I try to find something positive in the family stories. Does anyone see a loved one with BPD get better? Are the relationships ever repaired? At the sites I visit, the answer is almost never. One woman says, “If the person gets better, then obviously she’s not really borderline.” I’m so disturbed I have to go eat a pint of Ben & Jerry’s ice cream. The simplicity and elegance of the DSM symptoms have been scrambled into crime, abuse, and cruelty. The word “sociopath” gets thrown around with alarming frequency. I don’t know if I’m looking in a mirror, or if the people looking on are caught in their own distortions.
It seems like it might be better to focus on websites run by people with BPD, and, thank god, there are a couple of them. Not only do they have more factual articles on the disorder, they also have message boards with postings by self-identified borderlines. Finally. My own kind.
I dive in and read, and the first thing I notice is that anonymity is de rigueur. People post under names like “angelofdeath” and “criesforever.” I’m shocked by the sheer number of members who are registered to post—thousands of borderlines, from all over the world. And yet the countless messages, the voices of BPD, almost uniformly read like SOS signals: declarations of futility interspersed with cries for help. Unanswered questions cascade down the lines of postings: “I think I have this disorder.” “What is it?” “Why do I feel this way?” “How do I get better?” “Does anybody get better?”
These forums are lush with suffering and confusion and a quality of camaraderie found only in wars and at bars. People newly diagnosed, like myself, post long descriptions of their ordeals: multiple diagnoses, struggles with addiction, unremitting pain and loneliness, tortured relationships. There is a flurry of connectivity, as one person after another declares, “Yes! It’s like that! I’m so out of control! I can’t stop hurting myself either. It feels like everyone hates me and I’d rather be dead!”
There’s the balm of shared suffering: Oh thank god you understand. But then the bigger reality of these postings is how little help is available. I read how there are essentially no doctors willing to treat BPD, an almost total absence of programs for the disorder, and only a handful of programs based on dialectical behavior therapy. And then, further down, I see that “stopthepain” stops posting. And “angelofdeath” announces that she will be killing herself. A handful of moderators plunge in with wads of advice to stop the hemorrhaging, but it isn’t enough. These boards feel neither safe nor hopeful for me. At the end of reading these messages, I’ve gone through ten tissues and feel more lost then ever. Crying for help among the helpless is like trying to get sober in a bar. If 12-step recovery has taught me one thing, it’s that to get better, you need to connect with someone who has gotten through it. To believe that you can survive, you need to see that someone else has done it.
In the days after the diagnosis, I spend hours and hours on Alexis’s computer, clicking and scrolling, coffee at my side. Among all those websites with descriptions of symptoms, all the scholarly articles, all the bulletin boards of both borderlines and nons, a disturbing and glaring absence surfaces: No one wants to come out publicly as having BPD. This makes me wonder how real a diagnosis it is. Either it’s so horrible that none of the estimated two million people in the United States with BPD will come forward, or it’s not even real. Maybe it is just a “wastebasket diagnosis,” as one researcher complains, set up to collect all the riffraff who either refuse to be helped or cannot be.
This also brings up the question that Anna keeps raising: Does it matter if I believe I have BPD? Look at how much confusion and negativity I’ve already encountered. I don’t need any help hating myself. I’m already filled to the brim with self-disgust. Do I want to put myself in the same league as the incurable? Do I want to throw in my hat with people seen as sociopaths? Can’t I just go to the DBT group Dr. B recommended and forget the name borderline even exists?
I’ve seen other people refuse a diagnosis. And I’ve seen people who spent time in psychiatric hospitals but never labeled themselves as “mentally ill.” But when I look at myself squarely, it’s not just that I have a few difficulties or unresolved issues. Unlike those lucky people for whom therapy or medication delivers them back to themselves, I’ve been suffering from something that was unnamable for most of my life. Yes, I’ve had periods of relative stability, but the whole concept of “recovery” brings up some painful questions. What do I recover? With drug addiction, you hear that you can recover and reclaim your former self, the person you were before you started using. With other psychiatric illnesses, getting rid of symptoms means you’re more or less back to “yourself.” But what if you simply don’t have a solid self to return to—if the way you are is seen as basically broken? And what if you can’t conceive of “normal” or “healthy” because pain and loneliness are all you remember? “You were such a happy child,” my mother says. But I don’t remember that. So what do I recover?
