Borderline Personality Disorder (BPD) is a crippling psychological problem, one of the most difficult I’ve seen in my practice. Its main features are a way of looking at the world that lead to extreme shifts in emotion, chaotic relationships, and a lack of identity. Clients who suffer from BPD also report that they often feel numb or empty, almost like a shell of a person. What is perhaps most disturbing is that very often clients will engage in self-harming behaviors such as cutting, scratching, or burning of one’s own body (known as para-suicidal behavior) and some will periodically make full-blown suicide attempts.
It is not certain why the para-suicidal behavior occurs, but most of the people I have seen with BPD report that the physical pain not only serves as a distraction from any emotional pain, but can also serve as a reminder that they can experience pain, that the physical sensation of being cut or burned eradicates the numbness that they often experience. Traditionally diagnosed mainly in females, no one knows exactly what causes it, and it is certainly one of the more difficult conditions to treat, with people needing to be in therapy and on medication for years if not for life just to manage the symptoms.
The most prevalent form of treatment for BPD is known as Dialectical Behavior Therapy (DBT). In many ways DBT is more like a course than a therapy, with both individual therapy and a weekly group meeting where clients learn skills to help them deal with painful emotions. Medication is often used as well, which purportedly keeps the mood swings to a minimum and can help with concomitant disorders like depression and anxiety, but the bottom line is: how do you medicate a personality?
Right after I completed graduate school, I took a training position solely focused on the treatment of BPD. It was basically a one-year crash course in DBT, and I worked both individually and in groups with women who were in their own private hell. Because people with BPD often think in “all-or-none” terms, their relationships with other people are often horrendous. When they meet a new person who is nice, that person is placed on a pedestal. When that same person forgets to call a week later, he or she becomes the Anti-Christ.
Because I fancy my therapeutic style as nurturing and rarely confrontational at the outset of treatment, many of the women saw me as the beacon of hope and all that is good, pure and true. Within a month, however, I had one woman attempt to put out a cigarette on my forehead, another throw a half-full can of soda at my chest, and yet a third dump a cup of hot tea on my lap. Maybe it was naiveté, but I never got angry when these things happened. Make no mistake, however: each person was kicked out of session (for what is known as “therapy-interfering behavior”) and I held each one accountable by demanding an apology upon their return at the next session – I was told that I could charge them for dry cleaning if they ever damaged my clothes beyond laundry repair – but I never saw these women as being malicious. I saw them as sick and in pain and needing help.
The women were held to similar standards regarding their self-harming behavior, based on the treatment’s philosophy that the number one priority was to stop the person from inflicting physical pain upon herself. Clients would sometimes get distressed in the group setting and start to scratch at their face. Or a woman would slice the back of her hand with her car key when confronted on being late. I had a client who also suffered from Obsessive-Compulsive Disorder, so not only did she slice her arms up and down with a razor, she did it with precision: a one inch by eight inch box of incisions, making her arm look as if someone had painted a perfectly shaped brick on her arm.
When behaviors like these were done at home and reported to the therapist in session, it was discussed at length, regardless of what the client wished to focus on that session. If it was done in the office, the patient was either sent to the hospital or home. Every client in the program signed an agreement that they would always be nurtured by the clinicians but never coddled, and would be held accountable for what they did to their bodies.
When I went into practice on my own, I left most of that work behind. It’s very difficult to hold group settings in small offices in New York City, and clients with extreme problems such as those seen in BPD very often need to be seen in clinic settings, where there are multiple clinicians available to handle the inevitable emergencies and crises that are part and parcel of doing DBT. A single clinician attempting to tackle those difficulties is begging for a very high failure rate in his or her practice. Along those lines, research shows that a lack of success in one’s practice is the number one cause of “burnout” in therapists.
When Gina contacted me she asked to be seen for “fucking myself up.” She wouldn’t say much over the phone, as she had called from work, so we simply agreed to meet in the office as soon as possible. When she arrived, she proved to be a small woman who couldn’t have been more than 22, with long sleeves over her arms, despite the sweltering 90 degree heat. I flashed back to my days doing DBT, when embarrassed clients would often wear clothes that covered their brutalized skin, independent of weather.
