A funeral. A conference of death. Sixteen sit at a rectangle of tables placed side by side, and look into the rectangle’s centre as if it were an open coffin. And though sixteen human beings sit cramped together, each remains alone. There exists a general air that ‘I cannot be helped’. After all, some here have been surviving life, quite literally, for forty or more years, and have lost all faith in the medical profession.
Tattoos. Embroidered jumpers. Red lips, black lips, mascara. Occasional smiles met with nervous gazes. The group members sit within themselves, silent, as the course leader introduces herself as Brenda. Folders to contain the worksheets for the next twenty weeks of group therapy are passed around by two other psychiatric nurses as Brenda introduces STEPPS.
The Systems Training for Emotional Predictability and Problem Solving was developed by the American psychiatrist, Nancee Blum. The program educates group members about their diagnosis of Borderline Personality Disorder (BPD), known as Emotionally Unstable Personality Disorder in Europe. For two hours each week, the group will meet and learn about how traumatic pasts have created in our minds ‘negative filters’, which distort our way of feeling and thinking, leading to behaviour that breaks relationships or causes personal harm. The STEPPS program promises, through the teaching of skills, that the influence of these filters can be challenged, and in their place positive filters constructed that will help regulate our emotions, increase positive thinking, and ultimately bring joy back to our lives. The first of such skills is Awareness.
What is BPD? Through 8 pages of lengthy analogies, personal accounts and descriptions, read aloud by group members each in turn, BPD is described as an illness that makes our emotions:
So, a BPD sufferer, feeling stressed, might send a text to a friend. The friend does not respond, and their failure to respond is seen through a negative filter, triggering feelings of abandonment. Once again, they know deep in their heart that no one can be trusted. For two days the emotions rage and they attempt to ease the storm with a quick slash of the their shins, later hidden from the public eye by the wearing of trousers. And even after their friend texts them to say they had their purse stolen, with phone, credit cards and car keys, the BPD sufferer cannot return to baseline. Paranoia sets in. Their friend is obviously lying.
What is BPD? Through 8 pages of lengthy analogies, personal accounts and descriptions, read aloud by group members each in turn, BPD is described as an illness that makes our emotions:
- Highly sensitive and easily triggered
- Intense when triggered
- Slow to return to baseline once triggered.
So, a BPD sufferer, feeling stressed, might send a text to a friend. The friend does not respond, and their failure to respond is seen through a negative filter, triggering feelings of abandonment. Once again, they know deep in their heart that no one can be trusted. For two days the emotions rage and they attempt to ease the storm with a quick slash of the their shins, later hidden from the public eye by the wearing of trousers. And even after their friend texts them to say they had their purse stolen, with phone, credit cards and car keys, the BPD sufferer cannot return to baseline. Paranoia sets in. Their friend is obviously lying.
After a tea and cigarette break, Brenda reads aloud the traits associated with the condition, according to the Diagnostic and Statistical Manual, Fourth Edition, otherwise known as DSM-4. But why DSM-4? Published in 2000, the manual has since been replaced by DSM-5 (2013). Presumably, my own diagnosis in August 2018, and those sitting around the table, was based on the DSM-5 criteria for BPD? I begin to question the STEPPS program. Why hasn’t it been updated?
DSM-5 frames those diagnosed with BPD as being mentally chained by a mix of symptoms associated with:
Some sufferers have identity problems, and are not sure who they are, or feel that they change in personality from one minute to the next, becoming social chameleons who change their personalities in response to the social situation. Such individuals may be aimless, having no idea how to answer, Where should I go? What should I do? Who should I be? Others may feel empty, devoid of any sort of character, and live in a flat world without joy or colour, where life goes on without involving them. Like robots they live, adopting the appropriate mask according to the social situation. And if the mask is an ill fit, and their words or actions are misinterpreted by those around them, the sufferer spends days slicing themselves with self-criticism while over-analysing everything they’ve previously said and done.
Relationships can fail if the BPD sufferer has problems with empathy or intimacy. At times, but not at all times, some might not be able to understand the needs of others, and feel slighted or insulted if their friend, relative or partner does not respond in a way they think they should. Due to potential abnormalities in their brain, they tend to remember past events negatively, and misread the smiles and laughter of friends as grimaces and contempt. ‘Everyone can see right through me, into me. They know I am bad. I can’t stand being with people. I never do or say the right thing.’ The sufferer, though craving companionship, might isolate themselves, and become shipwrecked and alone on the barren island of their heart.
