A Trauma Informed Approach to Treating Borderline Personality (Repeat)

Hi there everyone, and welcome to this video on a trauma informed, strength based approach to recovery from borderline personality. I'm your host, Dr. Donnellice Snipes. In this video we're going to review the characteristics of borderline personality disorder, or what I'm going to call it from here on out. Borderline personality traits, or bpt. I don't like the term disorder because I believe that the symptoms were developed in order to help the person survive. Until now. The per. The symptoms were developed from a chaotic, from a dysfunctional situation and they continue to use those particular traits and tools in the present. However, it's not really disordered because those symptoms make sense from the that person's perspective. We're going to explore the functions of the symptoms and identify what may cause the symptoms to develop. We'll explore what's maintaining these symptoms, the effects of these symptoms on significant others, and identify interventions to help the person more effectively manage emotions and relationships. So let's start at the beginning. Personality disorders, if you, you want to use the term from the DSM 5tr. Personality disorders often begin in childhood and some in adolescence. What we recognize from that is that the thinking and the experiences and the tools that the individual has at that particular time are very different than what the adult has. So, so the reactions and the strategies that a child uses to cope with a situation is going to be very different than that of an adult. The course of borderline personality traits from adolescence to late life is characterized by a switch from affective dysregulation, impulsivity and suicidality to maladaptive interpersonal functioning and enduring functional impairments with, with subsequent remission and relapse. All right, so what does that mean and why does it happen? We're going to talk a lot about it, but basically they are going from an emotion driven state of impulsivity and affective dysregulation. They have figured out how to modulate their emotions a little bit. Maybe not super well because it results in enduring functional impairments, but they figured out ways to protect themselves from as much emotional dysregulation. So they may withdraw, they may isolate, they may do a variety of things in order to try to cope, but they have developed some coping skills. And it's important for us to look at those coping skills as strengths and say, all right, this may not be the best strategy for dealing with emotions or people or situations as an adult. However, it is a strategy that you developed and it helped you to survive till now. How can we build off that? How can we Mature that strategy into one that would be more helpful in the present. Beginning BPT symptoms tend to wax and wane, and presentation depends on contextual factors. Well, go figure. Context is where all of the triggers lie. Therefore, if people are in a context in which they feel safe and loved, they are going to react differently than in a context in which they feel threatened and powerless. If they are in a context in which they are not having to trigger their fight or flight mechanism, then they're going to react much differently than when they have to be hypervigilant. BPT behaviors seem to develop to help the person survive dangerous or threatening situations when other options are not available. People who grew up in chaotic or dysfunctional households often did not have a secure attachment figure to. To protect them, to comfort them, to help them identify their emotions and learn how to modulate their emotions. In fact, their caregivers may have actually been some of the sources of their threat and their distress. So the child had to develop any skills they could to survive in that particular context at that particular time. So, so we need to ask ourselves, this behavior we're seeing in the present developed many, many years ago. How did it make sense back then? What function did it serve back then? And again, how can we mature that into a different or a modified coping skill that's more effective in the present? It's very important, in my opinion, when we're working with people with b BPT symptoms or complex ptsd, that we understand behaviors through the lens of trauma. Not why are you doing this? But what happened in order to prompt the development of these behaviors? What happened to you? How does this behavior make sense from a neurological perspective? Childhood trauma may increase the rate of borderline personality trait development due to alterations in the HPA axis. Your hypothalamic pituitary adrenal axis, this is your threat response system. When the threat response system is chronically turned on, eventually the brain somewhere says, hey, we can't be on all the time. We need to rest. So it turns down its sensitivity to stressors. So things that used to bother the person, they just, they don't have the energy for anymore. They don't even hardly notice sometimes. But when they do get triggered, they go from 0 to 250 like that. And that's what I call the flat to the furious or the flat to the frantic. And. And people with borderline personality traits often show this hypothalamic pituitary adrenal axis dysregulation in what we call emotional dysregulation. They Go from flat, not feeling much of anything, not being very emotive, to feeling like they are overwhelmed by overpowering emotions. When all this happens, it means there is has been an alteration in neurotransmission. We actually can look at