Monthly Archives: February 2015

#22 – Proof That Borderlines Are Motivated for Psychotherapy and Can Fully Recover

This post will answer critics who say: “Borderlines are not motivated to attend therapy. Borderline patients don’t stay in treatment. At best, therapy can manage but not cure BPD.”

These statements are absolutely false. Yet these myths continue to appear online, often being communicated to people recently diagnosed. As the studies below demonstrate, most people diagnosed with BPD do want help, most will stay in good treatment, and most do recover to different degrees.

Earlier posts have elaborated my dim view of the (non) validity of the BPD diagnosis. Since it cites studies using the BPD construct, this post might be viewed as hypocritical. That may be a valid criticism! Nevertheless, these studies provide evidence that people with “borderline symptoms”, however defined, can be motivated and recover both with and without therapy

Study 1:  88 Borderline Patients Treated Twice a Week for Three Years

Highlights: Led by Josephine Giesen at Maastricht University, Dutch researchers treated 88 borderline patients for three years with twice-weekly psychotherapy. Patients were randomly assigned to either Schema-Focused Therapy or Transference-Focused Psychotherapy, which are described in detail below.

After three years, a large majority of patients showed significant improvement, with many considered fully recovered and no longer diagnosable as borderline. In the group of 45 patients undergoing Schema-Focused therapy, more than half were no longer diagnosable as borderline after three years, and many more had improved significantly.

The researchers commented, “These treatments demonstrate that patients with BPD can be motivated for and continue prolonged outpatient treatment… Three years of treatment proved to bring about a significant change in patients’ personality, shown by reductions in all BPD symptoms, increases in quality of life, and changes in associated personality features.”

Here are details from the study:

Patient Population:  88 Dutch patients diagnosed with BPD. Average age around 30 years, with most patients in their 20s or 30s. Over 90% of patients were female. The group had average educational levels for Holland; about half had attended some college or completed a degree. As for functioning before treatment, around 50% were on state disability, 20% were working, and the remainder were students or stay-at-home wives/mothers.

Trauma in Patients’ Histories:  Over 85% of the patients reported childhood physical abuse. About 90% reported childhood emotional abuse or neglect. More than 60% also reported sexual abuse. Over half the patients had seriously contemplated or attempted suicide within three months before treatment. About three-quarters were taking some type of psychiatric medication.

Intervention: For a three-year period, patients attended two 50-minute sessions per week of either Schema-Focused Therapy (SFT) or Transference-Focused Psychotherapy (TFP). Treatment occurred at outpatient medical centers in four Dutch cities. The type of therapy given was randomized.

Definition of Schema-Focused Therapy: SFT is a psychodynamic treatment which assumes the existence of schemas (mental models of relationships) expressed in pervasive patterns of thinking, feeling, and behaving. The distinguished modes in BPD are detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. Change is achieved through a range of behavioral, cognitive, and experiential techniques that focus on (1) the therapeutic relationship, (2) daily life outside therapy and (3) past traumatic experiences. Recovery in SFT is achieved when dysfunctional schemas no longer control the patient’s life.

Definition of Transference-Focused Therapy: TFP is a psychoanalytically-derived therapy which focuses on the transference relationship between patient and therapist. Prominent techniques are exploration, confrontation, and interpretation. Recovery in TFP is reached when good and bad representations of self and others are integrated and when fixed primitive internalized object relations are resolved.

Therapist Composition: 44 different therapists treated the 88 patients. Over 90% of the therapists had doctoral or master’s level training. All therapists had previous treatment experience with BPD patients. Therapists averaged 10 years of experience working with borderline individuals.

Outcome Measures: Patient progress was assessed every 3 months for 3 years. The primary outcome measure was the BPDSI-IV, a 70-item scale measuring the severity and frequency of borderline symptoms. Patients also completed regular quality-of-life questionnaires. These included the World Health Organization quality of life assessment, a 100-item questionnaire covering level of satisfaction with interpersonal relationships, level of independent functioning, psychological wellbeing, and physical health.

Dropout Rate: Of 45 patients treated with Schema Therapy, only 11 dropped out during the entire 3-year period. So 75% of this group persevered in intensive therapy for at least three years.

Of 43 patients treated with Transference-Focused Therapy, 18 dropped out during the 3-year period. However, the study notes that 10 of these 18 drop outs disliked the therapy method or their therapist, and 5 of 18 had issues around TFP’s method of enforcing contracts. Many of these dropouts occurred in the first few months. In my opinion, TFP is a more rigid, less effective form of treatment, and so it’s unsurprising that more patients dropped out. There’s no reason these patients couldn’t do better in another treatment.

Understanding Improvement in these BPD Patients

So how was improvement in these patients measured?

To answer this, one has to understand the measures used in the study. The primary gauge was the BPDSI-IV scale, which was filled out by patients every three months for three years. The BPDSI consists of 70 items arranged in 9 subscales. For each of the 9 DSM symptoms, 7-8 questions are asked to determine how severe and frequent the behaviors/feelings have been over the past three months, from the patient’s perspective. Each question is rated on an 11-point scale, running from 0 (never, not at all, low) to 10 (daily, very intensely, high).

