Borderline personality disorder and trust
A conversation with Dorde Radosavljevic
On October 24, 2018, I was smoking and shivering outside of the Centre for Addiction and Mental Health on College Street in Toronto. I had just finished my first DBT skills group. The group, rooted in Marsha M. Linehan’s work around dialectical behavioural therapy (DBT), is intended for people suffering from borderline personality disorder (BPD).
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), BPD is a, “pervasive pattern of instability in interpersonal relationships, self-image, and emotion, as well as marked impulsivity beginning by early adulthood and present in a variety of contexts.” BPD is signalled by five (or more) of the following symptoms:
Chronic feelings of emptiness.
Frantic efforts to avoid abandonment (real or perceived).
Identity disturbance with persistently unstable self-image or sense of self.
Impulsive and harmful behaviours such as problematic use of substances, overeating, gambling, or high-risk sexual behaviour.
Intense but short-lived bouts of anger, depression, or anxiety.
Pattern of unstable and intense interpersonal relationships characterized by extremes between idealization and devaluation.
Recurrent suicidal behaviour, gestures, or threats, or self-harming behaviour.
Transient, stress-related paranoid ideation, or severe dissociative symptoms.
As Linehan explains: “People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” BPD also has among the highest rates of suicide in personality disorders. According to information compiled by the Centre for Suicide Prevention in Canada, up to ten per cent of patients with BPD will die by suicide.
Needless to say, my first group session was very intense. Gathered in a tiny meeting room, with 12 or so other strangers whose emotions had the force of a magnitude 10.0 earthquake on the Richter Scale, I could feel the fear, anxiety, hostility, and hopelessness thick in the recycled hospital air. But, for as many perceived deficiencies those with BPD are meant to have, those with the disorder also have many gifts. People with BPD can be charming, gregarious, keenly intelligent, and fiercely funny. There was one person in that first group session who embodied these qualities with ease and provided much-needed tension relief in a room that was a literal vortex of emotions. That same person smiled and chatted with me as I smoked outside following the first session. That person was Dorde Radosavljevic.
Over the course of the three-month treatment, Dorde (or George, as he went by in group) and I became fast friends. When the group ended, we decided to stay in touch (in addition to a few others from the group) to help each other navigate the ups and downs of living with BPD. Our impromptu support group became an important resource in navigating crises, sharing gallows humour, and lamenting the state of the Canadian mental health care system.
While many of us in the impromptu support group have plenty of experience living with BPD, Dorde is the only one of us studying the disorder. A student at York University’s clinical psychology program during our time in group therapy, Dorde won the The Louise Biely Yolles Scholarship, the Dean’s International Student Award for Academic Excellence, and, for his thesis project, wrote the paper, Interpersonal Affective Dysregulation In BPD Patients: The Effects of Distress and Loneliness On Attachment Activation Patterns. He’s currently pursuing graduate studies on the subject.
As a result, Dorde and I have shared hours of insightful and illuminating conversations about all things related to BPD and I really wanted to interview him about his research. Since we’re a part of each other’s social bubbles, on October 22, I headed to his top-floor apartment in Corktown (which he shares with another member he met in the DBT skills group, Steph) for a freewheeling chat about BPD, trust, and parenting.
Can you tell me a bit about your personal and professional relationship with BPD?
Dorde Radosavljevic: I was diagnosed with BPD maybe four years ago. When that happened, it was very confusing. There was little information, and the information I found was extremely negative: everything is unstable, people with BPD are extremely chaotic, they’re extremely emotional, they manipulate, they ruin relationships, and it’s suffering all around.
I decided to make a point to go into it with my grad studies and do my PhD on the subject because from my personal experience of having BPD, there are many ways we can help prevent it and treat it. At its root, BPD can probably be prevented from even coming out.
What’s interesting to me is research that shows a link between trauma and BPD. Trauma is something that you can heal from. Therefore, professionals should be able to heal—maybe not BPD entirely—but components of BPD. With a personality disorder that’s based in trauma, should there not be more of an effort to heal the affected? What’s with the dearth of treatment? Is it the stigma of personality disorders? I think every personality disorder comes with its own distinct stigma, but people with BPD could probably be described as high maintenance patients—
DR: And that’s exactly what I was going to say. There’s some hesitation by psychiatrists and psychologists to take on or go further with patients with BPD because they tend to be described as extremely high maintenance. My own professor, a clinical psychologist, told me stories about a 12-year-old patient who would call her at 4 a.m. just to ask her if she was upset about something she said during their session. There’s a certain line of personal boundaries you can’t cross where you have to be the therapist as opposed to the caretaker and this is where that issue with BPD comes in. That caretaking role is where most of our symptoms spawn.
