It was a dark and chilly night in the UK last night, and by around 5 o’clock as night was beginning to fall, I had dark and chilling thoughts. Sometimes thoughts like these are gone when morning comes. These particular thoughts have remained, so I decided to write about them here…
…but not just yet. First, a warming tale.
About ten years ago Paul T. Mason and Randi Kreger wrote an amazing book called Stop Walking on Eggshells. It’s a book about borderline personality disorder (BPD).
(Do not, by the way, confuse BPD with bipolar disorder, a different illness with the same abbreviation. The post you are reading now is exclusively about borderline personality disorder.)
The book is not for people who suffer from BPD, or even for people who treat BPD. It’s a book for the families, friends and carers of people who suffer from BPD. And it’s not primarily about how those families, friends and carers can help the people who suffer from BPD. It’s a book about how those families, friends and carers can help themselves.
The book uses the term ‘borderline’ or ‘BP’ as a shorthand to mean ‘person suffering from borderline personality disorder’, and the term ‘non-BP’ as a shorthand to mean ‘family member, friend or carer of a BP’ and I will use that shorthand too.
Eggshells
Why do non-BPs need to help themselves? Because BPD causes sufferers to treat people close to them in ways that cause psychological harm.
This comes about because BPs have emotional needs that overwhelm normal relationships. They develop techniques of verbal abuse, emotional blackmail, manipulation and other defence mechanisms that:
…shatter trust and intimacy. They make the relationship unsafe for the non-BP, who can no longer trust that their deep feelings and innermost thoughts will be treated with love, concern, and care.
Here’s a selection from the list of typical BP behaviours (from Chapter 3). BPs may typically:
- Experience reality differently than you do.
- Blame you for things that aren’t your fault.
- Put you in no-win situations.
- Push you away just when you are feeling close.
- Act in ways that feel manipulative to you.
- Deny the effects of their behavior on others.
The harm that this kind of behaviour can cause in a relationship is serious, and non-BPs can end up seeming to be mentally ill themselves. Ironically, the kind of illness they seem to have is quite like borderline personality disorder. From Chapter 4:
BPD is not really infectious. It is not like the measles. But people who are exposed to these behaviors can unwittingly become an integral part of the disorder… take these behaviors personally, and feel trapped in a toxic cycle of guilt, self-blame, depression, rage, denial, isolation, and confusion. … Meanwhile, the borderline’s unhealthy behaviors are reinforced because the non-BP accepts responsibility for the feelings and actions that really belong to the borderline.
In a section on common non-BP thinking, the book lists some of the beliefs that are typical in non-BPs. Here’s a selection. All of these typical beliefs are faulty, and the book explains why, but I’ll leave out the explanations, and paraphrase just to give you a flavour of the list:
- I am responsible for all the problems in [my] relationship [with the BP].
- The actions of the [BP] are all about me.
- If I can convince the [BP] that I am right, these problems will disappear.
- …I should not hold [the BP] accountable for their behavior.
- Setting personal limits…is wrong.
- No matter what the BP does, I should offer them my…unconditional acceptance.
The good news is that all of these effects on non-BPs are avoidable and can be reversed. The faulty beliefs above can be challenged by logic and common sense. Non-BPs can take back control of their emotional lives, and either learn to protect themselves from the damaging effects of the BP’s behaviour, or make rational decisions about whether and how to continue the relationship.
An aside
As an aside, if you’re a therapist assessing someone who appears to suffer from “a toxic cycle of guilt, self-blame, depression, rage, denial, isolation, and confusion” and if you’re the kind of therapist who looks no deeper than the symptoms, then you might end up trying to treat someone who is not ill at all, just responding normally to a damaging relationship with a BP.
Think long and hard before becoming the kind of therapist who looks no deeper than the symptoms.
Jigsaw puzzles
Now, where was I? Oh yes…two jigsaw puzzles…
The relationship between BP behaviour and the symptoms that result in non-BPs is not obvious. You have to think hard to see how the pieces fit together, a bit like doing a jigsaw puzzle. Mason and Kreger have written a brilliantly clear guide to how these kinds of jigsaw puzzle fit together, and it has made the picture clear for many non-BPs, given them hope and practical plans, and given them their lives back. That’s why I call it an amazing book, and a warming tale.
The second jigsaw puzzle is incomplete, and I’m pretty sure I don’t even have many of the pieces yet. It’s the puzzle of why some people who start out to become CBT therapists end up not becoming CBT therapists. They do the training and get the qualifications and see patients and claim to practise CBT, and even seem to believe that they practise CBT, but what actually happens between therapist and patient is not CBT. How can that be?
