Dr Allens Book for Therapists about Treatment of Borderline Personality Disorder Now Available in Paperback

Now available in paperback at http://www.amazon.com/Psychotherapy-Borderline-Patients-Integrated-Approach/dp/1138012750/ref=mt_paperback?_encoding=UTF8&me=

Borderline Personality Family Dynamics The Parents Part I

In my post of 2/6/11, Dysfunctional Family Roles, Part I: The Spoiler, I opined that the basic problem in the "borderline" family (one that produces offspring with borderline personality disorder [BPD]) is that the parents in such families see the role of being parents as the end all and be all of human existence, but all the while, deep down, they either frequently hate being a parent or see their parent role as being an impediment to their personal fulfillment.

I also explained how the person with BPD develops the Spoiler role in response to the double messages that this emotional conflict leads such parents to give off to their children.

It's all well and good to try to understand the behavior of the individual with BPD in terms of a response to parental problems, but that just kicks the question of an explanation for the disorder back a generation. In order to fully understand BPD, we have to ask, "What on earth makes these parents so damn neurotic that they compulsively have children and then covertly resent them?" 

If the parents are not patients themselves, the only way for a therapist to get to the bottom of this is by helping the patient with BPD to construct a special type of family genogram.  A genogram is sort of an emotional family tree, and is a mainstay of the type of family systems therapy designed by family therapy pioneer Murray Bowen.

Murray Bowen

Using historical figures and geneology records as illustrations, the book Genograms: Assessment and Intervention by Monica McGoldrick and Randy Gerson describes how genograms can be constructed .

Monica McGoldrick

The genograms described by Bowen therapists are, in my mind, incomplete.  They concentrate on which relatives were overinvolved or underinvolved with which other relatives, and whether these relationships were hostile or friendly.  IMO, this leave out an awful lot of important information.  Two individuals may easily have a hostile and enmeshed relationships with each other over one area of functioning, say work or love, and yet still be very distant, friendly and uninvolved with each other over a different area of functioning. 

In other words, these genograms omit the content of the family squabbles.  When the content is added to the genogram, one can then look for the historical experiences of the family that may have created the picture that is taking place in the present.

While I have indeed seen the parents of adult children who exhibit BPD in therapy and traced their genograms, I have also coached patients with the disorder themselves to construct their family's genogram.  We try to go back as far as we can to figure out what family experiences led to the parents' conflicts.  Sometimes the story goes back more than three generations and we may lose the historical scent, so to speak, in that no one alive knows what happened way back whenever.  Usually, however, certain patterns come to the fore.

In Part I of this post, I will describe the one most common major issue, and the resultant behavior patterns, that I have discovered leads individuals within a family to develop a severe conflict over the parenting role.  In Part II, I will describe some other ones.

All of these issues may seem very common everywhere, and indeed they are.  Most families that face them do not produce emotional conflicts significant enough to create BPD pathology.  Rather, the issues in families that do have been magnified signficantly by an interacting tableau of historical events impacting the family and the individual proclivities of each and every family member and descendent. 

I will not describe the details of the magnification process here, but a full explanation can be found in my book, A Family Systems Approach to Individual Psychotherapy.

The most common cause of conflicts over the parenting role stems from cultural rules regarding gender role functioning.  Over the last century the opportunities open to women to explore their interests and ambitions have gradually expanded, and having a lot of children certainly put a damper on their ability to do this.  If a woman came from a family where the women were very bright and had a natural proclivity for being ambitious career-wise, this would often create difficulties for them since they lived in a male-dominated culture that was at best unfriendly to female career ambitions. 

To demonstrate how this might play out in a hypothetical family, I often discuss the evolving role of women in the United States since World War II. During the war, when all the men went off to fight, women in the United States entered the workforce in large numbers for the first time - in order to build the airplanes and tanks.  This phenomenon was known as "Rosie the Riveter." 

