Trauma Informed, Strengths Based Approach to Recovery from Borderline Personality
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs
Objectives
– Review the characteristics of BPD
– Explore the functions of these symptoms
– Identify what may cause these symptoms to develop
– Explore what is maintaining these symptoms (benefits to the client)
– Explore the effects of these symptoms on significant others
– Identify interventions to help the person more effectively manage emotions and relationships
Lifespan Perspective
– The course of BPD from adolescence to late life is characterized by a symptomatic switch from affective dysregulation, impulsivity, and suicidality to maladaptive interpersonal functioning and enduring functional impairments, with subsequent remission and relapse.Ā (coping skill development? Maturation of the PFC?)
– BPD symptoms tend to wax and wane and presentation depends on contextual factors.
– BPD behaviors seem to develop to help the person survive dangerous or threatening situations when other options are not available.
– Symptoms can often be understood through a lens of trauma
Neurological Aspects
– Childhood trauma may increase risk of BPD development due to alterations in
– Hypothalamic-Pituitary-Adrenal (HPA) axis
– Neurotrasmission
– Endogenous opioid system
– Neuroplasticity in the childhood
– Brain areas involved in stress response (MPFC, amygdala, anterior cingulate cortex, hippocamus)
Internal Reality
– Lack of a sense of selfāIf they arenāt someoneās something, then they are nothing
– Unlovable for who they are
– Constant fear of abandonment
– Emotional dyscontrol
– Inability to self-soothe
– Lack of coping skills
– Lack of emotional boundaries
– Anger is used to control others and is rewarded
First Step
– Address Emotional Dyscontrol
– Identify and prevent vulnerabilities
– Identify what works to help self-soothe
– Identify helpful distress tolerance techniques
– Develop a safety plan
Next Step
– Identify the most salient symptoms
– Their function and alternate ways to meet that need
– What is the behavior communicating?
– I am afraid ofā¦
– I needā¦
– What it looks like (i.e. āimpulsivityā)
– How that behavior is being maintained (what are the benefits and other ways to get the same benefit)
– Identify co-occurring issues: Depression, Anxiety, PTSD, Bipolar Disorder, Eating Disorders, Addiction
Frantic Efforts To Avoid Abandonment
– Function: Preventing abandonment means preventing death
– What does it look like (Benefits/Drawbacks)
– Hypervigilant/hypersensitive to rejection/criticism
– Anger at/belittling others to control them
– Acting out to control through guilt
Abandonment contā¦
– Origins
– Failure to develop a sense of self due to constantly trying to appease the caregivers (filling a role/conditional positive regard)
– Addicted Family āDonāt Talk, Donāt Trust, Donāt Feel
– Borderline Family āDo as I say or elseā¦
– History of abandonment/rejection
– If they are something to someone then they are filling a need and are less likely to be abandoned
– History of neglect/abuse (You (as a person) are not worthy of love)
Abandonment contā¦
– Effects for SOs:
– I cannot leave. It is my responsibility to care for him/her.
– They hate me. I cannot do anything right, but they will die if I leave.
– Benefits for the person with BPD
– I am not worthy or lovable and cannot survive without this relationship (lack of prior secure attachment)
Abandonment Contā¦
– Interventions
– Develop a sense of self
– Enhance self-esteem and self-efficacy
– Differentiate between who you are and what you do
– Explore what makes someone ālovableā
– Explore abandonment triggers
– Identify and address messages in the past that communicated unlovability or conditions of worth
– How would you have wanted your caregiver to act? (Do that)
Abandonment Contā¦
– Interventions
– Explore the notion of responsibility (Who and what are responsible for in the present context)
– Other people (including caregivers)?
– Yourself?
– Nobody else can make youā¦(drink, use etc.)
