Struggling Striving Surviving: Living with Borderline Personality Disorder

Copyright © 2013 by Dr Jenny Tohotoa.

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Rev. date: 03/05/2013

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CONTENTS

Preface

About the author

Overview of Struggling, Striving, Surviving

Chapter One

1.1 BACKGROUND

1.2 INTRODUCTION

1.3 DEFINITION OF TERMS

1.4 ETHICAL CONSIDERATIONS

Chapter Two

2.1 DEFINITION OF PERSONALITY

2.2 DEFINITION OF PERSONALITY DISORDER

2.3 CLASSIFICATION OF PERSONALITY DISORDERS

2.4 PREVALENCE OF PERSONALITY DISORDERS

2.5 DIAGNOSIS OF BORDERLINE

PERSONALITY DISORDER

2.6 CO MORBIDITY WITH BORDERLINE PERSONALITY DISORDER

2.7 DEFINITION OF BORDERLINE

PERSONALITY DISORDER

2.8 SELF-INJURY AND SUICIDALITY

2.9 FACTORS IN THE DEVELOPMENT OF BORDERLINE PERSONALITY DISORDER

2.9.1 Psychological factors

2.9.2 Biological factors

2.9.3 Social factors

Chapter Three

3.1 INTRODUCTION

3.2 QUALITATIVE RESEARCH

3.3 THE GROUNDED THEORY METHOD

3.4 DATA COLLECTION

3.4.1 Selection and characteristics of participants

3.4.2 Research Interviews

3.5 DATA ANALYSIS: DATA CODING PROCEDURES

3.6 WRITING UP THE FINDINGS

3.7 TRUSTWORTHINESS, CREDIBILITY AND TRANSFERABILITY OF FINDINGS

Chapter Four

4.1 STAGE ONE OF BEING VULNERABLE

4.2 Overview of stage one of being vulnerable

4.3 Living in a dangerous world

4.3. 1 Consequences of Living in a dangerous world

4.4 Being damaged

4.4.1. Damaged by being isolated:

4.4.2 Damaged by loss of mother

4.5 Neglect and Maltreatment

4.5.1 Consequences of neglect and maltreatment

4.6 Sexual abuse

4.6.1 Consequences of sexual abuse:

4.7 Physical abuse

4.7.1 Consequences of physical abuse

4.8 Loss of self

4.8.1 Consequences of loss of self

Chapter Five

5.1 STAGE TWO OF BEING VULNERABLE: STRUGGLING TO CONNECT

5.2 Feeling alienated

5.2.1 Consequences of feeling alienated

5.3 Communication difficulties

5.3.1 Consequences of communication difficulties

5.4 Fear of abandonment

5.4.1 Consequences of fear of abandonment

Chapter Six

6. 1 AN OVERVIEW OF STRIVING FOR AUTONOMY

6.2 STAGE ONE: LEARNING TO SURVIVE

6.2.1 Introduction

6.3 Reacting to being damaged

6.3.1 Adaptive behaviours

6.4 Self-harming behaviour

6.4.1 Drug use

6.4.2 Alcohol use

6.4.3 Physical abuse

6.4.4 Attention seeking

6.5 Ambivalence about living

6.6 Seeking safety

6.6.1 Hospital care—positive: contributing to seeking safety

6.6.2 Hospital care—negative: contributing to increased vulnerability

6.7 Summary

Chapter Seven

7.1 STAGE TWO: FINDING ANSWERS

7.2 Turning Point

7.2.1 Positive response to diagnosis

7.2.2 Negative response to diagnosis

7.2.2.1 Injustice

7.3 Finding a sense of self

7.3.1 Therapeutic intervention

7.3.2 Increased self worth

7.3.3 Self protection

7.3.4. Informal support

7.3.5. Role of employment

7.4 Family influence: positive

7.5 Family influence: negative

Chapter Eight

8.1 STAGE THREE: TAKING MORE CONTROL

8.2 Moving forward

8.2.1 Ways of taking control

8.3 Engaging in practical measures

8.4 Acquiring new skills

8.5 SUMMARY

Chapter Nine

9.1 CO MORBIDITY-INFLUENCES/IMPACT OF AN EXISTING MENTAL ILLNESS

9.1.1 Medication-negative effect

9.1.2 Medication-positive effect

9.1.3 Compounding symptoms

9.2 LOW THRESHHOLD TO STRESSORS DUE TO INCREASED VULNERABILITY

9.2.1 Internal conflicts

9.2.2. External conflicts

9.2.2.1 Intolerance and ignorance from others

9.2.2.2 Stigma

9.3 LEVEL OF SUPPORT

9.3.1 Formal support

9.3.1.1 Positive formal support

Chapter Ten

10.1 THE FINDING OF STRIVING FOR AUTONOMY TO OVERCOME BEING VULNERABLE WITH OTHER RESEARCH FINDINGS AND THEORIES

10.1.1 Maslow’s Hierarchy of Needs

10.1.2 Erik Erikson’s eight stages of development

10.1.3 Attachment Theory

10.2 A comparison of striving for autonomy to overcome being vulnerable with Cicchetti and Toth’s (2005) Child Maltreatment.

