The NICE guidelines for helping people with Borderline personality Disorder were published in 2009:
Here are some extracts from one of the case studies from the book: Does this story sound familiar?
[I think this woman is an undiagnosed, unaware womb twin survivor. What do you think? ]
As a child I was hyperactive and was more interested in my environment and learning new things than being held by my parents. I think my parents interpreted this as a rejection and as being difficult. In addition, the family dynamics were difficult and incomprehensible to me as a child and I blamed myself for them. However, I lived well and was lucky enough to be able to do most things that I wanted in terms of activities; my parents gave me everything that they could. Despite this, home felt too unsafe and volatile an environment to express my emotional and personal needs. Among my sisters I felt the odd one out. I felt that I didn’t belong in my family. My way of coping with these feelings was to throw myself into school, where my joy of learning, music and sport allowed me to immerse myself to the extent that my success at school somehow became a substitute for parenting.
What I didn’t realise at the time, however, was that I still had a huge yearning to be parented. I needed emotional connection, safety and understanding but didn’t recognise those needs nor knew how to get them met.
As I grew older, I struggled more and more socially because what I was missing meant that I did not acquire the empathic understanding needed to manage social relationships. This yearning for connection led me to seek refuge in any potential parenting figures that I came across. Unfortunately, one person who took me under his wing was interested in me for the wrong reasons – I was sexually abused and raped as a child over a period of 6 months to a year. This amplified my difficulties. I became even more socially isolated and emotionally inept as I tried to shut out these experiences that I couldn’t begin to comprehend.
Not long after this I moved with my family to a different part of the country. At first, this was a welcome change and a relief from abuse. People had no prior knowledge or judgements about me and this was welcome. I could be different from before –I could start again. However, this relief only lasted for about 6 months. Now as a teenager, my difficulties and the emotions and memories I had temporarily locked away began to resurface. My behaviour at school deteriorated, my moods became unstable, I was withdrawn, I frequently sought out teachers for support but didn’t know why, I’d leave lessons for no reason, I’d have arguments with teachers, I began to self-harm (hitting myself mainly), and became more preoccupied with the thought of suicide.
When I was 14, I was referred to child and adolescent mental health outpatient services where I began work with a clinical psychologist whom I saw weekly, sometimes twice weekly, for approximately 4 to 5 years. I was diagnosed with post-traumatic stress disorder.
Having a psychologist meant that I finally had someone who could partly meet my need for a parent (in that they could give me an emotional connection and understanding I so desperately needed). I undertook some important work around understanding the abuse, but when she tried to initiate conversations about my family I couldn’t say anything. All I knew then was that I didn’t feel safe at home. She described my family life as being a ‘ghost town’.
During this time my thoughts of self-harm and suicide became more prominent, but my drive towards destructiveness was most apparent in my relationships with men. Not knowing how to deal with men after the abuse, the conflict between needing to be close to someone and being frightened of intimacy became increasingly more difficult to handle as I was now at that age where male attention was inevitable. I would find myself in difficult situations where I would end up having sex with people I didn’t want to as a result of fear and an inability to express my needs and say ‘no’. After a while, I figured the only way to deal with this was to be the one in control. Instead of waiting to be seduced I became the seducer, placing myself in a number of risky situations.
Despite all this, I managed to get to university. Although I thrived in the freedom that university allowed and in being away from my family, I was still extremely fragile in my sense of self and in my emotions. There was still a lot I had to deal with and understand about my past, and this at times, especially combined with the pressure at university, meant that I found it extremely difficult to cope. I accessed the university counselling service on a number of occasions, but found that it didn’t work at quite the depth I needed. In the holidays, I occasionally had the opportunity to have a number of sessions with my previous clinical psychologist. This support often enabled me to be ‘topped up’ just enough in order to survive another term. However, the final year of my degree saw things start to disintegrate; the added pressure combined with my limited resources meant that I had nothing left at times. My closest friendships broke down and I ended up taking two overdoses as I couldn’t manage the situation with my friends, the exams, and the thought of leaving university – I wasn’t ready to be an adult.
Just prior to these overdoses I had been referred to a psychologist at university and had been prescribed an antidepressant (paroxetine) by my GP. I struggled to work with this psychologist as he took more of a behaviourist approach, which I didn’t find at all helpful. I also struggled with beginning a new therapeutic relationship after having had such a positive therapeutic experience with my previous psychologist. I eventually took myself off the antidepressant because I didn’t feel that it was helping.
Somehow, I managed to complete my degree and returned to live with my parents. As a result of my overdoses at university, my GP wished to refer me to adult mental health services when I re-registered. This resulted in my referral to another clinical psychologist who I met approximately biweekly. Things had settled since returning from university, but my difficulties hadn’t gone away – they were just more in the background. I still struggled a lot of the time, but I was able to keep this more private. I began working as a classroom assistant in a school with children with special needs, which I thoroughly enjoyed. I then started work in child and adolescent mental health. This proved to be a mixed blessing.
Therapeutically, the clinical psychologist and I had just started to unravel some of my family dynamics and make sense of my experiences growing up. I began to understand that my Mum and I had both struggled with insecure attachments throughout our lives and this helped me to understand some of the dysfunctional interactions I so often repeated in my other relationships. The combination of attachment and psychodynamic understanding worked well for me. It captured so much of the unexplained and helped me construct my life story, putting more solid foundations in place for a sense of self to develop. Understanding my Mum’s difficulties and, in addition, my Dad’s background (his Mum died when he was a teenager and he had had repeated episodes of depression and anxiety) also helped me understand the volatile interactions that often occurred in our family and my parents’ capacity to be mildly physically and emotionally abusive at times.