Abandonment Contā¦
– Interventions
– Explore and address abandonment/rejection triggers
– People, places, things, dates
– Sensory experiences including expressions/body language
– Explore faulty thinking
– Mind reading/projection (Facts)
– Personalization (Alternatives)
– All or nothing thinking (Exceptions)
– Emotional Reasoning (Facts)
Relationships are Unstable/Intense
– Function: Controlling others provides a feeling of safety and predictability
– What does it look like (Benefits/Drawbacks)
– Intense and unpredictable interactions
– If you do what I want, I love you
– If you do not, you are rejecting me and I hate you
– Everyone walks on eggshells
– Jeckyl/Hyde
Relationships are Unstable & Intense
– Origins
– Children were rejected (or the caregiver was unavailable) at an age in which they were still thinking in concrete, all-or-nothing terms
– The person with BPD expects rejection and has never experienced an authentic relationship with self or others
– Lack of a secure attachment produces an inability to self-soothe is terrifying and the person with BPD fears they cannot cope on their own
– Repeated rejections become most salient and support all-or-nothing thinking
Relationships are Unstable contā¦
– Effects for SOs & Benefits for the person with BPD
– Things are all or nothing, good or bad.
– I have little control over what happens, how others treat me or if I am lovable.
– Their perspective is right. Mine is wrong. If I would only listen things would be okay.
– Their needs come first.
– I canāt do anything right. Iām damned if I do. Damned if I donāt.
– I am not lovable unless I do what they want. My wants, needs, thoughts are not valid.
– Other people are not trustworthy. What is said one day may be different the next.
Relationships are Unstable contā¦
– Interventions
– Use CBT and backward and forward chaining to explore and address real and perceived rejection
– From others in real life
– From the gallery/hecklers
– From yourself
– Differentiate dislike of actions/ideas from dislike of person
– Learn about locus of control
– Wisdom to know what can be controlled
– Courage to change the things you can or how you react
Relationships are Unstable contā¦
– Interventions
– Learn to identify and assertively communicate needs and wants
– Explore characteristics of healthy relationships and address parts that feel scary
– Honesty
– Trust
– Hope
Self-Damaging Impulsivity
– Function: Distraction/Escape/Attention
– What it looks like (Benefits/Drawbacks)
– Self-harm
– Spending
– Addictive behaviors
– Violence toward self or others
– Overly sexualized behavior
Self-Damaging Impulsivity
– Origins
– Lack of coping skills in the face of overwhelming emotions
– Inability to self-soothe
– It was the only way to get people to pay attention/understand
Self-Damaging Impulsivity
– Effects:
– If I ā¦.she would be happier and take better care of herself.
– I am bad. If I were better, she would not have these problems. It is all my fault.
– Negative reactions of others are my fault and I must fix it.
– I am completely responsible for other peopleās thoughts, feelings and actions.
– āYou made meā¦.ā
Self-Damaging Impulsivity
– Interventions
– Distress Tolerance/De-escalation/self-soothing
– Vulnerability Prevention & Mitigation
– Mindfulness
– Coping skill development
– Acceptance and Commitment Therapy: Purposeful Action
Pharmacologic Treatment (2019)
– Aripiprazole (Abilify) produced reductions in anger, impulsivity, depression, and anxiety. (Antipsychotic)
– Olanzapine (Zyprexa) showed small improvements in anger and anxiety. (Antipsychotic)
– Valproate (Depakote) produced improvements in anger and depression. (Mood stabilizer)
– Lamotrigine (Lamictal) showed benefits for impulsivity and anger. (Anticonvulsant)
– Topiramate (Topamax) was effective for impulsivity, anxiety, and anger. (Anticonvulsant)
– Omega-3 fatty acids showed improvements in depression
Summary
– People with BPD first need to learn how to safely deal with intense feelings
– Specific Issues which may trigger intense feelings and interventions include:
– Poorly developed, or unstable self-image, often associated with excessive self-criticism and feelings of inadequacy
– Development of self-concept
– Differentiation of whats from whos
– Interpersonal hypersensitivity (i.e., prone to feel slighted or insulted)
– Self-Soothing
– CBT Interventions
– Intense, unstable, and conflicted close relationships, marked by mistrust, fear of abandonment, and difficulty trusting people due to alternations between feeling appreciated and condemned
– Learn how to be honest about wants/needs/fears
– Develop the ability to trust self
– Learn what it means to trust others
– Learn how to set healthy boundaries