the brain scans of people who've been exposed to chronic stress and people with borderline personality, and we see that different areas of their brain light up. We see that certain areas, like their hippocampus, have actually shrunk in size, and other areas like fear processing and the amygdala, have increased in size. So we see changes in the structure of the brain. We see changes in which areas are activated and how intensely they're activated. We see changes, interestingly enough, in the endogenous opioid system, Our natural painkiller system, shows alterations partly because of the changes in the brain. We also see alterations in the neuroplasticity. In childhood, the child, when they go through those windows where they have a lot of neuroplasticity, a lot of times they don't have information going in. When they're in those windows where they have neuroplasticity, Their brain is kind of like putty. And it's more malleable and more shapeable, but it's also more easily damaged. And we know that that when the brain is exposed to chronic stress, the chemicals like glutamate and adrenaline and the other excitatory neurochemicals can actually cause neuronal death in the brain, Whether it's a child or an adult. But it's more prompt pronounced in the child. When the brain is more malleable, it's more vulnerable to stress and distress. So we see more brain changes in the person with bpd. Brain areas involved in the stress response, such as the prefrontal cortex, amygdala, anterior cingulate cortex, and the hippocampus are all altered. It's important that we recognize this and we validate this for people with BPT and people who love them so they understand there is a neurological basis to what's going on. There is a foundational change in the way this person's brain is structured or wired, if you will, Right now. Does it mean that it can't be changed? Absolutely not. That is beautiful thing. We can help the person as they start to heal, as they're not under as much stress, the brain actually does something called neurogenesis. It starts to rebuild those neurons. So recovery is possible. Rewiring the brain is possible. And I actually have a video on rewiring the traumatized brain that talks about just that. So I'm going to move on from there. But if you're interested in how we address some of the neurological aspects, check that video out. In our internal reality, the person with BPT has a lack of a sense of self. If they're not somebody, something, then they're nothing. They don't know who they are, what they like, what makes them happy or sad. They were told, don't talk, don't trust, don't feel, nobody cares. So they never checked in with themselves. They didn't learn basic core mindfulness. They don't believe that they're lovable for who they are. So they have. In order to be lovable, the only way they got love is consistently, if at all, and actually probably never consistently. The only way they got love was to be doing something for their caregivers. If they randomly were able to do something right at the right time, then they were given approval and they just soaked that up. But most of the time, the caregivers, we were too dysfunctional to even notice that the child was there or the child being there was too triggering for the caregiver, so that the child ended up bearing the brunt of the caregiver's wrath, which the child interpreted as, I suck, I'm awful, I'm not lovable. Look what I make my caregiver do. They developed a constant fear of abandonment as a result, no matter what they tried to do, they couldn't get their caregiver's attention or love. They don't know who they are. They don't believe they're lovable for who they are. So they have to be something to somebody. But if they don't think that they can do that, you know, they're constantly trying to figure out, what is it that I need to do to make you love me? Instead of what is it that I am that makes me lovable? Very different. What is it that I need to do that makes you love me? And they don't as children, children don't walk up to you and say, what is it that you would like me to do to help you right now? Children come from this egocentric perspective of I will do for you what I think you need, and I'm going to try as many things as I can in order to meet your needs. So they try to mind read their caregiver. They lear they need to try to mind read their caregiver. And other people, they have a problem with emotional discontrol because when that HPA axis becomes disregulated they go from 0 to 250 like that. They go from kind of flat to a tidal wave of excitatory neurotransmitters. So where most of us would have, you know, a wave, a ripple of neurotransmitters, they have a tsunami of these excitatory neurotransmitters. So they are almost bowled over, if you will, by the intensity of their emotion. They've never been taught how to self soothe. They don't know about mindfulness and breathing and distress tolerance and all those other things. So as a child, they were sitting there going, okay, this feels really awful and really uncontrollable and I don't know what to do with it. Now as children, when they feel that way, what do most children do? They throw a temper tantrum or. Well, often it's a temper tantrum and that's their way of saying, I'm overwhelmed. I need somebody to help contain me. In the household that the person with BPT grew up in, that wasn't safe. If they threw a temper tantrum, it was probably going to cause them problems at the very best. Or they threw. They throw a temper tantrum and nobody pay attention anyway. So temper tantrums didn't work for