Based on the textbooks and materials, DBT can seem so formulaic. But as I see the contrast between this DBT program and the previous one, I’m growing increasingly aware of how, at heart, this therapy involves the seamless weaving of multiple strands, and that even one broken thread can unravel a supposedly solid treatment. If you can’t tolerate sitting in a group of people, for instance, how can you learn the skills? If you have trouble with being around men and it’s a mixed group, how do you endure it? Some people get triggered by the smallest glance and have angry outbursts, while others dissociate the minute a voice is raised.
In my all-women DBT group, almost everyone is either married or involved. Maria, with her fur coat and Gucci bag, is married to a dictatorial businessman who sounds suspiciously overinvolved with his Italian heritage. Darcy dates a boy who can’t keep a job and spends most of his time smoking pot in the living room. Jenny, who is three-quarters blind, has both a service dog and a boyfriend, though the boyfriend is confined to a wheelchair. Robyn is a quirky, petite artist married to a musician, both recently transplanted from Alaska. And then there’s Natalie, a stunning goth chick with an on-again, off-again boyfriend who occasionally beats her, and vice versa. She’s constantly in the midst of court proceedings and legal details involving her daughter and restraining orders. None are happy in their relationship except for a quiet older woman, Monica, who talks about a mysterious and loving man: “her David.” Plump and serene, Monica doesn’t seem to share our ongoing crisis and misery until she discloses, during a homework review, that her urge to kill herself is unremitting. Our one lesbian, Misha, is single, but she’s obsessed with her ex-girlfriend to the point of stalking. Ah, borderline love.
Except for our goth beauty, everyone in the group appears fully committed to learning the skills, which also seems critical to the success of the group. We aren’t rowing our own little lifeboats. The skills, like a language or a sport, develop through sharing, in addition to practice. I feel lucky that I’ve learned to share in groups. AA and NA taught me to tolerate the distress of exposure, once I understood the benefits. Here, the benefits include hearing how others with demons similar to my own try to tame and master them. At last I’m not entirely alone.
I am, however, the only self-identified borderline. And while this program is much more comprehensive than the last, it too doesn’t involve education or discussion specific to BPD, nor does it go into the philosophy or theory that Marsha Linehan based her therapy on—theories that grow more important as I examine my symptoms and how the DBT skills help reduce them. For example, Dr. Linehan (1993a) uses the word “dysregulation” to characterize BPD, not “instability” as the DSM-IV-TR does. All of the DBT skills, therefore, offer some means of regaining control of (or coming to terms with) our dysregulated selves. It might seem like a small shift in wording, but as our DBT group enters the emotion regulation skills module, this concept of dysregulation takes on immense importance. In her skills training manual, Dr. Linehan says that “from a DBT perspective, difficulties in regulating painful emotions are central to the behavioral difficulties of the borderline individual” (1993b, 84). This means that many of our “symptoms” can be seen as “behavioral solutions to intolerably painful emotions” (1993a, 149), including cutting, suicide attempts, desperately clinging to others, dissociating, getting high, jumping into bed with strangers. “Anything to stop the pain” might be a good subtitle for BPD.
So we need to learn how to work with our emotions. Mindfulness starts to teach us how to be aware of them, but we need to go further. When Simon asks us to define what an emotion is, no one in group can explain it, which is ironic since we are all people who have been consumed by emotions our entire lives.
Simon explains that emotions are complex physiological processes. When we look at an emotion, we tend to view it as a single event or experience, but in reality, many things are going on. He gives us a handout with a flow chart, and we take a trip down emotion lane, from the “prompting event” (like seeing a hot guy), to chemicals in the brain that cause changes in the body (arousal), to the urges that develop (Fuck me!). Then there are the actions we take (seduction, or avoidance, or shaving our legs), and then the aftereffects.