Some women found the experience of a career exhilerating, but when the war ended, they had to go back to just being wives and mothers once again.  The US govenment even made propaganda films thanking the women for their important work, but then encouraging them to go home and get barefoot and pregnant once again.  I have seen some of them; by today's standards they are positively jaw dropping. But effective. The Rosies did what they were told, and that is why we had the baby boom.

Rosie the Riveter

The daughters of this generation came of age in the sixties, when the women's liberation had started in earnest.  Women were more and more torn between the earlier gender role requirements and the new cultural opportunities expectations, and some women (as well as some men) did not make the transition very smoothly at all - for a variety of reasons.  One common reason: the Rosie the Riveters, having had a taste of the career world, would vicarioulsy live through the career aspirations of their daughters, but at the same time be extremely frightened by them.

Having children could easily bring the whole craziness to a head for some families.  Even today, parents feel very guilty about not spending as much time with their children as they would like, and they are often criticized at every turn by their own parents as well as the Phyllis Schlafly's of the world.  (Phyllis Schlafly was a career woman who made a career out of bashing career women).

Phyllis Sclafly

In doing genograms, one can often see just how far a family's operating rules lag behind the current cultural norms .  In anthropology, this problem is called cultural lag.  The cultural progression in Western nations, which is mimicked within certain families, was thus:  First, women really could not have careers at all.  Then, they could have careers, but only when they were single.  Then - and here is where many families with BPD members are stuck - they could only have careers when they had not yet had children.  Then, they could have careers even if married with children, but they had to give priority to the husband's career.  Last, both men and women were entitled to the same freedom.

Gender role confusion and conflict can, given the right combination of ingredients, create a nasty intrapsychic conflict over the very act of procreating. 

In Part II of this post, I will look at the rest of the historical factors and patterns that can create such a conflict: Deaths and illnesses, financial reverses, religious demands, parent-child role reversals, being the eldest child in a traditional family, and having children to "save the marriage."

Bipolar versus Borderline Disease Mongering Pill Pushers Stack the Deck

In my Psychology Today blogpost of 12/11/11, Bipolar or Borderline, I described how disease mongering, pill-pushing psychiatrists have done their utmost best to blur the distinction between the mood (affective) instability seen in borderline personality disorder (BPD) with the mood episodes characteristic of true bipolar disorder. 

This distinction is important because BPD is clearly a disorder of interpersonal relationships and behavior mixed in with a history of trauma and family dysfunction, while true bipolar disorder is a serious biogenic brain disease. BPD, while some of its symptoms do respond quite well to the right medications, should be treated primarily with psychotherapy, while bipolar disorder should be treated primarily with medication.

In the prior post I discussed the use of invalid symptom checklists in studies to exaggerate the incidence of bipolar disorder. They are also used by some incompetent psychiatrists to make diagnoses that justify snowing every patient who walks in the door with potentially toxic antipsychotic medication. In the June 2016 issue of the Journal of Personality Disorders, researcher Mark Zimmerman goes into some detail about exactly how corrupt researchers use slight of hand to distort their data (Improving the Recognition of Borderline Personality Disorder in a Bipolar World, pp. 320-335).

They are very good at it. And it matters. Zimmerman states: "Although BPD is as frequent as (if not more frequent than) bipolar disorder, as impairing as (if not more impairing than), and as lethal as (if not more lethal than) bipolar disorder, it has received less than one tenth [emphasis mine] the level of funding from the NIH [the National Institutes of Health] and has been the focus of many fewer publications in the most prestigious psychiatric journals."

And, Zimmerman points out, the difference is not due to just the fact that there were more drug studies for bipolar disorder. In fact, the amount of funding for the drug treatment of bipolar disorder was just a little more than 10% of the total.

As I have mentioned several times in this blog, self-report symptom checklists are meant to be screening devises. This means that if you are positive for bipolar disorder on the screen, it does not mean you have bipolar disorder. It means you should be evaluated further! Screening tests are designedto have a lot of false positives - people who come out as positive on the test but who do not actually have the disorder. In fact, the majority of people who screen positively do not have bipolar disorder.