I think trauma and BPD are comorbid so often because of the intensity and instability of the emotions of people with BPD. Events that wouldn’t necessarily be traumatic for anyone else are traumatic for us. Being broken up with may feel like a loved one just passed away, for example. I think it’s that intensity that leaves those traumatic neurons connected in our brains because this is just how strongly we feel. That’s the essence of trauma. The intensity and the feeling is what burns into your head.
Talk to me about the relationship between unstable attachment parenting styles and BPD.
Generally, for attachment styles, there are stable organized styles and then two or three different disorganized or unstable attachment styles. Most of what studies have found is that a very large number of people with BPD—maybe 85 per cent—have unstable and disorganized attachment styles with their caregivers. BPD in itself—it does have a biological basis, as does every disorder—without this addition of the attachment style it wouldn’t necessarily be exposed and the BPD would not really come out. The big issue with disorganized attachment styles is parents don’t know how to respond to their baby’s reactions and while, all with good intentions, they’re not having the back-and-forth of validating specific emotions.
For example, if one time you’re crying and your Mom hugs you and the next time you’re crying and she locks you in your room because maybe she’s on the phone, you start not trusting your own emotions and not trusting your parents or caregivers. When you’re in distress, initially your idea is, “I want care from this person, but I don’t know if this person will give it to me or not.” It’s the same thing with trauma.
Because of those invalidating parenting styles people with BPD never learn how to control and integrate their emotions so they are always at an extreme, almost pubescent level. People with BPD learn not to trust their emotions and they learn not to trust those that are closest to them when they are in distress.
It’s interesting you brought up the pubescent example because whenever I’ve been asked to describe BPD to someone who doesn’t know what it is, I describe it as an extended puberty. It’s like you still feel all the same emotions with the same strength you had as a teenager, it just never ends.
Going back to parenting styles, that’s definitely an interpersonal relationship. Can you speak more to the general relationship between BPD and interpersonal relationships?
Generally, I find because of the way people with BPD learn to attach, they tend to continuously crave and seek some kind of attention from a specific designated caregiver—somebody in their life they will pick who suddenly has this role, even subconsciously.
Interpersonal relationships are the most unstable aspect of BPD because our symptoms had some kind of function when we were younger in these dysfunctional relationships with our parents. This distrust was very warranted because, for example, you don’t want to go in and hug your dad and have him slap you out of nowhere because he had a bad day at work. But now, when we’re trying to maneuver in a functional environment when we’re grown-ups with people who have secure attachment styles, all these dysfunctional behaviours and symptoms no longer work. People with BPD don’t understand how these people function because we were never modelled this. Our brains are very connected to this idea of what our emotions are telling us. We become these emotions. People without BPD also completely misunderstand where we’re coming from. We do come off as needy, manipulative, intense. We don’t come off as somebody who just wants or needs to be soothed or taken care of.
When others want to be soothed they ask for help… They don’t say, “Do you still love me?” or yell or manipulate to test the love of somebody. Generally, if you have any kind of need or emotion there’s the action that relieves that and the immediate urge to change it in some way. Because people with BPD’s emotions are so mixed up, we don’t do the action corresponds with the emotion. Then our partner reacts in a way “normal” people would react in. For example, when you yell, they would yell back. They wouldn’t think you’re sad so then when your partner yells back, your ideas from when you’re younger are affirmed. It’s just a circle that keeps going.
One of the more frustrating aspects of BPD, for me anyway, is this misperception around my intentions… I think people with BPD can come off as manipulative or over-eager or not respectful of boundaries. When you have this inability to be direct about your emotions because you’ve been taught it’s not safe, what is the relationship then between BPD and trust or trauma and trust in a person’s life? How do you have trust?
Lack of trust has been one of the most reported symptoms of BPD, especially within interpersonal romantic relationships. This goes back to parenting styles, because people with BPD were initially conditioned not to trust their caregivers or their reactions.
This is where my study comes in. We wanted to see if a sense of distrust is just a general trait for people with BPD—are they paranoid and distrustful of everyone and everything? Or, is it something brought on by distress? Or, is it specific to certain situations?
