Ethan nods. “And I also know that in getting better, it’s not helpful to form your entire identity around the label. Any label. You remember Linehan’s concept of the dialectic? That two things can be true at the same time? I’m willing to say that you can have BPD and yet not have it.”
I nod, a little reassured. “Also,” Ethan adds, “insurance doesn’t cover it.”
“How is that possible?”
“Welcome to managed care. So right now you ‘officially’ have depression and an anxiety disorder.”
This is a whole new aspect of the BPD situation I hadn’t yet encountered, another facet to this insanity. I have the image of lemmings pouring over a cliff while a group of suited “managed care” providers cluster around with clipboards, marking down a decrease in therapy costs. They obviously don’t need to pay for people who are dead! The bad rap with BPD is seemingly endless. Therapists won’t talk about the diagnosis or disclose it. Insurance companies won’t pay for treatment. And even within a therapy like DBT—which Dr. Linehan developed specifically for BPD—no one mentions it. I still wonder how you get treatment for something unspeakable.
I’m about to learn. I pull out my diary card, and we go over the week’s emotional highs and lows. I haven’t cut myself since the Harvard Coop incident, and I’m not fantasizing constantly about overdosing, in no small part because I can call Ethan in the evenings when I’m crawling out of my skin and he’ll give me a DBT skill to try (self-soothe, distract, opposite action). So this is progress. Every session we look at the diary card and comb through my self-destructive urges and the moods I’ve rated on a scale of one to five. The problem, of course, is that being the unstable borderline I am (sorry, Ethan!), I can flip from two to five in an hour, then back again, so how can I rate an emotion’s level for an entire day?
“Do a daily average,” Ethan suggests, “unless you want to keep a notebook and rate your emotions on an hourly basis.” Even for me, that is a bit much.
Now it’s November again, which is always the worst. The short days are dark and empty; the long nights even more so. Without a day program, job, or lover to engage me, the overwhelming emptiness returns, along with depression. I’ve stopped going to ManRay because I can barely roust myself out of bed, let alone get it together to be a bad-ass. On the one hand, having Ethan keeps me going from day to day, but on the other, I’m actually feeling an increase in my hopelessness, especially since time is running out with my apartment and travel continues to be a horror now that my car has died.
It takes two buses and a half-mile walk through Cambridge to get to Ethan’s office, and as I go past the beautiful houses on my way to therapy, I’m consumed by envy. The diminishing autumn light sharpens the life behind those windows, each of them a diorama of unattainable treasures. I’m not envious of the polished dining room tables, the damask drapery, or the oil paintings hung on warm-colored walls. What I long for is the sense of belonging these people must feel, or that I imagine they feel, as Ethan points out when I describe this to him. He says, “You assume they are all happy in their lives.”
“Happier than me,” I reply.
“So if you felt like you belonged somewhere, you’d be happy?” Ethan asks. I declare that it would be a good start. And certainly I wouldn’t be happy homeless. So far I’ve visited two halfway houses and made appointments with three social service housing agencies. There’s a possibility I’ll be able to get into a state-run halfway house, but that isn’t an option until I’m officially a client of the Department of Mental Health. Scott helped me fill out those forms at MAP, but it might be a year before the application is processed. The last housing option for someone on disability with no other funds involves getting a voucher for a state-subsidized apartment. Anyone on disability has the right to this assistance. The housing vouchers are distributed according to your position on the waiting list, and also by a periodic lottery. But the waiting lists are long. Even the inner-city subsidized places have at least a year’s wait, and the closer you move toward the gentrified parts of the city, the longer the wait. When I call the city of Cambridge to put my name on a list, the receptionist can’t stop laughing. When she finally calms herself, she tells me it will be twelve years.
