The book explores the challenges of BPD through the interactions of a fictional married couple, Annie and Fred. Dowell uses them to educate the reader about BPD as well as to offer helpful suggestions in its management. Dowell stresses that BPD is “an affliction that can be healed.” She further emphasizes that knowledge and the assistance of trained mental health professionals is important to that healing.  

Dowell formats her book in a simple, understandable way. Each chapter is dedicated to a particular facet of BPD such as emptiness, identity, or narcissistic tendencies. She covers sixteen topics in all and follows the same format for each topic or chapter. She begins each chapter with a relevant quote and then uses a sample interaction by Annie and Fred to act out the topic. She then leads her readers to a more in-depth understanding of the issue and summarizes what was covered. For those who enjoy a touch of spirituality, she also includes a prayer at the end of each section. Each chapter concludes with a thorough list of pertinent books on the topic that she entitles “Bibliotherapy.” 

In the introduction, Dowell explains the use of Annie and Fred as a way “to illustrate the unstable relationships of borderline personalities.” For example, in Chapter 5, Annie and Fred demonstrate “emptiness.”

Because of her borderline personality disorder, Annie struggles with unbearable feelings of emptiness as in this episode.

Annie: “I’m sick of our boring lives, we never do anything.”  
Fred: “What would you like to do? Want to go to a movie?”
Annie: “No, I’m tired of movies.”
Fred: “How about a football game?”
Annie: “No, football is boring.”
Fred: “Then what would you like to do, Annie?”
Annie: “I’m going shopping, see you later.”

Three hours later, Annie comes back laden with packages. Fred, while going over the receipts, discovers that she has spent $2,000 — far more than they can afford.

Dowell then defines emptiness and how it connects to other maladaptive feelings and behaviors displayed in individuals with BPD. She also dissects the interaction between the characters and offers suggestions for how they could manage Annie’s BPD in a healthy manner.

Readers may find Dowell’s use of the DSM helpful to describe and break down the relevant topic. For example, Chapter 15 covers “splitting” and Dowell begins her discussion by quoting the DSM-IV:

The Diagnostic & Statistical Manual of Mental Disorders describes splitting as: A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

Dowell continues to describe the concept in more detail:

“Splitting” is a defense mechanism, a pattern of extreme thinking: all-or-nothing, 100–percent-good-or-100-percent-bad, no-shades-of-gray, black-or-white, for-me-or against-me, heroes-or-villains, good-or-evil, love-or-hate, 100-percent–in or 100-percent-out of relationships. Splitting bounces from love to hate, and there is no middle ground.

The book generally achieves its purpose “to encourage compassion … for those who suffer severe mental anguish.” However, in my opinion, the book is better suited for persons struggling with mild to moderate BPD, not suffering from severe symptoms such as ongoing suicidal gestures and self-mutilating behaviors.

In regard to Dowell’s use of the fictional characters to represent interactions that might occur with BPD symptomatology, the dialogue between her characters is a bit stiff and sometimes inauthentic. Nonetheless, Dowell still achieves her objective in using the characters as an example for the overall themes and issues that characterize the disorder.

Overall, Compassion for Annie: A Healthy Response to Mental Disorders is a book I would recommend to a general audience looking for more information on Borderline Personality Disorder. It is an easy guide to the basics of the disorder but I do not believe it gives mental health professionals any added insight into BPD. On the other hand, I do feel that it reminds mental health professionals to continue to be compassionate and patient with individuals struggling with this disorder. Most important, it offers a much-needed hope toward the healing of a very difficult and complex disorder.

Compassion for Annie: A Healthy Response to Mental Disorders
By Marilyn R. Dowell
Langdon Street Press: October 4, 2011
Paperback, 174 pages
$16.95

This very short book,Tragic Beauty by Arlene Diane Landau, analyzes this archetypical personality in great detail. She illustrates how a life built on sex, wealth, fame, and beauty results in disillusionment, disastrous marriages, drug abuse, prostitution, and even early death.

Landau writes from a personal and professional point of view, having begun her career as a Hollywood dancer, model, actor, and movie extra. Everyone from Playboy to Elvis wanted to be with her. What seemed like a fantasy life brought Landau total misery.

“At the time I did not know the words for what I was feeling and experiencing,” she writes. “I was suffering from a profound sense of emptiness over a lack of meaning in my life.” Then she discovered Jungian analysis and the power of interpreting dreams, which opened up a new and more positive pathway in her life. She headed back to college and became a Jungian analyst.

Landau devotes about a third of her book to defining the Aphrodite type, giving examples from literature (Madame Bovary), film (Gloria in Butterfield 8), and celebrities (Princess Diana, Marilyn Chambers, and all the usual suspects). From there, she explores Greek mythology, giving long and complicated genealogical histories of gods and goddesses–not just Aphrodite, but seemingly everyone on Mount Olympus. Frankly, I wanted to skim this section because it’s rather academic and tedious, full of names and complicated liaisons that boggle the mind and don’t seem related to the book’s mission: creating balance for Aphrodite types.

Past this, though, the book gains momentum, focusing on Jungian philosophy related to archetypes, and here I think Landau shines as she digs into her main point. “Jung’s theory of archetypes, which he formulated in the early part of the twentieth century, provides a means of uniting the multitudes of images produced in myth, religion, all forms of art, dreams, fantasy–in short, all forms of human creativity–into broad categories that facilitate understanding of the entire image-making process,” she writes.

In fact, Jung considered archetypes to be embedded in our unconsciousness, “a spiritual goal toward which the whole nature of man strives; it is the sea to which all rivers wind their way, the prize which the hero wrest from the fight with the dragon,” Jung wrote. Slaying monsters and great beasts is as old as time, part of human’s great psychology and storytelling, as is Aphrodite and her archetypical sisters, Athena (warrior), Artemis (adventurer), and Hestia (homemaker).

In essence, “archetypes appear as myths, though…have been modified by the individual unconsciousness of the artist or story,” writes Landau. “Myths reveal the nature of the human soul.” In other words, archetypes are primordial aspects of human nature, what Jung calls our collective unconscious and “contains the whole spiritual heritage of mankind’s evolution, born anew in the brain structure of every individual.” Blame Hollywood for our lustful desires, but blame should be placed on our natural psyche.

According to Landau, the Aphrodite woman is so unbalanced, edging toward borderline personality, that she needs to find balance–more Athena or more Artemis or other characteristics that will round out her personality. The author devotes an entire chapter to cases where she has helped Aphrodite women search within themselves by exploring and analyzing their dreams. Delving into the unconscious in this way has opened up many of Landau’s clients to new ways of looking at themselves and their lives.

I wish more of the book had been devoted to this and the focus directed a little more on how women can achieve more balance or derive meaning from their dreams in order to better themselves. Landau does address this, but it is buried beneath a lot of extraneous material that probably could have been trimmed back with the help of a good editor.

Certainly there are plenty of Aphrodites out there who can use a serious consciousness awakening and will likely find this book helpful. As Jung writes, “If a woman of this type remains unconscious of the meaning of her function…she will herself perish by the sword she brings. But consciousness transforms her into a deliverer and redeemer.”

Tragic Beauty: The Dark Side of Venus Aphrodite and the Loss and Regeneration of the Soul
By Arlene Diane Landau
Spring Journal Books: December 1, 2011
Softcover, 118 pages
$22.95

I found the book to be both hilarious and sad. There were points when the author’s frustrations were becoming mine. This book is a no-holds barred, educational read that keeps the reader unable to put it down. I tip my hat to Stacy Pershall for sharing such a personal tale with us. It has changed my understanding of these disorders forever.

It seems to me the author was trying to share her very personal journey through early adulthood with BPD, BD, and various other problems. This she accomplishes in both an effective and entertaining manner. She told us her story from top to bottom, leaving nothing out. She also speaks very highly of Dialectical Behavior Therapy, though I’m not sure if she emphasized this as much as she had intended.

Her small-town childhood, her constant questioning of her identity are things that many people can relate to. Not knowing where one belongs, or who one is, are universal questions. Some people have a much easier time answering these questions than others. This is a concept I can personally relate to quite well.

I love Pershall’s honesty. On the medication front alone she offers anecdotes about her use of speed and alcohol; the side effects of prescription meds; the lack of correcting the underlying problem she experienced with pharmeceuticals; and her list of the plethora of meds she was prescribed.

Pershall’s describing Dr. Phillip J. Thornton as her savior of sorts is an experience that I think many people can relate to. Finding that one doctor, therapist, spiritual leader, etc. who seems to understand you, after you’ve been through a hundred professionals who never quite “got you,” is often a turning point in many people’s lives — perhaps a life-saving one.

Her bout with anorexia and bulimia was fully and simply described by the quote “Playing with anorexia is like playing with heroin, fire, plutonium, or Scientology.” — Humorous, yet scarily true. She is so direct and maintains a sense of humor through it all.

