A Matter of Personality

From borderline to narcissism

"Borderline" Provocations: How NOT to Respond

Patients who have the traits of borderline personality disorder often are experts at inducing in those closest to them feelings of anxious helplessness, anxious guilt, or overt hostility. If you want to continue to feel that way, here is a list of the best ways to help them help you to do so. Read More

Good Article

I can't wait to see your recommendations. The "don't do" list is pretty extensive and doesn't leave much room for doing. I suspect the "to do" list will be short, and probably be something like: "run away from them."

Let Me Ask You This...

Dr. Allen:

Do you at all believe that people who suffer from BPD have the capability to recover? Please read:
http://www.psychologytoday.com/blog/both-sides-the-couch/201309/borderli...

Interested in hearing your response.

Gerri Luce

Let me ask you

Hi Ms. Luce,

Thanks for your question.

Absolutely, they can recover, but the psychotherapy is long and difficult.

BPD in my view is not a disease but an adaptation to a highly dysfunctional family of origin. I have devoted much of my life to developing a psychotherapy paradigm to help adults with BPD alter their interactions with their parents, which, when successful, in turn frees them up to stop acting out:

http://www.amazon.com/Psychotherapy-Borderline-Patients-Integrated-Appro...

Yeah that sounds good unless

Yeah that sounds good unless a GROUP is involved. BIG DIFFERENCE. Meaning a person has BPD but the group enhances the behavior. BIG DIFFERENCE. Oftentimes if people mind themselves and not others situations don't explode. Now we have a group of people with disabilities attacking another. Address that.

Yeah that sounds good unless

Hi anonymous,

This post is focused at the dyadic level - individual to individual. Group dynamics, however, is IMO at the heart of the disorder known as BPD, so several people are almost always involved, and you are absolutely correct that that makes a big difference.

Please them with Validation

Don't Try to please them yes and no ….BPD's just want to be validated… its ok to please them using empathy... so if you restate what they are upset about and tell them you can see how they would feel that way "if she treated me like that I'd be mad too.." you will get further.

Yes!

jill wrote:
Don't Try to please them yes and no ….BPD's just want to be validated… its ok to please them using empathy... so if you restate what they are upset about and tell them you can see how they would feel that way "if she treated me like that I'd be mad too.." you will get further.

This is right on. A lot of cutters and anorexics are diagnosed as borderline, even if they don't have symptoms of aggression and impulsive behavior. I think using empathy with such cases is remarkably effective.

This list is incredibly useful for people who actually have BPD

I can understand providing this list for people who claim that they have been seduced or manipulated by those with BPD. It give them a reality check and show them that they have chosen to behave in certain ways but I still very much doubt that these behaviours themselves are synonymous with an actual diagnosis of BPD.

I'm very skeptical also of this idea that those of us with BPD are seeking to provoke specific reactions in other people. I believe you are crediting us with too much premeditation. We are first and foremost creatures of impulse. We feel things intensely and that intensity impacts upon those around us. There is no intention behind it just the force of our own existence which is wrongly credited as being deliberate and conscious.

Having BPD is like experiencing grief on a daily basis out of nowhere, for no particular reason. Your head just falls way below your boots at a moments notice and there is no space in society to accommodate this malady. Therapy doesn't teach us good manners or how to respect other people's needs, wishes etc. We know these things. It simply teaches us to recognise our own needs and adapt to a world that does not/ can not.

This list

Hi Ms. Field,

On the question of intent, you are partly right. Kids in the process of learning to stabilize their parents (in this case, balancing the opposing forces of instability in the parents, guilt and anger) learn to elicit these responses through both trial and error and their own ingenuity. When they are successful, they then began to do this automatically and without any conscious thought - sort of subconsciously if you will, like driving a familiar stretch of road while being preoccupied with something else.

I disagree that the episodes of affective instability that you so nicely describe have no reason. There's always a reason, though often it's not at all obvious.

Do you accept that this list of "don'ts" doesn't apply to many people with BPD?

I can agree that if you are dealing with someone who is a bottomless pit of negativity and need that this list is useful. My life has been littered with such people because my poor boundaries and self sacraficial behaviour has invited them in. Therapy for my BPD diangosis has taught me how to live my life for me and not throw it away on people who are incapable of loving or respecting me.