For example, several questions would ask about the intensity/frequency of a patient’s feelings of emptiness (DSM BPD criteria #7), several questions would ask about the intensity/frequency of a patient’s suicidal thinking/behavior (DSM criteria #5), several questions would ask about how unstable or intense the patient feels their relationships to be (criteria #2), and so on.

The scores relating to each symptom are then averaged, producing an overall rating for that symptom. (For example, the scores for all questions about emptiness would be averaged to produce one “emptiness score”, a number between 0 and 10.) These 9 average rating for the 9 symptoms (numbers between 0 and 10) are added up to give a “BPDSI-IV” score, which represents the severity of the patient’s borderline problems over the last three months. This number will be anywhere between 0 and 90, with 0 being perfect mental health and 90 being the severest borderline disorder.

Although I dislike the BPD diagnosis, I don’t mind the method used in this study, because it involves asking the “borderline” patients how they feel. In other words, the BPDSI scale is not a judgment by clinicians, it’s a report from patients.

Improvement in BPDSI and Quality of Life Scales during the first year:

With this understanding in mind, here is how the patients did over the first year:

borderlineimage1

In the top left graph, we see that in the schema therapy group (line with squares), the patients started out at an average BPDSI rating of around 35 (out of 90, with 90 being the most severe, representing the worst rating for each of the 9 BPD symptoms), but this had dropped to almost 15 by the end of the first year. The patients in the transference therapy group also improved, but a little less so.

The other measures are as follows:

The bottom left Euro-QOL scale is a measure of the patient’s subjective feeling of well-being on a scale from 0 to 100, with 100 being the best. We can see that it improved significantly for both patient groups over the first year.

The top right WHO-QOL scale is another quality of life scale, and the bottom right scale is a measure of psychopathology, neither of which I researched in depth. But the trend lines in each case are positive

Outcome In Terms of Symptom Reduction

Now let’s take a look at how the patients did in terms of each of the 9 BPD symptoms. Here is the graph of the treatment groups’ averages for symptom severity over time:

borderlineimage4

The left-hand numbers on each graph represent the average BPDSI rating for the group for that symptom. For example, for item C (top right), the “Identity Disturbance” rating (DSM symptom #3) started at an average of 5 out of a worst-possible rating of 10. This rating is an average for all the patients in the group. It then drops to an average of less than 2 out of 10 after the first year, an impressive reduction.

Average group ratings over time for all 9 BPD symptoms can be seen. From the top left, the items are: Abandonment score, Unstable Relationships sore, Identity Disturbance, Impulsivity, Suicidality, Emotional Instability, Emptiness, Anger, and Paranoid/Dissociative Tendencies. All of these ratings are from the patients’ perspective. The reader can see that in every case the trend is positive (symptoms getting less intense and frequent).

Detailed Outcomes Over Three Years

Lastly, here is data showing the patients’ progress over three years:

borderlineimage3

We can see that the patients improved a lot in the first two years, and tended to maintain that improvement between years two and three. I don’t interpret this pessimistically. After a significant period of early improvement, there is often a time where a person works to become more secure in their new level of functioning and relating. This may partly account for the “leveling off” of the scores between years two and three. If the patients continued in treatment (or on their own), they could improve further.

After three years, at least half of the Schema therapy group’s patients had recovered to the point where they felt well enough to no longer be considered “borderline”, and more than two-thirds were considered highly improved. “Recovery” was defined in this study as achieving a BPDSI score of lower than 15 out of 90, and maintaining that level through the end of the study. Other patients who improved a lot (e.g. going from a BPDSI rating of 50+ down to 25 or 20) would only barely be diagnosable as borderline, even if they weren’t considered “fully recovered”.

These studies tend to be very binary (e.g. people are either “recovered” or “not recovered”, but reality is not like that). It’s important to remember that improvement is a process; it’s never all or nothing!

Jeffrey Young’s Comments

Dr. Jeffrey Young of Columbia University is the developer of Schema Therapy for BPD. He commented on this study as follows: “With Schema Therapy, patients with BPD are now breaking free from lives of chaos and misery. Not only are they learning skills to stop self-harming behaviors, as they have with Dialectical Behavior Therapy, but a high percentage of BPD patients are finally making deeper personality changes that have not been possible until now.”

For Young, this study demonstrates that therapy for BPD can lead to full recovery, and that longer-term psychodynamic therapy can be very effective. However, his comment might be a little grandiose, as people with borderline symptoms made “deeper personality changes” long before he invented Schema Therapy.

Young’s group added that this intensive schema therapy may have advantages over Dialectical Behavioral Therapy. According to Young, “DBT relieves many of the self-destructive behavioral symptoms of the disorder, but may not reduce other core symptoms, especially those related to deeper personality change.”