10.3 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with McDonald and Morley’s (2001) Shame and non-disclosure: A study of the emotional isolation of people referred for psychotherapy.

10.4 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with studies on self-harming Rosenthal, Cukrowicz, Cheavens, and Lynch’s (2006) Self-punishment as a regulation strategy in BPD.

10.5 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with the current models of treating people with BPD.

10.5.1 Dialectical Behaviour Therapy

10.5.2 Schema—focused therapy

10.5.3 Supportive Psychotherapy

10.6 A comparison of the finding in this study of striving for autonomy to overcome being vulnerable with McDonough, Wynaden, Finn, McGown, Chapman, & Hood’s (2004) Emergency department mental health triage consultancy service: an evaluation of the first year of the service.

10.7 Summary of the discussion

Chapter Eleven

11.1 IMPLICATIONS OF THE FINDINGS

11.1.1 Initiatives directed towards government planners

in the Health Department

11.1.2 Initiatives directed towards health professionals, mental health professionals in particular.

11.1.3 Initiative directed towards universities

11.1.4 Initiatives for teachers and day care centre staff

11.1.5 Initiatives for the general population

11.2 LIMITATIONS OF THE STUDY

11.3 FURTHER RESEARCH

11.4 CONCLUDING STATEMENT

References

Appendices

Appendix 1: Diagnostic and statistical manual of the American Psychiatric Association classification of disorders (DSM-IV-TR)

Table of Figures

Figure 1. Overview of Struggling, Striving, Surviving

Figure 2: The basic social psychological problem:Being Vulnerable

Figure 3: The basic social psychological process: Striving for Autonomy

PREFACE

This book is dedicated to all those people who struggle with childhood abuse and betrayal and who continue to strive for autonomy.

The book is the result of editing a four year Masters by research thesis and includes actual experiences and incidents as relayed to the author.

I would like to take the opportunity to thank all those participants who gave of their time and shared their life experiences with me. I hope you feel they have been respectfully explored and accurately described.

To my two supervisors for the Master’s thesis who contributed their expertise in academic writing and qualitative research methods: Professor Dianne Wynaden and Mr Brenton Lewis.

To Dr Karola Mostafanejad for her skill and passion in editing and revising the manuscript to better reflect the participants’ voice.

The book was written for health professionals, people diagnosed with a borderline personality disorder and for anyone who lives with or cares for someone with borderline personality disorder. It was written to enlighten health professionals and the general public to the lived experience of borderline personality disorder. It is a reminder of the incredible strength and persistence people can muster in their struggle to survive. It was also written to emphasise the need for greater empathy and sensitivity for people who have survived childhood abuse and betrayal.

ABOUT THE AUTHOR

Dr Jennifer Tohotoa has worked as a nurse in mental health for 30 years. Over the last 15 years, she specialised in the area of working with consumers who have a diagnosis of borderline personality disorder (BPD), both as a nurse and a counsellor. During that time, she has observed an overt negativity from health professionals in the community and in both the public and private health sectors to people with BPD. There is a tendency to negate their symptoms and a lack of compassion and empathy for their repeated self-harming or suicidal presentations to hospital. Lack of training and education about BPD is the most likely cause of this attitude and can hopefully be addressed. The seemingly manipulative, regressed and overt behaviours exhibited by people with BPD can overwhelm already over taxed staff, but the potential for improvement in this consumer group is she worth the time, effort and expense.

Jennifer believes people with BPD struggle to get their needs met within the current healthcare system and subsequently act out their frustrations, further alienating them from their caregivers. She supports short crisis admissions for stabilisation of acute suicidal ideation, followed up closely in the community with a key worker. Clinical supervision and support for the key worker is essential to stop staff ‘burn out’, from the emotional intensity involved with caring for BPD consumers.

OVERVIEW OF STRUGGLING, STRIVING, SURVIVING

The findings of this study are based on identification of the core category and its relation to subcategories. The findings identified a basic social psychological problem common to all participants, which was conceptualised as being vulnerable, and a basic social psychological process, entitled striving for autonomy, that participants engaged in to manage the problem of living in a dangerous world.

Two stages of the basic social psychological problem of being vulnerable emerged from the data. The first stage was called living in a dangerous world and involved two aspects. In the first aspect, participants described their experiences of being damaged by parents, family, friends and strangers that left them vulnerable and fearful. The damage involved neglect and maltreatment, sexual, physical and emotional abuse. This abusive childhood led the participants to experience the second aspect called loss of self and led to confusion with interpersonal relationships identified by never knowing who to trust, not having their feelings and emotions validated and being uncertain how to be. Not knowing who to trust, living in fear and unsure of how to be safe led many of the participants to the next stage of being vulnerable called struggling to connect.