them and they ended up kind of feeling overwhelmed and terrified of their own feelings and emotions and body. Before they became adults, they lacked emotional boundaries. Growing up in a dysfunctional household, many times, most times the child learns that it's not safe to have your own feelings. You need to feel whatever the dysfunctional others are feeling. If the dysfunctional other is angry, okay, you know, you need to respond appropriately. It's not okay for you to have your own feelings and your own thoughts at this point in time. If the dysfunctional other is angry, then it's your job to try to fix it. And anger is used to control others and is rewarded. This is what is taught in this family. The dysfunctional others, the caregivers that have addictions or mental health issues or whatever is going on with them causes them to feel threatened, to feel out of control, to feel angry and resentful for some reason, and they use that anger to control the child. Instead of being able to communicate effectively, safely in, instead of being able to model healthy coping skills and interpersonal skills. So the child, the only way the child learns how to interact is either through submission or anger. It's one or the other. So the first step in working with people with bpt, address emotional discontrol, help them identify and prevent their vulnerabilities or mitigate them when possible. Vulnerabilities are those things that make people feel, guess what? More vulnerable when they are exposed to triggers things that would trigger their distress. So for example, if they're in pain, if they are tired, if they are in a crowded busy place, some people feel very anxious like in, in grocery stores or airports or those sorts of things. Knowing what makes them more vulnerable to be triggered is important so they can figure out how to address it. For example, go shopping when it's an off time. Go to the mall in the middle of the afternoon on a weekday as opposed to a Saturday afternoon. Go shopping when it is a safer time or less stressful time for the person. Vulnerabilities are is another way of saying stress. When the person is already stressed, it doesn't take much to set them off. It's kind of like a pressure cooker. When they've already gotten up to pressure, it doesn't take much to blow the lid off. So it's important to help them identify and prevent vulnerabilities when possible. And this is going to mean getting adequate sleep, good nutrition, developing mindfulness skills. There's a lot of things that go along with that. But also knowing as, as I mentioned, what can I do if I wake up and I didn't sleep well and I've got to go to work because, you know, I got to put food on the table. I know that I'm more vulnerable to being irritable when I'm sleepy. So what can I do? And the answer is not super super chug caffeine. The answer for me is to close the door so I'm not being regularly interrupted. The answer for me is to tell my coworker because there's only two of us in the office, I didn't sleep well. I'm just going to do my thing today. And he understands that, okay, you know, today's probably not the day to be going in with every little thing that can be held until tomorrow. Identify what works to help self soothe, what works for that person to help them trigger their relaxation response, to help them trigger that vagus nerve and, and help them get into their wise mind. What are their helpful distress tolerance techniques? What is it that they can do? What techniques can they use in order to help them feel empowered, to sit with the distress, to tolerate it. I can feel anxious and not be overcome by it. I can feel angry and not have to act on it. I can tolerate this anger without feeling like I have to act impulsively and then develop a safety plan. This is the first step because it's important for the person to start feeling safe and empowered in their own skills skin to start understanding when they. When I present the concept of vulnerabilities for the first time, a lot of times people's, it's like a light bulb goes off in their head and they're like, oh, so that's why sometimes I'm more reactive than others. Yeah, that's part of it, at least. Help them develop a safety plan. Next, work with them to identify the most salient symptoms for them. There can be a lot of symptoms that a person with BPT has. What are the three that are most problematic for them at this time? It doesn't mean we won't get to the others, but what are the two or three that they want to work on first? What is the function of that behavior or why does it happen? What is it communicating? Maybe it's saying when they start acting, get very, very angry because they're afraid of abandonment. Frantic attempts to avoid abandonment. What is that behavior saying? That behavior saying, I'm afraid I'm going to die. I'm afraid that I can't exist if you go away. I need somebody to help me feel safe. That's what that behavior is saying. So we want to look at behavior as communication. What is that behavior communicating? What does it look like when this person acts in a particular way? A lot of times when people talk about those with borderline personality traits, they talk about them being unpredictable and impulsive and Jekyll Hyde. And when you step back and you look at it, their behaviors are actually very predictable and very understandable if you know what to look for. If you step back. A lot of times you can understand when somebody, when somebody gets triggered and they dysregulate, you can step back and look at it from their perspective and you can see if you will