Interestingly, Young noted that part of schema therapy’s success may involve its emphasis on “limited reparenting”, i.e. on the creation of a loving relationship between patient and therapist. This is closely related to what I discussed in article #10, in the phase of Therapeutic Symbiosis:

https://bpdtransformation.wordpress.com/2014/02/08/four-phases-of-bpd-treatment-and-recovery/

More information is available at www.schematherapy.com, and I adapted the statements above from this webpage – http://www.schematherapy.com/id316.htm

My View on Schema Therapy

I am by no means an expert on Schema Therapy, and I have no affiliation with Dr. Young. My understanding is that SFT involves a mix of cognitive-behavioral and psychodynamic techniques. It focuses on building a positive therapeutic relationship, on better managing daily life, and on working through past traumatic experiences. These elements are common to most therapies.

Schema therapy also contains an object-relations (psychoanalytic) foundation, in that it conceptualizes the borderline patient as using “schemas” in their mind to represent and relate to themselves and others. Examples of these are punishing parent and angry child, uncaring parent and abandoned child, etc.

Schema therapy helps the borderline patient understand how these faulty models developed – often due to trauma and poor parenting – and to stop the replaying of negative past interactions from destroying the potential for new, better relationships in the present. In this sense, it is based on Fairbairn’s object relations model, discussed below.

https://bpdtransformation.wordpress.com/2014/02/02/the-fairbairnian-object-relations-approach-to-bpd/

As Fairbairn said, “The psychotherapist is the true successor to the exorcist. His business is not to pronounce the forgiveness of sins, but to cast out devils.” 🙂

How Individuals Get Lost in Group Studies

My biggest criticism of this type of study is that it obscures individuals’ experiences behind numbers and averages. Of course, its intent is not to provide individual detail. But,I would like to hear from individual patients what their life experience was like at the end of treatment compared to the beginning. I’m sure many would speak very positively about their progress. Since we don’t have that, I recommend the reader to case studies referenced in these posts:

https://bpdtransformation.wordpress.com/2013/12/15/what-to-do-if-you-are-diagnosed-with-bpd/

https://bpdtransformation.wordpress.com/2014/08/17/18-heroes-of-bpd-jeffrey-seinfeld/

The Mystery of Why People Are Still Pessimistic About BPD Treatment

In the bigger picture, this study’s results are obvious. Intensive help helps people, just like the sky is blue and the sun rises in the east. “Borderlines” are no exception to this. If they can access effective support – and are given a reasonable sense of hope – people diagnosed with BPD will do very well. What we need to be doing is getting more people access to effective treatment, and leaving behind the outdated myths that BPD is untreatable or incurable.

It’s amazing how such common sense escapes people who say, “borderlines don’t seek help, borderlines won’t stay in treatment, borderlines can’t be cured etc.” In my opinion, they are about as well-informed as people who think the Earth is flat.

Here is the original study of the 88 Dutch patients: http://archpsyc.jamanetwork.com/article.aspx?articleid=209673

Other Studies on Psychotherapy’s Effectiveness for BPD

This study is one of many investigating psychotherapy’s effect on BPD. Below are additional examples, one from a hospital outpatient program, one from DBT, and one comparing different psychotherapies:

Treatment of Borderline Personality Disorder with Psychoanalytically-Oriented Partial Hospitalization, An 18 Month Follow-up: http://psychiatryonline.org/doi/abs/10.1176/appi.ajp.158.1.36

Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug Dependence: http://www.ncbi.nlm.nih.gov/pubmed/10598211

Evaluating Three Treatments for BPD: A Multi-wave Study: http://www.borderlinedisorders.com/images/AJPRCT.pdf

All of these studies show positive results. Again, this is not rocket science – good treatment helps people diagnosed with BPD!

What If Borderlines Don’t Get Good Therapy?

But what is people diagnosed with BPD don’t get good long-term psychotherapy? Do they inevitably do badly?

No.

Several studies address this question, including the one summarized below:

http://www.borderlinedisorders.com/images/AJPRCT.pdf

Here are the highlights of this study:

Study 2:  290 Borderline Patients In Massachusetts

Patient Population: 290 patients diagnosed with BPD, assessed at McLean Hospital in Massachusetts. They were first treated as inpatients during brief hospital stays.

Method of Study: This was a longitudinal-observational study. The patients were interviewed every two years for at least 10 consecutive years, starting in the early 1990s. During interviews, their level of functioning in work/school, satisfaction with interpersonal relationships, and degree and frequency of borderline symptoms were measured. After 10 years, 90% of the original cohort of 290 patients were still participating.

Therefore, this study followed the “natural course” of BPD. This medical-model idea is misleading (the notion that BPD has a “natural course”), but I won’t go into that now. Suffice it to say that the researchers in this study did not “treat” the patients – they just followed them after hospitalization and went to great lengths to see how they were doing every two years.

