Life on the Line: Negotiating Relationships with Persons With Borderline Personality Disorder

~
Borderline. . .

Feels like I’m going to lose my mind.   

You just keep on pushing my love over the borderline. . .

                                                          ~ Madonna - Borderline

A few days ago I discussed the difficulties with establishing boundaries and setting limits with persons in our lives who have personality disorders or personality disorder traits.  Fear, exhaustion, confusion, panic, apathy, and Guilt with a capital 'G' are intimate companions in the lives of  many people who resign themselves to existing in a sort of half-life as they enable and perpetuate the very behaviors that are sucking the life from them and the ones they love.


Complicating relationships and interactions involving a person who has personality disorder traits is the fact that personality disorders seem to like to congregate in herds. . .or in professional jargon, the APA states in the DSM-IV-TR, "Individuals frequently present with co-occurring Personality Disorders from different clusters."  That means there are typically more than one or two unpleasant behaviors grazing nearby, and our happy tranquil picnic is oftentimes interrupted by charging, stomping and snorting.  And what do we do?  Do we jump up madly waving our arms and charge, stomp, and snort our way into the melee?  Do we snatch up our watermelon, juggle our lemonade, and try not to trip over the blanket as we run lickety-split in the other direction?  Or do we sit still and quietly while hoping our warmth and compassion will be enough to slow the charge before we are errantly gored by a horn or crushed by a hoof?

Randi Kreger, owner of BPDcentral.com and author of the well-known books "Stop Walking on Eggshells:  Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder" and "The Essential Family Guide to Borderline Personality Disorder: New Tips and Tools to Stop Walking on Eggshells" has a blog on PsychologyToday.com.  After reading a recent blog on About.com by clinical psychologist Kristalyn Salters-Pedneault, PhD, in which Kristalyn voiced her thoughts and feelings after receiving what she described as "incredibly hateful" reader comments and email toward people with Borderline Personality Disorder.  Kristalyn  stated that she was "shocked by the level of vitriol," that "People with BPD deserve your compassion." and "Be grateful that you don't have to live with BPD.  And do something to help, rather than spewing out hate.  It's not helping you or anyone else." http://bpd.about.com/b/2010/12/23/have-compassion.htm

Randi dedicated a blog of her own to thoughtfully discussing the nuances involved in validating not only persons with Borderline Personality Disorder but also the persons who are partners and family members http://tinyurl.com/49y2c7t.  She asserts that these people are compassionate persons who hang in and hang on "Despite their BPD FM's (Borderline Personality Disorder Family Member') unexpected and unexplained anger; their impulsive, possibly reckless behavior; despite their inconsistent abandonment engulfment pattern; despite the fact the FM's (Family Members) often don't get their own needs met." Randi discussed healthy and unhealthy anger and grief.  All in all, a relevant and well  thought out discussion.


After reading Randi's blog I decided to take a look at Kristalyn's blog and comments as well as a NY Times article with comments that Randi had referenced.  As much as I appreciated Randi's and Kristalyn's thought-provoking blogs, I appreciated even more the discussion and comments by the people I consider to be the true 'experts' on this topic, persons having Borderline Personality Disorder traits and family members and friends of persons having Borderline Personality Disorder traits.  As a counselor who has worked with clients with Borderline Personality Disorder traits and diagnoses, but, most importantly, as a family member of persons with these challenges I find myself in the constant struggle of trying to balance compassion with limit-setting and maintaining a safe emotional and physical place for me and three 16 month old toddlers.  As the June 16, 2009 NY Times article by Jane Brody describes:

People with the disorder are said to have a thin emotional skin and often behave like 2-year-olds, throwing tantrums when some innocent word, gesture, facial expression or action by others sets off an emotional storm they cannot control. The attacks can be brutal, pushing away those they care most about. Then, when the storm subsides, they typically revert to being “sweet and wonderful,” as one family member put it.