the trigger. It becomes clear to you what may have been triggered in them that caused them to feel threatened. And then you can process it. It doesn't mean that everybody needs to. Everybody around a person with BPT needs to be walk on eggshells and try to anticipate anything that's going to trigger them. No, I don't want you walking on eggshells. It's important when someone gets triggered to be able to say, okay, let's get curious. Let's figure out what triggered you in this situation. Objectively, from my perspective, you are safe, you are empowered. However, you clearly didn't feel that way. So what was it in this situation that Triggered your stress response that triggered that schema that said, I'm not safe, I need someone to keep me safe. And then we want to identify co occurring issues. It is rare. I think I can honestly say in the 20 some odd years that I've been working with in behavioral health, I have never encountered somebody with BPT that didn't also have at least one, if not two or three other diagnosable issues. Why? Because they all feed on each other. People with bpd, BPT often have post traumatic stress. Now, whether it's complex post traumatic stress disorder, which by the way is actually a diagnosable condition in the ICD11 if they have complex post traumatic stress disorder or old fashioned post traumatic stress disorder, very, very common in people with bpt. People with BPT also often have depression and anxiety. Well, they are constantly fearful, they've never felt safe. So it makes sense that they would continue to have a lot of generalized anxiety. As children they were never helped to feel safe. So they began to see the world as a scary, threatening place. So it makes sense that as adults they continue to see it that way. There's been no reason for them to change their schema. Depression, a sense of hopelessness and helplessness. When you go from 0 to 200 like that, when you're emotionally dysregulating, when the environment, when the world seems like a safe, an unsafe place, when your caregivers didn't even seem to love you, it makes sense that someone might feel depressed, hopeless, helpless, guilty. So depression, anxiety and PTSD or CPTSD are very, very common co occurring issues in people with borderline personality traits. Bipolar disorder, eating disorders and addiction are also very common. Now bipolar disorder has a neurological component to it, but it's important to differentially diagnose and make sure the person actually has bipolar and not depression and anxiety. Because sometimes their anxiety can look like mania or hypomania and their depression looks like depression. So sometimes it's misdiagnosed as bipolar when it's actually depression and anxiety and vice versa. So it is important to differentially diagnose. Addiction is often used as an escape mechanism. It's used to help the person feel in control of something or to numb that untenable, overwhelming emotional distress. So let's talk about some of these symptoms. Frantic efforts to avoid abandonment and lack of a stable sense of self. Obviously that's two symptoms, but they go together. If the person doesn't have a stable sense of self, if they feel like a shell that must be filled by others, if they Feel like a shell that must be validated by others in order to exist. Then if others abandoned them, then they cease to exist. So it makes sense that these two things go hand in hand for them. Preventing abandonment means preventing death. As the child, a five year old can't survive on their own. So it was crucial that they did whatever they needed to do to survive that chaotic situation and to get their minimum needs met in order to keep going in order to exist. So preventing abandonment means preventing death. What does it look like? Well, the person, when they're trying to avoid abandonment and when they have a lack of a stable sense of self, they're often hyper vigilant or hypersensitive to rejection or criticism because rejection and criticism means the potential for abandonment. It means you hate me. And one of the things we're going to talk about is separating rejection of an idea or rejection of a behavior from the rejection of a person. But children don't make that different differentiation. Anger at or belittling others to control them. Now you may think, well if they're trying to avoid abandonment, why aren't they fawning all over the people? Well, fawning may not have worked. Fawning was not something their caregivers did for them. And fawning over their caregivers, like I said, may not have worked. They were controlled by anger and they may have learned to control others by anger and they may act out to control through guilt. And this is where the non suicidal self injury or the addictive behaviors may come in. Not always. There's a lot of reasons for NSSI and addictions, but sometimes it may be used as a tool to get people to stand up and take notice and con. Like I said, control through guilt. The origins Failure to develop a sense of self due to constantly trying to appease the caregivers. They were filling a role. Conditional positive regard the addicted family in the household that the person with BPT grew up, they may have said don't talk, don't trust, don't feel. So the person never checked in with himself to figure out what they like, what they feel. If they grew up in a family where somebody had borderline personality, the message was do as I say or else walk on eggshells because it's either going to be okay or there's going to be hell to pay. If they grew up in some other kind of dysfunctional family where a