Zimmerman specifically brings up the Mood Disorders Questionnaire (MDQ) that I discussed in the previous post. Get this: in one study by Frye and others in the journal Psychiatric Services in 2005, the authors found that one half of the patients who were positive for bipolar disorder on the MDQ were not diagnosed with bipolar disorder by the treating clinician.  

Their conclusion? They said the clinicians "failed to detect" or "misdiagnosed" bipolar disorder in these patients! Actually, the exact opposite is far more likely: it sounds like the clinicians' judgments tended to be correct.

Frye and others then went on to state that these patients were "inappropriately treated because they were given antidepressants instead of mood stabilizers." Again, exactly the wrong conclusion to draw from the authors' own data. Yet they went on to say that this completely false conclusion was "worrisome." Some of us would call this real chutzpah.

Bipolar, my ass researchers love to talk about the bipolar "spectrum," based on the crazy logic that if a given symptom appears slightly similarly in two people, they must both have a version of the same syndromic psychiatric disorder. Zimmerman asks why no one talks of a borderline spectrum, when clinically, many patients are diagnosed as having borderline traits. This means that out of the nine criteria, of which you are required to meet any 5,6,7, 8, or all nine to qualify for the diagnosis, the patients may only have three or four. 

In fact, as reported in the July issue of the American Journal of Psychiatry (Vol. 173, pp. 688-694), Zanarini and others followed 290 patients with BPD closely over 2 years. They found that "...the symptoms of borderline personality disorder are quite fluid..." This means that they come and go over time. This was particularly true for acute symptoms like self-mutilation. Therefore, people with the disorder may frequently go from 5 symptoms to 4, and suddenly they don't "have" it anymore - unless and until the 5th symptom recurs!

In actual reality, he said redundantly, those people who exhibit three or four of the nine symptoms look a lot more like those folks who have five or more than they do like those folks who have none of them. Now that sounds like a "spectrum" to me.

Borderline Personality Family Dynamics The Parents Part II

In my post of 2/6/11, Dysfunctional Family Roles, Part I: The Spoiler, I opined that the basic problem in the "borderline" family (one that produces offspring with borderline personality disorder [BPD]) is that the parents in such families see the role of being parents as the end all and be all of human existence, but all the while, deep down, they either frequently hate being a parent or see their parental role as being an impediment to their personal fulfillment.

In Part I of this post, I described the one most common major issue - gender role conficts - and the resultant behavior patterns, that I have discovered leads individuals within a family to develop a severe conflict over the parenting role. In Part II, I will describe the other ones.

To repeat a caveat from the previous post: All of these issues may seem very common everywhere, and indeed they are. Most families that face them do not produce emotional conflicts significant enough to create BPD pathology. Rather, the issues in families that do have been magnified significantly by an interacting tableau of historical events impacting the family and the individual proclivities of each and every family member and descendent.

Common issue #2 causing parental ambivalence over being parents: Untimely deaths. The loss of children, in particular, may make someone fearful over losing the others while, at the same time, may lead to parental resentment over the fears and insecurities created by the presence of the remaining ones.

For example, one grandparent of a patient in our clinic had lost 10 out of 11 children to disease; the 11th was the parent of the therapist's BPD patient. The grandmother was overprotective of the mother but at the same time avoided closeness for fear of the pain of losing yet another child. When the mother grew up and left home, the grandmother became depressed. The patient was then given up as a child to the care of the grandmother to help feel the void, and became the new focus of the grandmother's hyperconcern and insecurity. This is also an example of a parent giving up a child as a gift to a grandparent - the subject of my 10/15/2010 post.

Issues #3 and #4: Financial reverses and chronic illnesses - including severe mental illnesses. Because of the financial strains and general chaos caused by these considerations, the joy of raising children may be suddenly turned into a frightful burden, both emotionally and financially, and thereby generate parental ambivalence.

Interestingly, the presence of bipolar disorder - with which BPD is often confused these day by both incompetent psychiatrists and the public despite the fact that they do not look anything alike - in a parent may lead to the very chaos in families that generates BPD behavior in children. Children in such a family are at risk both biologically and genetically for bipolar disorder and environmentally for BPD.