I often begin the initial session by letting a client know that this is her time to tell me what is troubling her and that I will do my best formulate a plan that will hopefully be of use to her. I always tell clients that I may need to interject to ask a question or get some clarifying information, but that for the most part I will be doing much more listening than speaking. Gina quickly went into the story of her life and how she came to feel so miserable. When she had concluded, I immediately asked about her self-harming behaviors.
“Dr. Dobrenski, I know I have Borderline Personality Disorder,” she responded. “I’ve been reading about it on the internet, and I have the symptoms.”
Client Rule: Don’t diagnose yourself.
“Alright, let’s discuss the symptoms a bit. What particular ones are you talking about?”
“I hurt myself all the time.”
“How do you hurt yourself?”
“I hurt my arms.”
Even though I’m not a physician, I often ask to see the cuts that a client makes, just in case the injuries are serious enough to require immediate medical attention. Gina had no problem showing me her arms. She rolled up her sleeves revealing two red patches on each wrist, somewhat circular, about the diameter of a golf ball.
“These look like rug burns,” I said.
“They’re from a razor. My boyfriend’s razor.”
“This may sound like a stupid question, but what kind of razor does your boyfriend use?”
“A Norelco. Cool Skin, I think.”
“Were you trying to cut yourself with an electric razor?”
“I’m so stupid! I can’t even hurt myself the right way.”
It crossed my mind that she could try to swallow the razor, but failing that, she wasn’t doing any damage with her boyfriend’s hair remover.
“Is that why you think you have BPD, because of these attempts to hurt yourself?”
“Yes, that’s what girls with Borderline do,” she said.
“Well that’s what some people do who have BPD, but not everyone. Do you have other symptoms?”
“Um, I have problems with my boyfriend. He makes me so mad!”
“Okay, tell me about that.”
Gina went on to describe what was not the best relationship in the world, but I’d certainly heard – and probably had experienced – worse. Having met her boyfriend at age 16, they had had their share of fights over the years, arguing about things that teenagers argue about. Gina never viewed him as either a saint or vile sinner (one of the potentially necessary criteria for diagnosis of BPD), their arguments never went beyond the occasional hang-up in a fit of frustration (and therefore not a symptom), nor did she ever experience any unusual distress during the many break-ups that young couples have (again, not a symptom).
“Gina, do you ever engage in potentially dangerous activities (yet another potential requirement) to cope when you feel upset?”
“No, not really. I tend to sleep a lot, and sometimes I don’t follow my diet very well.”
These symptoms are more commonly seen in depressive disorders, so I took Gina through the series of questions to confirm that diagnosis. It proved to be a much more accurate diagnosis than BPD.
“Gina, this sounds like a depressive episode to me.”
“Then why was I trying to hurt myself?”
“Only you would know that for sure, but my guess is that you don’t really want to hurt yourself, you’re simply trying to get rid of your emotional pain. And people with depression make suicidal or parasuicidal attempts as well.”
“So I’m not that bad?”
“I would never suggest that you are in less pain than someone else, regardless of what your diagnosis is. It sounds like life is very hard for you right now and that you could use some help. I will say, and this is good news, that therapy and medication have a better success rate with depression than they do for BPD, so I hope that makes you feel a bit better.”
Gina looked relieved to know that she had misdiagnosed herself. “Well, my boyfriend says that there’s nothing wrong with me, that I’m just a crazy bitch. I guess he’s wrong then!”
Gina and I developed a treatment plan for depression, which involved Cognitive-Behavioral Therapy, a visit to the psychiatrist, and a contract with me to dispose of all speciously dangerous items in her home: electric razors, rubber X-acto knives and those little scissors with the purple handles that children use. Just in case.
Eight months later the boyfriend was history, Gina was enjoying life again, and her medication and therapy were done.
Readers take note: you only get one body, so if you’re damaging it, get help. Writing this piece reminded me of many women I worked with who were and perhaps still are suffering tremendously. Psychology and psychiatry certainly have their limits, especially with a condition as nefarious as BPD, but with the intensive help that is available, your life can be better.
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