caregiver had a mental illness, for example, they may have gotten the message do whatever I say or just do whatever because I can't focus on you right now, nothing you can do is actually going to be worthy enough to attract my attention. So the child just desperately flailed around trying to figure out is there something I can do in order to get security, in order to get love, in order to get noticed. They often have a history of abandonment or rejection. If they are something to someone, then they're filling a need and they're less likely to be abandoned. So it's important to remember this, that people with BPT often have a lot of symptoms that are very similar codependency because they're terrified that if they're not indispensable, if they don't make themselves something to someone, then they're going to be abandoned. So they need to had the other person need them. They often have a history of neglect and abuse which told them that they weren't worthy of love, it was their fault. All the things in the world that were wrong were their fault and they were not worthy of care being taken care of. For significant others that are in a relationship with someone with bpt, they start to develop this feeling, I can't leave. It's my responsibility to take care of them and, or they hate me and I can't do anything right, but they'll die if I leave. So we have children that grow up in borderline in households with borderline personality issues and they develop these thoughts themselves. But as adults, when a person with BPT gets in a relationship with another person, the other person starts to feel responsible. For the person with bpt, the boundaries start to become extremely enmeshed. And because the person with BPT often controls through anger and, and guilt, then the significant other is often being berated as a method of control. Why does this happen? Why does the person with BPD have this terror of abandonment and frantically work to avoid it? Well, survival. If they, they feel like if they don't have somebody to tell them that they're okay, if they don't have somebody to help them contain these overwhelming emotions, then they will spontaneously combust. They will cease to exist. Interventions help the person develop a sense of self. Help them work on mindfulness to figure out who am I? What do I stand for? What do I like? Enhance self esteem and self efficacy. Start having them figure out what they like about themselves. One of the activities that I have people do sometimes is make a list of all the things that they look for in a a good person or in a friend or what they like in in other people. And then I have them go back over that list And I say, okay, now tell me which ones of those you already have. Help them enhance self efficacy by helping them set small achievable goals. Not go the entire week without dysregulating. How about going an hour? Okay, two hours? All right. How about half a day? Can you make it from when you get up in the morning until after lunch before you start feeling dysregulated? Differentiate for the person. Help them differentiate between who they are and what they do. They can be a good person and they can make mistakes. Explore with them what they define as what makes someone lovable. And if they're not sure if they have children, ask them what makes a child lovable. Even if they don't have children, ask them, you know, if you had a child, what would make that child lovable. Explore abandonment triggers for that person and that will go back to their family of origin. There were often probably signs or warning signs that their caregiver was getting ready to leave or withdraw or get drunk or however they were abandoned. There were often probably early warning signs. So it's important to be aware of what those are so you can notice them and evaluate them in the present context. In the past, if when your caregiver got all dressed up, it meant that they were going to go out and they may be gone for an hour or a week, you know, that may be an abandonment trigger. So when you see people getting dressed up, that may bring back those memories. That may be a trigger for them. Or going out for happy hour with friends as an adult may be a trigger because it reminds you of events in your childhood. So it's important for each person to figure out what things and it. It can even be certain facial expressions that trigger that feeling of abandonment. If somebody looks at them and, and groans or like I said, makes a particular facial expression, it's important that they start becoming aware of those. There are probably going to be too many to list and try to mitigate all the time. But they can start noticing, when I encounter this trigger, I feel this way. So in the future, when they start feeling this way, they can say, I must have encountered a trigger. Now what do I do? Instead of when they start feeling this way, they start assuming there's a problem. They can start associating that feeling with the activation of childhood trauma and address it in a whole new way. We need to identify and address messages in the past that communicated unlovability or conditions of worth and have the person really describe. How would you have wanted your caregiver to act Sometimes empty chair can be really helpful. Sometimes writing a letter to them can be really helpful. Sometimes psychodrama can be helpful. But it's important for, for the person with BPT to be able to get out what that child wanted to say, what that child wanted. When I was a child, I wanted a caregiver that did these things that responded in this way that helps them