging, perceived manipulation, and excessive blame and criticism. You’ve also discovered that your reaction to your family member’s behaviors sets up negative patterns of behavior that leave both of you feeling frustrated and upset.

  In the second half of this book, you’ll find out about five powerful tools to help you organize your thinking, learn specific skills, and focus on what you need to do instead of becoming overwhelmed. The power tools are

  Power Tool 1: Take good care of yourself.

  Power Tool 2: Uncover what keeps you feeling stuck.

  Power Tool 3: Communicate to be heard.

  Power Tool 4: Set limits with love.

  Power Tool 5: Reinforce the right behavior.

  Each power tool will build on the previous one, so it’s essential that you learn them in order. As with any skill, you will need to practice to become better. Start with something simple and build on the strengths and resources you already have. Remember this is a process.

  While these power tools are based in research, both formal and informal, it’s impossible to predict how any one individual will react to them. BPD is multifaceted, and BPD behaviors can be wildly unpredictable. Therefore, you’ll need to take the information and customize it for your particular situation.

  Seek counseling with a mental health professional whose primary concern is you. Don’t allow yourself to be abused; it will not help your BP, and it will harm you. Always remember that safety—both yours and your family member’s—is of paramount concern.

  As you increase your mastery of these five basic skills, you will

  • feel less stressed and run down

  • become more confident and clear about who you are and what you need

  • know where to concentrate your efforts

  • be able to free yourself from nonproductive, aggressive conversations

  • improve your problem-solving skills

  • learn how to help your family member without rescuing him

  • feel more self-assured about setting limits without backing down

  Once you’ve read through the power tools, the next step is to sort through what you’ve learned and determine your priorities. If you own this book, highl
ight as you read. When you’re done, look through what you’ve highlighted and choose just one thing you’d like to learn to do. Make it simple and easy. A great first step is the breathing exercise you’re going to learn about in the next chapter.

  Then visit the resources section in the back of this book. Resources are divided by power tool so you know how to prioritize your reading. Of course, you don’t have to stop there: browse the Internet, go to a bookstore, or take a class in what interests you.

  Don’t expect to be perfect. You will need to practice using your tools. Some tools will come more easily to you than others; that’s normal. There may be habits you need to drop and habits you need to pick up. If you start to feel overwhelmed, you’re doing too much. You will find a wealth of resources at www.bpdcentral.com, including links to Web sites, support groups, and other training materials.

  If you don’t feel like putting all this in motion right now, that’s fine, too. Take your time. People go through different stages as they think about changes they might want to make in their lives, from thinking about making changes to tentative exploring, from tentative exploring to preparation, then from preparation to action and maintenance.1

  People also go through stages in their relationships with people who have BPD: the confusion stage, usually before they learn about BPD; the outer-directed stage, when they try to change their family member; the inner-directed stage, where they look inward; the decision-making stage; and the resolution stage, when they implement their decisions and make changes as needed.

  Now, on to the power tools!

  Chapter 7

  Power Tool 1:

  Take Good Care of Yourself

  A good night’s sleep should be declared a basic human right.

  • Pierce J. Howard, The Owner’s Manual for the Brain •

  The stress of having a family member with borderline personality disorder can lead to a number of physical and mental issues. They can be mild to severe, and include the following:

  • irritability or outbursts of anger

  • problems falling or staying asleep

  • crying spells

  • difficulty concentrating

  • feeling jumpy and easily startled

  • loss of interest in activities and life in general

  • feeling detached or emotionally numb

  • unintended weight gain or loss

  • feeling hopeless or ashamed

  • feeling fatigued and weak

  • unexplained physical problems (such as headaches, stomach problems)

  • loss of interest in sex

  • depression, panic attacks, or other psychological problems

  As a non-BP, you deal with stressful issues related to having a borderline family member daily. The problems surface in almost every area of life—finances, relationships, work. In addition, if you begin to isolate yourself out of shame, the result is a lack of social support. Each of these difficulties has serious consequences to your mental and physical health.1

  Power Tool 1 is the foundation for all other power tools. You can’t operate power tools safely and effectively if you’re too tired, distracted, or otherwise not at your best. That’s true whether you’re talking about the power tools in this book or those stored in your garage or basement.

  You can’t help your BP raise her self-esteem if yours is lodged twenty feet underground. Your “I love you’s” won’t be reassuring if you say them through clenched teeth because you haven’t dealt with your anger. And if you’re trying so hard to please your borderline partner that you’re losing what makes you you, then what’s the point?

  Establish Lines of Support

  Just as your family member may need a treatment team, you need a support team. Potential team members include your friends, other family members, your community, and perhaps a therapist.