High Remission of Symptoms: After 10 years, 93% of the formerly borderline patients had experienced at least two consecutive years during which they no longer qualified for the BPD diagnosis, according to DSM criteria:

Time to Remission

Low Recurrence of Symptoms: After 10 years, among the 93% of patients who achieved symptomatic remission, only 29% became “borderline” again. In other words, once they improved to the point of no longer being diagnosable as borderline, a large majority did not get worse and become “borderline” again:

Time to Recurrence

Good Social and Work Functioning: After 10 years, 78% of patients had achieved good psychosocial functioning – defined as good performance in a job for at least two years, along with at least one emotionally sustaining relationship with a partner or friend:Good Functioning

To me this last slide is questionable, as it’s not clear how “good work performance” was defined (and a certain period of work is not a prerequisite for “recovery”, anyway). Nevertheless, this study shows how, in a group of previously hospitalized borderlines, most people improve to the point where they are able to function in a job and have an intimate relationship. Again, the study authors provided these patients with no treatment beyond brief hospitalization, although many probably sought help on their own.

Other Longitudinal Studies of Borderlines Are Also Positive

There are many other ways to critique this study; for example, one could say it only applies to “borderlines” in the northeastern United States who went through McLean hospital. However, other studies following borderline patients for decades reach similar conclusions.

These include Thomas McGlashan’s Chestnut Lodge study (Maryland, USA), Michael Stone’s “Fate of Borderline Patients” study (New York, USA), and Joel Paris’ longitudinal study of borderlines (Montreal, Canada). All of these studies concluded that a large majority of borderline patients improved significantly, and many recovered in the long term. Collectively these studies included over a thousand patients. These studies can be found by searching online, as well as through the books by McGlashan, Stone, and Paris on Amazon.

The Limitations of Naturalistic Studies Based on Diagnosis

The anti-psychiatry side of me says that these longitudinal studies reveal what a meaningless and unreliable diagnosis BPD is. It doesn’t make sense that some percentage of people are initially borderline, then at varying points in time they are suddenly no longer borderline, then a few of them are borderline again, and so on.

Maybe BPD was never a valid illness to begin with. But such common sense seems to escape Harvard-educated researchers like Zanarini 🙂 Then again, to admit that what they’re studying is an unscientific fabrication wouldn’t be great for their careers, nor for receiving funding from the National Institute of Mental Health.

Although these studies have flaws, I hope readers will see that people diagnosed with BPD do seek help, and that they can recover to be emotionally well and free of “borderline” symptoms. These are not just opinions. They’re facts.

On The Nature of Quasi-Experiments

Lastly, it is important to understand that these studies – like most in psychology – are quasi-experimental. This means they are not perfectly controlled experiments, because when studying human beings many factors simply cannot be controlled. One can never study a person as reliably as one studies solar radiation or the molecular structure of uranium.

No one quasi-study can “prove” a point definitively. Nevertheless, quasi-experimental studies can estimate the effect of a variable(s) on a group of people under certain conditions. And a pattern of quasi-studies with similar results can show that something real is happening

These studies should also not be interpreted as applying to any particular person. Rather, they are averages of many different people’s outcomes, and only have meaning on a group level.

Wow, I am exhausted thinking about all this data. Time to get a beer!

——————————–

I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

– Edward Dantes

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#21 – My Nightmare of Psychiatric Hospitalization

“Mood disorders are biologically-based mental illnesses”, the psychiatrist announced authoritatively, surveying the 15 young-adult patients in front of him. “But while these illnesses might be biological, it doesn’t mean you can’t manage them effectively.”

My mind reacted explosively: How the fuck could you possibly know this, you pathetic excuse for a mental health “professional”? What actual evidence do you have?!

I desperately wanted to shout at him. But I remained silent, slouching backward in my chair in the mental hospital’s group therapy room.

After concocting a suicide plan that almost succeeded, I had been involuntarily committed to this hospital for my own protection. But I was now becoming a captive of a different kind: a prisoner of psychiatry’s hopeless ideology.

This is the story of my time in a mental hospital – what it taught me about myself, about my fellow human beings with “mental illnesses”, and about the web of lies that is American psychiatry.

Descent Into Hell

In my early 20s, having suspended my college career, I returned home to live with my family.  Living three hours away at college had become increasingly difficult – I felt isolated, depressed, scared, and hopeless. I couldn’t live on my own – my father’s physical abuse, and the lack of love in our family, had left me not knowing how to make friends, date girls, or feel secure living alone. But once I got home, the feelings of hopelessness continued unabated.

It’s hard to describe how bad things were to someone who hasn’t experienced these feelings.  I remember wishing that I could escape my mind and teleport into the body of another person whose mind was not as “diseased”. I read Dante’s The Inferno, and felt that I was literally living out the punishments of those condemned to the seven circles of hell.

Something felt profoundly unstable and “wrong” at the core of my being. It frequently felt as if my existence was under threat, that my core self might at any moment disintegrate. I remember reading an astronomy book describing how comets orbited the event horizons of black holes, constantly at risk of being sucked in and destroyed forever. That was how I felt.

