Latest / It’s All Your Fault: High Conflict People / Part 1: Borderline Personality Disorder for Those Who Suffer
Transcript
- Megan Hunter: Welcome to It's All Your Fault on TruStory FM. The one and only podcast dedicated to helping you identify and deal with the most challenging human interactions. Those that are with someone who may have a high conflict personality. I'm Megan hunter, and I'm here with my co-host Bill Eddy. Bill Eddy: Hi everybody. Megan Hunter: We're the co-founders of the High Conflict Institute in San Diego, California. In this episode, we're really excited to be joined by a very special guest Amanda Smith, who will talk about her specialty borderline personality disorder. In para one, we will focus on some BPD background and how someone who has it or suspects they may have it, what they can do about it. Next episode, which will be part two with Amanda, we will continue the discussion, but shift to information for family members of those who have BPD. But first, a couple of notes. If you have a question about high conflict situations or about Borderline Personality Disorder, send them to podcast@highconflictinstitute.com or submit them on our website @highconflictinstitute.com/podcast. Where you'll also find the show notes and links. Please give us a rate of review and tell your friends, colleagues, or family about us: especially if they are dealing with a high conflict situation. We'd be very grateful. Now let's talk borderline personality disorder with Amanda. So Amanda, why don't you tell us a little bit about yourself, your background, where you come from and we just love to hear more about who you are and what you do. Amanda Smith: I am a licensed clinical social worker. I live in Waco, Texas. I've been an intensively trained DBT therapist, for probably about six or seven years now. I have been involved in working with individuals with a diagnosis of BPD and their families, since about 2006, 2007, when I was living in Florida. And I actually helped create a nonprofit organization called Florida Borderline Personality Disorder Association, just about 12, 13 years ago. So I've been doing this work for a really long time. I'm also someone who was diagnosed with borderline personality disorder just about 18 years ago. So I have been a work in progress and I've really grown to love working with this population and celebrating their successes. Working with family members is something that's been very important to me. And yeah, I just love this work. And I love seeing people have an opportunity to grow and change and learn more about themselves; so that in Marshall Linehan's terminology, can create a life worth living. Megan Hunter: Yes. So I guess that leads to the first question, which is, oh, this isn't a throwaway disorder, meaning it's incurable or that people can't get better. Amanda Smith: Absolutely not. No. I wouldn't be doing this work if I didn't see a lot of successes, a lot of consistent successes. Especially when it comes to, when I see individuals working with a therapist who's been trained in an evidence based treatment for borderline personality disorder. So many reasons for people and again, for their families to feel really hopeful. Again, I think treatment makes such a huge difference. Megan Hunter: We will get to talk about treatment a little later in the episode. But I'm wondering if you could talk first about trauma and the relationship of trauma or what is the background of borderline personality disorder? Amanda Smith: We don't exactly know, although we have some clues, we have some ideas. We know that Marshall Linehan, the developer, the creator of DBT has referred to what we call a biosocial theory. So we know that for a lot of individuals, it seems like some of their traits related to borderline personality disorder are probably inherited. So that doesn't necessarily mean from a parent, but we can think about grandparents, aunts, uncles, cousins. Usually for about 95% of my clients, they can point to someone else in the family who has, or had similar traits; when it comes to emotional sensitivity, emotional reactivity, impulsive behaviors, maybe a history of anxiety or history of depression could be also a part of the diagnosis. So we think about family origins, we think about, is this something that could potentially be inherited? And it looks like from the evidence that's probably true for most people. And then we can think about the role of early childhood experiences, which could include trauma. Which could include exposure, to what we think of things that are difficult, that are challenging for children to grow up with or to grow through as children in adolescents. So sometimes we want to pay attention to those things as well. And to think about, when we're trying to understand the disorder, again, a combination of a genetic component, along with early childhood experiences for most people. Bill Eddy: My question would be, because I was a therapist, also family lawyer doing high conflict divorce work and all of that. And some people say, well, BPD, borderline personality disorder, isn't really anything other than PTSD, post traumatic stress disorder. And so people with BPD it's just really untreated PTSD. And I'm wondering what your thoughts are about that. And I'll just say, I think they're two separate things. Now that I've said that, I'm curious what you think. Amanda Smith: I agree with you. I think- [crosstalk 00:06:59] Bill Eddy: Oh, good. Amanda Smith: They're separate. And at the same time, I believe there's also an overlap. Bill Eddy: Yes. Amanda Smith: For many, not all of the clients I see, I work with. So no, I think that trauma can be a part of someone's