However, doing this type of therapeutic work while working in child and adolescent mental health proved to be a destructive combination. I thoroughly enjoyed the work and felt that I was good at it. However, I was giving so much to the children I was working with and at the same time was more open to my emotions as a result of the therapeutic work I was undertaking. Everyday, I saw in the children how I was feeling inside being acted out in front of me. This triggered so much that when I went home in the evening I couldn’t begin to recognise, name or understand the emotions I was feeling. Instead, all I experienced was a huge vacuum. I was being sucked into something I didn’t feel I could survive. I literally felt that this feeling would kill me – it was so huge and consuming.
The only way I could handle these feelings and to feel any sense of control was through self-destruction, although more realistically I felt simultaneously out of control and in control at the same time. The drive to self-destruct was so strong that I felt I had no choice but to self-harm; but through the act I also found some way of regaining some temporary stability, relief from that vacuum, and some control. Previously, I had kept busy to keep this emotion at bay, but as time went on and the therapeutic work continued I couldn’t do enough to stop feeling the emotions: overdosing, cutting, burning, blood-letting, balancing precariously on the top of car parks and bridges hoping I could throw myself off them – I tried almost everything. By day I was going to work and pretty much managing, but in the evenings and at weekends I was either being held at the police station detained on a section 136 or in A&E. No one in the police station or in casualty could understand that such a seemingly together person who had a good job could also be so destructive and wasting their resources. I was leading a completely parallel existence. Eventually, because I was so exhausted I started to struggle at work. I took sick leave, never to return.
As soon as I gave up work, which was the only thing holding my life together, I deteriorated rapidly. My self-destruction increased to two or three times a day, I didn’t sleep or eat, and my finances were in chaos. My whole life became a constant game of Russian roulette. Although I struggled with suicidal thoughts, most of the time I didn’t actively want to die. I just wanted to feel safe and access help, but equally, if I died by accident as a result of what I did, I didn’t care either. Let fate decide.
Eventually, this led to a point where I was admitted to hospital and was diagnosed with borderline personality disorder. I was an inpatient for 8 months. At first it was a difficult admission as my determination not to be medicated left the staff struggling to meet my needs. I did, however, manage to build up relationships with some of the more experienced staff. They helped me feel safer and they had the skills to work psychotherapeutically with me. This I found more helpful than the interventions of less inexperienced staff who tried to control me and my emotions by becoming more
authoritative. This tended to escalate situations.
The team was split between those who were more open minded about working with people with borderline personality disorder and those who felt I shouldn’t be treated in hospital. This was difficult for me to deal with at times as it always came across as a personal rejection. Eventually, as my ability to build relationships and to learn to trust and ask for support increased, I gained more respect from the team as a whole. This improved consistency in their approach, helped me feel that staff responses were more predictable, and this in turn helped me to feel able to trust them and ask for help, rather than self-destruct.
Throughout this time, as well as receiving support from the nursing team and psychiatrist, the work with my clinical psychologist continued. I was able to make much more progress in an environment where I felt safe. We continued to work primarily in a psychodynamic/attachment orientated way, however, some inputs from cognitive analytic approaches were very helpful in understanding the cycles and patterns of behaviour in which I would get entangled and would lead to self-destruction.
Despite the progress I made during this lengthy admission, I didn’t feel that I was yet at a stage where I could survive at home again. I had a mortgage, which made options such as supported housing feel too impossible, and I still didn’t trust new people enough to have care at home. A therapeutic community was therefore suggested and after some consideration and a couple of meetings with the community’s outreach team, I decided that it was probably the best way forward and a step that I now felt ready to make.
This transition was probably one of the hardest I have had to make: I was leaving the safety of the hospital and was going to have to interact with peers and to survive without parents in any form. However, the therapeutic community, although difficult, proved to be the right move. Its combination of different treatment approaches, group therapy and its emphasis on residents taking responsibility for running the place and for each other, meant that I became more honest with myself and others about how I was feeling, making it easier to identify my emotions and access the support I needed. It also allowed me to do what I hadn’t got around to in hospital – linking my past story with my current patterns of behaviour. I saw for the first time how much my current thinking, interpretation and behaviour replicated my past survival methods in the family, and how these strategies I used as a child could no longer work as an adult. I recognised the need to learn new skills and although it sounds a simple process, the reality was that it was difficult and at times traumatic. I had to face up to the fact that, at times, I could be selfish, blame others for things that were my fault, and shut others out. I had to learn to accept all facets of myself and piece those functioning and malfunctioning parts of myself back together so that I could start to build a sense of self.
Another important thing I learned at the therapeutic community was that I needed to be my own parent and that I had the skills to do it. I had to look after myself in the way I wanted to be looked after. This would help me feel better about myself, increase my sense of self-agency, which in turn would further strengthen my sense of self. Perhaps most importantly, I learnt to interact socially. The therapeutic community gave me an environment in which I could learn what was acceptable and unacceptable in terms of dependency, and through the process of seeing my behaviour mirrored in the other residents, I realised the negative impact I could have on other people. After a year, when I came to leave I felt like I was functioning better than I had functioned in my entire life.
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