I found her connection to certain authors and novels to be interesting also. From Sylvia Plath to Anthony Burgess’s A Clockwork Orange, she showed a very eclectic interest in books with very independent protagonists. She even mentions William S. Burroughs, an eccentric writer of the Beat generation. It seems as though her brief foray into acting was another way to explore, and even become other, various characters.

Pershall’s mention of “splitting,” a dissociatiove experience common to those with borderline personality disorder, shouldn’t be ignored either. Her reference to splitting just before her breakup with Reese was classic.

I’d like to touch on her relationship with religion in response to he disorders. She said it best on pg. 188 with “IF THIS COULD BE PRAYED AWAY I’D BE WELL. ” It also intrigued me when she mentions her father considering mental illness as a sin. That, to me, is a scary, seriously antiquated thought.

I couldn’t imagine writing this review without touching on her tattooing. I understand where she’s coming from when she discusses on pg. 153 ” . . . something that scared me is exorcised, incorporated, with me forever. ” Getting tattoos seems to be her way of facing, and embracing, her fears.

I will end this with her speaking of BPD as an illness “that should be placed on the spectrum of impulse control disorders.” This seems like a pretty solid idea to me, and she goes on to explain it better, getting into the brain chemistry of it. It must also be noted how strongly she speaks of DBT, and how it changed her “because of two things: the focus on the dialectic, or gray area, between good and bad, and the strict adherence to the rules required.” The author speaks so highly of DBT, it seems as though anybody yet to find treatment for BPD or BD should give DBT a shot.

Loud in the House of Myself: Memoir of a Strange Girl
By Stacey Pershall
W. W. Norton & Company (reprint edition): January 23, 2012
$14.95

As Shari Y. Manning, Ph.D, writes in her excellent book Loving Someone with Borderline Personality Disorder, “People with BPD have an exquisite vulnerability to emotions.” And this susceptibility is hardwired.

For instance, Manning cites one interesting study where researchers tickled infants on their noses with a feather. Their responses ranged widely: Some infants didn’t react at all, others moved around and still others started crying and it was tough to calm them down. These babies were seen as “sensitive to emotional stimuli.”

Like other disorders, BPD also involves an environmental component. (Not everyone who’s emotionally sensitive goes on to have BPD.) Individuals with BPD aren’t just genetically vulnerable to emotions; they’ve also grown up in an “invalidating environment.” So they might’ve never learned how to regulate their emotions, or their emotions were continuously ignored or dismissed.

What It Means To Be “Emotional”

According to Manning, being emotional isn’t a lack of control; it has more to do with “three separate tendencies that cause emotional arousal in different ways.” These are:

• “Emotional Sensitivity.” Loved ones aren’t the only ones confused when someone with BPD has an emotional reaction seemingly out of nowhere. People with BPD may be unaware of the trigger, too. But they still have a strong reaction. “Emotional sensitivity wires people to react to cues and to react to their reactions.” Manning explains that: “To understand emotional sensitivity, think of the person with BPD as being ‘raw.’ His emotional nerve endings are exposed, and so he is acutely affected by anything emotional.”
• “Emotional Reactivity.” A person with BPD not only reacts with extreme emotion (“what would be sadness in most becomes overwhelming despair. What would be anger becomes rage”), but their behavior also is intense and doesn’t fit the situation. They might sleep for days, scream in public or self-harm. Manning points out that emotional reactivity isn’t self-indulgent or manipulative, which is an unfortunate myth attached to BPD. Instead, research has suggested that people with BPD have a higher emotional baseline. If most people’s emotional baseline is 20 on a 0 to 100 scale, then people with BPD are continuously at 80. What can intensify their reactions are the secondary emotions of shame and guilt because they know “their emotions are out of control,” Manning writes. Let’s say your loved one is angry. “On top of the original anger, these secondary emotions feel intolerable, and their fear of all this emotion, ironically, tends to fire off another series of emotions—perhaps anger that is now shifted to you, for ‘not helping’ your loved one or for some unexpressed reason.”
• “Slow Return to Baseline.” People with BPD also have a hard time calming down and stay upset longer than others without the disorder. And there’s interesting evidence to back this up. “In a person with average emotional intensity, an emotion fires in the brain for around 12 seconds. There is evidence that in people with BPD emotions fire for 20 percent longer.”

An Exercise in Understanding

In Loving Someone with Borderline Personality Disorder, Manning also helps readers better understand what it’s like to be emotionally vulnerable. She suggests thinking about an extended period of time when you were very emotional.

For Manning her emotional explosion happened when the company she’d worked for was going bankrupt. Not only was everyone upset and Manning barely sleeping but then her friend passed away. “At that point I felt like every emotion that I had was at the surface of my skin. I physically felt like I would explode with emotion if one more thing happened.” She notes that she was “an emotional sponge.” She didn’t even want sympathy because she felt like this would put her over the edge.

When thinking about your own highly emotional experience, Manning writes:

…Remember what it felt like emotionally and physically. Remember how it felt like emotions were just building on each other. Remember the experience of no one understanding how bad the situation was and how emotional you were. Now tell yourself that this is the experience of your loved one every moment of every day.

How Loved Ones Can Help

Manning shared her insight on how family and friends can help in a two-part interview on Psych Central (Part 1 and Part 2). And loved ones can do a lot, especially when it comes to helping the person when they’re upset.

In her book, Manning provides readers with step-by-step strategies and detailed examples. Below is a brief list of suggestions from her book:

1. Assess: ask what has happened.
2. Listen actively; don’t contradict, judge, or say your loved one is overreacting.
3. Validate: find something in what happened that makes sense and is understandable, that you can relate to; say what that is.
4. Ask if you can help, not to solve the problem but to get through the moment.
5. If your loved one says no, give him or her space and remember the emotions of emotionally vulnerable people last longer.

Also, it’s important to remember that people with BPD do get better and simply need to learn the skills of managing their emotions. While this requires hard work and effort, treatments such as dialectical behavior therapy (DBT) have been shown to be highly effective. You can learn more about DBT here and here.

“You go from one extreme to the other, from trying to make sure nothing upsets the person you love to trying to get away from the person at all costs. You may feel like you’re caught in a riptide, unsure when the behaviors that upset you are going to stop and where you’re going to be dropped off at the end.”

However, you can take steps to become “unlost,” as Manning puts it, and improve your relationship.

In Part 2 of our interview, Manning reveals how to help defuse your loved one’s intense emotions, how to handle a crisis, what to do if your loved one refuses treatment and much more. (You can read Part 1 here.)

Manning also is Chief Executive Officer of the Treatment Implementation Collaborative, LLC, which offers consultations, training and supervision in Dialectical Behavior Therapy (DBT).

Q: You suggest using a technique called validation to help defuse a loved one’s intense emotions. What is validation, and how is it different from simply agreeing with what someone says?

Validation is a way of acknowledging some small piece of what the person says as understandable, sensible, “valid.” An important piece of validation that people miss is that we don’t validate the invalid. For example, if your loved one is 5’7,” weighs 80 pounds and says “I’m fat,” you wouldn’t validate that by saying, “Yes, you are fat.” That would be validating the invalid.

You can validate some part of what she is saying by saying “I know you feel fat (or bloated, or full)”, whatever is appropriate to the context of what she is saying. Try to find some small kernel of validity. Remember that tone and manner can be invalidating when words are validating. “I know you FEEL fat” can be invalidating because it communicates that the feeling is wrong.

Q: In your book, you talk about an emotional whirlpool where a person with BPD is triggered by some event that’s unpleasant or scary for them. Then they struggle with a torrent of emotions, which can lead to impulsive behavior. Loved ones can feel especially helpless in these moments. What can loved ones do?

The first thing that loved ones should do is regulate their own emotions. It is so difficult to watch someone you love who is in agony and behaviorally out of control. Loved ones can become fearful, angry, judgmental, guilty, a whole gamut of emotions and thoughts. When family members regulate their own emotions, they are better able to think about how to help their loved one.

Q: What’s the difference between self-harm and suicidal behavior?

Suicidal behavior is behavior with the intention of being dead. Many people with BPD engage in behaviors that inflict physical harm that aren’t about killing themselves. Self-harm behaviors often function to bring down (relieve) painful, extreme emotions. People with BPD can have suicidal behaviors only, self-harm behaviors only or a combination of both.

Q: What should you do if your loved one is suicidal?

There are many reasons for suicidal behavior. Studies have shown that some people feel emotional relief by picturing themselves dying. Thinking, talking, planning suicide may work to relieve emotions, at least for a little while. Some people are planful about how they will kill themselves and meet all of the warning signs that are on suicide prevention websites.

However, about 30 percent of suicide attempts are impulsive, meaning that the person thought about it for just a few minutes. One problem is that people with BPD often fall into the impulsive suicide attempts. So, it is important to remember that if your loved one says that she is going to commit suicide, you have to take it seriously.

