Borderline personality disorder (BPD) can seem like an enigma, even to family and friends, who are often at a loss for how to help. Many feel overwhelmed, exhausted and confused.
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.
When your loved one has borderline personality disorder (BPD), you might feel like you’re already overextending yourself but to no avail. You may feel “directionless, because all you can ever seem to do is react,” writes Shari Manning, Ph.D, a licensed professional counselor in private practice who specializes in treating BPD, in her excellent book Loving Someone with Borderline Personality Disorder.
“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.
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.