While I have never been attracted to mentally healthy men because I have BPD I do not recognise any of the behaviours you have identified here in myself pre or post treatment. I have always been the rescuer. I have always been the person doing the things that you warn against here and I know of many, many people with an actual BPD diagnosis who are the same.

do you accept

The post (and the ones that follow in the series) is about provocative behavior that is frequently seen in those with moderate to severe BPD, and of course only applies to those persons that engage in the specific behaviors - and to the people who are attracted to such individuals.

Thanks for the clarification

:)

Say What?

I have BPD. I do not go about my relationships looking to elicit in the observer one of three reactions: anxious helplessness, anxious guilt, and overt hostility. WTF??? I resent that.

I mean come on. That would imply I was like a sociopath with an agenda. I can assure you never in my life have I had an agenda (at least not a conscious one) in my interactions with people.

The fact that you posted this "negativity about BPD" is another subversive attack on a vulnerable population. What, quite frankly, is up with Psychology Today articles and all of their attacks on people who SUFFER with BPD? It makes me sick.

Can someone for once post some positive things about someone that suffers from BPD??? I like the person who said treat them with empathy! We are human beings. How not to treat us, wow why don't you just pretend we are dogs then you can train us how you like.

say what

Hi Jill,

Thanks for your comment, but if you do not get reactions like these from your intimates, then the post obviously would not apply to you or the people who deal with you.

If, however, you think that a lot of individuals with moderate to severe BPD do not often act like I describe, you'd be incorrect. I've been watching them do it for decades.(And their agenda is often subconscious, BTW).

Why do you think they have such a bad reputation among therapists? Granted, therapists should know better, and know how to handle them, but that's another issue.

No Dr Allen, I disagree with this completely

There is no question as to why therapists have dealt with BPD clients in a shocking manner historically and today also unfortunatley. It is because of the countertransference that they experience when dealing with patients they do not and cannot understand.

The tempestuous and terribly painful relationships that people with BPD experience with their therapists/clinicians, comes from the invalidation of their experience as decent and highly empathic people. Dr Blaise Aguirre gives a good lecture on this concern here if you would consider watching it - http://youtu.be/trtt-eiHtXQ

Part of the condition which goes horrendously underreported is that we have heightened empathy. If a clinician/therapist is in denial about this then they will misinterpret it. We also have fantastic insight, not that it enables us to control our brains to regulate our emotions, but we have it nonetheless.

When a patient with BPD is in a room with someone who is a professional, who does not share these empathic and instightful qualities then it is intensely frustrating and I have experienced it myself with my first therapist. The therapist believes they are right and the reason the treatment isn't working is because the patient is trying to elicit some response in them that they believe is unhelpful. It is their professional conceit and not the patients pathology that brings about this dysfunction in the therapeutic relationship.

New methods of treatment such as MBT, TFT and SFT are honing in on this fact and making great strides in effectively and speedily treating BPD. The therapist has to be open minded and willing to listen to what the patient is saying without prejudice. This way there is no need for the patient to bash at the therapists walls of ignorance to demand that their reality be validated.

Now while I gained some benefits from my poorly trained therapist they were slow and painful and when the therapepeutic relationship ended I broke down completely and came the closest I have in my life to suicide. His insistence that I was trying to manipulate him into feeling certain ways made me behave in ways with him that I have never had to with my properly trained SFT therapist or my EMDR therapist.

How I behaved in his room was no comment on my person or indicative of how I behaved outside of treatment with him. What he interpretted as my trying to elicit a response of anxiety, hopelessness and guilt was in actual fact his refusal to accept that his faulty course of treatment was making him feel anxious, hopeless and guilty. His refusal to acknowledge this made me very ill and I daresay he would agree with everything you've written here.

Bingo! You nailed it!

My vote goes to "Danielle Field" for just hitting the nail on the head in understanding BPD and the problems with the therapists that treat them! Finally someone who gets it around here!