That being said, our responses to suicidal behavior can reinforce the behavior. If every time your loved one gets suicidal, you go get her, bring her to your house, feed her and tuck her into bed, you could be inadvertently reinforcing her behavior, especially if you don’t do the same thing when she is doing well.

Figuring out the reinforcers for suicidal behavior is complicated work and the consequences for being wrong can be catastrophic. If you think you are reinforcing suicidal behavior, go talk to a behavioral or cognitive behavioral therapist. Create an alternative plan with your loved one that reinforces non-suicidal behavior. If your loved one is suicidal in the moment, here are a few steps to take with him:

• It may sound strange, but the first thing to do is to tell him not to kill himself.
• Focus on tolerating the moment. Don’t drag up old issues.
• Ask what emotions your loved one is having.
• Validate his emotions and his experience.
• Ask how you can help (if you are willing to help).
• Communicate your faith in your loved one’s ability to get through the crisis.
• If you are ever in doubt, call a professional.

Q: BPD is highly treatable. But what can family or friends do if their loved one refuses to get treatment or there’s no professional in their area who treats people with BPD?

Access to effective treatment for BPD remains an issue. Twenty years ago, clinicians considered BPD untreatable and it takes time to change perception, even when we have data that say that there are effective treatments. If there is no treatment available, start a grassroots campaign with the local community mental health center, NAMI (National Alliance for the Mentally Ill) Chapter or other advocacy groups. I have encouraged people to find a cognitive-behavioral therapist in their area if there is no one who specializes in treating BPD.

If your loved one refuses to get treatment, the key is to support her and take care of yourself. Make sure you are regulating your emotions and communicating limits about what behaviors you can tolerate and which you can’t tolerate. Be supportive when possible but try not to reinforce out of control behaviors. Validate, validate, validate while encouraging your loved one to get treatment.

Often people with BPD have had negative experiences in therapy. They have been fired by therapists, gotten worse, thought they were getting worse or were left with thoughts that they cannot be helped. Have honest, nonjudgmental conversations with your loved one about her reasons for refusing treatment and problemsolve if possible.

Remember that changing behavior is often like water over rocks: gently, consistently and in a validating way, continue to encourage her to go to therapy while communicating your belief in your loved one’s ability to have a life worth living.

Finally, find help for yourself. Many Dialectical Behavior Therapy programs have Friends and Family groups. Join a support program for family members of people with BPD. NEA-BPD and TARA and the Treatment Implementation Collaborative and others have distance programs for family members that provide support while teaching family members about BPD and how to help their loved one and themselves.

Q: Anything else you’d like readers to know about BPD and what loved ones can do to help themselves and the person with BPD?

At the end of the day, compassion is effective. If you are compassionate, you will try to help your loved one without judging or condemning him. If you are compassionate, you will care for your own physical and emotional health.

When in doubt about what to do, I always ask myself what the most humane response is that I can have. Then, I do it.

(You can also read Part 1 of How to Help a Loved One with Borderline Personality Disorder.)

Fortunately, there are specific strategies you can use to support your loved one, improve your relationship and feel better yourself.

In Part 1 of our interview, Shari Manning, Ph.D, a licensed professional counselor in private practice who specializes in treating BPD, shares these effective strategies and helps readers gain a deeper understanding of the disorder.

Specifically, she reveals the many myths and facts behind BPD, how the disorder manifests and what mistakes loved ones make when trying to help.

Manning also is Chief Executive Officer of the Treatment Implementation Collaborative, LLC, and author of the recently published book Loving Someone with Borderline Personality Disorder. (It’s a must-read!)

Q: What are the most common myths about borderline personality disorder (BPD) and how it manifests?

• People with BPD are manipulative. We have found that it is not effective to be judgmental of clients or each other. If you think you are being manipulated, you will be defensive in your responses to the person whom you think is manipulating you. You will act to protect yourself and not out of wisdom. Besides, as we tell our clients, the problem is that people with BPD are not artful at manipulating. Really skillfully manipulative people get what they want from others without them knowing they are being manipulated. People with BPD get caught.

• People with BPD do not really want to die when they attempt suicide. Depending on the research, and the severity of the disorder 8 to 11 percent of people with BPD die by suicide. Their lives are agony and they often want to escape the pain of their lives. Sometimes they do so by trying to completely end the pain with suicide; other times, they get temporary relief with other behaviors, e.g. cutting, burning, substance abuse, binging/purging, shoplifting.
• People with BPD are stalkers (like the character from Fatal Attraction). People with BPD often don’t have interpersonal skills. Their learning history has been one of losing relationships, often because of their extreme behaviors. There have been several studies done and it appears that four to 15 percent of stalkers were diagnosed with BPD. It is important to remember that some percent of stalkers may meet criteria for BPD but stalking is not a characteristic of BPD. Very few people with BPD become stalkers.
• People with BPD just don’t want to change (or they would do so). I have never met a person with BPD who wanted to be emotionally and behaviorally out of control. If there were a magic wand that “cured” BPD, I am certain all of my clients would have me wave it at them. The problem is that change is really hard for all of us and doubly (maybe triply) hard for people who are emotionally sensitive. Think of a behavior that you wanted to change (quitting smoking, exercising, dieting). Think of all of the times you failed. Did you fail because you didn’t really want to change or because you failed?
• People with BPD are uncaring and only think of themselves. In my experience (and I don’t really have studies to back this up), people with BPD are extremely caring. They get a reputation for only thinking of themselves when they get distressed and engage in behaviors that cause harm to their relationships (overcalling, over-texting, showing up when not invited). In the heat of the crisis, people with BPD are often so physiologically/emotionally aroused, that they cannot be mindful to others. However, they feel an extreme amount of guilt and shame about the effects of their behavior on others.
• BPD develops from childhood sexual abuse. Not all people who have suffered childhood sexual abuse develop BPD and not all people with BPD suffered childhood sexual abuse. Depending on the study, 28% to 40% of people with BPD had sexual abuse in their childhood. We used to think that the incidence was higher but as the diagnostic criteria for BPD have been more effectively used, we are finding that the incidence is lower than we initially believed.
• BPD develops from poor parenting. As I said above, some people with borderline personality disorder are sexually or physically abused as children. Some people with BPD had distant or invalidating families. However, some people came from completely “normal” families. People with BPD are born with an innate, biological sensitivity to emotions, e.g. they have quick to fire, strong, reactive emotions. Children who are emotionally sensitive take special parenting. Sometimes, the parents of the person who develops BPD just aren’t as emotional and cannot teach their child how to regulate intense emotions. We tell clients that they are like swans born into a family full of ducks. The duck parents only know how to teach the swan how to be a duck.

Q: What mistakes do you see loved ones make when trying to deal with someone with BPD?

Family members often try to encourage their loved one but inadvertently invalidate them and increase their emotional arousal. For example: the person with BPD says, “I am a terrible person” after seeing hospital bills from a suicide attempt. The family member responds, “No, you’re not a bad person.” The contradiction makes the person with borderline personality disorder more distressed.

Instead, try acknowledging the feelings/thoughts behind the statement then moving into something else. Say instead, “I know that you feel badly about how you acted and that makes you think you are a bad person.”

Another error is that family members give the person with BPD more care and attention when they are in crisis and then withdraw when they are not. This may inadvertently reinforce the crisis behavior and punish non-crisis behavior.

Q: In your book, you discuss the importance of gaining a deeper understanding of how BPD manifests so loved ones know what to expect and don’t feel so lost. You also note that Dr. Marsha Linehan, the founder of dialectical-behavior therapy, classified the disorder into five areas of dysregulation. Can you briefly describe these categories?

• Emotional dysregulation — extreme emotional responses, especially with shame, sadness and anger.
• Behavioral dysregulation — impulsive behaviors like suicide, self-harm, alcohol/drugs, binging/purging, gambling, shoplifting, etc.
• Interpersonal dysregulation — relationships that are chaotic, fearfulness of losing relationships coupled with extreme behaviors to keep the relationship
• Self-dysregulation — not knowing who a person is, what their role is, being unclear on values, goals, sexuality
• Cognitive dysregulation — problems with attentional control, dissociation, sometimes even brief episodes of paranoia

Q: You say that BPD, at its core, is an emotional problem. Why are people with BPD so much more emotional than others?

Our emotional sensitivity is something that is hardwired into us. Some people are more emotional than others. People with BPD are usually among the most emotionally sensitive people. Anyone who is emotionally sensitive must have skills to regulate those intense emotions. Skills are learned not hardwired.

In Part 2 of How to Help a Loved One with Borderline Personality Disorder, Manning discusses how to help defuse your loved one’s intense emotions, how to handle a crisis, what to do if your loved one refuses treatment and much more.

What exactly is BPD? Trying to explain it to someone who has never experienced it can be quite a daunting task. My psychiatrist describes borderline personality disorder as having an “emotional sunburn.” Imagine touching the skin of a person without a sunburn as opposed to touching the skin of someone with a horrible, blistering burn. While the person without a sunburn will be fine, the one with a sunburn will be in excruciating pain. Having BPD is like always having a bad sunburn but instead of covering my skin, it covers my emotions, making it so every negative thing I feel is magnified.