To put these feelings into a more understandable context, they were based on the belief that I had no chance of a successful adult future. I saw other young people having relationships with the opposite sex, but I had no idea how to talk to a girl at the time. I couldn’t think clearly about getting a degree or starting a career, because getting through the next day felt overwhelming, let alone concentrating on schoolwork. I couldn’t enjoy anything – movies, reading, friends, etc. The all-consuming anxiety made every day a struggle.

Suicidal Intent

This horrific state of emotional affairs set the stage for me to become seriously suicidal. After returning home, I decided that I had tried everything and didn’t deserve to suffer like this. I formulated a plan to end my life, which won’t be elaborated except to say that it involved a lethal method and might have succeeded. I prepared loving letters for my family and friends, and planned the date I would end everything.

After I made my suicide plan, I remember walking outside during a sunset. We lived near the ocean at the time. In my fragmented state of mind, I looked at the beautiful sea, the sunlight glinting off the waves, and felt an overwhelming sadness. Part of me was urging myself to find a way to survive, but I couldn’t see any hope. Despite the despair, I still appreciated the natural beauty of the ocean.

My Plan Fails

My plan failed because I am a bad liar. My friends noticed that I had withdrawn socially, was barely communicating, and had stopped taking physical care of myself. All my energy was focused on ensuring the suicide attempt’s success by planning it down to the smallest detail. But knowing my history of abuse, my closest friend sensed something was wrong. When he asked me what was going on, I denied any suicidal intent. But the next day, he found an opportunity to look through my bedroom while I was out of the house. Showing a remarkable sixth sense, he rapidly located my suicide notes stashed in the side pocket of an old backpack. I will always owe him for this.

When I returned home, my friend had told my parents everything and the emergency psychiatric response team was rushing to our house. I was completely taken by surprise. Two policemen and two psychiatric specialists soon entered our house and questioned me. I tried to deny that I was actually planning to kill myself, but it was no use.

After a brief discussion, I was led out of the house – in handcuffs – and put in the back of a police car. I was to be taken to the local emergency room, since space was not yet available at the mental hospital. The police explained that I was not being arrested; handcuffing someone was their protocol when someone is involuntarily committed to a mental facility. This made little sense, but I was in no position to question them.

The Emergency Room

The next day or so is a blur. I had to stay overnight at the hospital emergency room, where I could not sleep because of nurses talking loudly. A guard constantly watched my room; at one point he explained that I was being put on a “5150 hold”, which meant I was to be detained for at least 72 hours for evaluation. My mind churned the whole night, going through endless scenarios: Where was I going? What were my parents thinking right now? How dare my friend get them to call the police without asking me? Am I crazy? Should I lie to the doctors, get out of the hospital, and follow through on my suicide plan? Had I been wrong to give up hope? Might hospitalization not give me some time to find a better escape, one that allowed me to survive and live? Shouldn’t I give myself another chance? How could life be so hard?

The Mental Hospital

In the morning the guard told me to get ready because we were going to the psychiatric hospital. I expected to travel normally in a car, but instead I was strapped to a hospital stretcher and rolled into the back of a locked ambulance. I had the humiliating sense of being a prisoner, with everyone knowing why I was held hostage – because I was crazy and wanted to kill myself. The trip took almost an hour; at this point I hadn’t slept for about 36 hours. We finally arrived at the hospital, where I was wheeled inside a self-locking gate that led into “the ward”.

A Moment of Humor

Despite my horrible mental state, part of me was fascinated to see inside a real-life “asylum” for the first time. I was thinking about the movie One Flew Over the Cuckoo’s Nest, which I had recently seen. The ambulance drivers were pushing my stretcher along a hallway, taking me for evaluation in the Intensive Care Unit (ICU) – the place for the hospital’s craziest patients, as well as those arriving for initial assessment.

As we turned a corner, we came upon a long-haired, wild-looking young man. He looked like a young Jon Bon Jovi and wore an ill-fitting blue hospital gown. Four or five nurses faced him with looks of frustration on their faces.

“You’re nothing but a bunch of vaginas and penises to me!” shouted the young man in a loud, high-pitched voice. “Vaginas and penises! That’s all you are! You can go fuck each other for all I care! Go fuck each other, you hear me? What do you think about that, you motherfuckers?”

I could not help smiling at this. I was thinking, What kind of place is this? Are these people all crazy?

The nurses tried to convince him to go to his room, but the patient continued his verbal assault, eventually challenging a male nurse to fight him in single combat. At this point, two of the male nurses forcibly wrestled him to the ground. They pulled up his gown, and a female nurse plunged a syringe into his bare bottom. It must have been a fast-acting tranquilizer. With this done, the male nurses dragged his limp body to a nearby room.

I made a mental note not to call the nurses “vaginas and penises.”