And Dr. Allen if someone went so far as to actually try to kill you for your releasing them from the hospital… then maybe the release wasn't such a good idea and you could have shown a little more empathy towards how sick they felt they were if they went so far as to attempt murder…

just saying its usually a good idea that BOTH the patient and the doctor feel comfortable in a patient being released from the hospital… otherwise they might hurt themselves or someone else… and thats what the hospital stay is for.

bingo

Jill,

Yes, of course you're right: I should have asked her what horrors were waiting for her back at home. I know that now; like I said, I almost never get any such problem reactions nowadays.

But you are minimizing the patient's contribution to the problem.

The patient didn't even TRY volunteer ANY information about WHY she wanted to stay, or what she was afraid of. Even if she wasn't certain about it, she could have at least made the effort - but instead, she just acted out.

(I notice you didn't comment about the second patient I mentioned).

Back then, when BPD was quite rare, I had never met anyone, and we weren't trained to expect someone, with no obvious major psychiatric disorder who might WANT to stay in a MENTAL HOSPITAL. Who likes to be in such a place? Thrown in with a bunch of psychotic people? Remember, we knew next to nothing about the condition back then.

With the emphasis by today's CBT therapists on helping patients to suffer with more grace rather than on addressing the family situation that is creating the suffering in the first place, a lot of therapists still know nothing about the condition.

disagree

You're absolutely right about the lack of empathy by many therapists for the conditions that create acting out in patients with BPD. That does not mean, however, that pts with BPD don't act out and make things worse for themselves. As I have stated several times, patients with BPD who do the things I describe in this series of posts really hope that the therapist sees through them.

When I first started out as a therapist, there was NO good information about what creates the condition and no guidelines about how be empathic. That is not the case any more, but many therapists haven't got the message.

I'm sorry if you don't believe this, but retaining empathy was very difficult when, for instance, a patient literally tried to kill me when I told her I was going to discharge her from the hospital. I discussed this and several other such stories in my last book. The very first patient I saw in therapy as a psychiatry resident, back in the heyday of psychoanalysis, spend the first several sessions doing nothing but insulting me for the entire session (She later admitted that she was actually ADMIRING me the whole time she was insulting me, because I didn't throw her out of the office).

Because I now know how to respond to behavior like this, this stuff never happens to me any more. That doesn't mean that patients don't do these kinds of things.

Acting out

Your theory such as it is seems to suggest that even if those with BPD are not "acting out" then we fundamentally have a problem with trying to make people behave in a certain way, consciously or not. Those therapeutic interventions that work effectively and swiftly are those which are going beyond this anachronistic conception of what BPD is and how it manifests. I'm not buying you or this. You may have more success because of your ability to see the who family as dysfunctional and not just the identified patient but you've got a long way to go in terms of overcoming your misconceptions and prejudices.

acting out

Everyone tries to get other people to act in certain ways all the time, not just people with BPD. There's absolutely nothing wrong with that inherently. You seem to be assuming that I am criticizing them.

If their problem isn't with other people, then what IS it with? I know you don't think the problem is just in their heads, but that's the logical conclusion that follows from what you are saying.

This is how it works in SFT

When I am feeling overwhelmed by my emotions it makes people around me feel certain ways. There is no intention on my part to make other people feel anything when I am consumed in this way just as there is not intention on the part of someone in any kind of intense pain to try and make another person feel it. What I need in those situations is patience, understanding and the space to feel what I need to feel without other people slapping their own inaccurate interpretations on what they believe I am trying to make them feel.

Now with Schema Focussed Therapy the therapist recognises when a schema has been activated and, instead of questioning what it is that the patient is trying to make the therapist feel they ask the patient to explain what it is they are feeling. Even though I understand that the intensity of my emotions is incredibly difficult for other people to deal with having a therapeutic relationship with someone who is capable of sitting back and helping me understand what it is I am feeling without interpretting it is invaluable. We are making progress precisely because he doesn't assume he knows what I am feeling.

What you are doing is saying that in your experience of dealing with people who have BPD you recognise what they are trying to make you feel. This kind of therapy is not effective with people who have BPD. Like I said you are probably having some success in terms of validating their experiences in their family life but you harbour anachronistic views about interpretting your patients intentions conscious or otherwise.