If intimacy is the problem, an individual diagnosed with BPD may jump headfirst from one intimate relationship to the next, giving of themselves completely, and needing completely. But the partner, unused to such intensive need, step back. The one with BPD fears, ‘They are going to leave me. They are leaving me!’ The constant anxiety becomes mistrust, and the one, the only one on Earth who might love them, doesn’t love them anymore. ‘What a fool I was to think they were so great, so wonderful, the love of my life. Really, they were manipulating my feelings all along. What did they want? Money? Sex? Am I just an object to them? Did they think I have savings hidden away?’
Time moves on. The partner tries to reassure someone who is always nervous, always tense, ever-ruminating on the bad things that have happened, ever-fearful of the bad things that could happen. Eventually, the severe mood swings, with intense outbursts triggered by the littlest things, like a child wailing after it has dropped its ice scream, drag them down. The partner leaves, or the one afflicted with BPD subconsciously forces them to leave. The sense of abandonment grows.
When a new partner arrives, and the BPD sufferer tries again, despite believing, ‘They are going to leave me. They always leave me. Nobody ever stays. I have to do what they say else they will leave me. But, if I control them, they can’t.’ In some relationships the individual with BPD becomes submissive to the needs of their partner. They subjugate themselves, as would a slave. People may take advantage of this, and the they becomes the victim of further emotional, physical or sexual abuse. In other relationships, the one with BPD tries to become the slave master, their jealousy and possessiveness eroding the self will of their partner. Their fears drive them to cage the one they feel they love so intently.
Life goes on. Nothing seems to work. Friendships fail. Jobs lost. Lovers leave. ‘It must be me. I feel so ashamed for the way I think and feel. There is something wrong with me. I’m no good, and don’t do anything right. Everybody is better than me.’ According to DSM-5, these whirlwind thoughts and volcano emotions drain the BPD sufferer of light and energy, leaving only the shadow of depression, pessimism about the future, and inevitably, thoughts about suicide that never let you go. And why not suicide? Life is too tiring. The future is barren, bleak. And there are so many more symptoms associated with BPD to endure.
DSM-5 list other symptoms that must be present for the diagnosis of BPD to be given. Those with BPD generally experience persistent anger, Hulk anger. They also act impulsively, perhaps in response to what someone said, or if psychotic, what they imagine someone has said. The response has no plan, just happens, and even if there was one, it would never be followed. Impulsive behaviour might then lead to excessive risk taking that ignores a sufferer’s own limitations, potentially placing them in terminal danger. Imagine being angry, impulsive, without control, responding to something real or imagined. Where would you end up? How fast would you drive your car? Don’t those waves, crashing on the rocks below, seem inviting?
DSM-5 frames those diagnosed with BPD as being mentally chained by a mix of symptoms associated with:
- Personality - Problems with self identity and self direction
- Relationships - Problems with empathy, intimacy and anger
- Negative Emotions - Being emotional unstable, depressed, anxious and suffering from separation insecurity.
- Loss of Inhibition - Exhibiting risky, impulsive, erratic and extreme behaviour.
- Psychotic Symptoms - Suffering from paranoia, hallucinations and delusions
Some sufferers have identity problems, and are not sure who they are, or feel that they change in personality from one minute to the next, becoming social chameleons who change their personalities in response to the social situation. Such individuals may be aimless, having no idea how to answer, Where should I go? What should I do? Who should I be? Others may feel empty, devoid of any sort of character, and live in a flat world without joy or colour, where life goes on without involving them. Like robots they live, adopting the appropriate mask according to the social situation. And if the mask is an ill fit, and their words or actions are misinterpreted by those around them, the sufferer spends days slicing themselves with self-criticism while over-analysing everything they’ve previously said and done.
Relationships can fail if the BPD sufferer has problems with empathy or intimacy. At times, but not at all times, some might not be able to understand the needs of others, and feel slighted or insulted if their friend, relative or partner does not respond in a way they think they should. Due to potential abnormalities in their brain, they tend to remember past events negatively, and misread the smiles and laughter of friends as grimaces and contempt. ‘Everyone can see right through me, into me. They know I am bad. I can’t stand being with people. I never do or say the right thing.’ The sufferer, though craving companionship, might isolate themselves, and become shipwrecked and alone on the barren island of their heart.