Participants experienced an ongoing battle with being around people, feeling awkward, fearful and anxious. Three aspects of struggling to connect were identified in the data as feeling alienated, communication difficulties and fear of abandonment. Participants talked about feeling different from other people, thinking differently and seeing things from a different space. Not having a consistent, stable environment in which to flourish, many of the participants talked about their sense of futility and expressed their sense of alienation. Family and friends were seen as ‘good’ or ‘bad’ with no degree of compromise, so many of the participants had difficulties with their relationships and with their ability to adequately communicate their needs or wants. The fear of abandonment was explored by some of the participants and highlighted their vulnerability to rejection and their inability to take criticism without self-punishing.

To enable the participants to manage being vulnerable they engaged in the basic social psychological process of striving for autonomy. The basic social psychological process of striving for autonomy was a three-stage process and these stages were: reacting to the damage, finding answers and taking more control. Participants’ movement through the stages of the process was not related to the amount or type of abuse experienced in childhood but to their experience of being vulnerable and the conditions influencing that experience.

Reacting to the damage, the first stage of striving for autonomy, found many of the participants coping in a perceived maladaptive manner through the use and abuse of drugs and alcohol and engaging in serious self-harming behaviours. Data analysis revealed there were three aspects to reacting to the damage: perceived maladaptive coping mechanisms, ambivalence with living and seeking safety. Participants related their need to escape their dangerous world and this frequently involved illicit drug use and abuse and the use and abuse of alcohol in an effort to relieve the constant anxiety and distress they experienced. When drugs and alcohol were ineffective in reducing the feelings of despair, loneliness, emptiness and shame, many of the participants initiated self-harming behaviours of self-mutilation and overdosing, to get acknowledgement for and attention to their psychic pain or to relieve the unbearable tension they felt. For some participants the self-mutilation was a way to feel alive. The self-harming acts sometimes became suicide attempts and these desperate measures were described by several of the participants. Many participants talked about having suicidal ideation and experiencing a sense of futility and joylessness that added to their vulnerability rather than decreasing it. The final aspect of reacting to the damage saw the participants seeking safety. For some participants this included getting married, while for others it meant containment and safety in a hospital admission. This acknowledgement of their increasing vulnerability led to participants searching for safety to enable them to firstly, survive and secondly to continue their striving for autonomy.

The second stage of the basic social psychological process of striving for autonomy was called finding answers. This stage consisted of two aspects: turning point and gaining insight. When the participants reacted to their damage, they became more vulnerable and self-abusing. To enable them to survive, their self-harming behaviour and suicidal thinking needed to change. Struggling to understand their constantly changing moods and the ongoing emptiness that participants expressed, found many of the participants in crisis.

For most participants, the turning point consisted of a significant personal crisis, and a diagnosis of BPD, which prompted drastic action to find some meaning to their lives. For some participants, this meant giving up drugs and alcohol and participating in life, for others it meant making a commitment to themselves and decreasing the self-harming. All the participants reacted to the turning point by changing aspects of their lives to reduce their vulnerability and increase their striving for autonomy. In this stage, participants were beginning to learn about their BPD. For some participants that meant finally having an explanation for their dysfunctional lives, for others it meant another form of discrimination and alienation and it took them longer to be able to reduce their vulnerability. As participants gained insight into their disorder, they were more able to move towards the next stage of taking more control. This stage saw the participants engaging in self-fulfilling behaviours rather than self-destructive behaviours and thereby increasing their quest for autonomy. Taking more control consisted of three aspects that were identified as moving forward, engaging in practical measures and acquiring new skills. Participants experienced intermittent suicidal ideation but were now more able to control the intent. Many of the participants engaged in some form of formal therapy and continued to learn survival skills that would assist in their battle for autonomy.

Three conditions were identified in the data that influenced the basic social psychological problem of being vulnerable and the basic social psychological process of striving for autonomy. The first condition was the co morbidity—influences/impact of another mental illness and it highlighted the added difficulty some participants experienced with another illness superimposed on their BPD. The second condition was the low threshold to stressors due to increased vulnerability and recognised the heightened intolerance to both stress and anxiety that the majority of participants experienced. The last condition to affect the participants struggle for autonomy was the level of support the participants experienced in their lives from family, friends and health professionals.

In summary, the finding of striving for autonomy to overcome being vulnerable saw participants move from a state of extreme fear and mistrust to become more aware of themselves as individuals, gaining insight into the disorder of borderline personality and turning that insight into learning more about appropriate coping skills.

Figure 1. Overview of Struggling, Striving, Surviving

CHAPTER ONE

Chapter 1 includes the background and purpose for the book, introduces the reader to borderline personality disorder, incorporates a definition of terms and describes