Living with BPD can be tough, especially when you go through all of your childhood not knowing exactly what is wrong with you but having the overwhelming feeling every day that you aren’t exactly normal. Now, thanks to a concrete diagnosis, I can pinpoint the areas in my life that I have always had trouble with as symptoms of my disorder.

• I am extremely sensitive. I have zero capacity to accept even criticism that is being given with good intentions. I take it as a personal attack instead of seeing it from the logical standpoint that someone is simply trying to help me out. When people make negative comments about me, I overreact. I have a bank system in my brain of disparaging comments that people have made to me throughout my life. I still remember when girls were mean to me in kindergarten. I guess you can say that I have a hard time letting go of a grudge. This extreme sensitivity made growing up in a household where yelling was common very difficult.

• I can’t process stress. Stressful jobs, stressful relationships, people fighting, large groups of people, driving in traffic are all extremely difficult for me to deal with. Holding down a job when you have zero capacity to tolerate stressful situations is a challenge, along with being a college student.
• I change my identity … a lot. Finding one’s identity is a normal part of growing up but what isn’t normal is when you don’t eventually settle into one and when you alter yours so often that it eventually begins to take a toll on your wellbeing. One day I’ll be wearing Lilly Pulitzer and pearls and playing the role of a perfect Southern belle and the next I’ll be dyeing my hair black, wearing tie dye and hemp necklaces, smoking pot and listening to The Grateful Dead. I’ve been to three different universities since I started college three years ago, and I’ve changed my major about ten times. Not knowing who you are can make choosing one thing and sticking with it an impossible feat. One day I see my future self as a journalist, the next day I see myself as a psychiatrist and the next I see myself as a housewife married to a rich executive.
• I am terrified of abandonment and will do anything to avoid it, at any cost. In college my friends all wanted to join sororities. Because of my borderline personality disorder, I perceived this as them abandoning me, when in reality they really weren’t. It’s sort of a catch-22; I fear abandonment so much that I start to act so crazy when faced with the prospect of it that it ends up driving people away.
• I am extremely impulsive. I’ve shoplifted, I’ve drank myself into a coma, I’ve abused drugs, I’ve had sex with people I probably shouldn’t have had sex with, I’ve signed leases I couldn’t afford without telling my parents, I’ve gotten five speeding tickets, I’ve gone on food binges, I’ve gone on spending sprees when I didn’t have the funds.
• I think about killing myself virtually every day. This can be a tough one to deal with. It’s hard to function when you’re constantly thinking about how you want to slit your wrists or stick your head in an oven a la Sylvia Plath. My psychiatrist refers to this urge as a wave that I have to learn how to surf, instead of drowning in.
• I have severe dissociative symptoms. For example, I’ll be driving and 20 minutes later I’ll realize that I have blacked out and have no idea where I am, which can be extremely scary. Sometimes I convince myself I’m not real, or that the world around me is not real, a phenomenon that can be very unsettling. Life constantly feels like a dream (or sometimes a nightmare) to me. Sometimes I even go as far as convincing myself I am dead and that I am in purgatory. I tend to retreat into my mind when I feel anxious or stressed.
• I’m constantly paranoid that other people are talking to me, even though I know that logically they have no reason to be. My mind also tricks me into believing that my friends hate me and that they want me to go away.
• I’m constantly bored and will do anything to fill the big black hole in my heart. I’ve learned that filling it with meaningless sex, and drugs just makes things harder.

Being a college student with BPD can be extremely challenging at times. I have to closely monitor my thoughts and actions and separate the ones that are really mine from the ones that belong to my BPD. Seeing a therapist, attending support groups, sticking to a strict regime of taking antidepressants and mood stabilizers and finding ways to reduce my anxiety such as writing have helped me learn how to manage my disorder, however, and I am confident I can graduate college and have a normal life despite the hardships that stand in my way.

I Hate You—Don’t Leave Me was first published in 1991 and quickly became one of the first classic references for BPD; however, it was not universally well-received.  Borderline patients and their loved ones, especially, viewed the book as disturbing and hopeless, emphasizing as it did the dismal prognosis of the disorder at the time.  Research has progressed remarkably since then, though, and the authors have taken great care in this revised edition to feature the scientific, therapeutic, and cultural advances made in understanding and treating BPD.

The book opens with a broad, factual description of borderline personality disorder and dispels popular misinformation.  Profiles of borderline patients serve to demonstrate the disorder’s variability in presentation, and leads to a listing of the typical symptoms and worldviews one finds. 

Chapter 2 places BPD against a background of all ten Diagnostic and Statistical Manual of Mental Disorders (DSM) personality disorders, and compares and contrasts the different diagnoses, emphasizing how at times they can appear to overlap and co-present in a borderline patient. 

Chapters 3 and 4 deal with the different causes and contributing factors of BPD, including genetic, developmental (based in object relations theory), environmental (trauma), and finally, cultural.  This last category is explored in greater detail, as the authors theorize that recent shifts in our societal makeup have contributed to the prevalence of BPD over the past ten years.  The rise of social media, less static identity roles, and group and family fragmentation are all mentioned as important phenomena.

The middle part of the book, Chapters 5-6, is geared toward family members, therapists, and others who may have borderline patients in their lives.  The SET-UP (Support, Empathy, Truth, Understanding, and Perseverance) system of effective communication is explained, and the emphasis is placed on BPD as an illness that requires understanding and compassion, while simultaneously acknowledging the challenges inherent when dealing with a borderline patient:

It is important to remember that BPD is an illness, not a willful attempt to get attention.  The borderline lacks the boots, much less the bootstraps, with which to pull himself up.  It is useless to get angry or to cajole and plead with the borderline to change; without help and motivation he cannot easily modify his behavior.  However, this does not imply that the borderline is helpless and should not be held responsible for his conduct.  Actually, the opposite is true. (p. 127)

It also addresses encountering BPD in the workplace and in recreation, and includes helpful patterns for these interactions.

Chapters 7 through 9 progress to the therapy process, from what it takes for a borderline patient to willingly enter treatment to what types of therapeutic approaches may be most effective (including a compare/contrast analysis), as well as the challenges therapists can face when treating BPD, both for themselves and the patient.  Chapter 9 deals specifically with medications and the advances that have been made in the standardization of protocol, although medication remains a secondary part of therapy in BPD treatment.

The final chapter of the book summarizes everything by asking the question, “Can Borderlines Be Cured?”  It is here that the much-improved prognosis of BPD is detailed, including a typical path to healing (insofar as one can be created) complete with a graph that details how many of the hallmark features of BPD, such as impulsivity and excessive guilt, can be turned to an advantage.

I Hate You—Don’t Leave Me is an extremely helpful introduction to BPD and a wonderful overview of the borderline world for someone new to it, whether a patient seeking more understanding of what is happening to them or a family member trying to relate to this frustrating and confusing disorder.  The authors provide a strong scientific background of BPD from both the DSM and the most up-to-date research on its causes and treatment, but they also make the content relatable to the layperson through the use of anecdotes and metaphors:

Her supervisors said that she lacked the academic qualifications of others and that she was abrasive, but Annette wouldn’t accept those explanations.  Incensed, she attributed the rejections to racial discrimination.  She became more and more depressed and eventually entered the hospital.  In the hospital, Annette’s racial sensitivities exploded. (p. 114)

A borderline suffers from a kind of ‘emotional hemophilia’; she lacks the clotting mechanism needed to moderate her spurts of feeling.  Prick the delicate ‘skin’ of a borderline, and she will emotionally bleed to death. (p. 12)

The issues that plagued the 1991 edition seem to have been resolved, especially as the authors took great care in ending the book, and indeed each chapter, on a less despondent and more optimistic note.

There is some conflict, though, when attempting to address the authors’ sensitivity.  They seem incredibly aware of how a patient may read this book as opposed to a therapist, and attempt to remain responsive to each of their constituencies.  For example, a special “Note to the Reader” regarding BPD terminology is included to explain the use of “borderline” as a descriptor throughout the book rather than the more acceptable “patient with borderline personality disorder”:

Although we abhor the implied disrespect and dehumanization of referring to people by their medical conditions[…], we have nevertheless chosen, for the sake of clarity and efficiency, to sometimes refer to individuals by their diagnosis. (p. xv)

Later, though, the authors verge on offensive (at least for this reader) when they mention homosexuality, twice, in direct reference to sexual perversity.

Some writers have noted an increased incidence of homosexuality, bisexuality, and sexual perversions among borderline personalities. (p. 43)

Sexual orientation may also play a part of the borderline’s role confusion.  In line with this theory, some researchers estimate a significantly increased rate of sexual perversions among borderlines. (p. 90)

Beginning in Chapter 9, the book begins to restate earlier points and go deeper than perhaps is necessary into previously explained sections.  For example, although the genetic causes of BPD are presented in Chapter 3, they are again here, with little information added.  The rest of the book is streamlined and laid out in an easily digestible manner, so it does stick out when this tendency declines in the latter sections.