The main method that we used, which was based on a study done in Germany in 2013, is we split participants up into three randomized groups. Before that, participants would complete surveys to show the prevalence of their BPD traits and how much they perceived to trust their partners before the study. After being randomized into the three groups, each group had a specific condition. One was a neutral condition where participants would talk about something like a favourite movie or something that wouldn’t elicit specific feelings of distress. The second group talked about a personal fear, which would be talking about a nightmare or something they were generally afraid of. The third group talked about an argument they had with their partner and potential reasons as to why they might break up in the future. What we found from the study is that people were distrustful of their partners after the personal distress condition and the relationship distress condition, but not at the neutral condition, which did show that people with BPD aren’t mistrustful of everything and everybody.
The idea is that people become mistrustful of their partners no matter what type of distress there is in their lives because the patterns of their attachment activation revert them back to when they were kids. Essentially, when you’re in distress and when you’re a kid, you look for your caregiver to relieve that distress but they weren’t trustworthy… So now, whenever you are distressed your attachment patterns activate and you become less trustful of your partner because you connected the idea of distress and needing comfort to the idea of somebody not being there or not being consistent.
What was the most surprising finding from this study?
My most surprising finding from the study was how consistent the results were among any age group, racial group, or cultural group. I do, to some degree, agree that BPD does change over one’s lifetime and I think it’s influenced by culture, especially Western medicine, but it seemed to be prevalent in all groups, which was a big surprise.
Were any of your beliefs confirmed through this study?
I was expecting trust appraisal to go down in any situation. Not because I have a lot of knowledge in the field, but because I personally feel my trust goes down intensely whenever I’m in distress about anything.
To see that the lack of trust came from both conditions—it shows that it’s not anything the partner did wrong or an instability in the relationship, which is the biggest takeaway here. The aspect of the study we can learn the most from is that partners don’t need to feel personally attacked when this happens. This is just a person with BPD seeking comfort in their own dysfunctional way because their brain is in distress. It does latch onto a maladaptive idea of what comfort looks like but it’s not there to harm, it’s not there to blame, and it’s not there to accuse.
Based on the study, what would you like to see in terms of next steps? Is there another direction you’d like to take your research in? Or some sort of treatment you’d like to see?
Now that we notice that the way people behave in their relationships is completely connected to their attachment to their parents when they’re younger, if we can isolate specific behaviours through relationships to see how they correlate with specific parental behaviours, maybe some sort of checklist could be made that any kind of practitioner could use with a parent in the presence of a baby. All infants need to be vaccinated at three months, six months, and twelve months, and the parent has to be there. The idea is to see how the parent reacts to the child being in pain, to a child experiencing distress. Easily, while the parent is reacting, a nurse can check off whatever behaviours are applicable. If the child is crying and the parent is completely ignoring them, the nurse may check off inattentive in this way, or if the child is crying but the parent is laughing and smiling at the child and trying to make them feel better, in a positive manner, the parent is still not validating that this is painful and the child needs comfort in a specific way. Not to tell parents that they’re parenting wrong but, to suggest validating a baby’s experience. BPD doesn’t come out until later in life because it is completely influenced by rearing practices.
The second idea, the one I’d really like to pursue in my PHD, is since this intense connection with partners and sense of trust is such a prevalent symptom, I would like to use the symptom in a positive way as a form of treatment. If distress in any form of your life immediately correlates to you being insecure about your relationship, if you were, before a distressing situation, given some positive reaffirmation about your relationship—something positive your partner could say or do—would you experience less distress about an unrelated situation?
For example, if your partner sits down and says, “I love you. You’re very important to me,” before a big job interview, will you be less nervous and distressed about something that has nothing to do with the relationship? Would this effect carry over just like the other effect carried over? Distress anywhere seems to be tied with how stable the relationship feels. Because it’s such a prevalent symptom, it would be nice to use it in a positive way.
Can you talk about the role mentalization plays in BPD?
Generally, the idea of mentalization is an individual learning what motivates the other person in terms of their cognitive process. How this develops is through a back-and-forth with your parents when you were a baby. Initially, when you’re a kid, everything that happens and everything that’s done is just for you (I’m hungry so my Mom comes and gives me food). With consistent interaction, you start separating the motivation of other people from your own motivation. You’re able to start individualizing everybody else.
