Walls

The people in the walls are becoming noisier. Their previously whispered discussions are now more heated. There’s shouting, and it goes on half the night, making sleep impossible. What to do?

Maybe the doctor can help…

“Doctor, I can’t sleep. I haven’t had any sleep for ten nights. You must give me some strong sleeping tablets, otherwise I think I’ll go mad.”

From the patient’s point of view, the problem is lack of sleep. People in the walls are just something you accept. They’ve always been there, haven’t they? What do you mean, you can’t hear them?

From the doctor’s point of view, the problem is paranoid delusions.

Points of view

The conflicting points of view here are not like PoV in a computer game, where you can see the same scene through the eyes of various characters or from above. This is a scenario in which each PoV shows a different scene. It’s as if there’s a virtual wall between the patient’s reality and the doctor’s reality.

In a sense, this virtual wall is the definition of what it is to be mentally ill. No matter how confused and unhappy your life is, if you can describe it to other people and they can see it from your point of view, then you are mentally well.

Mental illness is when your point of view is somehow irreconcilable with other people’s points of view. You hear people in the walls, but no one else hears them. You are empty, but everyone else is happy, sad, contented, frustrated…something, at least. You are frightened, but no one else is too worried.

BPD

So…borderline personality disorder again. What does the point of view of the borderline patient feel like? The doctors see the person with BPD showing “pervasive instability,” but the patient sees herself as trying to stay upright in unstable world.

For example, take the secondary criterion:

Frantic efforts to avoid real or imagined abandonment.

Gail (who has BPD in this fictitious example) feels angry and let down by other people’s inconsistency. She just wishes there were someone she could rely on in life. She loves her mother dearly, but there are times when her mother just doesn’t seem to care. And it’s the same with everyone she knows.

The feeling is that other people are unreliable — her strong feelings of love, respect and loyalty towards other people are met with indifference or malice, and often just at the times when she most needs love, respect or loyalty in return.

So Gail doesn’t see her “frantic efforts” as insane. Gail sees other people’s behaviour towards her as incomprehensible and cruel.

Or take another secondary criterion:

Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

Gail often feels that her life is so bad she would rather just end it. She often decides to end it, and then she overdoses. But, so far, she has either not had the determination to take enough pills, or circumstances have led to her being rescued.

From the other side of the virtual wall, doctors and relatives see Gail’s frequent overdoses as phoney and manipulative. She will telephone several people to announce that she is going to kill herself, then be found to have taken just four painkillers. From Gail’s point of view she tried to ask for help but no one responded with the sympathy and understanding that she needed, and she only took four because she felt too hopeless to take the rest.

So Gail doesn’t see her recurrent suicide attempts as mere gestures. She sees herself hopelessly trapped by other people’s inconsistent and uncaring behaviour towards her.

After recovery?

In an article in the New York Times last week, someone described as “a recovered patient” explains what BPD is like:

…a serious psychiatric disorder involving a pervasive sense of emptiness, impulsivity, difficulty with emotions, transient stress-induced psychosis and frequent suicidal thoughts or attempts.

What’s wrong with this?

The words are mostly from the DSM, that’s what’s wrong. This is BPD from a doctor’s point of view, not from a patient’s point of view. So whoever made that statement was not a patient, or at least, not a patient who ever suffered from BPD.

The words that are not from the DSM are the words “difficulty with emotions”. Where did those words come from? They are there because the purpose of the article is to advertise a technique that treats BPD as merely ‘emotional dysregulation’.

The theory being advertised is that people develop BPD because they have not learned to regulate their emotions. To treat them, all you need to do is teach them how to regulate their emotions. It seems to work.

It may seem to work because most of the patients being treated do not really have BPD or anything so serious. Some of them might not be mentally ill at all. What they have is just some of the secondary symptoms of BPD, leading to somewhat asocial behaviour. Teaching them more acceptable behaviour is fine, but it’s not addressing BPD.

Subterfuge

Perhaps it’s worth spelling out the subterfuge behind this kind of treatment technique, in case it’s not obvious.

You start with a small number of seriously ill patients whom you cannot treat:

Now you dilute them with a large number of people who have some much less serious condition, or who perhaps are not ill at all, just unhappy with their lives:

Then you treat them all with whatever magic remedy you want to promote. It has no effect at all on the people who are genuinely ill. Let’s say it convinces two-thirds of the people who are not ill that they feel somewhat better about their unhappy lives:

Now, overall, your magic remedy has a 60% success rate. Great! You can market it using advertorials in the major newspapers…

…except that the people who really were ill in the first place still are.

Illness and recovery

BPD does not typically develop in childhood. People who suffer from BPD have almost always been emotionally normal as children. The idea that they never learned to regulate their emotions is almost always fiction.

Furthermore, the article repeats the common claim that DBT is “a derivative of cognitive behavior therapy” (CBT). The reality is that DBT specifically avoids the cognitive restructuring that is the foundation of CBT, and instead teaches patients an assortment of distraction techniques.

Feeling better about an unhappy life is, perhaps, a minor triumph, although not really anything to do with mental health. And feeling better about being unhappy is not quite the same as actually being happy. People who have unhappy lives, and who avoid distracting themselves, can change their lives. Distraction techniques have the unfortunate side-effect of making sure that things will never get better for real.

Recovery from BPD is a huge thing. There’s a huge virtual wall between the reality of a BPD sufferer and the reality of normal people. I see no theoretical or practical justification for thinking that DBT (or other similar behavioural approaches) can dissolve that wall, and I suspect that these approaches trap many people into thinking that unhappiness is all there is.