Our focus in therapy these first couple of months is entirely on safety. Not only to keep me from harming myself, but also to make sure our therapy isn’t jeopardized by my behavior, or by Ethan’s, for that matter. DBT takes the therapist’s behavior as seriously as the client’s. It’s an unusual contract in this sense, as is the fact that this DBT model, true to Dr. Linehan’s original vision, involves Ethan’s participation in a consultation team. So each week he meets with other DBT therapists to discuss cases and give and receive guidance. This is a bit unsettling, knowing strangers are privy to my personal details, but I’m also reassured that, for once, I’m not like a baby bird in the hands of one person. I’m more than a handful, that much is certain. And I’m terrified of being dropped.
The problem with this focus on safety is that I always feel unsafe. As Ethan and I look at the architecture of my life and try to figure out ways to build in more external support, I feel overwhelming grief. It’s not just my behaviors that make me unsafe; it’s how I experience the world and how I feel I’ve been treated, and how I experience my own emotions and myself. I don’t realize this is a common BPD trait until I read about borderline core beliefs. Cognitive therapists analyzed the perceptions of people with BPD through questionnaires and concluded that we tend to share three basic assumptions: The world is dangerous and malevolent; we are powerless and vulnerable; and we are inherently unacceptable (Beck et al. 2004). Dr. Zanarini (the researcher who wrote about borderline pain) made a similar list: We are endangered; we are like small children; and we feel uncared for (Bateman and Fonagy 2004)
As Ethan and I go over my current living situation and joblessness, he points out that my assessments are colored by a lot of these same beliefs. When I get on a bus, I perceive people as dangerous. When we talk about possible solutions, I have no faith that good things might happen. I feel helpless and vulnerable, and like no one cares for me.
“Is all of this true?” he asks. “Because on one level, you’re not being helpless. You’re looking for housing, doing your diary cards, and taking control of your therapy.”
I don’t know how to answer that, because although I am trying, as usual, to make things better, I continue to feel like I’m drowning, with no one to grab onto. Somehow, I don’t count Ethan as a helping hand, which is odd, given that he’s now the central person in my life and is actually helping me. I’m not entirely alone. My parents are also available—not in the way I want, but they haven’t disappeared. So how many of these core beliefs are colored lenses as opposed to truths? It’s not like I came to these conclusions out of the blue. Most of my life I’ve been unable to manage myself and looked to others to take care of me. This certainly resulted in my feeling like a child: powerless and vulnerable. And the people around me behaved in ways that, if not intentionally hurtful, still left me feeling neglected, misunderstood, and unprotected. So do I feel unacceptable because I have distorted beliefs in my mind, or because of the way people responded to me as I was growing up? Other kids called me a freak. I was often told that my behaviors didn’t make any sense, that I was paranoid and unreasonable. Those are hardly the kinds of messages that make people feel good about themselves.
I’ve arrived at one of the most important questions I will ask myself, and keep asking: How much of what I perceive is accurate, and how much is a distortion? Ethan points out that I’m coming up on ten years of sobriety. Certainly that shows I’m able to take care of myself on some level. I agree—and yet I don’t. I am capable—and yet I’m not. Ethan tells me to remember the dialectic. It’s not either-or. My experience right now is “both.” I am an adult and a child; protected and vulnerable. Ethan reminds me that DBT isn’t about discovering ultimate truths; it’s often about tolerating seeming contradictions.
How do you do that? The borderline mind is trapped in polarity. It needs to be trained to tolerate these multiplicities and ambiguities, but right now I can’t hold two things at once. In Dr. Linehan’s DBT textbook, she says that one of the primary goals of DBT is to “increase dialectical behavior patterns” (1993a, 120), both in our thinking and in our actions. Ethan points out my small successes. Yet all cheerleading and small pieces of evidence aside (Yay! I’ve showered today!), a backward glance at my life reaffirms that I’ve been caught in a cycle of failures and breakdowns for decades. This evidence outweighs everything else. In the dialectic of “I’m helpless” versus “I’m capable,” I need evidence beyond my own life. I need to see that others have moved beyond being stuck in this downward spiral. I need a faith, of sorts, that can create an actual dialectic, because right now, despite my determination to get better, the situation is “I’m fucked” and “I don’t know how to get better.” Whether you call it faith, or hope, or proof of recovery, I need some sort of evidence that on the other side of pain and helplessness is what Dr. Linehan calls mastery, and that it can eventually result in having “a life worth living.”
