Valerie Porr, M.A. understands intimately the ramifications of a family member suffering from borderline personality disorder (BPD). It was this experience and curiosity that led her to attend a lecture by Marsha Linehan, PhD, creator of Dialectical Behavior Therapy (DBT), an empirically proven treatment for sufferers of BPD. Consequently, Porr set up a conference to introduce Dr. Linehan and DBT to New York professionals and as a result, the first national organization to focus exclusively on BPD — known as the Treatment and Research Advancements National Associations for Personality Disorders (TARA NAPD) was formed.
Porr then wrote this book, which encompasses her investigation and research into the family experience of loving a member suffering from BPD. It teaches DBT skills training and mentalization, a highly useful treatment for families who want to learn how to decrease collective stress, increase effective communication, rebuild trust, introduce better-coping methods, process and debrief argument aftermaths and reduce challenging conduct that maintains BPD actions and behaviours. The purpose of this book is to feel, deal, heal and change the family system in a holistic manner, focusing on all members rather than the individual sufferer. It is not about blaming the “victim” and it gives much hope that transformation and reconciliation are possible.
BPD does not have many fine moments in history. Think Glenn Close in Fatal Attraction, Winona Ryder in Girl, Interrupted, Jessica Walter in Play Misty for Me and Robert De Niro in Raging Bull to name but a few. BPD is characterized by mood instability, efforts to avoid real or imagined abandonment, black-and-white thinking, idealization and devaluation of significant others, splitting into good and bad, impulsive behaviour, a history of unstable relationships, a distorted and wavering sense of identity and image with chronic feelings of emptiness, a tendency toward paranoia, self-harm and suicide ideation as well as completed suicide in 10% of people diagnosed. Borderline personality disorder is like emotional dyslexia because there is a disconnection between actual words spoken and interpretation of these words. It is these conversations and behaviours that undermine relationships with family, friends and colleagues and generally make life a misery for the sufferer and their loved ones.
While there have been many clinical and technical books written by professionals for professionals about BPD, recently there has been an influx of books written specifically for family members who need specific tools and strategies to help cope with these distorted and disturbing behaviours. A good book for a layperson about a psychiatric condition needs to be simply but elegantly written with minimal use of technical words, terms and psychobabble, resonate fully and responsibly with the reader, be helpful and hopeful and above all capture and engage the heart. Porr’s text fulfills those criteria superbly with some very unique and creative metaphors. The book demystifies a syndrome that is believed to affect nearly six out of 100 people, and it is both thorough and comprehensive.
Porr states, “As many as 5.9% of the general population meet the criteria for BPD. Professionals do not talk much about this disorder on TV, your friends may not believe it exists; even Oprah does not discuss it. There is no poster person for BPD rallying support [and] no telethon to help raise money.” It goes on to say that “Many people with BPD are able to control their behaviour in public situations or among strangers. They have the ability to appear calm and competent to outsiders, to act “as if” they are “okay;” but they seem unable to maintain this behaviour within intimate relationships, with partners or close family members.” This is frustrating for family members who feel they will be disbelieved and closed down by others if they mention this discrepancy.
This is also why a family approach is needed. There is a whole chapter devoted to BPD sufferers’ siblings and how these people have been neglected by the mental health community. The BPD sufferer absorbs so much of the family’s emotional and physical attention and concern that the siblings’ needs and achievements are overlooked. Siblings, spouses and other members are more likely to have an empathic approach if they understand the genetic component and neurological structures involved in BPD.
The section on the science of BPD discusses how changing the brain can change the behaviour. This chapter states that “The scientific findings brought together here will help you reframe BPD as a mental disorder with real, tangible biological underpinnings rather than a “character flaw” or a matter of “bad” personality.”
DBT is considered the treatment with the most randomly controlled clinical trials showing its effectiveness. One small quibble, I feel, is that the DBT process itself can be somewhat directive, rigid and inflexible which, ironically enough, are the very same disturbing traits one is trying to eliminate in BPD itself. It is stated by Marsha Linehan that “If your patient isn’t better in a year, you should find another therapist for your patient.” She also states that it is the therapy that is 100% effective and that it is the therapist who is failing the patient. My thoughts are that any therapy that claims such a high success rate needs to have long term follow-up (2, 5, 10 or 20 years) to see if that success has any subsequent longevity.
The last section deals with mentalization and understanding interpersonal misunderstandings. Mentalization Based Therapy treatment for BPD, developed in England by Anthony Bateman and Peter Fonagy, is evidence-based and a reasonably new method of treatment for BPD. Peter Fonagy is a prominent contemporary psychoanalyst and clinical psychologist and his clinical interests center on issues of borderline psychopathology, violence and early attachment relationships. He has also written extensively on attachment theory and psychoanalysis.
If DBT focuses on controlling emotions and changing behaviour, MBT focuses more on understanding the misunderstandings that occur in relationships by changing perceptions, interpersonal situations and experiences. Mentalization is defined as making use of mental representations of one’s own and another’s emotional state. Lack of effective parenting can leave children unable to modulate and interpret their own feelings, as well as those of others. It explores the separation and merging of the minds of two people in a significant relationship and how they perceive each other. It focuses on awareness and acknowledgement, explores alternative interpretations and intentions from both points of view.
The chapter explains that an inability or failure to mentalize seems to be at the core of BPD. It deals with helping the non-BPD family members with the BPD sufferer and gives much accurate and detailed explanation on how to take the high road in order to make a difference; on being supportive, empathic and compassionate, how to ask lots of questions, be a detective, to listen, observe and validate, to be humble, to take responsibility and if necessary apologize, be consistent, do not get sidetracked, be careful of the use of language, do not be dogmatic and inflexible, always label feelings, find alternative perspectives, be vulnerable, radically honest and authentic.
I found this book managed to encompass the entire family experience, offered much supportive and constructive advice, demystified effective evidenced-based therapy and gave not just hope and reassurance but concrete and anecdotal evidence that there is a cure for a personality disorder once considered untreatable. It was riveting to read and easy to understand. It placed familial love, compassion, respect and empathy as the secret ingredients to complete the therapeutic recipe, important ingredients which were lacking from so many previous modalities and treatments.