get that out there. Once it's out there, not only is it helping them start to work through that grief and identify some of their loss and anger issues, but it's also saying, okay, this is how you wanted your caregiver to respond to you. Now how can you do that for yourself when, when you were scared, you wanted your caregiver to give you a hug and tell you it was going to be okay? All right, how can you do that for yourself now when you're scared, how can you give yourself a hug? How can you help yourself feel safe? And how can you use your distress tolerance skills to let yourself know that you have the ability to handle this situation? Explore the notion of responsibility with the person. Who and what are you responsible for in the present context? And this is where we start talking about learning boundaries. I'm responsible for my thoughts, wants, needs, and behaviors. You're responsible for your thoughts, wants, needs, and behaviors. Now you know, I can help you meet those things, but it's important that I take responsibility for how I react to certain situations. It's important that I take responsibility for my feelings. And then once I've taken responsibility, I'm having this feeling that I'm angry. I take responsibility for that. I take responsibility for what I'm going to do with that anger as well. Explore and address abandonment and rejection triggers. People, places, things, dates. What are those rejection triggers? Identify sensory experiences, including expressions and body language. And explore faulty thinking like mind reading or projection. So if somebody makes a particular facial expression, I'm assuming I know what they're thinking. That's mind reading. I don't know that it's important that I get the facts. When they make that facial expression, what exactly are they saying? My husband has progressive lenses and whenever he's looking at me at a distance because his prescription's not right, he looks over his glasses at me. Now, a lot of us associate somebody looking over their glasses at you as a non verbal, indicating condescension. And so that triggers that feeling of anxiety or threat in me when he used to do that. And instead of assuming, you know, what he was thinking or feeling, it was important for me to ask what was going on in order to most appropriately respond to the situation. Once he explained to me, I'm just doing that so I can see you clearly because my glasses are messed up. Oh, well, that has a whole different tone to it. And projection is when somebody does something like they make a particular facial expression and you assume based on how somebody from your past acted that they're going to do the same exact thing. Personalization. When somebody is acting a particular way, maybe they're withdrawn and they're going, your significant other is going to bed early and hasn't been as communicative. Personalization would say, it's me, they hate me, they're getting ready to leave me. Alternatives might say, maybe they're coming down with the flu, maybe work's been really busy and they've got something on their mind, or maybe they're just not sleeping well. All or nothing thinking. We've already talked about that being very common in bpt. Having the extremes of love and hate, safe and unsafe, all or nothing thinking. It's important to evaluate exceptions. You know, I love you or I hate you. Can I do both? Can I love you and hate behaviors that you've done? Okay, that's a different perspective. And as I mentioned earlier, emotional reasoning. Assuming if you feel anxious that there's a threat is faulty reasoning. And assuming that if you feel anxious that it must mean somebody's getting ready to abandon you, that's faulty reasoning. You need to get the facts. If you feel that way. Is that what's actually going on? Or is there something in the present triggering a memory of being abandoned in the past? Are you responding to the present or are you responding to a memory? Emotional dysregulation. The function is threat evasion. When somebody goes from 0 to 200, they've perceived a threat, so they are going into threat evasion overdrive. Often it looks intense and unpredictable with mood swings and behavior swings, and it causes everyone in the house or everyone around the person with BPT to walk on eggshells. This has its origin in that chaotic, traumatic environment. And we talked about this at the beginning of the class. When there's chronic stress, it leads to neurobiological changes that result in emotional dysregulation. A lack of secure attachment for the child. Al also prevented them from learning the skills to identify and manage their own emotions and effects effectively communicate their needs, which is what we call emotional intelligence. So not only were they in a chaotic, traumatic environment, but then when they did have all these feelings, they couldn't label them. They couldn't figure out what to do with them. So they were left feeling completely overwhelmed and overtaken by their emotions which imagine how powerless it feels to feel powerless to control your own body. For significant others. When the person with BPD disregulates, they experience a lot of stress and anxiety because it's intense when they do this and it can be verbally abusive sometimes or it can be terrifying if the person is engaging in self destructive behaviors. So there's a lot of stress and anxiety for the significant other who may have started to develop weak boundaries and start feeling like it's their responsibility to prevent the person with BPT from dysregulating. Ultimately, it's the person with BPT's responsibility