Therapy for BPD has to start first and foremost with the therapist helping the patient to be able to express to the therapist what they feel so that the therapist can correctly understand this. In a therapy session I will go through numerous schemas which may look the same and feel the same to an untrained therapist but each one has a distinct character and the more I understand about them the better I can equip my therapist to help me to overcome them.

My therapist is constantly asking me "Have I got this right?" and sometimes he hasn't. We sit with an emotion I am feeling for a whole session sometimes just so that he can accurately understand it. If he was to do what you are doing by assuming that you have a professional position which qualifies you to know above and beyond your BPD patients own experience what it is they are trying to do you will make them ill.

The example of your client who tried to kill you and then went on to kill herself is a particularly prejudiced and blinkered example of your interpretation of "acting out". In what universe is someone being so desperate at your inability to understand or help them with their problems that they are drawn to the conclusion that death is the only answer a good example of a BPD patient acting out? I wanted to kill myself after my therapeutic relationship ended. Your guilt at that experience has significantly coloured your ability to truly see BPD for what it really is.

SFT

I know my patients try - at times - to induce feelings in others because they tell me so themselves. It can be hard for them to deny it after I empathically point out the evidence - which comes entirely from other things they've said themselves during the course of therapy. (I keep track. Thank goodness for notes).

I did not say that everything they ever do is designed for this purpose, nor that they are going for the three reactions I discussed in the post all the time, so please don't accuse me of that. The example you give of being consumed by pain and sitting there quietly may or may not be designed with this purpose. The clue is when they do such things in a highly provocative manner. If you've never done that, great. I believe you.

And of course I check with my patients about ANY hypothesis about them and the way they are feeling that I am entertaining. BTW, the patient who tried to kill me did not go on to suicide. Also, I know the founder of schema therapy, Jeff Young, personally and we are in substantial agreement about far, far more things than those on which we don't completely agree.

Feel free to have the last word on this issue. I've said about all I can say.

You have not considered all I have said and are now provocatively closing down communication

Listen, Dr Allen, I have met people who have BPD who also happen to be provocative people. There having BPD does not determine their being provocative people. I have met people who project all their faults onto other people who also have BPD and similarly I have met people who do not have BPD who do the same. What you are doing here is making a connection between a person's provocative behaviour and their BPD diagnosis and it is this that I am challenging as it feeds stigma and encourages the mob to go round diagnosing provocative behaviour as being indicative of BPD.

When you have a personality disorder everything you do, every human quality you have is reduced to a manifestation of your personality disorder which is intensely invalidating and inhibits recovery. Of course projection, transference, manipulation and provocative behaviour are human qualities, not the nicest ones, but human all the same. When people with BPD exhibit these qualities it is not because they are human but because they are "borderline". Why are you having so much difficulty in recognising this point?

In future when you are discussing negative human qualities in reference to your patients who happen to have a diagnosis of BPD then please, as an experiment, try replacing the word BPD with black person and see for yourself just how provocative your theories are. For example "When dealing with black patients it is important to understand that their provocative behaviour is caused by their unconscious desire to elicit in you a response of hopelessness, anxiety or guilt." I hope now you can see why it is offensive to be constructing theories about the specific nature of provocation as it relates to your patients with a BPD diagnosis.

Provocation is human behaviour. When anybody engages in it they are doing so for specific reasons to elicit a response in the person they are provocating. You did so yourself just now with your "Feel free to have the last word" comment. You made me feel anxious, hopeless and guilty. I almost decided not to respond based on your provocation but after a nights sleep I realised that this issue was too important to allow your manipulative behaviour to control this debate simply because you are attached to believing that people with BPD are peculiarly provocative.

considered

I didn't mean to provoke you, but I've addressed these points in several posts as well as the comments section of those posts, and of course I should not have expected that you'd have read all of them.

Sorry, but ethnicity and personality disorders is not a valid analogy. The definition of a personality disorder: "Personality disorders are characterised by enduring maladaptive PATTERNS of behavior, cognition and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual's culture. These patterns develop early, are inflexible and are associated with significant distress or disability.

"Exhibited across many contexts" does NOT mean ALL contexts. In fact, I know, unlike many therapists, that the behaviors of a person with any p.d. are quite context specific, although to several seemingly different contexts.