story. So someone with a diagnosis that could be part of their story. And I also think that again, with an evidence based treatment, sometimes we see even if that individual also has a co-occurring diagnosis of PTSD. Sometimes we can see those symptoms related to previous traumas remit with treatment, with new coping skills, with having a strong therapeutic relationship that comes with a lot of validation and support and encouragement. So, I agree with you, I believe that they can be connected for many people, but they're not the same. Bill Eddy: Yeah. That's helpful to know, because I think it is something that gets its own treatment and each of these have treatment. But I think I agree with you that working with one often benefits working with the other. And another question I have is, one of the most dramatic characteristics of BPD is the emotion dysregulation. And I know especially in high conflict divorce cases, that divorce professionals tell someone who may have borderline personality disorder in my view, never diagnosed, they'll say just stop being so upset. And my view is that, the person in many ways is being driven by their emotions and they don't really have this conscious control before they go through a method like DBT. And so they're not doing this on purpose. This is just taking over their whole body. And just your thoughts on that. And then how you treat that, how you help deal with that. Amanda Smith: And I think this also touches on one of the primary assumptions DBT therapists are asked to believe, and that's that the person in front of us is doing the very best that they can, at any given moment. So I absolutely believe that. And then the second part of that is the idea that even when we're doing the best that we can, there's usually an opportunity for us to try harder and to do better. Especially when we get some validation, we get some support, we have people on our side who are helping us and encouraging us. I think that makes a big difference. And when I think about what you just described, one of the things that I do with all my clients is talk about the idea of, are you doing the best that you can? And having a very honest conversation about that. Megan Hunter: That's fascinating. Because I think those around someone maybe who has BPD they're like they have to walk on eggshells. And they can't have an honest conversation. Amanda Smith: And that may be true, especially in the beginning or especially when someone has not yet either been in treatment, or it's early on in treatment. And yet I think there's also a benefit to having those honest conversations. Especially when it's coupled with, again, a lot of validation and a lot of support, and coming from a place where there's not a lot of judgment makes a difference for people. When people feel like they're being judged or they're being criticized, or they're being told what to do, our reaction is to become really defensive. And sometimes we fight back, we argue, we say things we really don't mean: we do things that go against our values. So when we begin to have, again, that honest, vulnerable discussion about, are we doing the best that we can? And what about other people in our lives? Are other people doing the best that they can with what they have? Or do they also have an opportunity to do better, try harder, be more motivated to change. And again, I think when we understand that about our own experience, but then also extend those ideas, those assumptions to other people in our lives, I think most of the time our relationships really improve. That doesn't mean that they'll be perfect or that everyone's always going to get along, but I think it does make a difference. And yet, boy is that hard sometimes. When we're just starting out and all we want to do is fight and argue and lash out. Boy, is it hard to, again, sit with that idea of, yeah maybe I'm doing the best that I can, but at the same time, maybe I can do a little bit better as well. Bill Eddy: So I guess treatment with borderline personality disorder in the old day; when I first became a therapist in 1980, therapist said, if you diagnose someone with borderline personality disorder run the other way. And then by 1990s, it's like, no, you can do something with them, but it takes 10 years or 15 years. And so by 2000s, I think DBT starting to take hold. And so do you have an idea of how long it takes to treat, say emotion dysregulation, extreme anger, et cetera? And also, can you tell from how severe it is for the person, how long it's going to take for good treatment to really help the person manage themselves? Amanda Smith: I think that good treatment takes time. I would hate for anyone who's suffering to imagine that they go to treatment for a few weeks or a few months, and life suddenly looks very different. I also sometimes run into that assumption with family members or family members think, well, six months of therapy and everything should be all different and better. And that's not the case for most people. So we think about how DBT is more of a time limited treatment. We don't necessarily keep people in treatment forever and ever. Most of my clients work with me somewhere between 12 and 18 months, that includes individual therapy, and a group skills component. Which I believe is really important when it comes to healing and recovery. But yeah, I think that this does take time and yet I'd also hate for people to imagine that they need to be in treatment or in therapy for year on end. I don't know that, that's accurate for most people. And when it comes to severity, I have been pleasantly surprised many times when I thought, oh, if I'm just meeting with someone and I