In the life cycle of an intense emotion, if it isn’t acted on, it eventually peaks and then decreases. But as Dr. Linehan explains, people with BPD have a different physiological experience with this process because of three key biological vulnerabilities (1993a): First, we’re highly sensitive to emotional stimuli (meaning we experience social dynamics, the environment, and our own inner states with an acuteness similar to having exposed nerve endings). Second, we respond more intensely, and much more quickly, than other people. And third, we don’t “come down” from our emotions for a long time. Once the nerves have been touched, the sensations keep peaking. Shock waves of emotion that might pass through others in minutes might keep cresting in us for hours, sometimes days.
I can see it happening in group every week. We’re like a pack of skittish animals sensing a brewing storm even as we try to sit calmly in our seats. Any sudden social noise can send first one of us, then the pack, into a tizzy. As anyone with BPD knows, the charges so often leveled against us include being overly sensitive, overly reactive, and emotionally intense and unpredictable. Luckily, DBT doesn’t present these tendencies as pathologies; it views them as basic biological vulnerabilities. They aren’t symptoms to be cured, but inherent qualities that we haven’t learned to manage. If you look at people’s personality traits in general, it’s obvious that tendencies don’t always become disorders. Not everyone who has a temper ends up throwing furniture, and not everyone who’s depressed ends up in a mental hospital.
So why do some people who are sensitive and reactive develop BPD while others never do? Marsha Linehan (1993a) speculates that BPD behaviors and experiences develop through a combination of biological vulnerability and an environment that is unable to respond adequately to our special needs. She calls this the biosocial model. In one sense, it’s like growing a plant. You have the seed, but you need to give it certain elements: sun, water, soil. We have the seed. But how do you grow a borderline? Her word for the environment that cultivates our disorder is “invalidating.” She doesn’t use the term “abuse” or even “neglect,” but “invalidation” to describe how a vulnerable child’s inner experiences—thoughts, emotions, sensations, and beliefs—are either disregarded, denied, erratically responded to, punished, or oversimplified by caretakers and nurturers. There is a “nonattunement” of response in the family (or school, or even culture) that ends up aggravating a basic biological vulnerability. According to Dr. Linehan (1993a), invalidating environments put a premium on controlling or hiding negative emotions. Painful experiences are trivialized, and blame is put on the vulnerable person for not meeting the expectations of others and living by their standards.
The biosocial model describes a horrific feedback effect: Every experience of invalidation compounds the intensity and dysregulation of our emotion, and feelings of abandonment, isolation, and shame increase. Because we don’t know how to manage the feelings, our behaviors grow ever more destructive and desperate, which results in more invalidation and blame. The end result is a person with all of the BPD symptoms who has learned to expertly invalidate herself.
What makes DBT therapy so critical to BPD isn’t just the skills. It’s the approach to the borderline tension between needing to be accepted and validated versus needing to be pushed into making changes. I see this with Ethan: He always recognizes my perspective and how I feel, while also showing me that there are other ways of seeing and responding. The difference between being told “There’s no reason to feel that way” and “I can understand how you feel that way” is the difference between taunting a rabid squirrel and giving it a tranquilizer. Ultimately, we need to learn how to validate ourselves, but right now that’s beyond me. I need others to do this for me, and as anyone with BPD knows, getting this kind of support is all but impossible.
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But I am making progress toward self-validation. Understanding my emotional life and the biological basis of my experience is a start. And embedded somewhere in DBT’s skill sets, especially the emotion regulation techniques, are the skills necessary for moving into stage two: learning to deal with emotional experiences. But to do that, we have to understand what emotions are and investigate the myths we’ve believed about them. We have to understand that some of our core beliefs increase the intensity of our inner pain: beliefs that our inner experiences are evil or meaningless or not worthy of being understood, that emotions are bad, that there are right and wrong ways to feel. In my sessions with Ethan, I’ve discovered that I view all negative emotions as enemies, and changing that perception isn’t easy.