I agree with you about "human" qualities. The problem behaviors that characterize BPD are exhibited at one time or another by all of us. That's why I do not think it's a "disease," but an adaptation to a very human family dilemma.

A specifc TYPE of provocative behavior (there are a lot of other types, so "provocativeness" in general is not the issue) is part of the maladaptive behavior that defines the disorder.

Do an anonymous survey of therapists asking about whether or not a large majority of their patients (but not ALL) with BPD exhibit the type of behavior I'm talking about on a frequent basis, and you'll have your answer. I've talked to a LOT of therapists, as well as most of the American academics who study BPD. I've also treated them in very comprehensive, long term therapy where I ask about a lot of areas of their lives that DBT therapists tend to ignore.

Patient's with BPD also characteristically "split" (although they really don't believe that people are all good or all bad, but they often act as if they did). We're talking about behavior, not skin color.

Just as an aside, either of the following is fallacious when it comes to taking responsibilities for one's interpersonal problems: "It's all my fault" and "I had nothing to do with it."

Your profession is responsible for creating the stigma surrounding BPD

And your profession is still propogating that stigma. Only those that listen hear. Those like yourself who still cling to this conception that BPD is more than an emotional regulatory disorder keep the fires of stigma alive.

We are damaged, yes. We have special needs that require specific methods of rearing in order for us to flourish as they highly sensitive and empathic people that we are. We are not like everybody else and those of us that are lucky enough to have exceptional parents go on to become highly sensitive but incredibly strong individuals.

Those of us who are not so lucky experience an incredibly invalidting life. We have no frame of reference for how to express and develop our emotions. What you and others perceive to be pathological tendencies are simply what anyone would experience if they lived a life of intense frustration and invalidation.

You do not get what BPD is. If you did you wouldn't be contributing to stigma the way you are in this article and in the comments here. You're not alone. Perry Hoffman president of the NEABPD propogates stigma herself so why shouldn't you? We need help to learn how to do something that most people never have to learn how to do - to become healthy hypersensitive individuals. You are not a hypersensitive individual.

You're a regular Joe with an ego to match. I don't need to read all your preceding materials if they have done nothing but bring you to the conclusions you've drawn here. Like so many other therapists you are part of the problem, not the solution. I have no need to read another word you have to say on the matter.

Dr. Allen, I so thoroughly

Dr. Allen,

I so thoroughly identify with the many 'do not's' that you have listed. I have a wife the may suffer from BPD- comparing my experiences with her to the information identifying BPD leads me to this finding. I have done many of the do not's and have had no success. Zero! Zilch! And dealing with her has resulted in my becoming someone I do not like. In fact, my own psychologist has advised me to not do certain things; the same things you have listed in your article.

Thank you for reminding me of the foolish things I should have never done.

This is exactly what I am concerned about and why I am so frustrated with what you are doing here Dr Allen

In the anonymous post above we have a person who has a provocative wife that he suspects has BPD based on his analysis of her external behaviour. Now while I have no reason to doubt she is a provocative/argumentative woman I am suspicious about the fact that it is her partner and not herself that suspects she has BPD.

If his wife has BPD she will be experiencing intense emotional pain that she will likely be seeking help for herself. But now that the anonymous poster above has read here that by practicing your list of how best to deal with a provocative person generally and linked that to his suspicion that his wife has BPD you have added fuel to this already dangerous fire.

Like I said before this list of don'ts that you have posted here is relevant to anyone dealing with a provocative person and are not in anyway specific to dealing with a person who suffers from BPD. If you continue to post articles focusing on negative human qualities which exist across the entire human population and link them specifically to people with BPD who happen to share these human traits you will be adding to the stigma surrounding the disorder.

exactly

Sorry, but I do not agree with you.

more effective advice please

sorry but I don't see how it is effective to post what "not to do" over what "to do"… it is much more helpful to post your theory of what to do then perhaps you wouldn't have to backtrack and "clarify" yourself on what you didn't mean so much

less drama more substance ...

more effective

Hi anonymous- this is the second in a series of posts. The next post in the series will be the first of several that will offer advice on what TO do when provoked in certain ways.

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David M. Allen, M.D., is a Professor of Psychiatry at the University of Tennessee and author of the book How Dysfunctional Families Spur Mental Disorders.

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