think, oh, this might be really tough. And then I think again, when people feel validated, they feel heard and they feel understood, I think sometimes change comes together in a really nice way. And sometimes comes together sooner than we had expected. Now that's not everyone's story. But to say that never happens would also be inaccurate, I think. Bill Eddy: I have another question and this is a little difficult to frame, but I deal with a lot of high conflict family law cases, divorce cases, and sometimes have an opportunity to recommend a treatment. And my experience has not been good with people who have seemed to have high conflict behavior, which we talk about as preoccupation with blaming others, all or nothing thinking, unmanaged emotions and extreme behaviors. And if they have those towards a child, then there's usually a history of, this isn't good and this parent should probably have limited time until they can manage themselves better. And so what my experience has been, is people who seem to me to have borderline symptoms and never been diagnosed. And a judge may say, "Well, looks like you maybe would benefit from a DBT. And so find a DBT counselor and work with them for six months and have 50/50 parenting and everything will be great. And what I see is, perhaps the time period's too short or they don't also have a group. And I'm glad you said that having a skills training group is an important part of the treatment. And I've tentatively come to the conclusion that someone that has BPD and a high conflict personality totally focused on blaming the other person won't change. Because they're in a high pressure situation, high conflict divorce court case, and all that. And they're preoccupied with blaming the other. So even six months of counseling doesn't seem to touch the surface. And so I'm curious if you have thoughts, if you've dealt with cases that have been in parenting disputes, in family court and what really does help the most? Amanda Smith: So I've had clients like what you've just described. And I think in that case, that six months is not enough. I absolutely agree. So yes to DBT, I still believe in DBT, DBT skills. But again, I think there's also some wisdom in helping clients who have families who have children thinking about parenting skills, I think is incredibly important. And has not traditionally been a part of DBT. So I think about the skills and how the individual learns to use the skills to manage their emotions, to improve their relationships. But then I think about the missing component, which is doing a lot of parent coaching. And helping individuals have a better relationship with their children, with their ex spouse or partner, I think is incredibly important. And again, not necessarily something that I think most therapists have been trained to do, or to even really think about. Bill Eddy: Yeah, let me fit in here, are new ways for families' method that we develop first as a counseling, very short term counseling intervention, and then turned into an online program. And now we train people to coach with the online program. And I really think that for therapists, that's a really good arrangement, because it can add to what's being done. And the therapist can teach the skills we have, because we're very skills focused. And I want to give Marshall Linehan and DBT credit for influencing me towards a skills focus. Because that really takes a lot of pressure off people defending their past behavior, and let's learn these little skills. So we teach how to write emails with managed emotions. And how to give yourself an encouraging statement and all of that. So I think I just want to emphasize there's methods available for this piece. And that we totally agree that I think people going through recovery from borderline with kids really can benefit from learning a handful of key skills and repeating them a lot. Amanda Smith: Absolutely agree. And again, I think for a long time, this has been a missing piece or a missing component, especially for my clients who have children who have families. Bill Eddy: Yeah. Megan Hunter: So are you saying that with DBT some people can diagnose out of the borderline disorder diagnosis? Amanda Smith: Absolutely. I'd say most of my clients who work with me, for again between 12 and 18 months, that when they graduate from my practice and we in our group, we make it a party. So this is something we really do celebrate. I would say that most of those individuals no longer meet diagnostic criteria for borderline personality disorder. Again, that doesn't mean that people will never struggle again or will not need additional help in the future. But for most people, especially I see this with younger clients. So clients in their late teens, or early twenties, boy, they are really primed most of the time for getting help and getting better. And success seems to come a little more easily to those clients. And maybe it's a little bit harder for clients who are in their thirties or forties or fifties, not that again, those individuals don't have success stories because they absolutely do. But it can be a little bit harder, for older clients who are getting diagnosed a little bit later in life. And just getting treatment. That seems to be a little more challenging for a lot of people. Megan Hunter: So that brings up a couple of questions or thoughts. And one is, it seems like from where we sit and the work we do, that BPD is on the rise, particularly in that 20 something, maybe 30 something category. Is that your experience? Is that what you've observed in the last maybe five years or so? Amanda Smith: I have seen more people, especially younger people be more accepting