As I wait for my spot to open in the DBT program, I read much of Dr. Linehan’s textbook, Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993a). It’s over five hundred pages and isn’t required reading for anyone in a DBT group, but as I discover, it offers an unprecedented level of insight into the borderline condition. I’m in Starbucks one afternoon, trying to get a better handle on how DBT is actually practiced in a program (I’m not going to be suckered again), when I come across a list of DBT goals and stages on a handout, adding a fourth stage to the three Dr. Linehan described in her textbook. Stage one is exactly where Ethan and I are now: focused on the DBT skills and decreasing suicidal and self-harming behaviors so that I can stay alive. Stage two, which is supposed to happen after safety is established, involves dealing with emotions and traumatic experiences from the past, exposing yourself to triggers, and learning to survive them. The handout, a FAQ from Linehan’s training organization, describes this stage as addressing “inhibited emotional experiencing” and moving “from a state of quiet desperation to one of full emotional experiencing” (Sanderson 2008, 2). Stage three is related to working through problems of everyday living, dealing with ordinary happiness and unhappiness. And stage four (I begin to cry when I read this part) says that a person with BPD will “move from a sense of incompleteness toward a life that involves an ongoing capacity for experiences of joy and freedom” (Sanderson 2008, 2).
Four stages. Linehan doesn’t use the word “recovery” to describe this process. But I will, because this is what I’ve been looking for. Some kind of map or path that shows how someone with BPD can cross over the border—or, better yet, transcend it. Discovering this list is the closest I’ve come to envisioning a way out.
12
Keys
After four months out of the hospital and three months with Ethan, I suppose you could say I’m getting stabilized. From the outside, it seems I’ve made gains: My typically constant crisis mentality is becoming more periodic, and I haven’t cut myself since September—not that I haven’t felt the urge, but Ethan and I have contracted for safety. I committed to calling him before I do anything self-destructive, and this safety net, the Ethan-net, holds me surprisingly well. Finding the right fit between therapist and client is definitely an elusive science. Ethan admits later that the reason we were assigned to each other was because no other potential clients showed up that day for an intake. He also says that, despite his training, postdoctoral work, and current position on the DBT team, he’s probably only three pages ahead of me in reading through Marsha Linehan’s textbook, Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993a). We’re freestyling it in some ways, but in other ways, not at all. He has his DBT consultation team, and I have our therapy sessions, homework, and phone coaching. All I need is a life.
I’m coming to see that the DBT stages aren’t necessarily sequential, and that I’m often in multiple stages at the same time. Some days it’s all about survival, but the next day, I may be grappling with issues of daily life, which is stage three. DBT’s catchphrase of developing a life worth living means you’re not just surviving; rather, you have good reasons for living. I’m also getting better at keeping another dialectic in mind: On the one hand, the disorder decimates all relationships and social functions, so you’re basically wandering in the wasteland of your own failure, and yet you have to keep walking through it, gathering the small bits of life that can eventually go into creating a life worth living. To be in the desolate badlands while envisioning the lush tropics without being totally triggered again isn’t easy, especially when life seems so effortless for everyone else.
The most pressing issues at this point are where to live and what to do with myself day to day. Having no structure outside of therapy isn’t helpful. I spend too much time in coffee shops nursing lattes, feverishly writing in journals, and hating people. I hate that they have things I don’t: love, purpose, discretionary cash, functional lives. My sense of being dislocated, trapped on the other side of a glass wall, doesn’t diminish. In fact, I actually have a better view of how barren my life is now that I’m not fighting quicksand every minute. Every day I come home knowing that as soon as January arrives, I won’t be able to afford rent. Yet even the mention of real employment unhinges me. I’ve worked probably ten jobs in the last ten years, from washing dishes to giving lectures, and there isn’t one among them that I could survive.