The Strange Ward

Upon arrival, I was assessed by a series of nurses, who asked questions like the following:

“Are you planning to hurt yourself right now?” (No…)
“What’s your height and weight?” (6’2, 175)
“Are you carrying any weapon or sharp object?” (No… Of course, they had to body-check me)
“Will you tell us if you start feeling like you want to hurt yourself?” (Yes…)
“Are you feeling pain anywhere in your body?” (No…)

It was all so awkward. No one asked why I was there, or what had been going on to make me suicidal. They said the psychiatrist would talk to me. I had to fill out a superficial anxiety and depression questionnaire, and was then shown to my room.

The ward was a spartan place of accommodation. The rooms didn’t differ much from prison cells seen on shows like MSNBC’s Lockup. Each room had a small, uncomfortable bed bolted to the floor along with a basic toilet. They also had some old wooden cabinets, which made them luxurious compared to jail! Almost nothing else was in the room. Every 15 minutes, all day and all night long, a nurse would come to check that I hadn’t discovered some ingenious way to hurt myself. This made it hard to sleep at night.

Soon I wondered into the ward’s common area, a large square space with old sofas and a TV. Ten or twelve mostly young adults were sitting there, watched by three or four nurses. Some were staring into space, others watched the TV, one woman was talking to herself. Everyone seemed to be quietly doing their own thing. I had no interest in talking to anyone at first. I thought they were all crazy and hoped I didn’t become like them.

A nearby board listed group therapy sessions that occurred each day. I cannot remember what type of therapy they all were, but there was at least one Dialectical Behavior Therapy and one Cognitive Behavioral Therapy session.

Group Therapy

I went to a couple of these group therapies the first day. The CBT session featured a young psychology intern lecturing. He drew pictures explaining how thoughts, feelings, body, and the outside world were interrelated. I found it so superficial as to be no help in understanding anything (I was in a very negative mindset at the time). I wondered why they were not asking people to tell their own stories, or at least for their responses to the information provided.

I would soon find that exactly the same lecture was repeated every two days, with no variation based on the patients. Anyone new got to hear it for the first time, while everyone else got a repeat.

In the DBT session, the speaker explained the concept of wise mind, the place where emotions and thoughts overlap. He described how to distract oneself from negative feelings and be “in the moment.” He also stressed repeatedly “thoughts are not facts!”. The tone of this session annoyed me, because it felt like we were being talked down to like simple-minded children, or like computers needing to have our software reprogrammed.

The Psychiatrist

Being horribly depressed and ashamed, I was not in a mindset to appreciate these sessions anyway. I spent most of the time in my room brooding about the thwarted suicide plans, thinking bitterly about how unfair life was. On the second day, the psychiatrist assigned to my case called for me. I went into a small office to find myself facing an old man who looked like a mob boss out of the Godfather. He appeared Italian, with dark, tanned skin, and a smooth sense of accomplishment about the way he spoke.

“What’s so bad that you want to kill yourself?” he asked me.

I remained silent for a while, then told him about how depressed I was, how I couldn’t stop obsessing over negative thoughts, and how my father had physically abused me.

The psychiatrist thought about this, then asked for my family history of “mental illness.” I described how my dad had severe OCD and depression.

“It sounds like you have OCD too, plus depression” the psychiatrist said. “We have medications that will really help your obsessing, and they’ll help the depression too.” He prescribed three medications – including two antidepressants and an antipsychotic mood-stabilizer, if I remember right – all of which I was to start taking right away. At that time I didn’t know much about medications, otherwise I would have refused his prescription, or at least refused to take that many.

The psychiatrist also prescribed writing exercises. I was to “obsess” in a journal for thirty minutes a day – writing down every negative thought that came to mind. And the rest of the time I was meant to tell the negative thoughts to “go away, I’ll deal with you later!”

Toward the end of the session, I told the psychiatrist about my BPD diagnosis also. He responded that this was a tough condition that could be “comorbid” with OCD and depression. He said something like, “We don’t have a cure for borderline personality, but the symptoms can be managed”. I hated this idea right away. If I couldn’t really get better, what point was there in trying?

“These type of things can get better. We want you alive, that’s why you’re here and that’s why we’re treating you,” the psychiatrist said. I didn’t like this one bit – the messages seemed to be all confused – but it was more positive than some of the other things he said.

My View of the Psychiatrist

The psychiatrist’s worldview was alien to me. I intuitively felt that the medications would not help, while the writing exercises seemed ridiculous. The psychiatrist didn’t appear to see me as an individual. Instead he saw “borderline” and “depression” and “OCD” sitting in the chair, and he was trying to manage these “illnesses.”

When the psychiatrist said that BPD could not be cured, I felt furious. If I had a gun, I would have liked to shoot him right there and then. I imagined how satisfying it would be to put a bullet through his forehead, see his chair topple over onto the ground, the blood spilling everywhere, and for there to be one less idiot psychiatrist able to medicate patients into oblivion. It made me think of the opening scene in the movie Casino Royale, where James Bond confronts the traitorous section chief, whom he dispatches with a handgun (shown in the last 30 second of this clip):

Of course, I did not execute the psychiatrist. Nor would it have happened if I had had access to a weapon. Even in my crazy state, some part of me knew that this man probably had a family and didn’t mean badly – he just didn’t know how to understand people other than as illnesses. But my fantasies of hatred for his views were vivid, and I wanted to destroy what he stood for.