4
Mindfulness and the Big Mac
In late winter a space finally opens for me in the DBT group—and not a minute too soon. Dr. B’s lithium diet has resulted in two extreme states: My anxiety level is cresting so high I can no longer go into grocery stores or drive a car without shaking and crying. The other effect is overwhelming horniness. When Bennet comes home from work, I’m waiting like a dog in heat.
“Jesus,” he says one night, “whatever problems you’re having right now, sex drive isn’t one of them.” I’ve never been this orgasmic before, and it’s a bizarre contrast to how nonfunctional I am in every other way. When I’m not sleeping twelve hours straight or having an anxiety attack, I’m waiting to be fucked again. Bennet’s bed is like a life raft, but it’s anchored to my illness. We’re both relieved when I get the call from the DBT program saying I can start as soon as I come in for an orientation.
In the orientation and interview, the DBT group leader, Molly, explains the purpose of the therapy: to learn how to reduce my pain and misery through specific skills. She hands me a set of papers listing all the rules of the group, and then she asks me why I want to join the group. I tell her that I can’t go on the way I’ve been living. I show her the broken blood vessels in my nose, from crying so hard and so long while Bennet and Alexis are out at work. Molly’s hair is a brown cloud masking the window’s light as she studies the side of my nose.
“You want to stop crying.”
“I want to stop feeling this way. I just don’t know how much longer I can keep dealing with it.” She nods and gives me the last of the paperwork to sign. Starting on Tuesday, I’ll be attending an hour and a half of DBT skills group once a week.
Dialectical behavior therapy isn’t like other types of therapy. You don’t sit around sharing your feelings. You don’t dredge up memories of the past and analyze your issues. It’s an approach that focuses on developing skills to help you regain control over your emotions and behaviors. Dr. Marsha Linehan, a therapist in Washington State, developed the techniques in the early 1990s while working with borderline women who were chronically suicidal and self-harming, and at the time I enter this program, it’s the only researched therapy that’s shown to actually reduce some of our symptoms (Linehan et al. 1991; Linehan et al. 1999).
When I show up at the group, I expect it to be Borderline Central, and I’m excited and a bit nervous to finally meet other people with the disorder. I carry my copy of I Hate You, Don’t Leave Me to show I’m serious about this thing. I’ve been using a highlighter while I read, and by the end, I’ve painted its pages neon yellow.
“Do you have BPD?” I poll the others before Molly arrives. There are eight of us. We run the gamut from an elegant woman in heels to a sullen teenager with silver hoops glinting from his eyebrows and nostrils, the only guy in the group.
“It’s not a real diagnosis,” the elegant woman says.
“Sure it is,” a girl sitting next to her says, “but only if you piss the doctors off.”
Molly sweeps in with a stack of
handouts and a small metal bowl. “Diagnosis isn’t the important thing here,” she says, overhearing our conversation. “Remember the list I gave you? Skills training is for learning how to change the things that cause you misery and distress—to regain control of your mind, your emotions, your behaviors.”
The bodies gathered in the room certainly document our lack of control. On several of the women’s arms, evidence of cutting rises faintly in pale pink ridged lines. A heavy woman with long, billowy sleeves reveals, in a gesture, circular red burns along her forearm, made from holding cigarettes against her skin. On more than one person, the insides of the wrists are scored with long strokes made by a razor.
Molly sits down with the DBT workbook she’s just made copies from. On the cover is a stark black silhouette of a woman’s face tipped down as through she were weeping, or possibly hiding in shame. In bold white letters inside her head, the title of the workbook reads Skills Training Manual for Treating Borderline Personality Disorder.