"Brutal" attacks are indeed brutal, but that brutality may take a much more insidious form than overt aggression.  It is patronizing toward family members of persons with personality disorder traits to define "brutal attacks" as yelling and cursing and name-calling and slamming and throwing without understanding the more dangerous brutality in quiet, seething, passive-aggressiveness.  Ask anyone who is a survivor in a relationship with a family member who mixes up their traits-of-the-day potpourri with flavors from other personality disorders and metes out his or her brutality through ambiguity, “forgetfulness”, blaming, obstructionism (resentment and opposition), victimization (complaining about feeling underappreciated or cheated), stubbornness, , inefficiency, procrastination, sullenness, irritability, AND/or cynicism.

As I related in my discussion about personality disorders a few days ago, it is problematic to openly express genuine feelings about our personal experience of the chaos that oftentimes occurs in relationships with persons with Borderline Personality Disorder traits.  I described one of the reasons for this being because it is not 'politically correct' to say something negative about a person who has an illness, and in a timely manner I happen upon Randi's and Kristalyn's blogs and readers' comments discussing this very issue.  Sure enough, some people maintain that your sainthood will be revoked, and you may be burned at the stake for uttering a disparaging remark about someone with an illness. . .  Another obstacle to expressing  how we feel or describing our experiences may be because discussions with persons with these traits can oftentimes be quite frustrating and dangerous on many levels.   

Adding another layer of complication is being a professional counselor or in some other helping field because your family member may nastily complain that you are NOT his or her counselor, nurse, doctor, teacher, etc. AND THEN LATER nastily complain that you should be more "understanding" (i.e. allow whatever negative behaviors he or she wishes to exhibit at the moment) because you ARE a counselor, nurse, doctor, teacher, etc.  So to say that it is easy to vacillate between anger and guilt and empathy and compassion and exhaustion and apathy is an understatement.  Not only is it easy, but I maintain it is normal. 

Anger is one of the many emotions we experience when we are dealing with the up and down and back and forth and black and white of the Borderline Personality Disorder experience.  How we express that anger is the key issue.  You can feel angry and express anger without reacting aggressively - and aggression being not just a physical behavior but also an emotional tone and verbal script.  Although persons with Borderline Personality Disorder traits tend to balk against, be unable to tolerate, and launch an attack against anyone expressing anger or any sort of negative emotion toward them, if we do not remain genuine to ourselves we can lose our hearts and our spirits.  And, ultimately, we can lose the person we love with Borderline Personality Disorder traits.  I firmly believe that some people end up stuffing their feelings because they feel they cannot express them with full-on empathy and compassion, and this can become toxic and poison the interactions as resentment builds and builds.  It is certainly a precarious line to walk because you may very much want to be gentle and supportive while also taking care to neither enable nor perpetuate the unpleasant behaviors.

I have experienced the range of severe behaviors one might experience when having a family member with Borderline Personality Disorder traits, and I experienced many of the worst while pregnant with triplets.  Trying to stay alive in a world that doesn't make sense during the times when someone with Borderline Personality Disorder is having difficulties managing his or her behaviors can be a challenge, and there may be times that simply breathing seems to take more effort than you are able to expend.  So ensuring that you filter all of what you say can be a crazy unreasonable expectation for even the most compassionate of peaceful love-muffins.  I desire to be a person who thoughtfully responds rather than impulsively reacts, but the humanity in me allows me to have moments of ugly thoughts and accidental verbal vomiting. 

Do I sometimes feel so angry that I can't imagine ever feeling compassion for the evil monster my family members with personality disorder traits can become?  Yes.  Do I still love my them even after the unmentionable things I have experienced in the throes of personality disorder rages?  Yes.  And one of the reasons I can still find love in my heart and go on after a particular grueling episode is because I have looked within myself and decided that I am not an infallible victim of Borderline Personality Disorder.  What I am is a regular human-being with a full range of emotions who sometimes sits quietly hoping.  . . .and sometimes charges wildly with an occasional snort.