Even if your personal view of the book is less than positive, however, every reader will appreciate the extent of the appendices and resource lists that conclude it.  Appendix A covers a background of the DSM classification system, Appendix B traces the evolution of BPD as we know it today, and the section of resources includes everything from textbooks to first-hand accounts to reference websites to treatment centers.

The main message of I Hate You—Don’t Leave Me is one of understanding and hope.  The book does a laudable job of presenting the main points of BPD to those who may not have previously encountered it, while also serving as a useful resource for those familiar with borderline patients, both in a professional and personal context.

I Hate You— Don’t Leave Me: Understanding the Borderline Personality
By Jerold J. Kreisman, MD, and Hal Straus
New York: Penguin Group (USA) Inc., 2010
Paperback, 271 pages
Paperback, $15.00

This title will be published in December 2010.

Porr then wrote this book, which encompasses her investigation and research into the family experience of loving a member suffering from BPD.  It teaches DBT skills training and mentalization, a highly useful treatment for families who want to learn how to decrease collective stress, increase effective communication, rebuild trust, introduce better coping methods, process and debrief argument aftermaths and reduce challenging conduct that maintains BPD actions and behaviors.  The purpose of this book is to feel, deal, heal and change the family system in a holistic manner, focusing on all members rather than the individual sufferer.  It is not about blaming the “victim” and it gives much hope that transformation and reconciliation is possible.

BPD does not have many fine moments in history.  Think Glenn Close in Fatal Attraction, Winona Ryder in Girl, Interrupted, Jessica Walter in Play Misty for Me and Robert De Niro in Raging Bull to name but a few.  BPD is characterized by mood instability, efforts to avoid real or imagined abandonment, black and white thinking, idealization and devaluation of significant others, splitting into good and bad, impulsive behavior, a history of unstable relationships, a distorted and wavering sense of identity and image with chronic feelings of emptiness, a tendency toward paranoia, self-harm and suicide ideation as well as completed suicide in 10 percent of people diagnosed.  Borderline personality disorder is like emotional dyslexia because there is a disconnection between actual words spoken and interpretation of these words.  It is these conversations and behaviors that undermine relationships with family, friends and colleagues and generally make life a misery for the sufferer and their loved ones.

While there have been many clinical and technical books written by professionals for professionals about BPD, recently there has been an influx of books written specifically for family members who need specific tools and strategies to help cope with these distorted and disturbing behaviors.  A good book for a layperson about a psychiatric condition needs to be simply but elegantly written with minimal use of technical words, terms and psychobabble, resonate fully and responsibly with the reader, be helpful and hopeful and above all capture and engage the heart.  Porr’s text fulfills those criteria superbly with some very unique and creative metaphors.  The book demystifies a syndrome that is believed to affect nearly six out of 100 people, and it is both thorough and comprehensive.

Porr states, “As many as 5.9 percent of the general population meet the criteria for BPD.  Professionals do not talk much about this disorder on TV, your friends may not believe it exists; even Oprah does not discuss it.  There is no poster person for BPD rallying support [and] no telethon to help raise money.”  It goes on to say that “Many people with BPD are able to control their behavior in public situations or among strangers.  They have the ability to appear calm and competent to outsiders, to act “as if” they are “okay;” but they seem unable to maintain this behavior within intimate relationships, with partners or close family members.”  This is frustrating for family members who feel they will be disbelieved and closed down by others if they mention this discrepancy.

This is also why a family approach is needed. There is a whole chapter devoted to BPD sufferers’ siblings and how these people have been neglected by the mental health community.  The BPD sufferer absorbs so much of the family’s emotional and physical attention and concern that the siblings’ needs and achievements are overlooked.  Siblings, spouses and other members are more likely to have an empathic approach if they understand the genetic component and neurological structures involved in BPD.

The section on the science of BPD discusses how changing the brain can change the behavior.  This chapter states that “The scientific findings brought together here will help you reframe BPD as a mental disorder with real, tangible biological underpinnings rather than a “character flaw” or a matter of “bad” personality.”

DBT is considered the treatment with the most randomly controlled clinical trials showing its effectiveness.  One small quibble, I feel, is that the DBT process itself can be somewhat directive, rigid and inflexible which, ironically enough, are the very same disturbing traits one is trying to eliminate in BPD itself.  It is stated by Marsha Linehan that “If your patient isn’t better in a year, you should find another therapist for your patient.”  She also states that it is the therapy that is 100 percent effective and that it is the therapist who is failing the patient.  My thoughts are that any therapy that claims such a high success rate needs to have long term follow-up (2, 5, 10 or 20 years) to see if that success has any subsequent longevity.

The last section deals with mentalization and understanding interpersonal misunderstandings.  Mentalization Based Therapy treatment for BPD, developed in England by Anthony Bateman and Peter Fonagy, is evidence-based and a reasonably new method of treatment for BPD. Peter Fonagy is a prominent contemporary psychoanalyst and clinical psychologist and his clinical interests center on issues of borderline psychopathology, violence and early attachment relationships.  He has also written extensively on attachment theory and psychoanalysis.

If DBT focuses on controlling emotions and changing behavior, MBT focuses more on understanding the misunderstandings that occur in relationships by changing perceptions, interpersonal situations and experiences.  Mentalization is defined as making use of mental representations of one’s own and another’s emotional state.  Lack of effective parenting can leave children unable to modulate and interpret their own feelings, as well as those of others. It explores the separation and merging of the minds of two people in a significant relationship and how they perceive each other.  It focuses on awareness and acknowledgement, explores alternative interpretations and intentions from both points of view.

The chapter explains that an inability or failure to mentalize seems to be at the core of BPD.  It deals with helping the non-BPD family members with the BPD sufferer and gives much accurate and detailed explanation on how to take the high road in order to make a difference; on being supportive, empathic and compassionate, how to ask lots of questions, be a detective, to listen, observe and validate, to be humble, to take responsibility and if necessary apologize, be consistent, do not get sidetracked, be careful of the use of language, do not be dogmatic and inflexible, always label feelings, find alternative perspectives, be vulnerable, radically honest and authentic.

I found this book managed to encompass the entire family experience, offered much supportive and constructive advice, demystified effective evidenced-based therapy and gave not just hope and reassurance but concrete and anecdotal evidence that there is a cure for a personality disorder once considered untreatable.  It was riveting to read and easy to understand.  It placed familial love, compassion, respect and empathy as the secret ingredients to complete the therapeutic recipe, important ingredients which were lacking from so many previous modalities and treatments.

Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change
By Valerie Porr, M.A.
Oxford University Press USA: August 2010
Paperback, 424 pages
$24.95

Or are you involved in codependent relationships that deplete your energy and resources and don’t even help your loved ones to become healthier?

One way to figure out if the time and energy that you are investing in a relationship is truly helpful to your loved one is to look honestly at what controls your relationship choices. Is it fear?

For example:

1. Do you make choices in your relationships based on your fear of being seen as selfish and uncaring? If you try to assert your needs with a loved one, and they call you selfish or say ‘it’s always about you,’ do you always give in and let go of your own needs and preferences?

2. Do you make choices in your relationships based on your fear of being abandoned or cut out of your loved one’s life? Are you so scared of being left that you will do anything to prevent it? Are you tormented by the idea of seeing yourself or being seen by others as ‘the kind of person’ who has a broken relationship or shattered family?
3. Do you make choices in your based on your fear of your loved one becoming angry? If your safety or the safety of your children is truly at risk, please try to get help to get out of your current situation. If it is not a safety issue, however, is it that you cannot tolerate the experience of intense conflict with someone you care about? Are you highly tuned in to your loved one’s moods and always trying to do whatever it takes to prevent him or her from becoming upset?
4. Do you make choices in your relationships based on your fear of shattering your loved one’s fantasies? Are you afraid of being seen as pessimistic? When your loved one is on a high of hope or is painting a picture of ‘happily ever after and things are going to change,’ are you scared to burst the bubble? Are you afraid of pointing out that you’ve both been on the rollercoaster many times before, where ‘it’s going to be different this time’ is always followed by the crash and burn of disappointment? Are you afraid of what might happen if your loved one actually faced his or her limitations and unhealthy patterns?
5. Do you make choices in your relationships based on your fear of losing your own romantic fantasy? Are you sacred to give up on the fantasy that love conquers all, and that true love transcends dysfunction and unhealthiness? If your loved ones call on you to honor the power of love, are you unable to stand your ground with a limit you’ve tried to set with them?
6. Do you make choices in your relationship based on your fear of your loved one seeing the situation differently from how you see it? Are you unable to tolerate it when your loved one’s version of ‘reality’ is radically different from your own version? Are you so afraid of your loved one seeing things in a way that seems crazy to you that you are unable to let go of trying to force them to see it your way?
7. Do you make choices in your relationships based on your fear of facing the reality of what you can and cannot control? Are you unable to accept that ‘carrying’ another person’s pain inside of you, or sacrificing yourself to be everything they ask you to be, does not give you the power to change them or alleviate their suffering? Are you so afraid of your own powerlessness that you cannot let go of trying to fix or change things that are not in your power to change?