With parents who are parenting someone that develops BPD, this back-and-forth usually isn’t there. If the back-and-forth was there the attachment style would most likely be secure. So, this person with BPD doesn’t learn that whatever is happening around them isn’t happening because of them. This is where mentalization comes into play later: studies show that people with BPD have much lower mentalization rates than other disorders.
Mentalization is severely weakened during moments of intense emotion and distress and, unfortunately, in BPD that is very often. It feeds this circle of “she left the room because she hates me” and now you’re in distress and then you go and attack because you think that she hates you… Meanwhile, she went to go to the bathroom and now you’re arguing.
BPD is a little more prevalent in females than in males, and I wonder if that’s just because of the gendered nature of women being allowed to be more hysterical than males? Is this maybe something that goes under-diagnosed in males?
It’s quite possible that because men are expected to be the way they are (this idea of stoicism) they don’t seek treatment, they don’t seek help, and they don’t say they feel these things. They push it away and repress it so there may very well be a large number of males out there that don’t get treatment. This is still extremely prevalent because only recently has mental health been normalized. We’re still in the midst of a generational change. Kids that are growing up now are more open to these things. Three or four generations behind, they don’t necessarily believe in BPD.
Is there anything else you would like to add?
My biggest issue is the complete misrepresentation of what BPD is in everyone’s minds. I’m reading books about BPD that describe it as this awful horrible thing that just wreaks havoc on people that know you and yourself. I want to say, from a personal perspective, BPD has probably been one of the best things in my life in a lot of aspects. It is a consistent and constant challenge, an opportunity to learn, to think in a completely different way, to better myself, to understand how others think, to be more patient with them, pick up on social cues a lot easier, and be there for people.
Honestly, I feel joy as intensely as BPD joy is and love as intensely as BPD love is and nothing in this world compares. I’ve heard from partners, “I’ve never been loved this way.” BPD is not this black hole that people make it out to be.
Yeah, and I mean I’m six years into a relationship. While it can be a lot of work, I believe people with BPD can have healthy and long-term relationships, but a lot of literature makes it sound impossible.
Exactly. And people reading it won’t want to get into a relationship with a person with BPD because they’ll feel it’s doomed to fail. The issue is that aspect of communication—not just that the partner can’t understand your feelings, but that people with BPD often don’t understand their own feelings. They can’t put them into words.
People are not just BPD. They have BPD. We’re not always unstable. We’re not always emotional. People that have depression are not depressed nonstop for the entirety of their lives. You get episodes. You get situations, emotions overflow you, you either control them or they burst, but it’s also just waves.
This issue: A brief history of BPD
An individual’s life can be impacted by a mere definition. BPD wasn’t officially defined as a mental disorder until the DSM-III came out in 1980, which means the disorder I live with every day is only (technically) a decade older than me. Prior to that, BPD was thought to have some relationship to schizophrenia.
Treatment for BPD in the 1980s was psychotherapy, a method which produced negative reactions among patients. Instead of considering alternative treatments for people with BPD, they were written off as difficult or hard to treat. By the end of the 1980s, as more studies emerged that demonstrated BPD was more closely linked to trauma, multimodal treatment began to replace psychoanalytic methods.
By the 1990s, Larry Siever’s work recognized BPD as an impulse spectrum disorder or an affective dysregulation disorder. In 1993, Marsha M. Linehan developed DBT to treat BPD, which diminished rates of self-harm, suicides, hospitalizations, and the need for medication. In the late 1990s and early 2000s, Peter Fonagy and Anthony Bateman designed mentalization-based treatment (MBT) for people with BPD.
These days, the prognosis for BPD isn’t as dire as it once was; however, it should be noted that we’re still exceptionally early into studying, understanding, and treating the personality disorder. Mental health professionals still avoid working with people with BPD due to stigma and, as a result, the disorder remains behind others when it comes to awareness, research, and funding.
Building a Life Worth Living: A Memoir
By: Marsha M. Linehan
Possibly what makes Marsha M. Linehan such a shining star to those who have lived with BPD is not just that she created a therapeutic treatment that alleviates symptoms of the disorder, but that she herself suffered from it. Building a Life Worth Living is more than just an admirable individual’s memoir. It’s a pathway to hope for all those who have experienced the emotional intensity she writes about and aren’t sure they can weather the storm.
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