  A Therapist for You

  Therapists who practice dialectical behavior therapy in a clinic meet two to four times a month to obtain suggestions and support for their work from their fellow clinicians. When therapists specially trained to work with the borderline population require the assistance of other therapists, you can be sure that family members need help, too.

  Because therapists are not emotionally connected to your BP, they see your situation in an unbiased and nonjudgmental light. In addition to listening and validating your feelings, they can guide you in separating the truth from your family member’s distortions and help you become aware of your role in the relationship. They offer practical help, too, such as suggesting different courses of action or helping you practice new communication skills.

  Some non-BP partners have a pattern of getting into unhealthy relationships. This is something to explore in therapy so it doesn’t happen again. If you and your borderline partner have a child together who is a minor, the child may need support, too, depending on the family environment. Be watchful; non-BP partners almost always underestimate the effects of a chaotic and argumentative home environment on children.

  If you are a sibling or an adult child of someone with BPD, you probably have two issues: coping with your family member in the here and now, and examining how having a borderline sibling or parent has shaped your own personality.

  Friends and Family

  If you only get one thing out of this chapter, let it be this: Do not become isolated. Reach out to others. Don’t let yourself be embarrassed into isolation or pushed into it by threats, implied or outright. That is no way to live.

  One of the best things friends and family members can do is listen. They don’t need to have answers. They may not understand everything you’re going through—in fact, they probably won’t. That’s okay. You need a pair of ears to hear you and a pair of arms to hug you. The mouth is optional.

  Depend on friends to give you reality checks. When you’re in a relationship with someone who has BPD, it’s easy to lose sight of what is normal. If two or more friends are giving you the same message, listen carefully, even if you don’t want to hear it. (On the other hand, look for aid elsewhere if you’re feeling judged or invalidated. Like everything else, it’s a balancing act.)

  Depending on the situation, it may be helpful if your support people are not too close to the situation. If they also have close relationships with your BP, that could interfere. You should feel safe with whomever you talk to.

  A Community

  Communities are places where we feel part of a larger social whole. People in communities may share a web of relationships, common values or interests, and a shared history. Whether your community is small or large, right next door, or online, these connections matter.

  You may find your community (or communities) in your actual neighborhood. Take the time to learn the names of your mail carrier and pharmacist. Say hi to the older gentleman who’s always sitting in the yard when you take your dog for a walk. Churches, workplaces, and schools harbor communities. The Web site www.meetup.com can help you find or start a group for non-BPs.

  Today, thousands of communities are a keystroke away on the Internet. Some, like Welcome to Oz, revolve around BPD (see “Resources” on page 243). You can find them by interest, by geography, by faith, by age, by ethnicity, by gender, and by just about anything else. If you’re a fan of a celebrity, book, movie, or musical group, you can find groups of people who share your interest. If you like underwater basket weaving under a full moon, there’s probably an online community for you.

  Take Things Less Personally

  When you personalize what someone says, you essentially bring down a hail of guilt, shame, and loss of self-esteem on yourself. You end up running around in circles trying to figure out what is wrong with you, all in a futile effort to control another person’s behavior—in this case, someone whose behavior is hardwired into her brain.

  Personalization is actually a two-step process. Have you ever seen slow- motion video of a car crash test dummy hitting the windshield? There are actually two crashes. The car moves
forward, then bang—hits the wall. That’s hit number one. In the next second, the dummy (or you, if you don’t wear your safety belt) is propelled forward, hitting the windshield. That’s crash number two, the crash that does the real damage.

  Something similar—but much more subtle—happens when you take things personally. First comes our BP’s behavior: an accusation, an insult—whatever. That’s crash number one. Half a second later, thoughts like these flash through your mind:

  • “I must have done something to provoke her.”

  • “He’s doing this to hurt me.”

  • “If she says this terrible thing about me, it must be true.”

  All these thoughts constitute crash number two, personalizing the behavior. You can’t stop crash number one, which is whatever your BP says or does. It hurts. But you can stop the useless pain from crash number two because it’s going on in your mind, and you have control over your mind.

  Elayne Savage, PhD, the author of Don’t Take It Personally! says, “When we take things personally, we think the world revolves around us. It’s all about me-me-me. If we lose sight that there may be something going on with the other person, we’ll miss the opportunity to empathize, or put ourselves in their shoes.”2

  Keep reminding yourself that wildly out-of-place and senseless behaviors are the result of a brain disorder that can be explained scientifically. When you feel yourself starting to take something personally, reread the first part of this book. Let those chapters be your safety belt.

  Get a Handle on Your Emotions

  Is it normal to feel like you’re going crazy, like you want to scream in frustration, pummel a punching bag, and lie in bed and sob into the pillow? You bet! Having a loved one with BPD can bring about an amazing number of concerns. Space permits us to look at only four: worry, guilt, low self-esteem, and anger.