If you answered yes to all or most of these questions, then you have some work to do before you can be of true help to your loved ones. When your choices in your relationships are based on fear, you are acting from a place of weakness. Fear blinds you from seeing things clearly, and takes away your ability to make choices based on seeing the whole situation clearly. Fear prevents you from accepting the limits to your power, and keeps you stuck in relationship patterns that suck your time and energy into black holes. Fear leads to your emotional, physical, mental, spiritual, and financial depletion, while your loved one continues to cycle through their same old patterns.

Your first priority in transforming your codependent relationships into healthy ones is to get support to face your fears and to move beyond them to a place of strength and stability. If you are not on your own healthy ground, you are of no help to anyone.

With proper support, you can develop the ability to prioritize your own wellness as a matter of self-respect and in order to ensure that you have enough reserves to give to others. You can start to see yourself as a human being, which means having needs of your own that sometimes conflict with others’ wants. You can become skilled at setting limits, saying no, and refusing to be pulled into emotional guilt manipulation. You can begin to make careful and creative choices about how to be there for loved ones while also remaining strong in yourself. You can slowly learn to let go of things that are beyond your power.

This is not easy. Changing the way you relate to the people you care about is challenging and confusing. When you set limits and say no, or even when you refuse to be pulled into another person’s drama, it will scare and upset them. You are likely to face their anger, rage, and withdrawal. They might make dramatic predictions of death and loss and destruction, and scary threats of hurting you or hurting themselves.

Learning how to stay the course amidst this storm is a lifelong process. But it is possible, and the reward is your growing confidence that your precious time, energy and love are being given in the service of real health and wellbeing.

If you’re someone with BPD or a loved one of someone with BPD, you probably already know this. The devastation this disorder causes is immense but the misunderstanding and lack of treatment may be just as heavy. With The Buddha & The Borderline, I believe that you’ll find relief, reputable information and hope. It’s far from an easy read. But it’s real, authentic and truly valuable.

In this memoir, Van Gelder documents her diagnosis, treatment and recovery from BPD. She begins the book when she’s 30 years old, when she’s already attempted several times to take her own life, gone through a handful of hospitalizations, been diagnosed with depression, anxiety and post-traumatic stress disorder and recovered from alcohol and drug addiction. She is in the arms of yet another boyfriend, attaching herself to him in such a way that she loses herself completely. (She writes later in the book: “If Taylor were gone, it would be like pulling the plug in a basin that holds all the shapeless, turbulent liquid of my life. I would drain away.”) This is a pattern: With every boyfriend, her identity, her musical tastes, how she dresses, what she believes tend to change. Yet she doesn’t know why. After each relationship ends, she starts searching for another savior.

Van Gelder desperately wants to find out what is wrong because as she writes, “…despite being clean and sober for almost a decade, I’m still a mess.” For almost two decades, she’s been in therapy. She has tried various types of treatments, medications and 12-step programs, but yet nothing seems to be working.

When she’s finally diagnosed at a local hospital, Van Gelder witnesses firsthand the stigma, shame, myths, insurance woes and unavailability of treatment. Yet even as she’s struggling with out-of-control symptoms and suicidal urges and grappling with such a stigmatized diagnosis, Van Gelder continues fighting. Her initial motivator? Rage. She writes:

Ultimately rage, not hope, hurls me into recovery when I finally understand that it’s not simply my illness, but incompetence and avoidance from the mental health system that has created my ‘incurable and hopeless’ condition.

This book is a must-read for several reasons. One of the main reasons is that Van Gelder demystifies BPD, clearly defining the symptoms both from a scientific level and a personal one. She writes about deeply intimate slices from her life so readers receive an inside look into what it’s like to have BPD. This is very uncommon, as BPD is largely marred in mystery in our society. The public gets very little solid information about what this disorder really looks like.

Van Gelder also addresses her loved one’s denials of her diagnosis — also common. In the beginning, her mom repeatedly questions her being “mentally ill.” In a therapy session with her mother, Van Gelder says:

But why can’t you take my mental illness seriously? I feel like I’ve been set up, over and over. Like I’m a cripple without a wheelchair, and everyone keeps signing me up for marathons, then shaming me for not winning the race.

She also faces similar frustrations as she tries to share information about BPD with her grandparents:

Indeed, I discover that the less I say, the happier everyone seems to be with me. I sometimes wonder if I wouldn’t have been better off as a paraplegic or afflicted by some tragic form of cancer.

Secondly, she demystifies dialectical behavior therapy (DBT) — a treatment developed by Marsha Linehan, Ph.D., which has scores of research studies to back up its effectiveness — and informs the reader in great detail about this treatment. So while this is a memoir, it also serves as a valuable teaching tool. Loved ones and individuals with BPD will benefit from learning about their options and the nitty-gritty of DBT, which like BPD itself, many people have no clue about. Therapists and graduate students also will learn a lot.

Relying on research studies and books on DBT, Van Gelder quotes Dr. Linehan (and other experts) and describes the theories, goals and techniques of the treatment in layman’s terms throughout the book. As she gives readers the theory behind each step, she illustrates this in relation to herself and her therapy.

For instance, DBT focuses on the concept of dialectics, which on a practical level is, according to Van Gelder, “…what happens when opposites combine to create something new…On a deeper level, dialectics is a viewpoint that recognizes reality and human behavior as fundamentally relational.”

Throughout the book, Van Gelder tries to reconcile the opposing parts of herself. Can she really resist something and long for it at the same time? Can she be healthy in some ways but still lack a secure sense of self? Interestingly, the book, too, mirrors this dialectical nature. It’s painful, frustrating and potentially triggering while being uplifting, soothing and hopeful.

In the last part of the book, Van Gelder discovers Buddhism and explores how it applies to BPD and her life (dialectical behavior therapy is actually based on Buddhist philosophies). Just as she does throughout the book, in the end, she provides several profound insights.

In addition to the perceptive content, Van Gelder’s writing is beautiful and heartbreaking. Van Gelder is a gifted and eloquent writer, and readers will instantly get pulled into her story.

As mentioned briefly above, parts of the book may be triggering to some readers. Van Gelder writes poignantly and often in-depth about painful experiences, including her cutting, suicidal urges and sexual abuse. So while this level of detail may be necessary for readers to gain a better grasp of BPD’s desperation, confusion and grief, it can have a negative effect on someone who’s vulnerable.

As much as this book is about seeking the correct diagnosis and the struggles of recovery, The Buddha & The Borderline is also about Van Gelder’s journey to find herself and lead a life worth living — the ultimate goal of DBT. Even though this is a memoir, it’ll no doubt echo the stories of other sufferers and help readers better understand BPD and its treatment.

The Buddha and the Borderline: My Recovery from Borderline Personality Disorder Through Dialectical Behavioral Therapy, Buddhism and Online Dating
By Kiera van Gelder
New Harbinger Publications: August 2010
Paperback, 246 pages
$17.95

Misconceptions

• Individuals with BPD are manipulative. BPD is the result of a combination of causes, including biological factors and a history of being invalidated, which may result in an inability to regulate emotions, according to Michael Baugh, LCSW, an expert in dialectical behavior therapy (DBT) and mindfulness at Third Wave Behavioral Center, his private practice in Seattle. Picture a bell curve of emotionality, Baugh suggested. “Individuals at the more emotional end of the spectrum (like people with BPD and many good therapists) are more easily and strongly triggered by events in their environment, and it takes longer for them to return to baseline — but they can learn the skills to manage these more intense emotions,” he said.

  Baugh gave the following example: An emotional child grows up in a stoic family, where he’s constantly told to calm down. He tries to follow the family’s rules by suppressing the awareness of his emotions. As the intensity of his emotions ramps up, however, it eventually bursts out of the zone where it can be ignored. When this happens, the emotions appear to go from zero to 60 on the emotions speedway, and their intensity can’t be controlled. “At that point everybody in the family has to deal with it, and because people need to have emotions responded to, this only reinforces the person getting to emotional extremes,” Baugh said. Consequently, this becomes the only way the person knows how to manage emotional situations.

  In other words, a person with borderline personality disorder rarely makes a conscious decision to manipulate anyone. When a person isn’t having their needs met, they resort to extreme behaviors, according to Neil Bockian, Ph.D, founder and president of Behavioral Health Associates and co-author of New Hope For People with Borderline Personality Disorder. These behaviors then get reinforced when family members or people who don’t normally pay attention to them rush in, he said. When loved ones get burned out, the person with BPD starts escalating the behaviors.