 

~ 

You cause me so much pain.   

I think I’m going insane.   

What does it take to make you see?   

You just keep on pushing my love over the borderline. 

                                                          ~ (still) Madonna - Borderline

Personality Disorders: To End or Not To End the Reign of Terror? That is the Question. . .

Let me hear from you.

Do you have something to say on any or all of these?  Or maybe something more to share.

• Who out there has been effected by someone. . .or many someones in their life who have personality disorders or personality disorder traits, or do you have a personality disorder yourself?
• What is the craziest thing that ever happened to you because of personality disorder craziness?  
• If you have been able to maintain something resembling a sense of humor, is there something funny that you recall? 
• What questions do you have about things?  
• And, most importantly, what have you done to survive?

I believe that of all the mental health disorders and diagnoses out there the most insidious and the most nasty are personality disorders.  Countless numbers of people out there have never been formally diagnosed, but there are legions of us who are still effected by these people with "traits."  You know the people, the ones who keep the pot stirred and leave a nasty taste in your mouth.  The people you dread being around and who you attempt to avoid entirely whenever possible.  The people who seem to suck the very life out of a room and color the world black with their negative energy.  These are people who create conflict and chaos and then are in crisis because they have been 'victimized'.  Or at least that is their story, and they are sticking to it.  And if you know what is good for you then you had better stick to it too because anyone who has had to deal with one of these people knows that World War III is not far behind any confrontation of this person's craziness.  And so, unfortunately, many people end up enabling and perpetuating the very nasty thought patterns and behaviors that need to be extinguished.

Why?  Why, you ask, would someone do ANYTHING that would allow these people to continue on with their crazy-making?  The answers are varied, but while it may be easier to just avoid the craziness of acquaintances and distant relatives and appreciate the built-in respite from co-workers when you leave the office each day, when the crazy person or people are your spouses/significant others, parents, children, or other family members with whom you are forced to frequently and more intensively interact then the situation becomes more complicated.  And overwhelming.  Some people allow these toxic persons to continue their reign of terror because they are immobilized by fear, exhausted, confused, panicked, or lazy, or they may have developed a self-protective sort of apathy.  Some people are either unable or unwilling to establish boundaries and set limits with these persons who poison everything in their paths.  Perhaps, similarly to the cycle of abuse and violence where the abuser acts out, expresses remorse, then promises change, and since no one is always 'evil' or always 'good', during those times that small windows of relief open up we are so busy catching our breaths that we can't mobilize into action.  Whatever the reason, at some point we all feel as though we cannot go on one more minute, but on we go.

Perhaps that is when we become sad, or perhaps that is when we get angry.  Sad as we grieve the loss of healthy relationships as they could have been or 'should' have been, and angry at this villain who would have us remain prisoner of our guilt for being mad at someone with a mental health disorder.  It is not seen as politically correct to 'blame the victim', and on some level most of us can rationally wrap our heads around the idea that the person with the disorder is a victim, but as the people with these personality disorders go crashing through our lives we are the ones standing. . .or sitting. . .or laying in the devastation while they dance off to create more chaos.  Sometimes with no insight but oftentimes knowing perfectly well what they are doing  they shout their innocence and demand retribution for their own victimization.  And what is too often lost in the effort to empathize with these 'victims' is the sight of the countless other victims left in their wake.

For myself, I know that while it has always seemed uncomfortable to me I have very different feelings and interactions when it comes to people in my personal life who have personality disorders versus my clients who have personality disorders.  While I can empathize with my clients with personality disorders, and I have even liked some of them quite a lot, I have almost no tolerance for people in my personal life who infect my space with their personality disorder traits.  Cognitively, I remind myself of all the things I 'know', but emotionally, I can't stand the distorted thinking and the crappy behaviors.  I don't feel especially therapeutic, and I want to scream, "Go get a therapist!"

