Why didn't therapy work for my borderline personality disorder (BPD)?
Borderline personality disorder is also known as emotional dysregulation disorder or emotionally unstable personality disorder (World Health Organisation, 1992). Despite being referred to as a ‘personality disorder’, it is not a character flaw but is best understood as a limitation in a person’s capacity to regulate emotions.
If you can identify with traits of emotional instability, you may find that your feelings are constantly shifting, or you feel that you are on the verge of spiralling out of control. However, sometimes it is more than just a mood shift. You may get the feeling that you can go from being ‘normal’ one minute to feeling and acting like a completely different person the next. It is as if there are different personalities, or ‘modes’(Young, Klosko, and Weishaar, 2003) inside you. All these modes come with their own mannerism, feelings and personalities. For instance, you can be particularly prone to anger in one mode (the angry child mode), and feel sad and completely fragile (the vulnerable child mode) in another. One moment you are impulsive, the next moment you are numb, detached and shut down. When you are in a destructive mode, the other healthier, more resourceful parts of you seem to vanish and you are not able to bring yourself back to calm.
What makes it even more difficult is that sometimes the triggers for your emotional flips are not known to you. You may simply ‘wake up feeling bad’ without know why. This is a core issue for those who struggle with emotional regulation, and the constant mode shift also makes it difficult to hold onto a solid sense of self, and as a result, you may be left with the dreadful feeling of hollowness on the inside.
By combining theories in the field of cognitive psychology and neuroscience, this article explains how this kind of sudden and drastic shift in your feelings and behaviours happens, and why traditional therapies such as cognitive behavioural therapy (CBT) may be limited when it comes to addressing these issues.
The power of our memories
Everyday we absorb information from the outside world through our five senses. As adults, we automatically connect the day to day information coming our way with what is already in our system to make sense of what is going on. For instance, right now you are linking up the words you are reading to your knowledge about English grammar, vocabularies and syntax that were previously stored in your memory network. In other words, your memories are the basis of your current perception, and how you respond to people and events in your life is to a large degree based on your past experiences.
In psychology, the relationship between conscious and unconscious memories is illustrated as an iceberg, with the majority of our memories remaining buried and unconscious. Your current attitudes, emotions, and sensations are not simply reactions to a current event but are also manifestations of physiologically stored information in your memory. Everything that has ever happened to you was recorded in your memory, even if you do not consciously recall them.
According to the adaptive information processing model (Shapiro, 2007), our brain has a processing system that is naturally geared towards integration and healing. When uninterrupted, it has the ability to link up useful and restorative memories with the difficult ones, to help us maintain a certain degree of emotional equilibrium.
However, when we come across a particularly difficult or traumatic situation that overwhelms us, the adaptive processing is disrupted. The distressing incident will then get stored in our mind in a way that is ‘frozen in time’. It becomes a stand-alone piece of information that is disconnected to the other parts of our memory network. We may not even consciously remember it. Often, our negative behaviours and uncontrollable feelings are the results of these dysfunctionally held informations (Shapiro, 2001).
The 'invisible trauma' of BPD
Much of how we relate to the world around us is learned in the first few years of our lives.
New findings in neuroscience let us know that our early attachment patterns deeply affect the way we process information throughout life. Securely attached children learn from an early age that they can trust not just the world and those around them, but also how they feel in themselves. As adults, when distress happens, they can trust their own ability to regulate and modulate their own states.
However, in other cases where the caregivers were unavailable, aggressive, unpredictable or were not able to regulate emotions themselves, there would be a rupture in the children’s attachment patterns.
Children are not meant to be left on their own to deal with emotional upsets. Without a responsive caregiver to be there to mirror their feelings and to model healthy regulation, a child would not know what to do and would be overwhelmed by his/her own distress.
This is being vividly demonstrated in the still face experiment (a famous psychology experiment conducted in 1975 by Edward Tronick, a short Youtube video clip can be found here: https://www.youtube.com/watch?v=apzXGEbZht0). As you can observe in the video, the emotional dysregulation caused by the lack of mirroring is so horrific that it cannot be taken in or understood by the child’s brain. It overwhelms his natural processing system, resulting in psychological trauma.
Most psychologists support the theory that BPD is a result of early traumatisation (Timmerman & Emmelkamp, 2001), often of a chronic, developmental and relational nature. These traumas are the results of a series of repeated, often ‘invisible’ childhood experiences of maltreatment, abuse, neglect, and situations in which the child has little or no control or any perceived hope to escape. As a result, these children’s memories will be dissociated into fragments. There is a breakdown in their capacity to process, integrate their experience and their own states. As a result, even as adults they feel ungrounded, fragmented, and unable to hold onto a solid sense of self.
Within the first six years of life, we live in what is called a delta theta brainwave state. Before we are able to think rationally or express ourselves, all the experiences, good, bad and ugly, are all recorded through the reasoning level of a child. This is particularly problematic when the memory is negative because the memory of the original distressing situation will be stored in the brain in its original form, with the visceral reactions and logical reasoning of a child’s mind. For instance, even when nothing objectively disastrous had happened, if as a five-year-old we had felt unloved or rejected by the world, that would be how the memory remains in us - with all the helplessness, hopelessness, and fear of a five-year-old.
