The BPD world rocked today. If you didn't see the article in the New York Times, you can find it here. Marsha Linehan of the University of Washington and founder of Dialectical Behavior Therapy "came out" as a borderline disorder sufferer herself.

 In the article, titled Expert on Mental Illness Reveals Her Own Fight, Linehan says: 

"[Once she recovered and became a clinician] I decided to [study] supersuicidal people, the very worst cases, because I figured these are the most miserable people in the world -- they think they're evil, that they're bad, bad, bad---and I understood that they weren't," she said. "I understood their suffering because I'd been there, in hell, with no idea how to get out."

In particular she chose to treat people with a diagnosis that she would have given her young self: borderline personality disorder, a poorly understood condition characterized by neediness, outbursts and self-destructive urges, often leading to cutting or burning. In therapy, borderline patients can be terrors--manipulative, hostile, sometimes ominously mute, and notorious for storming out threatening suicide.

Dr. Linehan found that the tension of acceptance could at least keep people in the room: patients accept who they are, that they feel the mental squalls of rage, emptiness and anxiety far more intensely than most people do. In turn, the therapist accepts that given all this, cutting, burning and suicide attempts make some sense.

In that passage, Dr. Linehan decribes the "conventional" type of BP few non-BPs in family member communities would recognize: those who willingly go into treatment and are self-destructive. Over the last 15 years, thousands of family members on Welcome to Oz and other online communities have told of their struggles with people who are the exact opposite of that described by Dr. Linehan.

I call these higher-functioning, acting out BPs the "invisible BP" because they are invisible to the mental health profession (but not to everyone else). They may be miserable somewhere in their souls, but to most people they come off as very charming people who have friends and do well at their job.

 In private, however, they make family members miserable by their intense and pervasive blaming, false accusations, irrational jealously, and verbal and emotional abuse (such as calling people horrible names and cutting them down in hostile ways). They project all that misery onto others and, perhaps, make them feel as bad inside as they themselves do.

These tactics work all too well. Where there was one miserable yet high functioning person, now there are two or more miserable people with at least one showing signs of post traumatic stress disorder.

And there's something else.

By coincidence, yesterday I received a book in the mail called, Loving Someone with Borderline Personality Disorder by Shari Manning. Manning takes Linehan's DBT techniques and shows family members how to use them when communicating with their BPD family member.

One section caught my eye that turned the BPD world I live in upside down. When I read it, I actually laughed. Here it is, in part. 

"It Was All My Fault," (said Laura, a person with BPD)

Laura had been sobbing for hours, begging her husband Steve to understand that her sadness was out of control. She wanted him to do something--anything--to make the pain stop. ..."I shouldn't be feeling this way at all, and now I'm hurting you, the person I love most....I'm a terrible person and I don't deserve to have you.." ...[the author continues] People with BPD often have times when they beat themselves up, insisting the are worthless, undeserving, and inept.

This is true--for a smaller subset of those with BPD. They're called "consumers" because they "consume" mental health services. In other words, by definition, they are treatment seeking.

If you have read any of my books based on the experiences of hundreds of family members (especially partners) you know that your situation is completely the opposite. the non-BPs family member gets all the blame--and I mean ALL the blame--and is accused of being worthless in language I can't use here. Sometimes these BPs show flashes of insight, but often not enough to save the relationship.

I've been dealing with this "great divide" for many years: the one clinicians write and talk about and the ones my family members experience. And I'm getting more and more frustrating that people in the clinical community either really don't see or chose to ignore (and invalidate) the aptly-named "invisible" BP and their family members. In my experience, some are more concerned about terminology than the suffering of thousands of people, non-BPs and BPs alike. That's a strong thing to say, but someone needs to say it, and I guess that's me.   

In fact, my belief is that the higher-functioning, blaming BPs are the rule and those in therapy are the smaller subset. A recent study showed that the incidence of BPD is nearly triple the 2% statistic in the DSM-IV-TR. Where did all these extra people come from? Not from the hospitals. From the community.

I believe that a certain percentage of these blamers have comorbid NPD because they fit so many of the NPD criteria. NPs have no awareness of their problem and don't seek treatment. They criticize others for being less superior. Studies have found that about 35% of people with BPD also have NPD (and people with NPD also have BPD).

But many of the "invisible" BPs show no signs of NPD.

In some ways, it's nice to have a publishing niche that no one else has. But on the other, it is terribly sad to see there's almost no recognition (let alone help) for "invisible" BPs and their family members. I donj't know what it will take to change it. There is barely enough research money now, and what's the point of developing resources for people who don't seek treatment? Right?

I urge family members of invisible BPs to keep letting the clinicial community they exit, and that they need help too.


Like everyone else, I feel proud of Dr. Linehan for making this announcement. I should have mentioned that at the beginning of this blog post, even though I used it as a springboard to discuss a larger issue. The mental health system must have a way to treat such a large and needy population. And to that end Dr. Linehan has (as I think it is obvious) been probably the most important person in advocating for their needs (not to mention developing an effective treatment written about the world over). She and John Gunderson, M.D. are probably the mother and father of the classification and treatment of this disorder.