Issue #5: Ambivalence over religious or cultural values concerning childbearing, child rearing and filial responsibilities may lead to parental ambivalence. Examples include:

• 1.  The Roman Catholic emphasis on large families in a day and age when children cost a small fortune to raise. This may lead parents to follow the church rules but be extremely unhappy about the results.
• 2. Children, often the eldest female in a traditional family, may be called upon to take care of younger siblings in large families. In doing so they are often forced to give up exciting adolescent activities in which their peers at school freely indulge. The result may be that they become identified with the caretaker role yet resentful of it. When they leave home and have families of their own, this history may lead them to resent their own children. 

I     I used to practice in Los Angeles where I saw many Chicano (Mexican American) patients.  I saw several females who had functioned as "mother's assistants" when they were growing up. They were the eldest sister in large families. They had to stay home and take care of their younger siblings, and frequently had to miss important social events in school such as their senior Proms. Their younger sisters, however, got to go to and do everything the olders sisters had missed. When these older sisters grew up and had their own children, this recreated the family of origin issues for them and induced ambivalence in them about their brood.



•  The eldest male in a traditional family, such as seen in some Asian cultures, may be called upon to take over the family business in a career that he may just happen to hate. The costs incurred in raising children may lead to continuing family pressure to keep the business going when he wants out. The anger of Son #1 in such a situation may be displaced onto his children.

Issue #6: Parent-child role reversals. If adults in the family become incapacitated for whatever reason, and the children are therefore called upon to take over heavy adult responsibilities prematurely, the children may become resentful in a manner analogous to the situation of the eldest female in a traditional family described above.

Such individuals often describe this state of affairs with statements such as “I never got to be a kid.” [This is not the reason, however, that Michael Jackson said that]. A similar situation occurs when parents who were infantalized by their own families of origin appear to be unable to take care of themselves. Their children then try to fill the power vacuum and take care of them before they are really equipped to do so.

Issue #7: A couple has a child to “save the marriage.” The child then becomes the reason that the parents must continue in their miserable relationship. The resentment within the marital dyad becomes symbolized by the child whose presence was supposed to make the relationship better, but instead has led to the continuation of the same old marital misery.

The child then begins to believe that the family problems are all his or her fault, and the parents do not seem to try very hard to counter this belief. Children in such a bind usually come to the conclusion that their very existence is the reason their parents seem to hate each other. They may also feel that it is their reponsibility to provide a distraction to the parents' anger at one another by drawing anger on to themselves. This is one of the functions of the spoiler role.

Two or even several of these issues can present themselves simultaneously to a family, thus increasing parental ambivalence over the presence of children almost exponentially. The whole family becomes embroiled in quite a stew, and the abuse and neglect of children that sometimes results from these conflicts becomes more understandable, although still not excusable.

Expressing empathic understanding of the family's behavior, without condoning it, is far more productive in helping a family to stop troublesome behavior patterns than raking them over the coals for their misbehavior.

Some Questions Answered About Family Dynamics in Borderline Personality Disorder

"Letters, we get letters

We get lots and lots of letters"

I had an interesting exchange with a reader who asked me some questions about my ideas about the family dynamics of people with borderline personality disorder. I thought other readers may have similar questions, and she gave me her permission to reproduce the exchange in a blogpost. So here t'is, with my answers in blue:

I think my mother has BPD. I am trying to make sense of it, and I am digging into my family's history, to see if I can find a possible cause for her BPD.

The mother of my mother seems to be like the mother in the movie Thirteen, that you commented on in your article. She is always stating she would do anything for her children, but at the same time she sometimes drops things like, 'I sacrificed my life for them." Which pretty much sounds like playing the victim, to me.

It is new to me, that parents who are not physically or emotionally abusive, can also provoke BPD in their offspring. Thank you for attracting my attention to that.  Researching more about this, I read an article that stated that parents who are 'over-involved' can do the same, because they don't allow their children to grow into beings with clear boundaries. Do you agree on this statement? If this is true, than the hypothesis, that BPD patients always have poor attachment to their primary care givers, doesn't stand? 