In DBT group Simon explains that emotions serve a purpose. “Despite how horrible they feel or how much trouble they seem to cause, they do important things for us: They communicate. They motivate. They self-validate. They give our lives richness and meaning.” As the season turns, I try to find meaning in my intense loneliness without concluding that I’m a pathetic loser. My work at the office remains steady, challenging, exhausting, and occasionally satisfying. My walks to work become my mindfulness practice. I try to notice my body state, the thoughts that run through my head, and all the smells and sounds of a Cambridge morning. This year spring appears and then retreats like a jack-in-the-box. The daffodils poke their heads out of the soil only to get bombed with snow. As soon as the snow melts, they rise up again, yellow prongs of hope, only to be battered by freezing rain. I never realized how foolishly enduring nature is. Or maybe it’s blindly determined? Where does that power of endurance come from?
On my mini fridge, I put a magnet with a Zen quote: “Barn’s burnt down… Now I can see the moon.” I’m trying to value the simplicity of this new beginning and hold onto the notion that from destruction comes creation. But what I wonder more and more often is who is creating? For decades I’ve been a tangle of crossed wires, misdirected impulses, distorted views, exaggerated emotions, facades, and aching, exposed nerves. Even right now, there’s the me who wants to kill myself, the me who is ripe for cults and controlling men, the me who sleeps for twelve hours just to recover from a grocery shopping excursion, and a host of other identities I can trace all the way back to Kiki at Camp Good News, desperate for a savior. And now, there’s me the receptionist—the lonely and increasingly horny receptionist.
Despite the reoccurring snow squalls, students returning from spring break mimic the flowers in their hope for warmth, baring their skin and wearing bright floral shorts and flip-flops in the slushy streets. The couples emerge too, strolling, holding hands, cuddling. When I see them, I have chest pains and feel possessed with envy and the conviction that I will never be loved that way.
It’s been over a year since I’ve been touched. I’ve been so well behaved. No more lusting after young mental patients. No more ManRay. Therefore, sessions with Ethan involve a higher-pitched lament of loneliness. How intense is it? On a scale from one to ten, it sucks beyond that. And this longing is no longer confined to the night; in daylight I feel chilled inside, hollow, and achy, and then I catch a glimpse of a messenger boy on a bike, tattooed, wearing shorts, and sweating, and I’m flushed and disoriented with desire. Harvard Square blooms with bared skin as the weather grows warmer—a festival of privileged flesh parading through the crosswalk between Out of Town News and the Harvard Coop. The bodies pull my eyes so hard that walking is difficult. Men, women, young, old—it doesn’t matter. I want, I want, I want… I want a connection with someone, anyone.
Good relationships are said to be the greatest factor in happiness after basic material needs have been met. And yet BPD symptoms sabotage relationships. So it’s a vicious cycle. Being alone is torture, but so is being close to others, needing them, having them. You’re like a starved baby unable to draw milk from the breast, or a diabetic hooked on candy. Worse, you can’t explain this in rational terms to anyone. And now, wanting a relationship brings on an onslaught of fears and uncertainties: Am I healthy and stable enough? Can I control my behavior better, not get so triggered that I start screeching when my boyfriend looks at another woman?
I’ve now been in therapy with Ethan for over seven months. Between the two DBT groups, I’ve been attending skills groups for over a year. And I am making progress: I’m not hacking myself up, not thinking every ten minutes that I might as well kill myself. There’s a saying that pain is the craft entering the apprentice, and while I’ve felt pain all my life, the emotional hell I’ve been going through these past six months is actually yielding positive results. This is clearly due to the DBT skills—and to finally having a cohesive group of people supporting me in effective ways: Ethan in sessions and by phone; Renee, Gail, and Richard at work, and Raymond nearby; the DBT group in our weekly meetings. The doctor who’s now prescribing my medications is doing a good job. Everyone, even my parents to some extent, understands that, despite being thirty-two, I’m only now learning how to live, and I need their help. If I didn’t have this unusual patchwork of support, I’d be clinging to the first person who looked at me kindly, and sucking them under in no time. I’ve come to realize that if I put all my eggs in one basket, I’m setting myself and the other person up. The question now is, can one of those eggs be a lover, and can I stop making such a mess that eggshells end up all over the floor?