I will leave it up to others who are much closer to Dr. Linehan and the DBT community to write more about her announcement, since I am not an expert in that area. My purpose in this post wasn't to talk about her but the population she represents, and those she does not represent. We've gone far in giving visibility to one subgroup of the borderline population. We have a very long way to go to make the "invisible" group not invisible anymore.

For anyone interested in listening to an expert's take on the BPD classification I mentioned, I recommend listening to this audiotape from the National Education Alliance for Borderline Personality Disorder Go to MAY 2009
NEA-BPD Call-in Telephone Hour with Dr. Robert Friedel.

It is by Dr. Robert Friedel, Distinguished Clinical Professor of Psychiatry at Virginia Commonwealth University, and Professor Emeritus at the University of Alabama at Birmingham. He received his undergraduate and medical degrees from Duke University, and completed an internship in internal medicine and a residency in psychiatry at Duke. He served for two years as a research fellow at the National Institute of Mental Health in Bethesda, Maryland.

We differ in that he believes the "invisible" BP is the subset rather than the "conventional" kind. But he reviewed and approved of my categories.

Previously, Dr. Friedel was Heman E. Drummond Professor and Chair of the Department of Psychiatry and Behavioral Neurobiology at the University of Alabama at Birmingham. He has also served as chair of the departments of psychiatry at Virginia Commonwealth University and the University of Michigan, and Executive Director of the Mental Health Research Institute at the University of Michigan. Dr. Friedel has worked in the private sector as Senior Vice President, Physician-in-Chief, Director of Research and as a member of the Board of Directors of Charter Medical Corporation.

Dr. Friedel's research interests have focused, in part, on developing effective pharmacological treatments for patients with borderline personality disorder, and on identifying biological defects in patients with this disorder. He has founded Borderline Personality Disorder Clinics at UAB and at MCV/VCU, and now directs the MCV/VCU Clinic. In 2004, Dr. Friedel published a book for patients with borderline disorder, their families and mental health professionals titled Borderline Personality Disorder Demystified.

Dr. Friedel serves on the Scientific Advisory Board of the National Education Alliance for Borderline Personality Disorder, and was named a Psychiatrist of the Year in 2007 by the National Alliance on Mental Illness (NAMI). He is co-editor-in-chief of Current Psychiatry Reports, and is on the editorial board of the Journal of Clinical Psychopharmacology. He is a member of Alpha Omega Alpha Honor Medical Society and a number of other professional and scientific organizations. Dr. Friedel has published over 100 scientific articles, book chapters and books, and is listed in Who's Who in Medicine and Healthcare and in Who's Who in America.

UPDATE 6/24/11

To read more about Dr. Linehan's announcment, go to

UPDATE 6/26/11

Following is more information about the categories mentioned in this article.

The types are lower-functioning conventional, higher-functioning invisible, and combination.

Characteristics of lower-functioning, "conventional" BPs:

1. They cope with pain mostly through self-destructive behaviors such as self-injury and suicidality. The term for this is "acting in."

2. They acknowledge they have problems and seek help from the mental health system, often desperately. Some are hospitalized for their own safety.

3. They have a difficult time with daily functioning and may even be on government disability. This is called low functioning.

4. If they have overlapping, or co-occurring, disorders, such as an eating disorder or substance abuse, the disorder is severe enough to require professional treatment.

5. [PC2] Family members' greatest challenges include finding appropriate treatment, handling crises (especially suicide attempts), feelings of guilt, and the financial burden of treatment. Parents fear their child won't be able to live independently.

Because lower-functioning conventional BPs seek mental health services, unlike the higher-functioning invisible BPs we'll talk about next, they are subjects of research studies about BPD, including those about treatment.

Higher-functioning, invisible BPs:

1. They strongly disavow having any problems, even tiny ones. Relationship difficulties, they say, are everyone else's fault. If family members suggest they may have BPD, they almost always accuse the other person of having it instead.

2. They refuse to seek help unless someone threatens to end the relationship. If they do go to counseling, they usually don't intend to work on their own issues. In couple's therapy, their goal is often to convince the therapist that they are being victimized.

3. They cope with their pain by raging outward, blaming and accusing family members for real or imagined problems.

4. They hide their low self-esteem behind a brash, confident pose that masks their inner turmoil. They usually function quite well at work and only display aggressive behavior toward those close to them. Family members say these people bring to mind Dr. Jekyll and Mr. Hyde.

5. If they also have other mental disorders, they're ones that also allow for high functioning, such as narcissistic personality disorder (NPD).

6. Family members' greatest challenges include coping with verbal, emotional, and sometimes physical abuse; trying to convince the BP to get treatment; worrying about the effects of BPD behaviors on their other children; quietly losing their confidence and self-esteem; and trying-and failing-to set limits. By far, the majority of Welcome to Oz (WTO) members have a borderline partner.

BPs with overlapping characteristics:

Many BPs (perhaps a majority) possess characteristics of both lower-functioning conventional BPs and higher--functioning invisible BPs. Get Me Out of Here author Rachel Reiland is typical of a BP with overlapping characteristics. When she insinuated she was going to shoot herself, her psychiatrist admitted her to a psychiatric hospital. Yet she held a job as a full-time mother and was active in church. Although she acted out toward her husband and psychiatrist, she was able to appear non-disordered toward most people outside her family.

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