# MHApps BPD – Audio Interview Consultant Psychologist Clinician BPD EUPD – Testimorial Describing Recovery Medical Perspective

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- Clinician View of BPD
- Defining borderline personality disorder: Not a simple task Hi, my name is Jim Lyng. I’m a counselling psychologist with the Cluain Mhuire Service in Dublin, Ireland and an adjunct assistant professor at the School of Psychology in Trinity College Dublin. I’m here to talk for about ten minutes about borderline personality disorder, a problem people experience which I’ve helped treat with a team of colleagues for a number of years There is no short answer to the question ‘what is borderline personality disorder?’ The art and science of mental health is far from precise, and defining borderline personality disorder is an area where there has been much debate – and also much confusion. Anyone who has googled the term borderline personality disorder will be well aware of this situation. It would be misleading of me to try and break-down borderline personality disorder into an easy ‘sound-bite’. That said, the general understanding of borderline personality has improved in the past number of years due to work of some talented and committed clinicians and researchers who have attempted to better define borderline personality disorder beyond menu of symptoms. Following the pioneering work of Dr. Marsha Linehan, a research psychologist based in Seattle, many leaders in the field now recognise borderline personality disorder as first and foremost a problem with emotions. Almost all of the ideas that follow in this talk come directly from the work of Dr. Linehan and her large team of collaborators over the past twenty years.
- Start at the beginning: What are emotions? Let me firstly take a moment to talk about emotions. We all experience emotions all of the time and need them for survival. Emotions provide us with vital information - such as ‘is something safe or unsafe?’ - while helping to organise our actions – for example do we pull away or move towards something. At the same time emotions help us communicate clearly to other people - believe it or not less than 10% of what we communicate is based on what we say, the rest is posture, tone and facial expression – all of which are powerfully influenced by emotions. So, fear tells us something dangerous is going on, sadness can let us know we have lost something important, guilt tells us we have crossed some line regarding our own values, and so on.
- A portrait of emotional dysregulation However, imagine what would happen if someone was vulnerable to having their emotional responses triggered with little provocation … where feelings like guilt, shame, anger and fear ‘fire’ into action with very little stimulation, not justified by the facts of the situation. And imagine if those emotional responses, when they do happen more regularly than most, occurred with greater intensity than most people experience. And finally imagine if those emotions were far slower to cool down to a ‘switched off’ level than for most folk. So, you have a picture where emotions trigger easily, are very intense, and stay turned on for a long time. Scientists sometimes would call this picture one of enduring severe ‘emotional dysregulation’….where the emotion system isn’t working like it should. This is also the problem many specialists believe lies at the heart of borderline personality disorder, where individuals can find themselves in a sea of changing, out of control emotions, through no fault of their own.
- Dysregulation of relationships, actions, thoughts, and identity: The other consequences of emotional dysregulation Unfortunately, the problem of emotional dysregulation opens a flood gate of other problems for the person living with borderline personality disorder – relationships, actions, thinking and self-identity can also end up in a state of chaos. Relationships with other people can be characterised by instability and conflict, which makes sense when you think about the impact of out-of-control emotions. Similarly, impulsive actions can become common place as ways of attempting to avoid emotional suffering – after all, only the most skilled among us finds it easy to sit with extreme emotional states. People living with recurrent extreme emotional dysregulation can slip into destructive and self-defeating patterns of impulsive actions – gambling, dangerous sex, alcohol or drug abuse, forms of self-harm – in desperate efforts to reduce emotional suffering. In the short term these ways of coping might be a distraction from immediate suffering, despite being extremely dangerous and even life-threatening. However, these actions often have a way of making matters worse in the medium term. You might say that these ways of coping are attempted solutions that are also the problem. In addition to impacting on relationships and actions, severe emotional dysregulation can also destabilise thinking. Extreme emotion states tend to go hand in hand with black or white thinking styles or very mistrustful views of other people and the world. This kind of thinking can back anyone into a very inflexible and upsetting corner. Extreme emotions can also ‘short-circuit’ the whole thinking system. This can lead to becoming blank or totally tuned out from whatever is happening around. A final area where emotional dysregulation can have a huge impact is around a person’s sense of identity. Having a relatively stable emotional life is necessary to have an anchor to knowing ourselves well – if your emotions were consistently erratic, unexpectedly kicking off in different directions, just think about how hard it would be to hold onto a centre of gravity around who you are, what you like, what’s important to you, what your goals are… Some people with borderline personality disorder have difficulties in all of these areas, others in only some of them, although emotional dysregulation will be common to all with borderline personality. And like most mental health difficulties, there is a continuum of severity with borderline personality from milder to extremely serious, although it is likely that keeping a life on track which feels satisfying and manageable will be tough for anyone with borderline personality disorder – and may also be tough for those that love and care for them.