of the diagnosis. Megan Hunter: Which is part two of my question. Amanda Smith: And I think part of that is due to YouTube and Instagram and Facebook and- Megan Hunter: TikTok. Amanda Smith: Now TikTok, where people are talking about these diagnoses. Sometimes they're diagnosing themselves or they're diagnosing other people on social media, which can be interesting. So I think there is an increase in people receiving the diagnosis also being curious about the diagnosis, getting more information about the diagnosis. I think it's become easier for even therapists to talk about the diagnosis of borderline personality disorder. For the longest time, when people Googled or used Yahoo to search for borderline personality disorder, there was a lot of really negative experiences that would come up. When someone does that today, there's a lot less negativity, and a lot of stories that are a lot more hopeful and encouraging. So I'm glad to see that. Because I think it makes it easier for everyone. I think it makes it easier for therapists. I think it makes it easier for families, for people who are getting diagnosed and are curious about the diagnosis. So in that way, I think it's been really positive. Again, especially over the past five or six years now. Megan Hunter: If someone's listening to this, and they know that they've had some behaviors that are maybe a little extreme. And they've done their Google search and thought, oh, I may have this, but they're resistant to admit it, acknowledge it and seek treatment for it. What would you say to that person? Amanda Smith: I would say one, I think that's perfectly okay. I don't think that people need to be accepting of the diagnosis in order to get better. We have a lot of evidence that are treatment like DBT, can be very beneficial for a lot of people, with a lot of different diagnoses. That doesn't mean that it's an evidence based treatment for absolutely everyone. But I think for people who say, "People keep talking about borderline personality disorder, but it doesn't seem like it's me" Even that individual can probably benefit from learning some coping skills. And learning ways to soothe themselves and learning mindfulness skills, or learning how to validate themselves. So even if someone says, "That's not me, I don't see why people keep talking about that" I think that's still okay. I think there's still room for that person to potentially learn more about DBT and to see if this might be a treatment that's helpful to them: no matter what their diagnosis is. Megan Hunter: Yeah. And it's unfortunate that there is this whole stigma around it. It's unfortunate, although on one hand, many people who get the diagnosis, feel some relief because they now understand. But I just wish it were called something else. So that it wouldn't be so stigmatizing and people wouldn't feel that they're judged or that they're inferior, or have to completely change their whole being with some treatment. Bill Eddy: I noticed, I think on your website, that you had an online course, is that correct? Amanda Smith: I do. I have a course for families. Yes. Bill Eddy: Oh, okay. Because I was curious if an online course would be part of treatment, or if so and how effective? Because we have an online course for our parent skills method, which isn't a therapy, but it does seem to have some impact. And so I was curious if you were doing it as a treatment method, but it sounds like it's more for family members. Amanda Smith: That's correct. And I think that an online course for individuals diagnosed with BPD can be beneficial. I don't know that it's a replacement, or working with someone who has extensive training and supervision and the education they need to work with someone diagnosed with a personality disorder. Megan Hunter: A follow-up question to that is, if someone's out there, they've heard about DBT and oh this is amazing, I should go to it. And they Google for someone in their local area; if someone puts out there that they provide DBT, do they have to follow some standard or protocol? Do they have to give both individual and group? Do they have to give in person or can it be virtual? What are the parameters around that? Amanda Smith: Anyone can call themselves a DBT therapist. Megan Hunter: Really? Amanda Smith: Even if they went to a weekend training, that's why it's really important that people ask a lot of questions. So when they're interviewing a potentially new therapist to ask about their training, and to ask about supervision. And to ask about consultation; and to ask about what they do for ongoing continuing education, and what that looks like, I think is really important. But now unfortunately pretty much any therapist can list DBT as one of the treatments they provide, but they don't necessarily have to be trained in DBT. We want people doing the treatment the way Marshall Lenahan intended, or at least moving in that direction. I don't think it's enough to buy the book and think, okay, well now I'm a DBT therapist. There's a lot more to this treatment than even just teaching the skills. There's a way of communicating. There's a way of validating clients who are more emotionally reactive, more emotionally sensitive. And not every therapist receives that training in graduate school. Megan Hunter: Yeah. And I see DBT listed on many websites these days and that's why I was so curious about it. I also am seeing, or have heard reported that, DBT skills are being taught in schools. Have you heard about this? Amanda Smith: Oh, it's so wonderful, isn't it? Megan Hunter: Isn't it? Amanda Smith: Yeah. So DBT for adolescents, or DBT in schools and yeah, this is a fantastic curriculum developed