One last question is: Can patients who have BPD get cured without professional help? I am asking this question, because I realize that I also have had several traits of BPD during the course of my life - although they never co-occurred. Coming to a point where I am realizing that my mother probably has BPD, I am also evaluating my own personality, and if I am honest, I can see that, especially during my twenties, I have had several symptoms, though never more than one at the same time.

Can you please provide me with some clarity ? I would be most grateful. I however will understand if you don't have the time to answer.

In answer to your questions as they apply in general - I am not able to speculate about your situation in particular without having seen and extensively evaluated you and your family situation:

1. The family dynamics of BPD involve the parents being conflicted over the role of having kids. They go back and forth between hostile under-involvement and hostile over-involvement. In a given family, one of these sides may predominate most of the time, but if one waits long enough, the other side shows up.

2. BPD is not a "disease" but a combination of traits by which someone adapts to the above family behavior. Some people have a lot of these traits, some many fewer. The traits can range from very mild to very severe, and severity levels can change dramatically in a short period of time. They can also appear and disappear depending on what is going on in a person's family life at any given moment.

Even in people who show these traits most of the time, many of the traits may start to get better on their own as the person gets older, although certainly not in all cases. Their relationships may continue to be poor, however.  Professional help can be very useful, but whether it's absolutely necessary in every case , the answer is that it depends on a lot of different factors.

Family-oriented psychotherapy is hard to find.  The models I recommend are listed at the end of the post:  http://www.psychologytoday.com/blog/matter-personality/201205/finding-good-psychotherapist. I'm not sure which ones might be available where you are. In England, the most common one is cognitive-analytic therapy (CAT).

What if no other siblings had symptoms while living in this 'borderline producing family?' Does it make sense to develop symptoms only after having left the parental nest? (Because in this case, the 'spoiler' doesn't develop his behavior to balance the mother's moods: instead she only starts to be a spoiler once married, like my mum ... Then this behavior is of no use? (only to act out own frustrations maybe .. but it is not in the interest of balancing the family system). Does this make sense then ?

(Going to a family therapist in my/my mother's case is a non-option for my mother, so unfortunately I have to kind of figure these things out by myself.)

Again, many possible explanations, so I can't say anything about your situation in particular.

In general, in the type of situation you are describing, the person's spoiling behavior with the new spouse stabilizes his/her parents in some way, but is only needed by those parents when the adult child is in the context of a marriage. Often gender role conflicts and repressed anger are at the root of such a pattern - for example, a daughter might act out the mother's repressed rage about having to cater to her (the mother's) own inadequate husband (the daughter's father or step father). Through the daughter's behavior, the mom experiences vicarious satisfaction of her own rage as she watches her daughter frustrating the daughter's husband efforts to "take care" of her.

If a mother acts in a way that produces BPD in her offspring, is it always the case that the child will become a spoiler? In the particular case of my mother, everyone from her family of birth tells me how "good, quiet, well behaved..." she was. It is like she only started to have BPD symptoms when she got married and had kids. Does that make sense? 

No, not always. In fact, family dynamics are like the proverbial true-false test: nothing happens "always" or "never." There are an almost infinite number of other factors which may alter the developmental course of a child - especially other relationships including the other parent, other relatives, or supportive mentors. There is what they call a "chaos" effect - small differences in initial conditions can multiply into big differences later on. Also, in some families, only one sibling will volunteer and/or be chosen to be "it," while the others remain relatively unaffected. If the "it" child stops playing the spoiler, one of the other siblings may suddenly step into that role ("sibling substitution").  The more severe the parental internal conflict, the more additional siblings will be affected or recruited at the outset.

If BPD is not a disease, how is it that the amygdala in people with BPD seems to be different ?