I feel like the person pointing at the elephant in the room. If BPD isn’t an issue here, why is it in the title of the book? Dr. B said this therapy was created specifically for BPD. Now it’s apparently a nonissue. To confuse matters even more, this hospital is home to the most famous BPD doctor in the world. In fact, his office is right across the hall from our group, but some invisible moat seems to divide us from him, or me from getting connected to anything that will directly address borderline. I’m growing upset about this, but there’s no time to discuss these things. Molly strikes the metal bowl with a wooden dowel and asks us to focus on our breath in silence, to allow the reverberation of the metal bowl to transition us into another space. While anxiety jackhammers inside me, I try to take some deep breaths and settle in. And I discover that this one minute of silence, of simply being present and breathing, is more difficult than any physical exercise I’ve ever done.
DBT, as it’s done at this hospital, consists of the weekly group where Molly introduces us to specific techniques and skills, and then we focus on exercises and homework assignments meant to help us apply the techniques in our daily lives. The manual has four skills modules, each addressing a specific set of problems. Because we have so much trouble managing our emotions, we’ll learn emotion regulation skills. And since we’ll do just about anything to get away from intense pain, we’ll learn distress tolerance skills. Because we have so much difficulty managing and keeping relationships, we’ll learn interpersonal effectiveness skills. And because we experience our own minds, thoughts, and feelings—everything, really—as being out of control, we’ll learn core mindfulness skills. Despite what Molly says about the BPD diagnosis being irrelevant to the therapy, I learn quickly from reading the workbook Molly held, Dr. Linehan’s Skills Training Manual for Treating Borderline Personality Disorder (1993b), that every aspect of DBT was developed with an exquisite sensitivity to the borderline condition.
In fact, Dr. Linehan devised this approach to therapy after discovering that trying to help people with BPD could be like pouring salt in a wound. We can’t tolerate criticism and judgment. For us, therapy’s constant emphasis on “fixing ourselves” and the pressure to change is like pushing someone whose back is already against the wall—a wall full of spikes. When the focus is solely on change, we tend to flee therapy or stay very angry and defensive. On the other hand, too much unconditional acceptance by the therapist can keep us stuck. In either case, we often get worse. So Dr. Linehan took an approach that no one else seemed to have considered. While her psychiatric training was in cognitive behavioral therapy, which focuses on changing problematic thoughts, feelings, and actions, her personal experience with Zen Buddhism taught her that compassion, nonjudgment, and mindfulness can normalize our experience and help us trust and accept ourselves. The Zen Buddhist and mindfulness techniques in DBT are called acceptance strategies, and the combination of these with the change strategies she initially used forms the core of DBT’s “dialectical” approach (1993a).
Although we never discuss the concept of dialectics in group, it’s actually critical to every skill and practice in DBT. If you pick up Linehan’s Skills Training Manual for Treating Borderline Personality Disorder (1993b), you’ll see that the concept is presented on the very first page. Even before she delves into the topic of BPD or the skills being taught to help us, Dr. Linehan makes it clear that the theory of dialectics structures DBT on every level. So, what is a dialectic? On the most practical level, it’s what happens when opposites combine to create something new. Bringing change and acceptance techniques together is an example of this. On a deeper level, dialectics is a viewpoint that recognizes reality and human behavior as fundamentally relational. According to Dr. Linehan it has three main characteristics: First, that “dialectics stresses the fundamental interrelatedness or wholeness of reality.” Second, that “reality is not seen as static, but is comprised of internal opposing forces (thesis and antithesis) out of whose synthesis evolves a new set of opposing forces.” And third, that “dialectics is an assumption, following the two above, that the fundamental nature of reality is change and process rather than content or structure” (Linehan 1993b, 1-2).
If you read through this section, it also becomes clear that these aspects of reality are often impossible for a borderline, like me, to grasp. I’m trapped in polarized extremes. The smallest changes in relationships devastate me, I experience myself as cut off and separate from the rest of the world, and I can’t see the other side of things because I’m so caught up in my own reality. In essence, I’m not very dialectical. Or as Linehan puts it, BPD characteristics can be viewed as a failure of dialectics (1993b).