• It’s untreatable. “The research shows convincingly that some treatments for BPD are remarkably effective,” said Kristalyn Salters-Pedneault, Ph.D, a clinical psychologist who specializes in BPD and writes a blog on About.com on the disorder.
• BPD is a life sentence. According to Alexander Chapman, Ph.D, president of the DBT Centre of Vancouver and co-author of The Borderline Personality Disorder Survival Guide: “In a recent study of patients with BPD who were hospitalized and then released, up to 70 percent no longer met criteria for the disorder at some point in a six-year follow-up period. Of those people who stopped meeting criteria for the disorder, 94 percent of them never met criteria again across the six years.”
• People with BPD aren’t trying hard enough. According to Joan Wheelis, M.D., director of the Two Brattle Center in Cambridge, Mass., “it isn’t that clients aren’t motivated, but that there is significant emotional, cognitive and behavioral dysregulation associated with the disorder.” People don’t realize just how considerable their deficits are. Many are very intelligent, talented and productive so it’s hard to believe, she said. “The person is doing the best they can given their current mental state,” Bockian said.

Treatment

According to Salters-Pedneault, “BPD is best treated with a multi-method team approach,” which might include an individual and group therapist and a psychopharmacologist to manage medication. It’s this team who then “can determine the treatment of choice for an individual patient,” said S. Charles Schulz, M.D., head of the department of psychiatry at the University of Minnesota Medical School.

However, too many treatments can result in a “non-treatment treatment,” where the client isn’t fully engaged effectively in therapy, Dr. Wheelis said. She noted the importance of having “a primary clinician who’s responsible for the architecture of the whole treatment.”

Psychotherapy is the central treatment for borderline personality disorder. “To date, the gold-standard treatment for BPD is DBT (dialectical behavioral therapy),” Salters-Pedneault said. While there’s no way to say that DBT is superior — to date, no studies have compared all treatments in a “horse race” — judging by the quantity and quality of the studies that support DBT, it’s currently the best form of treatment, she said. Other promising psychosocial treatments include schema-focused, mentalization-based and transference-focused therapy.

Medications are sometimes prescribed to reduce symptoms of BPD or to treat a co-occurring disorder (such as bipolar disorder) and may help in conjunction with psychosocial treatments. According to Dr. Schulz, while studies haven’t been conclusive, some research has found that individuals who participated in DBT and took olanzapine (Zyprexa) experienced a reduction in symptoms when compared with individuals who attended treatment but took a placebo.

Dr. Wheelis, who advocates the use of medication, worries that “medication may be prescribed too frequently, leading to polypharmacy.” Additionally, “medication for symptoms of BPD can sometimes interfere in teaching the client that they can tolerate and cope with their emotions head-on,” she said.

Finally, there is a sympathetic, wise, insightful, blame-free, plain and simply written discourse aimed at non-BPs with significant other BPs in their lives.  It explains what BDP is, symptoms of which can include abandonment and rejection issues, lack of self-identity, chronic emptiness, impulsivity, inappropriate anger, emotional instability, paranoia, splitting of people into all good and all bad and suicidal ideation.  It provides everyday solutions for coping with BP behavior, how to get help for the affected person, what additional traits occur which the DSM does not mention, deals effectively with universal myths and everyday realities, explains succinctly why BPs act the way they do and generally destigmatizes BPD.

It is a most comprehensive book written for both sides of the borderline fence with easy to read chapters ending in succinct summaries.  Text boxes are outlined in an attempt to highlight the main message of the relevant passage and although this is somewhat distracting, it does serve a higher purpose.  However, a word of warning for any BPs reading this book: Although it is written in a very compassionate voice, it may unearth repressed memories from childhood and evoke unconscious triggering behavior you may not even be aware of until the damage is done.

Many technical and learned books by eminent psychiatrists have been published with regard to the behavioral and cognitive processes of people with BPD without actually explaining at a humanistic level what this diagnosis can mean to the person suffering and their mentally healthy wives, husbands, partners and children.  This book augments and expands on our current knowledge of BPD with much additional important information including lesser known BPD traits such as pervasive shame, undefined boundaries, control issues, lack of object constancy, interpersonal sensitivity and situational competence.

Within some psychology circles, BP sufferers are considered the “cane toads” of therapy, a seemingly ugly, rampant species, much maligned and vilified, out of control, multiplying fast and taxing the health insurance system and the patience and time of all concerned.  It is not unusual for these people to be weeded out of therapy by ruthless and unscrupulous mental health professionals who see them as excruciatingly difficult, exceedingly demanding, almost untreatable and virtually incurable with their perceived “divide and conquer” ability to split at will.  In contrast, there are some very enlightened therapists who are changing the course of treatment and the quality of life for these people (think Marsha Linehan, founder of Dialectical Behaviour Therapy, specifically designed for BPD).

Stop Walking on Eggshells explains and defines BPD behavior in the historical context of genetic predisposition, a traumatic upbringing or social environment that needs to be viewed as dysfunctional early coping mechanisms and survival skills internalized at a very early age.  This book offers new and healthier techniques for dealing with significant relationships that overlays old experience with new.  I feel its most important message explains BPD behavior in terms of manipulation vs. desperation.  In other words, BPDs do not deliberately consciously manipulate people; rather, they are emotionally desperate in their panicked and frantic efforts to connect with others in a most genuine and authentic manner.

The book is divided into three parts.  Part One is Understanding BPD Behavior.  This section gives much needed validation and vindication to children of BPs who need to understand their BP parents’ inexplicable behavior.  Explained in graphic detail and with many anecdotes, it attempts to impart the knowledge that parental BP behavior and criticism is not about the non-BP child and everything to do with the other.  It defines how the inner world of the BP develops, grows and explodes out of control and just how this critical voice can seriously damage non-BPs’ self-identity and self-esteem.  As one non-BP said:

Even my body functions were criticized.  My borderline mother claimed that I didn’t eat, walk, talk, think, run, sit, urinate, cry, sneeze, cough, laugh, bleed or hear correctly.

Many BPs fluctuate between extremes of idealization and devaluation, otherwise known as “splitting” which is an unconscious defense mechanism.  BPs see people as either the wicked witch or the fairy godmother.  The book states:

Because people with BPD have a hard time integrating a person’s good and bad traits, their current opinion of someone is often based on their last interaction with them – like someone who lacks a short-term memory.

Part One also explains how BPs lack a sense of self, feel empty inside, that they are different people depending on whom they are with, are dependent on others for behavioral cues, are panicked and bored when alone, judge themselves and others harshly, never feel good enough and see themselves as helpless victims of other people.

It further explains why BP impulsivity and substance abuse often go hand in hand with self-mutilating behaviors which include cutting, burning, breaking bones, head banging, needle poking, skin scratching, pulling out hairs and ripping off scabs.  The purpose of self-injury is relief of mood violations, stress and anxiety symptoms, to feel more alive and less numb, to express anger at others and to punish themselves rather than gain attention or commit suicide.  Self-sabotage and self-destruction is succinctly explained in this poignant quote:

When my father stopped abusing me, I had to make up for the hurt that had suddenly disappeared.

I was stunned to discover that some people learn to sew up their own wounds so they don’t have to seek medical attention.  BPs are intellectually aware of the reasons they hurt themselves, but this does not make it any easier for them to stop.  This lack of reasoning can be explained with this quote from Marsha Linehan:

People with BPD are like people with third degree burns over 90 percent of their body.  Lacking emotional skin, they feel agony at the slightest touch or movement.

As this is an information guide and educational book for non-BPs, there is a section that focuses on appreciating, in a sensitive manner, destructive borderline behavior, and wisely explains you “have to leave your own world and journey into theirs.” It gives much “how-to” advice on non-BPD responses to borderline hysterics and tantrums and the positive effects and calming influence this has on the relationship, explaining how to hold steady under intense pressure and relentless provocation to actively retaliate with equal venom.

Part Two is labeled Taking Back Control of Your Life, and explains how to make the necessary changes within yourself.  You can lead the BP to treatment but you can’t make them well or feel better; that is up to them.  It clarifies the illogical basis of a BP’s self-denial that a problem exists and sheds light on the fact that a BP will seek help when they feel the benefits of doing so outweigh the obstacles in their path of change.  Here is one woman’s unfolding epiphany:

My own shock was the look in my four year old son’s eyes when I lost it and began smacking him until his thighs and face was red.  He hadn’t done anything wrong.  I was beating him for being a kid when I didn’t feel like being a mother.  And when he initially started bawling, it made me angrier.  I hit him harder.

There is a part on using coping strategies for self-care, how to seek support and validation, how to seek out Internet help and community groups and above all how to keep a good sense of humor.  Taking care of yourself, detaching with love, taking your life back, not allowing yourself to be abused, taking the heat out of the situation by gently paraphrasing and reflexive listening, creating a safety plan for imminent self-mutilation, how to bolster your own self-identity and self-esteem, taking responsibility for your own behaviour and remembering that sometimes, “… splitting and other BPD behaviour can be catching.”