- How does borderline personality disorder develop? An important question you may have is how does someone develop borderline personality disorder? There are different ideas about this, and no one is absolutely sure. Researchers in the field of dialectical behaviour therapy, which is a treatment for borderline personality developed by Dr Linehan, believe there is almost certainly some form of biological or genetic component to the disorder – some people are simply born more emotionally sensitive than others. We see this clearly with our own eyes with newborn babies – some babies are simply more sensitive than others… they cry more, they are more affected by their environment. But being emotionally sensitive in no way guarantees the development of borderline personality disorder. Most emotionally sensitive people go on to live lives without mental health problems. Dr. Linehan’s view is that there is some kind of transaction between the existing emotional sensitivity and certain life experiences which manage to undermine or invalidate emotional reactions – covertly or overtly teaching the young person there is something wrong with the emotions. Sometimes these experiences can be clear and obvious, like certain kinds of trauma, whereas sometimes they are subtle and can be difficult to trace. The result of these invalidating experiences is that often perfectly healthy and necessary emotions tend to be pushed down or avoided by whatever means necessary. The problem is that supressing emotions actually makes them stronger – this is a fact! - and these patterns of emotional suppression and avoidance can lead to a vicious cycle of emotional chaos and suffering. Most people who go on to develop borderline personality disorder start to show signs of the disorder by the time they are teenagers and the disorder tends to be at its most pronounced during early to middle adulthood.
- Treatment for borderline personality disorder Up until twenty years ago, the news on treatment for borderline personality disorder was very discouraging. Drug based treatments had largely proven ineffective, and there was little evidence that forms of counselling or psychotherapy were of much benefit. However, Dr. Linehan’s development of dialectical behaviour therapy changed all that. Dialectial behaviour therapy – or DBT as it is commonly called - has shown pretty solid outcomes in the treatment of borderline personality disorder. About 3 in 4 people in DBT when delivered properly show significant improvements over one year of treatment. Dialectical behaviour therapy it has to be said is no easy path. It demands a lot of effort on the part of service users and with the help of a team of therapists, the person with borderline personality disorder works on developing the skills and motivation to tackle the problems arising from out-of-control emotions. The focus in DBT initially is always on reducing dangerous behaviours and overtime moves to help a person experience emotions in more healthy ways. More recently a team of researchers at University College London, Prof. Peter Fonagy and Prof. Anthony Bateman, have developed a therapy with solid initial results for borderline personality disorder called mentalisation-based therapy which draws on a modern version of psychoanalysis. There are also promising early developments in an approach from the United States called transference-focused psychotherapy and also schema therapy. None of these therapies work for everyone who undertakes them – but it’s good news that there are an increasing number of options. The crucial consideration in my view for anyone accessing help for borderline personality disorder is that they find clinicians or services that have specific training in treating borderline personality disorder – ask about qualifications, training and experience, and as a rule of thumb, if someone is reluctant to discuss these issues, it’s not a promising sign.
- A life worth living is possible With the right help borderline personality disorder is anything but a continuing life sentence. Yes, it is a problem that causes untold suffering, but it is also a problem from which a real and meaningful recovery possible. As Dr. Linehan says it is indeed possible to build a life worth living.

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