The Dead Zone

Over the next few days, I went to several more group therapy sessions, which continued to feel superficial and boring. I wanted someone to listen to my experience, not hear lectures about the mind and how to rigidly cope. But I started to become less suicidal and began talking with some of the other patients.

I continued meeting with the psychiatrist daily. He would only see me for a few minutes, asking how the medication was working and if I was having any more suicidal thoughts. I thought it was ridiculous that he was not talking to me for a longer time, getting to know me and understanding what might have caused me to become so hopeless. I would always say that I didn’t know how the medication was working, because I couldn’t possibly tell what was the effect of the medication and what was due to other factors. This frustrated him.

Before I spoke to other patients, the atmosphere on the ward often seemed stagnant, tragic, empty. It felt like being in a morgue with dead people walking around. The nurses “managed” the patients – watching them take their medications, controlling the difficult patients, coordinating mealtimes. Their were some kind nurses, but the majority seemed not to care about getting to know the patients. The most positive thing about the ward was its breakfasts – I remember we got French toast, bacon, eggs, and cereal most days!

The Other “Crazy People”

After about four days, I asked the psychiatrist when I could leave the hospital. He wanted my family to meet with the social worker and establish a plan for my starting therapy, plus establish ground rules to prevent me from hurting myself. This involved restricting my access to money for a period.

I was to stay for a few more days and, if it seemed like I was functioning ok, attending some groups, and not feeling suicidal, then I would be released. Until my release, since there was not much to do most of the time and I was feeling better, I began talking to other patients. That was one of the most interesting things about my stay. Let me describe a few of my fellow “crazy people”:

“Paul” was a big Latin-American man in his late 50’s with a jovial, outgoing personality. He spoke a little strangely, but was very friendly. He would always call me “Sir Edward” for no apparent reason. I told him about my English heritage; he was fascinated by my grandfather, a Jewish scientist who escaped from Nazi Germany. He told me how his family emigrated from South America to the US and established their own hotel business. Like me, Paul was a big racquet sports fan. We would talk about Agassi, Sampras, Federer, etc. debating who was the best. We had several table-tennis battles in the court-yard of the hospital ward. I would always beat him but it was close. I eventually asked Paul why he was there – to me, he wasn’t crazy at all. He said he had bipolar episodes, but they were now controlled with medication. I never saw any evidence of him being manic or depressed.

“Nicky” was a young woman in her early 20s. She was an attractive brunette, the kind of young woman to whom I was attracted but scared to approach. Eventually I struck up a conversation and found out that she had been hearing critical voices after using drugs, which led her to be hospitalized. She had a difficult relationship with her parents that led to the drug use and breakdown. But she kindly supported me when I told her how difficult things had been with my family. She also had coloring books which she would bring into the common area and get me to work on with her.

“Susie” was a middle-aged bipolar woman who had been experiencing hallucinations of sharp-fanged animals invading her apartment. She had had a difficult childhood with physically abusive parents. Nevertheless, she was an intelligent, interesting lady who had a successful career in a professional field. We would play board games together and she would beat me at Scrabble. I shared with her what had brought me to the ward, and she was warmly supportive. She reminded me of how important I was to my family; how hurt they would be to lose me.

“Ray” was a young man diagnosed with schizophrenia who had hallucinations and had been hospitalized several times. But he was a sweet person. It was clear that he wanted to be liked and to connect with other people, despite his “illness”. He didn’t even seem crazy to me. It turned out he had been able to work part-time on-and-off for several years, but the psychotic episodes, which I saw no overt evidence of, kept interfering with his functioning. He was on at least four or five different medications, which seemed like a lot. His mother would visit the ward every day and she clearly cared about him a bunch, sitting with him and holding him as if he were a young child. I was touched by her devotion, and introduced myself to the mother, telling her how nice I thought Ray was. I hope he got better going forward.

“Anouk” was a Middle-Eastern woman whose husband had physically assaulted her, leading her to flee from him, become severely depressed and suicidal, and eventually require hospitalization. She had a warm, motherly personality that was attractive to me at the time, lonely as I was. She told me about her five daughters and her dreams for their careers, and about how evil her husband was! She took a particular liking to me, and would give me high-fives and hugs when she saw me in the corridors. This went on even though patients weren’t meant to touch each other; somehow it seems that psychiatry has forgotten that friendly touch can be a healing thing.

“Jeanette” was another pretty girl in her early 20s. She had been admitted after running away from home and hitchhiking cross-country to “find herself”. She believed that plants had personalities and that you could be friends with them. She would keep a special hard-boiled egg in her room that had significance to her. Apart from these things, she spoke just like a normal person. I found her energetic personality quite likeable. But she was a social rebel and frequently argued with the nurses about rules. When they wouldn’t let her family bring in an I-pod, she became furious and acted out by stripping down naked and running through the common area with no clothes on! She was an absolutely gorgeous blonde. Hopefully she got better, and some lucky guy got to experience her beauty in a more private setting!