Just like in relationships, I make great first impressions at jobs. I show up and get gold stars. Yay, Kiera! But it doesn’t last. Performing under stress, showing up at regularly appointed hours, enduring criticism, and playing the politics—all of it eventually wears me down to one raw nerve, and I disappear, just as I did with the job at the Harvard Coop; though there I didn’t last long enough to make a good impression—or probably much of an impression at all. I don’t have any options for good references. And it doesn’t help that for most of my life I’ve heard that I wasn’t living up to my potential, wasn’t trying hard enough, wasn’t giving things a real chance, or was sabotaging my success. But when every excursion into responsibility feels like being dropped into a pot of boiling water, any job seems like a setup for devastation, not an opportunity to practice my skills.
These days there are a couple of programs for people with mental illness that focus on “psychosocial rehabilitation,” but none for BPD. Now that I understand this disorder, I know that I have different needs, and that the way people treat me and the environment I enter will have a huge impact on how I react and perform. If I get triggered, I need to be able to self-soothe and calm down. I need a way to moderate the pressure and stress so I don’t freak out. I need a workplace filled with Ethans—or at the very least, one where I can keep him permanently on speakerphone.
The house/job/money crisis is not a new one. And each time I hit this place of need, I feel ashamed of myself, and angry—at the world, my family, and whoever stands too close to me in the supermarket. Most painful is how everyone (except Ethan) seems to think I just need to get back on the horse that threw me. Phone conversations with both my mother and my father are barely endurable. Both give advice and suggestions without understanding the illness, and I end up defending myself or mindlessly agreeing with them just to end the call. I’m ready to raise the deflector shield even with Raymond, who takes me out for dinner toward the end of December and suggests I do some reception work for a friend of his. I tell him that having to perform and be “normal” seems beyond my capacity right now. Raymond disagrees and says it’s the simplest job in the world: I’ll answer phones, run errands, and do some photocopying in an office run by his best friend.
“I don’t know.” I push the mashed potatoes around my plate. “You know my track record.”
“I’m sure you can handle answering phones, Gamine.”
(Raymond’s nickname for me is Gamine Brioche, which can be roughly translated as “Waifish Street Urchin French Pastry.”) “What you need is a place where you feel valued. Someplace with low stress and good people.” We stop talking for a moment as the waiter refills our glasses with Pellegrino.
“And answering phones is something they’ll value?”
“Don’t underestimate yourself, child.”
“But I’ll be alone…” He promises I won’t. He’s renting a room in the office for his own company, so I’ll have insta-Raymond—and no lines of impatient customers. Plus, they’ll pay me as much in one week as I get in a month from disability. Raymond coaxes me with crème brûlée and hints of a Christmas bonus if I can stick it out.
I’m to start next week.
With Ethan’s pager number written on both of my hands, I arrive at a brick building in the heart of Harvard Square. The office spans parts of the third and fourth floors, with windows looking out over Massachusetts Avenue and Brattle Street, and by an odd trick of entranceways and atriums, the company sits directly above the Harvard Coop. It seems I’ve moved up in the world!
When Raymond said it was a low-stress environment with good people, he wasn’t exaggerating. The word “office” automatically brings images of people in suits and cubicles, phones ringing, and heads buried behind computer monitors; instead I discover Renee, my new boss, covered in glitter and bits of ribbon, working on the company holiday cards in a glass conference room. The office itself is all skylights, interior windows, and iron detailing. From the reception desk, I can just glimpse the crosswalk of Harvard Square, the intersection of many of the lives I’ve led. Now I’m going to be a receptionist, though my first week is total arts and crafts: cutting and pasting pieces of paper, tying bows on the cards, and running across the street to Starbucks for Renee, who insists on paying for my mocha lattes as well. The president of the company, Richard, visits our card production line on his way out to rollerblade the first afternoon and oohs and aahs over our handiwork. He’s wearing a hoodie and sweatpants, an interesting contrast to his white beard and hair. If Santa worked out every day, he’d look like Richard, right down to the warm, amused eyes and delighted smile.
Buddha and the Borderline Page 11