The amygdala is subject to neural plasticity like many areas of the brain, which means that it normally changes in size and activity as it adapts to the environment - especially the social environment.  It's one of the bases for conditioned responses. See http://www.davidmallenmd.blogspot.com/2014/05/borderline-personality-disorder-why.html and http://www.davidmallenmd.blogspot.com/2013/02/neural-plasticity-and-error-management.html

Why do almost all of the experts state that BPD is as good as is incurable, even if the patient is willing to cooperate?

"Cure" is a strange word to use since it's not a disease. Borderline traits absolutely can go away, and the relationships of someone with BPD can change for the better, especially with treatment that focuses on family-of-origin behavior.

You say that the traits of BPD sometimes disappear with aging, as they are not needed anymore. But I thought that BPD primarily stems from a fear of abandonment. So I don't see how someone can get rid of this deeply rooted feeling, even when he doesn't live with his parents anymore / is not being abused by them anymore / or maybe they even died. If there is a 'hole' inside you because of non-attachment with your parents, I thought that this emptiness will always be there, and it will just manifest itself by clinging to - pushing away spouses instead of the parents, or the same behavior towards offspring.

The issue of what happens after the parents die is still somewhat of an open-ended question for me.  For some people, they are freed up for the most part, although the "emptiness" never completely goes away. Other people get worse than ever after the parents die, even if other family members do not seem to be feeding into their problems. I think it has something to do with PTSD-like effects. The more obsessive a patient starts out, the more likely they are to obsessively recreate conversations with their parents in their heads. 

I had one patient who got a lot better after seeing the movie A Beautiful Mind. She realized that even though she couldn't stop hearing those conversations in her head, she didn't have to believe them. She discovered the secret of "Acceptance and Commitment Therapy" (ACT) before it had been "discovered" and written about - although I don't think ACT really works if the parents are still feeding into the problem, as they are more powerful in shaping a person's behavior than any therapist.

Are there cases in which a person with BPD manifests traits towards her spouse, but not towards her children? What does it mean?

There are all kinds of different permutations and combinations, and plenty of traits of other personality disorders that can co-exist and come and go with any patient. The family issues that the patient's behavior is designed to solve determines this, and every family is different. The details matter.  The stuff I write about only represents prototypes or the most common patterns.

Psychotherapy Outcome Research and Treatment for Borderline Personality Disorder Part I

The purveyors of Cognitive-behavioral psychotherapy (CBT), one of the large number of “schools” of thought in the fields of psychology and psychiatry, like to tout their randomized controlled outcome studies (RCT’s) as proof that theirs is the most “evidenced based” type of psychotherapy. When it comes to the psychotherapy of borderline personality disorder (BPD), which provides a microcosm for almost every type imaginable of behavioral/relationship issues that are confronted by psychotherapists, two of the most studied paradigms are actually related more to what many psychologists consider to be the opposite type of psychotherapy: humanistic/psychodynamic psychotherapy.  Those models are called transference-focused psychotherapy, TFP, and mentalization-based treatment, MBT.  

A third “empirically validated treatment” called schema-focused therapy (SFT), while based initially on some CBT concepts, takes quite a detour from those and employs techniques adapted from a number of alternate psychotherapy schools.

Actually, the one type of RCT-studied therapy for BPD that is most associated with CBT, dialectical behavior therapy(DBT), also borrows considerably from other schools of thought.  Not only that, but it really has been shown to be effective only for a couple of BPD symptoms, most notably self-injurious behavior (SIB) such as self-cutting.

John F. Clarkin is a highly respect psychotherapy researcher who has perhaps the most experience of anyone in the field.  He recently published an article in the Journal of Personality Disorders (Vol, 26 (1), Feb. 2012, pp. 43-62) entitled, “An Integrated Approach to Psychotherapy Techniques for Patients with Personality Disorder.  In it, he makes what I consider several extremely important and crucial points in the debate about the various treatment ideologies.

John Clarkin, Ph.D.