GO/NO-GO
One of the pieces in that puzzle came to me as I was writing Evasions. It’s the idea that some therapists might be people who avoid emotion. Or perhaps they have been taught to avoid emotion in their work. Anyway, avoiding emotion might explain why they try to treat emotional disorders in a roundabout and distant way, without actually working with the emotions that are at the heart of the problem.
Although I say this ‘came to me’ while I was writing, and that’s how it seemed at the time, it’s really based on my own experience of talking to people. When I’m talking to someone in a social or business conversation, I generally avoid emotional topics. If something seems to have emotion attached, it’s as if I think to myself, “Oh-oh, that’s a sensitive subject, better not go there.”
But when I’m talking to someone in order to help them explore an emotional difficulty, it’s the opposite. I generally home in on emotional topics, as if I think to myself, “Ah-ha, that’s a sensitive subject, better make certain to go there.” So it’s as if there’s a little switch in my brain that’s set to GO or NO-GO where emotional conversations are concerned.
When I tried to imagine being one of those therapists who can only deal with superficial issues, I imagined that little switch getting stuck on the NO-GO setting, which would make me behave in that way. And it seemed to fit with what little I know of the way these therapists work.
Another piece in this puzzle is the way some less-than-competent mental health professionals use the term “borderline” to mean various things other than a proper diagnosis of BPD. Alone explains at length in: The Diagnosis of Borderline Personality Disorder: What Does It Really Mean?
Somehow, assigning private meanings to diagnostic terminology, effectively making diagnosis meaningless, is part of the mindset of ineffective therapists. Where it fits with avoidance of emotions, or indeed whether it fits at all, is unclear.
Breaking a rule
When I was a child and I really did jigsaw puzzles from time to time, one of the rules that came in handy — particularly with old puzzles found under the stairs in the houses of elderly relatives, when some of the pieces would be missing and other pieces would be in the wrong boxes — was never to try to make a piece from one puzzle fit in some other puzzle.
Yesterday evening at about 5 o’clock, as night was beginning to fall, I broke the rule.
What, I wondered, if the puzzle-piece about misuse of the terminology “borderline” really fits in the BP/non-BP puzzle? Do therapists who avoid emotion in their work cause the same kind of effects in their patients as BPs cause in non-BPs? I went to the book and re-read some sections, taking ‘BP’ to mean ‘bad psychotherapist’ instead of what it originally meant. You can scroll up to the Eggshells section in this post and try it for yourself.
So until 5 o’clock yesterday I believed that incompetent therapists probably did little harm. There would be an opportunity cost of delayed treatment, additional risks and so on, but no direct psychological damage.
Now I’ve changed my mind. Incompetent therapists might generate temporary symptoms in their patients that mimic some aspects of borderline personality disorder, seeming to justify the label “borderline” with reference to actual diagnostic criteria. The more frustrated and defensive the therapist becomes, the worse the patient’s symptoms would become.
Of course I can’t be sure, because I never get to speak to patients while they are caught up in incompetent therapy with someone else. I only hear about these things afterwards, when investigating this explanation is almost impossible. It’s just a dark and chilling thought.
[...] or would like to know a bit more about Borderline Personality Disorder, then you might like to read an article published by CBTish today. Seems particularly topical if you follow this blog, and makes for [...]
I never thought of it that way round, you know? It does seem like BPD is almost a….**searches for the word**….self-perpetuating (?) label if used incorrectly. And it has to be said, the more you struggle against it, the more firmly it sticks. Diagnosis quicksand…
Wow. On what basis did you think that “incompetent therapists probably did little harm”? And did you also believe that incompetent doctors do little harm? Both assumptions seem counter-intuitive and a little bit scary to me.
The basis is in part because the incompetent therapists I actually know are unsuccessful in doing anything much at all, harmful or otherwise. They report that their patients simply resist, or mysteriously stop attending. And patients who have been to incompetent therapists report the same — that the therapist’s ideas were irrelevant or impractical, so they just could not take the therapist seriously, although they often feel bad about this.
Doctors do often prescribe treatments that their patients do not adhere to, but patients have less information to go on when there’s a physical illness. For example, you don’t have any sense of how well your liver is functioning and what the pills are doing to it, so you could possibly take pills that harm it. But you do always have a sense of how your mind is functioning, so you’re very unlikely to adhere to a treatment that makes it worse.
So although I agree when you write “scary” I don’t agree that these are “assumptions”. I’m trying to formulate ideas based on my actual experience and on my understanding of how things work, even though both my experience and understanding are limited, and avoid simply making assumptions.
I take it your experience is different?
I am the coauthor of “Stop Walking on Eggshells.” I wrote the copy you see above.
Therapists do, in fact, have those same sorts of reactions as family members. In fact, the term “non-BP” encompasses therapists. That’s why we used that term instead of “family member.”
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