“If you find yourself involved with a BP, you can bet that you have unfinished business with a parent.” The book explains this is an unconscious bid to duplicate the experience to resolve unfinished business with the parent.  It gives information on how sexual, physical and emotional abuse has violated a BP’s personal boundaries and limits and the humiliation and shame that damages.

Abused children feel confused about what to let others do to them physically, how to let others treat them emotionally and how to interact with others in socially appropriate ways.

…

Children who experience abuse also learn to deny pain and chaos or accept them as normal and proper.  They learn that their feelings were wrong or didn’t matter.  They learn to focus on immediate survival.

To explain this another way, they are bound from scripts from the past.

Part Three focuses on Resolving Special Issues such as coping with the Borderline child.  There is a heartfelt story about parenting challenges from a mother and father of an out-of-control 14-year-old daughter diagnosed with BPD after bipolar medication was ineffective.  Various anecdotes explain how a family can be torn apart by a BP child and most importantly how they can be brought back together with therapy, the right medication, patience and most importantly unconditional love.

This book addresses the many complex and complicated issues for BPs and non-BPs.  It is original, well-written and gave me a much greater understanding of what the non-BP experiences.  I thought I knew mostly everything there was to know about BPD, but this informative book has opened my eyes further.  If you have a BP person in your house or suspect a friend or family member might have BP, this is the book to go to for that helpful piece of advice that just may save your sanity.

Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder

By Paul T. Mason and Randi Kreger
New Harbinger Publications: Second edition January 2010
Paperback, 260 pages
$18.95

Girl in Need of a Tourniquet is one of the most intimate and complex portrayals of a woman living with borderline personality disorder that a reader could choose. The book is not for the person who is simply seeking bulleted information, rather it is for a person looking for an inside perspective and a new outlook. I read this book as a person who is not afflicted with the disorder, but Johnson’s writing seduced me into feeling exactly what she felt during the worst periods of her life.

Before I even reached the first chapter I encountered a quote by singer/songwriter Aimee Mann that clearly explains the title: “You look like a perfect fit, for a girl in need of a tourniquet. But can you save me….” Throughout the book Johnson shows us her world by bleeding — in the most poetic way possible — all over the book, crying out for help to both the reader and her current lover.

Johnson begins her story with someone else’s, that of Lisa “Left Eye” Lopes. Lopes was a rapper and member of the girl group TLC who died in a car accident in 2002. In a symbolic reference, Johnson says when Lopes lit her boyfriend’s (NFL star Andre Rison) shoes on fire in the bathtub and consequently burned their home down, she could feel the flames of Lopes’s mansion burning and see it from her house.

This theme of burning and being out of control continues throughout Johnson’s entire book and life. She refers to many other people in her memoir including her parents, sisters and even the infamous Alex Forrest from the movie “Fatal Attraction.” The book has the pacing of a Hollywood movie and that helps it stay fresh and exciting for the reader.

The first time Johnson talks about herself we learn that she has been married and divorced by age 20 and that her current boyfriend is physically abusing her. She therefore chooses to run away and seek a new life without him. Subsequently she meets an emotionally abusive woman with whom she realizes that she is a lesbian. This experience ultimately pushes her over the proverbial edge of her sanity and forces her to try and find out what is “wrong” with her.

Along the way we learn that Johnson is a cutter, she has a fondness for stealing lovers from other people and that she flees when situations get difficult. However, we also learn that she is very intelligent, has two sisters who she basically mothered (yet she still feels guilty for leaving them with her real mother) and that all she really wants is to love someone and be loved in return. It is impossible not to feel compassion for her.

Do not pick up this book if you are searching for light reading. It contains strong emotions, complex symbolism and a large number of words that might be in the vocabulary of a poetry aficionado. It takes Johnson about two thirds of the book to start divulging any real information on borderline personality disorder. Instead, she lets the reader try to discover on his or her own what he or she thinks borderline personality disorder is. If the title did not reveal the name of the disorder, then the average reader would not know this book was about a specific issue until the end. Instead, they would think it was a typical memoir about a troubled or “difficult” person.

This choice is overwhelmingly intentional. Johnson’s memoir is something more than an essay on a personal cathartic experience; it is an open invitation to readers to change how they think about people with borderline personality. She does not use the word “disorder.” According to Johnson, most therapists and most people in general are afraid of people diagnosed with borderline personality disorder. Even she admits to having a very negative first reaction to her diagnosis. “BORDERLINE PERSONALITY DISORDER. Shit. Those people are crazy.” (p. 137).

However, in the next paragraph she goes on to venture a guess as to why the term had such a negative connotation.

I had heard of borderline personality disorder when I worked in the university counseling office as an undergraduate English tutor. A woman walked in one day, a streak of dark hair and an open black raincoat. She asked to see one of the graduate-student counselors. No one would tell her anything. Everyone just wanted her to leave. When she left the office, the student worker staffing the front desk turned to me and said, ‘She’s a borderline. They’ll stalk you,’ That’s the start and finish of what most people know about borderline personality. (p. 138)

Near the end of the book we are offered information about the current debate in the psychology world over the name, borderline personality disorder and its destructive nature. The new name that has been proposed is “emotion regulation disorder.” In Johnson’s mind this name is a lot less threatening and would encourage therapists and people who think that they might have the disorder to be less afraid of the diagnosis.

After reading this book I have to agree with its concept. Although borderline personality disorder is serious, it seems to be a collection of unhealthy behaviors that many people exhibit at some point in their lives (such as cutting, using sex as an outlet for anger or frustration and throwing tantrums). The only difference is that people diagnosed with borderline personality disorder exhibit these behaviors more frequently and it begins to drastically affect the quality of their lives. Treatment is necessary, but most people need help from time to time. Johnson is just proposing that we help remove the stigma from the disorder’s name.

The end of the book is uplifting and suggests that there will always be bad times, but that the best thing we can do for ourselves is simply to “wait for a better season” (p. 222).

Girl in Need of a Tourniquet: Memoir of a Borderline Personality
By Merri Lisa Johnson
Seal Press: June 2010
256 pages
Paperback, $16.95

Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral therapy originally designed as an outpatient treatment for people diagnosed with borderline personality disorder. DBT was developed by Marsha Linehan and was originally aimed at reducing the high-risk, impulsive and treatment-interfering behaviors in women who self-injured. Clinical trials have found DBT to be effective in reducing self-injurious behavior and inpatient psychiatric days in women diagnosed with BPD. These trials also found it to be helpful in reducing anger and improving social adjustment. DBT has also been adapted and evaluated for other populations, including adult ADHD.

DBT’s approach balances a focus on behavioral change with acceptance, compassion, and validation for the individual receiving services. DBT strives to enhance an individual’s capability to manage psychological and emotional functioning, improve motivation, ensure that new behaviors are generalized to daily life, structure the environment to support adaptive behaviors and enhance treatment provider ability and motivation.

Core elements of DBT include the biosocial theory, stages of treatment, guidelines on identifying treatment targets, acceptance, change and dialectical treatment strategies and five specific modes of treatment, which includes a weekly skills group. In initial stages of treatment individuals often experience extreme behavioral dyscontrol and engage in problematic behaviors such as self-injury, suicide threats, severe eating disorders and substance use. The initial goals of treatment focus on stopping problematic behaviors and gaining behavioral skills to manage extreme emotion and impulsivity. Once greater behavioral control is achieved, focus in on improving quality of life, emotional experiencing and achieving ordinary happiness in ife.

Adaptations to DBT often focus on DBT skills training. Skills training group is generally a weekly group with half of group time structured to teach skills and half of group time spent reviewing homework and use of skills in daily life. The group is highly organized and focused on teaching and practicing new skills and improving motivation to use skills outside of group.

Although it was originally designed as an outpatient treatment for women diagnosed with borderline personality disorder, DBT has grown into an effective treatment for people with a wide variety of diagnoses and problems. Its effectiveness in modulating extreme emotions and reducing negative behaviors makes it an attractive treatment especially for people who struggle with impulse control and emotional instability. The emotional instability, disorganized behavior and impulse control problems make DBT a potentially good match for the treatment of adult ADHD.

In 2002 Hesslinger and colleagues developed a 13-week group as an adaptation of a DBT skills training group. The adapted group included trainings on 3 of the 4 skill modules taught in traditional DBT skills groups. The ADHD group focused on mindfulness, acceptance and tolerance of crisis and painful life events and managing emotions. The ADHD group added training on behavioral analysis, which is typically a part of DBT individual therapy. The purpose of each of these skills modules is to teach individuals to focus attention, accept and survive difficult life events without engaging in impulsive or dangerous behaviors and to reduce vulnerability to extreme emotions. Behavioral analysis teaches individuals to analyze their own behavior patterns and the thoughts, feelings and actions that contribute to impulsive and problematic behaviors.

Although the study size was small, the ADHD participants in the adapted DBT treatment experienced significant reductions in depression and ADHD symptoms. They also saw improvements in attention and ability to focus.