When you go through an emotional trauma, even a small one, your higher rational thinking is disconnected. When you are in shock, your brain dissociates - it tries to ‘lock up’ the incident and all the associated feelings in a drawer of your memory bank. In other words, you remain ‘stuck’ because that piece of traumatic experience is stored the memory in isolation, it is unintegrated within the larger system and therefore it is unable to link up with the newer, more useful and adaptive information (e.g. I am an adult now and not everyone hates me) that promotes healing.
Why do I do things I don't want to do, feel things I don't want to feel, say things I don't want to say?
Your subconscious mind works by association, and without your conscious awareness, it can be triggered by seemingly random imagery and sensory associations. Sometimes it is so subtle and rapid that your reasoning mind is not able to catch up or make sense of it.
Whenever something occurs that the mind associates with your original upset, the memory of that bad experience is re-activated. You may suddenly feel drastically different, have certain intrusive thoughts, or act in a certain way. When you have a ‘mode flip’, it is as if you suddenly switch from being a rational adult into being a tantrum-throwing child. This is because, in a way, you are re-living the trauma at the level of that of a child. As a result, you may lash out at your partner, have unexplainable rage, or engage in addictive or self- sabotaging without knowing why.
While the image of the event may not come back consciously (flashback), as it often would if you have actual post-traumatic stress disorder (PTSD), the negative self-talk that you consistently have (e.g. ‘I am no good’, ‘I am not safe’, ‘I cannot trust anyone..’) is also directly related to the perspective you had at the time of the original bad experience. The knot in the stomach, tightness in the chest, the feeling of fear, the shame and the powerlessness are all directly related to the original event or series of events you experienced as a child.
We have little control of these episodes of collapses or outbursts because whenever our trauma memories are reactivated, the conscious, logical, thinking mind is bypassed. This is a mechanism that is hard-wired to protect us. Since there is a perceived threat, our fight-flight system kicks in and take over for the purpose of survival or protection, and it is given priority over reasoning and logic.
The reason we cannot easily identify our actions are responses is that we may be totally unaware of the stimulus that caused it. However, it is useful to know that when our reaction seems ‘illogical’ or ‘disproportionate’, the real stimulus is actually almost always a memory.
"That’s why time doesn’t heal all wounds, and you may still feel anger, resentment, pain, sorrow, or a number of other emotions about events that took place years ago. They are frozen in time, and the unprocessed memories can become the foundation for emotional problems… And since the memory connections happen automatically, below conscious level you may have no idea what's really running your show." (Shapiro 2015, p. 23)
Why didn't therapy work?
It is proposed that there are generally about ten-20 unprocessed memories that are responsible for most of the pain and suffering in most of our lives (Shapiro 2015). However, the number may be a lot higher for the chronically neglected or bullied child.
Traditional forms of therapy, such as CBT, may not be effective in healing the deep emotional trauma that causes your current reactive responses because most of these pre-language trauma memories are shielded from your cognitive process. Your intellectual, ‘logical’ brain is bypassed when you are triggered. So even if you logically know that your reactions are ‘irrational’, it doesn’t change your emotional reality, which still contains the feelings, perceptions and physical sensations you once had as a child. Where CBT may teach you to suppress or argue with your negative emotions, most often than not, before your logical mind can take over, you have already acted out from your emotional brain.
Traditional cognitive behavioural therapy also assumes that it is your ‘irrational’ thoughts that cause all the problems. It assumes that thoughts precede emotions, which as we have seen, is not true in most cases. For emotional pain that finds their roots in developmental and attachment injuries, it is unrealistic to think that one can ‘think’ oneself into healing and integration.
Moreover, as an emotionally sensitive and intuitive individual, having a real, synergistic relationship the person that you are working with is essential. Not only that it is about trust and rapport, it is also about what your therapist emulate, and the ‘health’ of the energy in the room where healing occurs. One of the ‘roadblocks’ (Markowitz, 2005) to CBT being effective is that if the therapist focuses solely on what he considers as ‘dysfunctional thoughts’, she neglects the fact that she is facing a multi-dimensional individual with his own unique psychological, social and biological make-up. After all, the whole point of therapy is not just to download a set of skills that you can find from self-help books, but to gain from the synergistic work between you and a therapist who has done work on him/ herself and is able to model qualities such as assertiveness and resilience from the inside-out.
Therapies that create lasting changes work on a visceral and relational level. On top of the therapeutic relationship, your therapist may also incorporate experiential techniques that evoke impact in an emotionally connected way. These techniques aim at producing changes on a physiological and even neurological level, bypassing the cognitive mind.
EMDR, for instance, uses a technique called ‘bilateral stimulation’ to directly evoke healthy connection in your memory network, linking up the bad, locked up memories with the good, adaptive ones. Schema therapy uses certain experiential strategies and the therapeutic relationship to promote healing on an emotional level. Other body-based techniques such as somatic experiential are also effective in creating changes from the ‘bottom-up’, rather than ‘top-down’.
The treatment protocol for people with BPD has radically changed in recent years. The newest research challenges the old assumption that long-term intensive treatment is essential for good outcomes, as it was found that therapies with various integrative modalities can have equally, if not, even more, positive outcomes. If you had felt ‘stuck’ in the talking therapy or were frustrated with constantly arguing with your own mind, it may be worth explore these alternatives.
Although it can be tempting to paint people with BPD with a single brush, but the truth is that people with the same diagnosis may have different presenting issues, and therefore want different things from therapy. Real therapeutic work comes from honouring your specific needs as an emotionally sensitive and intense individual.
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