Reflections on The Patients Versus the Staff

Ironically, I got much more help from talking to patients than from the staff. The nurses mostly didn’t care about the patients as people, simply wanting to keep them under control. All the patients could sense this. The psychiatrist was worthless since we spoke only a few minutes a day about medication and practical matters.

But several patients treated me with genuine kindness. I kept in contact with a few of them afterwards via email and phone (even though the hospital warned against contacting other patients post-discharge… another stupid policy). To me, these patients didn’t have “mental illnesses”; they were just people dealing with serious challenges in living. I felt as if anyone could have reacted the way they did facing the same life challenges; but that wouldn’t make them “schizophrenic” or “borderline” or whatever. This experience influenced my thinking about BPD and other so-called “mental illnesses” being invalid diagnoses.

Several patients told me they hated taking medications, that they didn’t feel these medications helped, and that they got little out of the group therapy. One depressed man refused to take any medication; he just wanted to be there to be safe. The one good thing about the hospital – and I must acknowledge this for my own case – was that it kept me safe during a time when I might otherwise have hurt myself. For that protection I am grateful. I improved somewhat by the time of discharge, and was less of a risk to myself afterwards.

Psychiatry Doing More Harm Than Good

I believe that in many cases, mental hospitals dominated by psychiatry’s medical model do more harm than good. Ironically and perversely, psychiatry thereby becomes an obstacle to the recovery of the very people it is supposed to help. It promotes the message that people have biologically-based “illnesses” that they are stuck with for life. As I discuss in many other articles, this is a complete lie. And yet, it is presented as if it is the best that people can hope for.

Why limit people’s dreams with this type of reductionistic thinking for which there is scant evidence? Why not tell them that they are heroically dealing with understandable reactions to extremely challenging life situations, and that with understanding and love, they are likely to get better?

The answer, in large part, is that psychiatry’s reductionistic view of emotional problems as “mental illnesses” has infected the minds of most psychiatrists, who in turn infect their patients. And thus is promoted the pessimistic view of mental illness as a lifelong “disease”, rather than as a primarily psycho-social experience that can be overcome with sufficient support.

Psychiatry is also eager to prescribe as many medications as possible, which unfortunately do nothing to address the root causes of people’s problems. A prime motive is to perpetuate the billions of dollars in profit that companies like Eli Lilly, Janssen, Pfizer, etc. make, and to support the psychiatrists and shareholders allied with these companies. Helping the patient comes second, and if these patients could have done better with other forms of treatment and/or without medication, then too bad.

In my opinion, the network of drug companies and psychiatrists who weave lies about medication represent a fraudulent house of cards. Patients can protect themselves by learning just how ineffective medications really are over the long term. If more of us educate ourselves, then psychiatry will be progressively undermined. Newer studies are showing that most psychiatric drugs are barely or no more effective than placebos, and that the long-term side effects can be very dangerous. This is discussed in detail in the many articles on http://www.madinamerica.com

Lastly, the whole approach of the hospital was to “manage illness”, not promote healing and recovery. Even though there were signs on the walls extolling positive values like Hope and Responsibility, the interactions with the nurses, psychiatrists, and group therapists did not promote a sense of “we’re in this together” or “you can recover and do what you want.” Rather, the emotional message was, “You are the sick people, and we are the “normal” ones who will teach you how to manage your unfortunate afflictions.” Ironically, many of the patients were more helpful to me than the mental health professionals.

Conclusion: A Sad Reality

Such is the reality of inpatient mental health treatment for many in 21st century America. I urge people to avoid inpatient facilities wherever possible, unless they are in real danger of hurting themselves or others, in which case hospitals can provide a critical protective function. As much as possible, seek help from outpatient therapists, family, and friends who are outside of the traditional psychiatric system. I believe the chances of recovery from BPD and other conditions is greater following this path. Getting stuck in a cycle of going in and out of hospitals, being overmedicated, and being treated as if one is an illness, doesn’t promote recovery.

I would also direct readers to these websites that are great resources promoting recovery outside of the traditional psychiatric system:

http://www.madinamerica.com – Many fascinating articles about the worthlessness of psychiatric diagnosis, the ineffectiveness of medication, and the value of therapy, understanding, and love.

http://www.mindfreedom.org – Another anti-diagnostic site that rejects labels and is similar to Mad In America.

http://www.isps.org – The International Society for Psychological approaches to Schizophrenia and other psychoses. Many of the clinicians listed on this site are also well-trained in treating Borderline Personality Disorder. Much of their writing about psychosis could be applied to BPD. They are an extremely empathic, innovative, and optimistic group.

Feel free to share any experiences you have with “the psychiatric establishment” in the comments!

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I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

– Edward Dantes