First, he points out, the empirically "validated" models often focus only on symptoms and not on the more important and enduring aspects of personality. In fact, in longitudinal studies of affected individuals, the personality disorder criteria and symptoms change over time, often all by themselves, while their interpersonal dysfunction does not change very much at all.  This implies that that, while symptom reduction is important, it is the interpersonal issues that should be the major long term focus in therapy. The heart of the matter in personality disorders is the patient’s conception of self and others.  The ultimate goal of treatment should be interpersonal functioning that allow for pleasure, interdependence, and intimacy in relationships.

Second, the literature on outcome studies is based on average scores on symptom-based outcome measures. This covers up the obvious fact that in any treatment, some patients change and some do not.  This is further complicated by the issues of “comorbidity.”  Patients with BPD, for instance, often meet criteria for one or more additional personality disorders, not to mention additional psychiatric disorders. And even within the definition of a single personality disorder, many different combinations of traits are possible to arrive at the diagnosis. Much more so than in any other field of medicine, patients with personality disorders are highly unique. Therefore, no one treatment can or will work for everyone.

Third, as Clarkin states, “A close examination of the treatment manuals…suggests that each manual contains some strategies that are unique and essential to the treatment, and some that are common (sometimes with different jargon) with other approaches."

A fourth important point he makes is that all of these therapies consist of multiple interventions, and the studies do not show which ones are important and which ones are not, or even more importantly, which ones may even be counterproductive: “…most probably contain low doses of effective practices, ancillary but important aspects that make delivery of the treatment more palatable, superstitious behaviors (those we think that matter but do not), and factors that impede or fail to optimize therapeutic change.”

A fifth point he makes that I would like to mention is that it is the delivery of the techniques that is often more important than the techniques themselves.  Techniques can be done skillfully, “…or in an abrasive, authoritarian, or uninterested aloof way.  There is plenty of research data that suggests that the skill of the therapist can be, in many instances, far more important to good results that an individual techniques."  Clarkin adds, “The therapist is not a technique-dispensing machine. Many of the techniques are applied common sense, and could be read out of a book."

Last, let us not forget that the receptivity of the patient is another major factor in whether or not therapy is successful.  If patient factors are not taken into account, the effectiveness of any technique “approaches zero.”  Furthermore, despite the rejection of the concept of transference by CBT therapists, “Some patients with severe needs for attachment with no relationships outsider of treatment may become intensely attached to and preoccupied with the therapist in ways that are detrimental to growth.”

In short, it makes a lot more sense to integrate the various techniques across treatment strategies from the treatment manuals in a way that tailors them to the particular patient in front of the therapist.  Throughout treatment, individual decisions must be made, which takes a skillfull therapist indeed. 

Of the four treatment paradigms that have been subjected to RCT’s, in my opinion schema focused therapy does the best job. Of course, the concepts of "mental schemas" and “mentalization” share much in common. (I will not be defining them in this post).  

My own model, unified therapy, has not been subjected to an outcome study. I applied for an “exploratory” grant to get some initial (pilot) data and was of course turned down by the National Institute of Mental Health. That may or may not have something to do with the fact that the only family-systems-oriented reviewer on my NIMH review committee was replaced at the last minute by DBT founder Marsha Linehan. Someone on the panel accused me of not being “mindful” enough.  I wonder who that might have been?

  

But maybe I’m just being paranoid. As Nassir Ghaemi says, the NIMH's "...limited funding is sparingly distributed: the highly conservative, non-risk-taking nature of NIH peer review is well-known." The study most likely to be accepted by the NIMH is one that has either already been done, or whose outcome is not really in doubt.

To be fair, doing meaningful psychotherapy outcome studies is diabolically difficult. In my book, How Dysfunctional Families Spur Mental Disorders, I went into great detail about a lot of the reasons for this. I’ll summarize what I said in part II of this post.

How to Disarm a Borderline Last Part

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), Part VI (March 2), Part VII (April 30), Part VIII (June 5), and Part IX (August 2). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

This post, the last one in this series, will continue to describe specific countermeasures to the usual strategies in the BPD bag of tricks used by them to distance and/or invalidate you, as well as to induce you to feel anxiously helpless, anxiously guilty, or hostile.