to develop their emotional regulation skills. They can get support, but it is no one else's job to walk on eggshells. It's no one else's job to treat them with kit gloves. As as my mother would say, it's important to be nice to them, to treat them like you would want to be treated. But it's not. For people with bpt, they are actually not that fragile. They have a lot of resilience in them or they wouldn't have made it till now. Interventions help the person develop an awareness of vulnerabilities and triggers. Do you hear a theme here? Strengthen vagal tone and you can do this through deep breathing. You can do this through a variety of activities that help strengthen the body's ability to trigger the relaxation response, help them develop distress tolerance skills and learn to identify and manage intense emotions in themselves and others. So when others express intense emotions, it's important that the person with BPT does not start to feel terrified or overwhelmed. It's important that they're able to maintain their boundaries and recognize that it's okay for that person to be angry and not jump to conclusions based on their past history. It's important for them to be able to evaluate in the present context relationships are unstable or intense. Well, for the person with bpt, controlling others provides a feeling of safety and predictability. If they know what's going on, if they can control the situation, then they may be safe. It often again still looks like intense and unpredictable interactions. The message being if you do what I want, I love you. If you don't, then you're rejecting me, which means you're unsafe and I hate you. That sounds very immature. And ultimately, if you believe in inner child work, for a lot of people with bpt, that is their inner child coming out. That's that child who never learned to differentiate between who never learned to set boundaries. So it's really important that we examine these, quote, unpredictable interactions from the perspective of what is this behavior communicating. So if a person with BPT is being extremely intense and controlling, then that indicates that they're fearful. They're fearful. If they lose control, then they will be abandoned and they will disappear. This unstable, intense relationship dynamic originated because children were often rejected or the caregiver was just simply unavailable at an age in which they were still thinking in concrete, all or nothing terms. My caregiver loves me, my caregiver hates me. They're there or they're not there. The person with BPT expects rejection and has never experienced an authentic relationship with self or others. Nobody is even themselves has ever consistently been there and been comforting and supportive of them. A lack of secure attachment produces an inability to self soothe and is terrifying. And the person with BPT fears that they can't cope on their own. Well, think about it. I mean everybody occasionally has overwhelming emotions. Well, take that and multiply it times 10 and that's about what the tsunami of emotions for somebody who emotionally dysregulates. That's about what it feels like so you can understand where it might be terrifying. Especially if until they understand what triggers it and what makes them more vulnerable to it and they start developing confidence in their skills to tolerate it, repeated rejections become most salient and support all or nothing thinking. When people with BPT get in relationships, they're intense and can often scare people off or push other people away or cause friction because of the the anger that the person with BPT has because of the terror that the person with BPT lives with. So many times they have multiple failed relationships and then they start expecting everybody will reject them and they start thinking there's nothing I can do to make myself lovable. The effects for significant others in unstable relationships, well, things are all or nothing. It's either all good or all bad, which is extremely stressful. You don't know what you're coming home to and you don't know when it's going to turn. The significant other feels like they have little control over what happens, how this person with BPT treats them, or if they're lovable to that person. So the significant other, their self esteem starts becoming eroded. The person in the relationship, the significant other starts having to believe or embrace the notion that the person with BPT's perspective is right, theirs is wrong, and if they would only listen, things would be okay. Does this sound at all controlling? Codependent or even abusive. Yes, it can be. What we see here is the more the person, the significant other, tries to maintain their individuality, the more terrified the person with BPT becomes and the more controlling and domineering they become. That's what they learned, that's what they've experienced. That's what's worked till now to try to keep somebody sort of in their orbit. If they were controlling enough, they were able to keep people around for a little while longer. Interventions use cognitive behavioral therapy and backward and forward chaining to explore and address real and perceived rejection. Yeah, people with BPT have been rejected. Their behaviors were intolerable to others. It wasn't that they weren't lovable. Their behaviors were intolerable. They were also rejected by the gallery or the hecklers in their own head. The people that they've encountered, the experiences they've had that the tapes that they recorded and keep replaying in their head and their own inner critic when they look at