As usual, I’m hoping to get brownie points for reading the important text, but it turns out that the actual practice of DBT is infinitely harder than reading a couple of chapters of theory—even something as seemingly basic as mindfulness, which is the first of the four skill sets I’ll be learning.
Mindfulness is the technique of simply observing what is happening without any judgment or attempts to change it, and it’s the basis of all of DBT’s acceptance strategies. For our group exercise, we’re instructed to close our eyes and imagine a river flowing past, with leaves floating on the surface. Each leaf is like a thought drifting by. There’s no need to grasp onto the leaves—no need to chase them, and no need to deny their presence. Our job is to let everything pass by, even if it turns out there are severed heads and old tires bobbing by. This isn’t easy. I last maybe three breaths without getting distracted. Then my brain is off and running. I’m thinking, I’m antsy, and I want the group to end.
After we do that exercise of simply observing, we go on to describing. Now as we watch the stream, we label the leaves: An emotion just passed by. There goes a thought! Stomach is grumbling. The girl next to me smells like cigarettes and roses… I’m better at describing, but I still can’t stand how it feels. And how ironic is it that after doing so much LSD as a teenager and trying to be a hippie, I’m getting my first real taste of Zen meditation in a mental hospital—if you can call feeling tortured for two minutes Zen.
As soon as we end group and Molly leaves the room, I turn to the heavy woman with the cigarette burns and take one last stab at the borderline issue. “Were you diagnosed with BPD when you got in here?” I ask her. I grip the book I Hate You, Don’t Leave Me in my hands, and she holds the Skills Training Manual for Treating Borderline Personality Disorder in hers. Borderline seems written all over us in the scars on our arms, all over me in the jagged pathways of my life, ending over and over in a hospital—all fractures and edges, and nothing that can stay the course.
“I don’t know what I have,” the woman says flatly, tugging her sleeves down. “I don’t care what it’s called. I just want to stop feeling this way.”
When we return the following week and report on how our homework went, I’m humbled listening to how the others practiced the observe and describe homework. The heavyset woman describes her experience with a McDonal
d’s hamburger: how the Big Mac, all warm inside the wrapper, made her mouth water, and how the special sauce dribbled down her chin when she bit into it. She describes the touch of the soft brown bun against the roof of her mouth, the motion of her jaw as she brought her teeth together, and how a lump of Big Mac slid down her throat. By the time she finished, it felt more like food porn than a therapy assignment.
The previous night in Bennet’s room with my homework, I too tried to be mindful, to observe and describe how I felt. But it had been another excruciating day. One of the few people in NA I still had contact with, a poet named Brian, convinced me to go to a gallery opening and poetry reading with him, and as soon as arrived, I knew I’d made a big mistake. After so many months of being housebound, my senses went on overload and my heart wouldn’t stop racing. I wanted to crawl into a corner and curl up in a ball. By the time Brian found me, I was sitting on the front stoop with my head in my hands. He immediately took me home, apologizing all the way. But I wasn’t mad at him; I just hated myself even more.
So later that night, I sat at Bennet’s with my mindfulness homework assignment. Bennet and Alexis were visiting his mother. I decided to be mindful of the horrible feelings inside me. I would observe and describe it all: The bird flapping in my chest, raking me with its claws. Observe, I told myself. I imagined sitting on the banks of a river and instructed myself to calmly watch the flowing water. But nothing came to mind. And inside that “nothing” lives something awful: a falling through black, blank space with my insides on fire. I knew I needed distance between myself and my feelings so I could observe, but just being with my feelings was like being possessed. I didn’t need mindfulness; I needed an exorcism.
Perhaps a minute passed, maybe five. The possession was in full swing. I don’t think I’m doing this right, whispered a part of me. Another part began a familiar litany: Nothing is working. I can’t stand this. I am so fucked-up. I can’t even sit for one minute without falling apart.
Buddha and the Borderline Page 4