When I was in graduate school a guest speaker in one of my classes was a private practice psychotherapist who specialized in working with people who had personality disorder traits and/or diagnoses.  Little did I know at that time that just a few years later I would find myself in a situation where I was receiving numerous referrals and requests from colleagues and other professionals to transfer clients to me because I had gotten as reputation for doing good work with clients with these specific challenges.  At the time I was listening to this speaker I found her to have some head-shaking interesting stories, but the relevance was lost on me since my focus was a tract in children and families and school social work.  I had no idea that in less than a year I would be beginning an 18 year career as a psychotherapist.

Of all the things she must have said that day I remember only one thing.  It stayed with me into my first job when I had one of those "A ha!" moments that quickly become an "Oh no!"  The adage that the ones who are hardest to love need it the most  was embodied for me on one particular day as I paced back and forth between my office and the front desk every few minutes wondering if she was going to show up late again and quietly hoping the phone would ring in the next minute with her leaving a message canceling until next week.  She was a young woman in her early 20s with a lot of issues she wanted to address (i.e. Me to 'fix'.).  To say that her appointments were draining was an understatement.  If she arrived at all she would typically show up for her appointments 30 to 45 minutes late.  Then she would make herself comfortable on the couch in my office and look as though she was settling in for a long winter's nap.  Okay, not a nap because a nap would have meant that I could relax a bit and be a little less vigilant about what she was going to say next.  And to be more clear, with people with personality disorder traits it is oftentimes not what they say but how they say it.  The actual crisis or events occurring in their day to day lives may indeed be distressing to even the most ordinary individual, but the subjective experience of people with personality disorders takes things to a different level.

To say she irritated me or to admit out loud that I just didn't like her seemed like a betrayal to all clients I had ever seen, would ever see, and most importantly to myself.  That just wasn't who I am.  I felt that if I didn't like her I was a complete failure as a therapist because what warm, caring, "good" therapist would not like another human being???  Isn't that somewhere in our professional code of ethics?  It certainly felt as thought it should be.  I felt guilty for even having the thought that I didn't like her and hoping on a weekly basis that she would either call to cancel her appointment or just not show up at all.  I knew that 'no-shows' were a "very bad thing" for community mental health centers who depended on keeping their sessions filled, so I heaped another helping onto what was slowly becoming a small hill of guilt.  But I couldn't deny the relief that would wash over me when I realized that I was free from our appointment together for one glorious week.  I mean how many times could one moderately sane counselor explain to a client that it was really a bit difficult to do any work in a 15 minute session?  And how many more times would I find myself pushing back the rest of my appointments for the day because as she slowly put her hand upon the doorknob to leave she glanced back over her shoulder and dropped some dangerous bomb out of her mouth.

I don't remember how long it took me to come to my "Ah ha!. . .OH NO!" moment, but it couldn't have been much longer than a few weeks because of the way our diagnosing system worked in that mental health center.  A few veeeerrrrrry long weeks.  And then it came.  I realized that I had the piece to this puzzle in my memory all along!  Yes!  This was exactly how she described it!  I recalled that guest speaker from my class somehow managing to look serious but yet slightly amused and telling us that a significant diagnostic indicator (not in any books, mind you. . .) for a person with a personality disorder was when you found yourself hoping the hell he or she would not show up for your appointment, and if that didn't happen then counting the seconds until your session was over.  Something else about that client exhausting you until you felt as though you wanted to crawl into a cave and hibernate until the next spring.  Or maybe the one after.  Check, check. . .and after a quick confirmation from the trusty diagnostic manual, yep.  There we have it.

