Borderline Personality Disorder (BPD) has to be one of the most maligned and stigmatised conditions there is in mental health. There are nine symptoms of criteria to get a diagnosis of BPD, efforts to avoid abandonment or rejection issues, unstable and intense interpersonal relationships, identity confusion and an unstable sense of self, impulsive behaviour, suicidal ideation and self-harm, emotional dysregulation, chronic feelings of emptiness, anger management issues and brief paranoia and/or dissociation.
In my private practice I counsel people (both male and female) suffering from BPD. My experience with them has been mostly positive. What people with BPD want is accurate up to date information, psychobiosocial education and evidence-based treatment. Clients also want to learn how to recognise and circumvent increasingly distressful body sensations and memories. An articulate client described BPD as like this:
“Every social interaction is an ordeal. Every interaction with a person creates a sensation of ants crawling down my back, my arms feel electrified, my head is buzzing, my face is burning off and I feel the start of a tension headache. I feel as though I am holding on with both hands to a live wire. My brain replays the words, the tone of voice, the things said, the things not said along with the endless possible permutations and interpretations of the motives of the other person.”
One of the ways a client can develop awareness is to recognise how brain and body can affect behaviour. An excellent identifying and teaching tool for clients is Behavioural Chain Analysis (BCA).
This is an important part of Dialectical Behaviour Therapy. BCA works with vulnerabilities, a prompting event, links in the chain, problem behaviour and consequences. It goes like this:
Heather had gotten a bad haircut the day before, her sniffles developed into a cold, she was not sleeping well and was missing meals due to anxiety (vulnerabilities). Heather woke up to find the dog had vomited on her new carpet (prompting event). She was angry because her partner had overfed the dog the night before (1st link) and they had no effective pet carpet cleaner in the house (2nd link). She was late for work, due to cleaning the carpet the best she could, and was in a highly emotionally aroused state with butterflies in her stomach (3rd link), she got a speeding fine, was rude to the policeman and had now worked up into quite a rage (4th link). Her boss was not happy with her work and she was fearful of getting the sack as she’d been sacked before (5th link). She had eaten no lunch, drank little water and along with the cold felt lightheaded (6th link).
On the way home there was a long detour due to road works and her rage grew. She was having some awful spidery sensations crawling over her body and her legs were restless (7th link). She got home, went to the computer and the internet was deathly slow for some reason and she smashed her fist into the keyboard breaking off a few keys (8th link), then she drank three glasses of wine to compensate for her toxic feelings (9th link). Her partner came home and didn’t notice he was tramping mud through the hallway (10th link). Heather then exploded with rage and threw the wine glass and bottle against their newly painted wall (problem behaviour). On the weekend Heather had to repair and repaint the hallway wall , all the while enduring her shame and guilt and her partner’s frustration and anger at her behaviour (consequence).
The idea of a BCA is to go into excruciating detail and try to remember all the emotions, sensations, memories, thoughts and feelings around each link and identify where she could have done something different. Perhaps if Heather had eaten lunch, got to work on time, chose not to go on the computer after work knowing the internet was down for the evening, chose to go to yoga instead of drinking too much wine, then the problem behaviour might have been circumvented. This is where choices lie, where she could have put a pause between the stimuli (vulnerabilities and links) and the response (unwanted behaviour ).
I tell clients to reward yourself plenty if you do take the high road and find that pause. That is not a small thing you just did. It is epic. It adds to the body of knowledge you already have about yourself. When you keep repeating a behaviour it becomes a habit. If you do this often enough, your “go to” behaviour can be healthier and more productive, eg a gym workout, power walking, journalling your thoughts and feelings, cleaning the bathroom, colouring in swear words or some vigorous weeding and pruning in the garden. Any physical activity will help dispel some rage and anger.
I welcome all clients with BPD in my practice. I get great satisfaction out of seeing someone gaining insight and understanding how their thoughts, feelings, sensations, memories and behaviour are all linked and affects both themselves and others. The devil, as always, is in the detail.
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