themselves and they tell themselves, you're a piece of crap, you know. So they've experienced repeated unstable relationships and rejection. It's important that they learn to differentiate dislike of actions and ideas from a dislike of a person and learn about locus of control. Start figuring out what is it in life that I can control and what is it that I cannot in each situation, what aspects of the situation can I control and what aspects are completely out of my control and how do I deal with the stuff that's out of my control? Learn to identify and assertively communicate needs and wants and explore characteristics of healthy relationships and address the parts that feel scary. Like all of them. Honesty, trust, hope, respect. All of those can feel really terrifying to somebody who's never experienced them. And self damaging impulsivity is very common and it can be used as a distraction from those overwhelming emotions. It can be used to help them escape escape from those overwhelming emotions. Or as I mentioned earlier, sometimes it's used as a means to get attention. It's like, okay, you weren't paying attention when I said it was bad. Maybe if I act out and show you how bad it is, it will be sufficient enough to actually get your attention. This can take the form of self harm, overspending addictive behaviors, violence towards others, or even overly sexualized behavior. What are its origins? Lack of coping skills in the face of overwhelming emotions. The child had to figure out a way to tolerate this tsunami of excitatory neurochemicals and feeling just completely out of control. They had an inability to self soothe and ultimately they figured out some way that they would be able to get some people to sometimes pay attention. The effects of self damaging impulsivity the significant others start blaming themselves and thinking if I were a better significant other they would be happier and take better care of themselves. Their self esteem starts becoming eroded. They start taking on the responsibility for the thoughts and feelings of other people. So we start seeing the boundaries just crumble. Interventions help the person develop distress tolerance, de escalation and self soothing skills. Help them identify and prevent vulnerabilities and when they can't be prevented, mitigate them. Help them develop mindfulness so they can identify early warning signs of impulsive behaviors. Early warning signs of distress and they can intervene before they get to the point of having to try to do whatever to make it stop. Coping Skill Development Build on what's worked. Try to take the strengths that they already have and figure out how you can turn them into more mature coping skills and explore acceptance and commitment. Therapy with Purposeful Action Purposeful action means using your energy to address the things that you can to help you move toward what you define as a rich and meaningful life in terms of pharmacology. Update for 2021 Abilify is still used and has been shown to produce reductions in anger, impulsivity, depression and anxiety. It is an antipsychotic medication. Zyprexa used to be recommended but it is no longer showing really robust evidence so it was taken off the list. Depakote or Valparate produced improvements in anger and depression. Now it is a mood stabilizer. Obviously somebody with borderline I'm sorry bipolar disorder is probably going to be on a mood stabilizer. So if Valprate works then we also may be wanting to evaluate whether they have concurrent bipolar disorder. Lamictal, which is an anticonvulsant has showed shown that it improves impulsivity and anger. Another anticonvulsant, Topamax was effective for impulsivity, anger and anxiety. And Naltrexone which is an opioid antagonist is effective for non suicidal self injury and dissociative symptoms. So there are pharmacological treatments out there for specific symptoms. There is no one one size fits all medication that's going to quote fix borderline personality because it is far too complicated to even think that that would work. People with BPT first need to learn how to safely deal with their intense feelings. They need to feel safe and in the container that is their body. Specific issues which may trigger intense feelings and and require interventions include poorly developed or unstable self image which is often associated with excessive self criticism and feelings of inadequacy. So we want to help people develop self concept and separate the what's from the who's. What I do is not who I am. We want to help them with emotional dysregulation through the development of emotional intelligence, healing the HPA axis, releasing trauma and helping the brain recover and improving vagal tone. We want to help them address interpersonal hypersensitivity where they're prone to feel slighted or insulted. They're hypervigilant to rejection by helping them learn self soothing skills and cognitive behavioral interventions to use to address their cognitive distortions, their all or nothing thinking, mind reading and personalization and finally intense, unstable and conflicted close relationships that are marked by mistrust, fear of abandonment and difficulty trusting people due to alternations between feeling appreciated and and condemned. To address this, we need to help people learn how to identify and then effectively communicate their thoughts, wants, needs and fears, develop secure attachment with themsel be able to know what's going on inside them and respond appropriately as well as developing secure attachment with others and learn how to set healthy boundaries.