I would say that this young lady was my baptism by fire into the realm of interacting with people with personality disorders.  And during our time together I developed a fondness for her, and she was able to make some amazing positive changes.  Within the next couple of years more and more clients with personality disorders kept being directed my way labeled as "difficult to treat" or "unsuccessful" with other counselors.  These clients seemed to be able establish relationships with me that helped them make improvements, and my personality seemed to lend itself to a good skill set and good practice that helped reign in the craziness of characterological, or what most people call personality, disorders.  Some of them you may have heard before:  Paranoid Personality Disorder, Antisocial Personality Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, Histrionic Personality Disorder, and Dependent Personality Disorder.  Then there are the less familiar Schizoid Personality Disorder, Schizotypal Disorder, Avoidant Personality Disorder, Obsessive-Compulsive Personality Disorder (not to be confused with Obsessive-Compulsive Disorder), and the most nasty diagnosis of them all, Personality Disorder Not Otherwise Specified, which includes both situations where someone may have mixed traits of several different personality disorders without meeting the criteria for one specific diagnosis AND/OR situations where someone meets the criteria for a personality disorder but the diagnosis is not included in the current diagnostic classifications - such as Passive-Aggressive Personality Disorder or Depressive Personality Disorder.

I will be talking in more detail about some of the specific disorders later, but now I am looking forward to what you have to say.  Please feel free to leave your comments here, email me at kristie@kristietalk.com.

Magic Pill? *sigh*

Anyone who has been a client of mine has undoubtedly heard my soliloquy on "No Magic Wand." While there is no magic wisdom to impart, question to ponder, step to dance, or ceremony to perform for a quick fix to those thoughts, emotions, and behaviors that challenge our lives, there is also no magic pill. And on that point I am vehement.

Now, anyone who has been a client of mine would also undoubtedly know my stand on using psych meds. Absolutely, without a moment of hesitation, I believe that psych meds can be invaluable tools in our tool chest to help effect positive changes with people. I have seen adults who suffered for years since childhood and heard children themselves describe for me their tortured experiences until some psychiatrist happened upon the right medication(s) at the right dose for them and their particular difficulties. I have witnessed medications work what seems like 'magic' simply because the symptom relief may be so incredibly significant in the life of someone, but the danger lurking around the corner is the potential for someone to have tunnel-vision in his or her endeavor to get some relief from whatever is bothersome and rely solely on another pill.

While I would say that most of my clients took the long road and lots of repeating, cajoling, bargaining, and downright badgering to consider being evaluated for psych meds when I felt strongly they might be helpful, there has been the handful of others across my practice who showed up for their initial appointment, plunked down in a seat, and waited for the time they thought was 'right' to inform me that they didn't really think counseling would help them, but what they needed was a pill. Ummm. Well, that is not exactly the way it works. Yes, a pill may be a useful tool. I mentioned that already, didn't I? But it is like putting a bolt in without having a nut for the other end. Sort of useless in holding things together.

So when someone tells me that a pill is the solution for this or that I have to be careful not to either vomit on his or her feet, stand shrieking with fists full of my hair, his or her hair, a mix of hair, or a combination of vomiting and shrieking. The pill addresses a symptom. Under which is lying the cause. Which, if not taken care of, will not change and will be there bubbling away and waiting to potentially suck an assortment of innocent people along with the pill connoisseur into the mire when the timing is most sucky.

And let's face it, as much as I respect some of the psychiatrists I have known and feel confident that there is some good practice going on out there is it not completely obvious that evaluating for medications, prescribing medications, and then monitoring medications is their specialty??? And isn't it somewhat obvious that prescribing a 'helpful' medication is the solution a psychiatrist may recommend as front-line treatment? I do not think most doctors are above maintaining some measures of job security by suggesting their services are the best answer to the problem. Might counselors do this too? Sure. Most definitely. There must be slimy unethical professionals in every profession out there including counselors who might drag out treatment by scheduling session after session after billable session, but as I see it the chief difference in what a good counselor should be doing from what many psychiatrists are doing is that a counselor should be working from the first session to make himself or herself unnecessary to clients. If I am doing my job then my job is to get you to the point that you are ready to stop coming to see me. If a psychiatrist is doing his or her job then his or her job is to get you to keep coming to your appointments for medication monitoring.