I’m no longer in stage one. I’m not trapped in the dysregulation zone, bombs constantly exploding. For long moments, I can see the eternal optimism of the flowers and taste the air without thinking of emptiness and bitterness. I’ve found a small perch, and I’m able to look around without falling or jumping off. From here, I’m able to see how my fears compete against each other: fear that if anything changes, I’ll fall again, and fear that this sprawling, empty loneliness will destroy me just as easily. Another dilemma of the borderline: Connection gives us our life, yet it also threatens to take it from us. But like the flowers, I have to move toward the warmth if I’m to grow at all.
14
No Blow Jobs on the First Date
At my next session with Ethan, I declare my intention to do online dating. He nods. Someone else might ask if I’m really ready for such a step. Instead, Ethan wants to know what my goal is. What has my motive always been? To be loved, cared for, protected, affirmed, and kept away from the great black hole in the center of my soul. And I want sex. It’s been a while.
You can view this need as pathological, or see it as the most natural thing in the world. For me, it’s often both. Inside all this hunger for someone else is a simple yearning for companionship, human touch, and connection. I just never know how to separate these out and proceed accordingly. When Ethan asks what my greatest challenges are about dating, I hesitate to tell him. I remember that when I was in my twenties, one of my therapists made the polite suggestion that I not give blow jobs on a first date. I promised to try, but inevitably, I’d relapse. To clarify, I didn’t just go around giving blow jobs to anybody. It’s that once I’m approached by someone attractive, my longing for touch blurs my reason, and the next thing I know, I’m on my knees. Contrary to folklore, it’s the easiest way to a man’s heart.
Ethan fiddles with his pen a little more than usual as I explain this habit in detail. “So I guess,” I conclude, “I don’t know how to develop a relationship. I sleep with people, and most of the time they choose me. My boundaries are obviously not that strong.”
I reason that online dating can at least provide some artificial boundaries. I’ll have more control over the process. For example, face-to-face, a cute guy might steer me into the shrubbery with a couple of kisses. That would be more difficult through a computer screen; at least, I should hope so. Making informed decisions is not an easy task when you’re under the sway of BPD-induced loneliness and a sex drive that, despite Zoloft’s deadening effects on my clitoris, can overrule all reason. As Bennet once said, “You love indiscriminately.” I can
fall into a delusion of eternal compatibility before I even know a man’s last name—and then fall out of it a week later with a conviction bordering on religious faith. If there were a way to slow this process down with some external speed bumps, perhaps I’d be less impulsive and operate more from my wise mind. Dr. Linehan might call this approach “structuring the environment.” Match.com calls it “guaranteed compatibility.” It’s like man shopping, and I get to drink coffee while I do it.
But in order to enter this new mating dance, I must create a profile for others to see. Attraction, seduction, and all the small nuances of romance now boil down to this public offering, a canvas of self-promotion where you try to paint every last interesting, compelling, appealing detail of your existence without giving any hint of desperation. I’m somewhat at a loss as to how to do this. Putting yourself out there isn’t easy in the best of circumstances, let alone when you have a personal history that reads like Go Ask Alice and a diagnosis that makes grown men run for their lives. Ethan asks me what kind of partner I’m looking for, and one thing is clear: I need to be with someone who can understand and accept BPD. My family might not want to discuss it. The DBT groups may avoid it. Even Ethan may only speak of “BPD tendencies,” but whoever I become attached to better know what my issues are and how we can deal with them. Otherwise, it won’t be pretty.
I honestly don’t know what’s going to happen when I finally say to a potential partner, “By the way, I have BPD.” Obviously I’m not going to mention this in my profile. I toy around with hinting at a “history”: “I’ve been through a lot,” I could say, “and come out stronger for it.” Or I could allude to being in recovery through all the various codes, like saying, “I’m a friend of Bill W” (the founder of AA). How about “friend of Marsha”? I spend an entire day wrestling with three paragraphs for the “Who I Am” introduction and filling out the numerous questionnaires and preferences, and in the end I have an ambiguous description of an artsy chick with only oblique references to pathos. I’ve been working on my profile all day at the office, and after I press the “submit” button, I realize I haven’t eaten or peed in almost seven hours.
Buddha and the Borderline Page 13