by a husband and wife team. And boy, do we need this in schools? Absolutely. Bill Eddy: That's great. Amanda Smith: But no, I love the implementation because if we can begin to teach these skills, these ideas to children and adolescents, boy, we're going to have healthier adults. So important. Megan Hunter: Yeah. I love it. So one sideways question, I guess, is there often seems to be a presence of substance abuse and, or maybe bipolar disorder or other disorders, maybe [inaudible 00:30:26] tipple others, how much does this complicate DBT treatment? Or what can be done around that? Because what I'm hearing from many people is that, well, we just need to treat the substance abuse, if we get that done, then everything else will clear up. But I think it's the opposite. If you clear up the other first, then the substance abuse probably will dissipate. Amanda Smith: That's what I have found most of the time in my practice. Every once in a while, we may think about how we really do have to treat substance abuse first and have to prioritize that treatment. But no, I have found what you've found, that when people learn skills they can use to cope and cope consistently well, they find that they don't necessarily need alcohol or marijuana or other substances to get through the day. I absolutely agree with that. And it is complicated when someone comes to treatment with multiple diagnoses or more than one personality disorder. One of the things I have consistently seen in my practice is a combination of borderline personality disorder and either narcissistic features or narcissistic personality disorder. And when this comes up, one of the things I'm honest about is that DBT is not an evidence based treatment for narcissistic personality disorder. It doesn't mean that the skills cannot be helpful for that individual, but I would hate for anyone to imagine, okay, we're going to get the same benefit with narcissism that we do with borderline personality disorder. When we think about a full DBT program, I have not found that to be true in my practice. So when I'm working with families, or I'm working with individuals, and it seems like narcissism is the primary diagnosis, sometimes we begin to have a conversation about how a psychodynamic treatment may be something that may be more helpful for that individual. Bill Eddy: I just think this has been great. And I look forward to the other half of our discussion with you. And that is how we're going to help family members and those close to them. Megan Hunter: Yes. And I also wanted to mention your website Amanda, which is hopeforbpd.com. People can find a lot of resources there. And one of the things, I can't believe I haven't brought this up yet, but is, you're the author of two books, they're both published by Unhooked Books, which I happen to be a part of. And they're wonderful books. So the first one is, The Dialectical Behavior Therapy, Wellness Planner. Why don't you tell us just a little bit about that if you would, Amanda. Amanda Smith: So a big part of DBT is tracking skills and tracking behaviors and identifying thoughts. So it's really important to really focus on that, in the treatment as a way so that the treatment is successful. And I have found that many of my clients didn't like the traditional diary card approach, which is just an eight and a half by 11 sheet of paper to track a lot of information. And I found that most of my clients wanted to have a little more information that they wanted to include about their day or their week. And so the wellness planner met that need for a lot of people now, over the past seven years or so. So that's where that idea came from. Megan Hunter: Yeah. If you go on Amazon and look at the reviews for this book, it's just excellent reviews. And I pulled one off, someone says, "As a border liner, my life was dramatically improved by being able to see where I was making progress and which areas of my life I was missing completely; such as eating regular meals and being kind to myself. I would definitely recommend to BPDers" I thought that was all encompassing of what it's supposed to be. And I haven't even seen or heard from other people who have used this book, even if they don't have BPD or they aren't in DBT. They just like it as a way to be kind to themselves and track themselves, and take care of themselves: and drink less, things like that. So we'll put a link to that book in the show notes. The other book we'll talk about, in the next episode is Amanda's second book, The Borderline Personality Disorder, Wellness Planner for Families The next week we'll continue this discussion with Amanda, specifically focusing on family members of someone with BPD. If this is you, don't miss this next episode. In my opinion, Amanda's is one of the world's leading experts at helping family members of those with BPD. And I guarantee you will learn something new that will be very helpful. So we'll wrap this one up for now. And if you have questions about BPD or anything to do with high conflict situations, send those to podcasts@highconflictinstitute.com or submit them on our website. Please tell your friends about us. And we'd be very grateful if you leave a review wherever you listen to our podcast. If you're dealing with a high conflict situation at work or at home, keep calm and use your skills. You'll find the missing piece, P-A-C-E. It's All Your Fault is a production of TruStory FM, engineering by Andy Nelson, music by Wolf Samuels, John Coggins, and Ziv Moran. Find the show, show notes and transcripts @truestory.fm or highconflictinstitute.com/podcast. If your podcast app allows ratings and reviews, please consider doing that for our show.