It’s early but without any further ado, I give you THE INTERVIEW. (Oh and these aren’t in any certain order.)
Why do you think so many doctors and therapists refuse to work with people who have BPD? Have you ever refused to work with someone who had BPD and if so, why? I have never refused to work with someone with BPD because of their BPD per se. Same goes for my two colleagues that I talked to. I had one client with severe BPD, and she was the client who inspired me to develop the DBT group. I spent hundreds (literally) of hours researching and developing the group, and then she refused to attend because it would make her too uncomfortable. For some reason she discontinued individual therapy and then wanted to resume about a year later. I said I would see her only on the condition that she also attend the DBT group…she refused again. This is the only person with BPD who I have refused to treat, for the above mentioned reasons. My colleagues told me that they have refused to see someone NOT because of their BPD, but because of their noncompliance…either they have spotty attendance, or are not working to make progress in therapy, i.e., the therapist is working harder than the client (like my client mentioned above).
I can say that many therapists do not like to work with people with BPD. My colleagues say that this is because they are “gamey”, “big excuse-makers”, and frequently non-compliant with their treatment plans. When I asked my colleague what “gamey” meant, she said it’s when she can’t figure out what’s true and false; she wonders if the client is telling the therapist how she really thinks and feels, or if she’s telling her what she believes the therapist wants to hear.
When clients do this, I don’t believe they are doing it intentionally (most of the time). I believe it’s because they really don’t know what they think and feel, because of the way they were invalidated in childhood. They have learned early on to stuff their own “invalid” responses and to scan the environment for how they are supposed to think and feel.
There is a client with severe BPD at our agency that I would refuse to treat, if I ever were asked. This is because she has been extremely verbally abusive to many of our staff members, including two different psychiatrists (who have since refused to see her). I have heard her verbal rages, and I do not want to be on the receiving end of them.
How can manipulation be damaging to the therapist/client relationship? I partially answered this above. To expound, I believe that the verbally abusive client “manipulates” others to stay away from her by raging at them, then becomes angry when they do. Another example is when a client says, “I’ll kill myself if you ever drop me”. I’ve never had that happen to me, but I know it has happened. This is classic manipulation, because it is saying in effect, if you don’t do what I want, I will kill myself. This is very different than a client saying that they have suicidal thoughts right now. My one client who refused to attend the DBT group basically said this to the Dept. of Disability, who wanted her to go through a job-readiness program. She told them that if they made her do this she would kill herself. Clients who manipulate others (or try to) in this way will rarely make progress. This kind of manipulation causes much chaos in their relationships, which increases stress, which intensifies their moods and exacerbates all their symptoms, and so on. This is how it is damaging to the client/therapist relationship—because the client will rarely make progress unless they begin to change the way they relate to others.
Some people with BPD describe themselves as terminal, how do you feel about this? I’m not sure what you mean by ‘terminal’. Do you mean that they believe they will live shortened lives? I know that some of my clients with BPD feel this way, but so do a lot of other clients without the BPD diagnosis. This sounds more like a symptom of depression, which is something that the person with BPD frequently has. It may also mean that they feel they will eventually commit suicide. I’m not sure of the prevalence of suicide among people with BPD, but I’m pretty sure that it is greater than that of the general population.
There is great debate over the name Borderline Personality Disorder, what do you feel would make a better name, or do you like it as it is? I don’t like the name as it is. I’m more on the side which believes that the constellation of symptoms that describe BPD have their origins in childhood trauma of some sort (emotional, physical, sexual). For that reason, I believe a better name would be ‘Childhood Trauma Personality Disorder’, or ‘Prolonged PTSD’, or something to that effect.
There are some really good books about BPD out there. Which one would you recommend the most and why? I have read a number of books about BPD, but unfortunately have not read most of them. Of the ones I have read, I really liked, “Get Me Out Of Here: My Recovery from BPD”, by Rachel Reiland. I like this book because it is a firsthand account from a woman who believes she has recovered from BPD. It offers much insight and hope. Other therapists have cited the book, “I Hate You, Don’t Leave Me”. And I know you like the book ‘Borderline Personality Disorder Demystified’, but I have not read this yet.
Out of all the skills taught in DBT, which do you find to be the most beneficial? This would be better answered by my clients, so I referred back to the final evaluation forms at the end of the groups. I looked at 21 evaluations, and the answers were all over the board, but the MOST beneficial group of skills was deemed to be the Core Mindfulness Skills (observing, describing, wise mind, separating feelings from thoughts, identifying and challenging distorted beliefs, etc.). I do not ask them for what they believe to be the most beneficial specific skill, just the group of skills. The most common LEAST beneficial group of skills was the Distress Tolerance Skills, although this group was cited by some as the most beneficial. It really depends on the individual and what they need to learn.
On that note, have you ever disagreed with anything taught in DBT? Of course! The founder of DBT, Marsha Linehan, did not include cognitive skills (separating feelings from thoughts, identifying and challenging distorted beliefs, etc.) in with the Core Mindfulness skills, because she thought they were too ‘invalidating’. I think these skills are too important to be left out, so I have included them. I have also frequently asked my clients if they found them to be ‘invalidating’, and they have said NO.
Because of DBT and medication treatment seeing success in individuals with BPD, is it possible that BPD is not really a personality disorder and that it should be moved to Axis I? First, none of the diagnoses are absolutes, so it is possible that BPD is not a personality disorder. However, I don’t think this will change when the new DSM comes out, nor do I believe that it should be. According to the DSM-IV, a personality disorder is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, and has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (page 629). The operative phrase here is “is stable over time”. I don’t think the authors meant that there would be no change at all over time…just no significant change, and this is certainly subject to quite a bit of interpretation. I would also wonder that if somebody recovered from BPD, was he/she given the right diagnosis. Diagnoses on Axis I can also have the same characteristics as a personality disorder, as in dysthymia, or a chronic depression. So there is a lot of overlap among all the diagnoses, and this is why one can go to 3 different therapists or psychiatrists and come away with 3 different diagnoses. This is clear as mud, right?.
Do you have a message of hope you would like me to pass on? Yes. People can and do recover from BPD, but it takes a lot of work, time, and conscious effort. The DSM-IV (Diagnostic & Statistical Manual of Mental Disorders, 4th Edition), the bible of psychiatry, says that, “The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning” (page 652-653). I believe this happens because, even without therapy, people will generally learn from their mistakes as they age and will make corrections. With therapy and DBT, however, people with BPD can make more rapid progress. If you’re a person with BPD, there are DBT groups out there to help you—seek them out, attend, and practice the skills!