If intimacy is the problem, an individual diagnosed with BPD may jump headfirst from one intimate relationship to the next, giving of themselves completely, and needing completely. But the partner, unused to such intensive need, step back. The one with BPD fears, ‘They are going to leave me. They are leaving me!’ The constant anxiety becomes mistrust, and the one, the only one on Earth who might love them, doesn’t love them anymore. ‘What a fool I was to think they were so great, so wonderful, the love of my life. Really, they were manipulating my feelings all along. What did they want? Money? Sex? Am I just an object to them? Did they think I have savings hidden away?’
Time moves on. The partner tries to reassure someone who is always nervous, always tense, ever-ruminating on the bad things that have happened, ever-fearful of the bad things that could happen. Eventually, the severe mood swings, with intense outbursts triggered by the littlest things, like a child wailing after it has dropped its ice scream, drag them down. The partner leaves, or the one afflicted with BPD subconsciously forces them to leave. The sense of abandonment grows.
When a new partner arrives, and the BPD sufferer tries again, despite believing, ‘They are going to leave me. They always leave me. Nobody ever stays. I have to do what they say else they will leave me. But, if I control them, they can’t.’ In some relationships the individual with BPD becomes submissive to the needs of their partner. They subjugate themselves, as would a slave. People may take advantage of this, and the they becomes the victim of further emotional, physical or sexual abuse. In other relationships, the one with BPD tries to become the slave master, their jealousy and possessiveness eroding the self will of their partner. Their fears drive them to cage the one they feel they love so intently.
Life goes on. Nothing seems to work. Friendships fail. Jobs lost. Lovers leave. ‘It must be me. I feel so ashamed for the way I think and feel. There is something wrong with me. I’m no good, and don’t do anything right. Everybody is better than me.’ According to DSM-5, these whirlwind thoughts and volcano emotions drain the BPD sufferer of light and energy, leaving only the shadow of depression, pessimism about the future, and inevitably, thoughts about suicide that never let you go. And why not suicide? Life is too tiring. The future is barren, bleak. And there are so many more symptoms associated with BPD to endure.
DSM-5 list other symptoms that must be present for the diagnosis of BPD to be given. Those with BPD generally experience persistent anger, Hulk anger. They also act impulsively, perhaps in response to what someone said, or if psychotic, what they imagine someone has said. The response has no plan, just happens, and even if there was one, it would never be followed. Impulsive behaviour might then lead to excessive risk taking that ignores a sufferer’s own limitations, potentially placing them in terminal danger. Imagine being angry, impulsive, without control, responding to something real or imagined. Where would you end up? How fast would you drive your car? Don’t those waves, crashing on the rocks below, seem inviting?
But the DSM-5 criteria, as numerous as they are, do not paint the complete picture. The term Borderline Personality Disorder was originally coined to describe those whose experiences sit somewhere between neurosis and psychosis. DSM-5, and the STEPPS program, seems to place more weight on the neurosis side (depression, anxiety, obsessive behaviour, hypochondria, etc) than on psychotic symptoms, such as hearing voices, seeing and sending things that are not there, or believing the one you married is secretly trying to kill you. According to one academic paper, psychotic symptoms in BPD are more varied and frequent than what DSM-5 criteria suggests. Paranoia, hallucinations and delusions are often experienced by those with BPD, leading to the misdiagnosis of schizophrenia or some other primary psychotic disorder. Unhelpful, or even harmful pharmacological (drug) treatments might be prescribed, while helpful therapies, such as Dialectic Behaviour Therapy, may not be offered. Misdiagnosis is common with BPD, and patients can receive the wrong treatment for years before BPD is considered. Yet, diagnosis can be difficult, especially as those diagnosed with BPD can also suffer schizophrenia, major depressive disorder, substance use disorder, post traumatic stress disorder, anxiety, and eating disorders at the same time. Other research suggests that bipolar disorder and other mood disorders can also be added to the list.
Brenda starts packing away. Group members leave individually, independently, without a word. For me, the STEPPS program seems geared towards the management of the dysfunctional personality side of BPD. But I’ve already done several years of mindfulness and psychodynamic therapy. How can STEPPS help with the psychotic symptoms? How can it prevent those I love from leaving me? Will my girlfriend leave me? My time in the forest (STEPPS 1) was not enough. Need more time to calm myself and see the world as it is. . . .
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