So when someone I know told me today that his psychiatrist prescribed a psych med for being tired I was stuck somewhere between disbelief, dismay, and disgust. Eegads. Trying to keep the vomiting at bay and the shrieking under wraps I had a brief discussion about what exactly had transpired at the doctor's appointment this morning. Perhaps a little background information would be helpful first. This person has been going to appointments for over a year and a half with medication changes, dosage adjustments, and more changes and adjustments, and more changes and adjustments. Sometimes because the medication combination didn't seem to quite help mood and thinking, and sometimes because, as with many people struggling with mood and thought disorder processes, the patient had one of many new reasons to insist on a change. Oftentimes confusing, and sometimes making a shadow of sense, but nevertheless change it was. Then a good mix seemed to be found. More stable mood? Check. Less irritability and aggressive behavior? Check. Less distorted thinking and reactivity? Check. Both objectively and subjectively the reports were good that the psych med combo seemed to be what Goldilocks ordered. . . just right. And with this good result the person told me a few days ago that because the medications seemed to be adjusted so good at this point he was absolutely not going to have the doctor make any medication changes at this point; however, he did want to talk to him and get some ideas on what to do for the tiredness he was feeling.

During that conversation we discussed that, unfortunately, some of the unpleasant side effects of the medications that were working were tiredness, but the benefit outweighed the cost in this situation. We also talked about the fact that this person is in his late 40s and some of the tiredness that he may be experiencing may be the result of not being 20 years old anymore. And we talked about various things he had not been doing for his overall health that might help with feeling less tired such as diet, exercise, supplements, and nighttime sleep behaviors.

My belief was that he would be talking with his psychiatrist about his tiredness and desire to make no medication changes and hear similar ideas with, perhaps and hopefully, some interesting and useful other options we had not considered. To say I was taken aback when I received a telephone call saying that the psychiatrist had recommended addressing the tiredness BY ADDING A STIMULANT to the psych med combo is a nice euphemism (refrain from cursing in blog. . .refrain from cursing in blog. . .). Let me get this straight. The front line solution to feeling tired was to add a stimulant to a medication course for a patient with irritability, anger, and negative thought patterns. Ummm. . .

When I asked about the plan to not change the medication course the person tried explaining that this is why they didn't change any of the meds he was taking. They just added a new one. What? Apparently there is some alternate reality with which I am unfamiliar where adding a medication is not making a medication change. I did make an attempt to explain that "just adding a new one" did, in fact, change the chemistry of the combination and create a change with mood, thoughts, and behaviors. Perhaps for the better. Perhaps not. Either way, this change was going to effect not only this person but also significant people involved in his life. People who were beginning to be a little less gun-shy and a little more hopeful that there was going to be some consistency with the good changes that had finally happened after over a year and a half of appointments and adjustments. Now everyone was going to have to live with this adding-a-new-one-nonchange.

*sigh*

And my take on this -
A big jumble of inability to tolerate discomfort, self-focus, a desire for instant gratification, and laziness. Is it easier to swallow a pill than to exercise or eat healthier or take a vitamin, or stop the habit of drinking copious amounts of soda (so there are subsequent multiple bathroom breaks from sleep each night) and eating snacks in the middle of the night? Sure. But there is cost. Both with another prescription drug charge, more follow-up appointments with the psychiatrist to monitor this non-change, and, in my opinion most importantly, the impact on the relationships in this person's life if adding this pill disrupts the good thing they had going. So is it really worth it to just take one more pill rather than exert some effort? Wow.

Yes, psychiatric medications can be a positive life-changing tool, but by prescribing a medication for tiredness before looking at the bigger picture and considering the impact of adding more sludge to the mire is more suckiness. What a disservice we are doing to people if we are enabling them to maintain the illusion that there is a 'magic' pill so they can take the "easy road". . .to the mire.