Today's subjects are what to do when none of the previous interventions seem to decrease the angry responses of the family member with BPD, and what to do when you yourself blow your cool and react with a nasty comment that might kick off a variable intermittent reinforcement schedule than can undo all the fine work you have done until this point..

When all the suggestions in these posts fail

The next suggestion is useful in cases in which, no matter what you say, the family member with BPD continues to escalate with more and more outrageous accusations or oppositionalism. It only works when all others have failed, and not before.  It probably can be used only once or twice. The reason for this is, in order for you to be confident in the assumption you are about to make, the Other's negative patient behavior must have already persisted in the face of your consistent efforts to be conciliatory.

The Solution? Inquire, "Why are you picking a fight with me?"  Once again, you have to refuse to get sucked into a debate about whether or not the family member with BPD is indeed picking a fight.  It will have by this point become damn obvious, and therefore you do not have to prove it.

In response to this question, people with BPD will usually do one of two things.  First, they could conceivably stop the behavior, admit that they are picking a fight, and begin to explain why they feel it necessary to do so.  In the unlikely event that this happens, hear them out!  You will probably learn something important about your relationship.  Try not to be defensive but look for the kernal of truth in what they are saying, as described in Part IV of this series.

More usually, they may suddenly stop the provocative behavior and go on to talk about some other, completely different subject, and nicely proceed as if the fight had never even happened! In this scenario, the family member with BPD suddenly drops whatever he or she was complaining about right in the middle of a heated interaction. 

This maneuver is a lot trickier than you might think.  Because of the abrupt nature of the change in subject, you may feel drawn back into continuing the previous angry discussion yourself.  This happens because the interaction that preceded the switch feels unfinished.  You should remind yourself that the Other's goal may just have been to keep an argument going, not to settle any actual complaint or win an argument.  In other words, the actual content of the argument may be something that is somewhat unimportant.

The feeling that one gets after an argument is suddenly dropped is somewhat akin to the way one feels in the following situation: you have repeatedly tried to get a talkative friend off the telephone.  You know, those conversations when you've said several times that you'd love to talk longer but you have to go, and your friend says OK after each time, but then keeps on talking as if you had not said anything at all. Finally, you raise your voice and firmly say, "I really have to go!" In response, the friend angrily says, "OK, GOODBYE!" 

The natural response is "No, wait!" even though ending the conversation had been one's goal in the first place! 

I advise you to resist the temptation to re-ignite whatever fight had been taking place before you asked the question concerning why the family member was picking a fight, and move on to whatever new and friendlier topic the Other has chosen.  Just like your partner in conversation, act as if the earlier argument had never even taken place.

The fine art of apology

The last bit of advise on disarming someone with BPD concerns the situation in which the family member with BPD gets the best of you and you react with a statement or action that invalidates or insults the patient.  Despite being well versed in the kinds of interventions described in this series of posts, you may still find yourself responding poorly to a family member's provocations. 

The person with BPD, after all, has a lifetime of experience in creating these reactions.  Unfortunately, intermittent emotional overreactions from another tend to make such a person try even harder and longer to illicit said reactions. This is due to the variable intermittant reinforcement process desribed in Part I of this series of posts.

Solution:  After you and your targeted other have calmed down, own up to your mistake and apologize for it!  Be a person of integrity. Be someone who is responsible, has a sense of right and wrong, and is the sort of person other people can look up to.

Having said that, however, an effective apology in this situation should not have the slightest hint of self-denigration attached to it.  If you put yourself down in some way, the person with BPD may then go for your jugular in response.  Basically, there are two characteristics this kind of apology should always have:

First, be good-natured about your error.  After all, you are only human.  Be able to laugh at yourself.  Say, "Gee, I sure did get frustrated with you that time."

Second and most important, apologize only for what you actually said or did, but not for the feelings that led to it.  Example: "I am sorry for sounding so critical, but I just had the feeling that you were dismissing everything I said out of hand."

This sort of statement frames the former explosive interchange as a mutual problem that the two of you need to work on solving in a constructive manner.   And after all, solving interpersonal problems is what effective metacommunication is all about.