BPD & CPTSD | Debrief w/ Dr. Choi-Kain after Jake Session | Borderline & Trauma

can you tell me um where you find Jacob's like what was your experience in the session well first I want to say it was just such a pleasure to meet Jacob because I think he's just an illustration of both fragility and the resilience of people and I think that the process that we had together really represents his problem which is that I think he experiences both a painful sense of fragmentation and incoherence but then he's constantly working hard to hold himself together and I think that was Illustrated in our interchange is that he was trying so hard to communicate not just to me but to everybody out there watching what's meaningful about his journey with BPD but then I think he was managing a lot about himself you know this self-criticism he has and his difficulty with letting himself be experienced as good and worthy and having a positive impact on others so I found it both understandable but difficult because I think in his process of self-management he kept sealing himself off and covering things up just to contain himself which of course he needs to feel more in control and like he can manage the moment but then that interrupts his ability to connect with the person who's there like me in the interaction but also with the outside world right so you can feel the kind of challenge he has with his on one hand the desire to have a meaningful fulfilling connection with others but also the difficulty of feeling comfortable enough to let people in if someone was working with him for a period of time what do you think would be helpful to him I think that Jacob has an incredible intuition for how to make things work the fact that he survived his life experience and is continuously trying to make something productive and constructive out of it is just a sign of his survivorship and I do think that this turn that he had that he mentioned very early on into a creative process of writing was probably the best he can do as a first step to understanding himself better without the intrusions of others because he's so interpersonally sensitive the experience of not just having traumatic abusive um interactions with family but also this kind of exploitation and validation and crushed hopes for a better relational environment has really scarred him in a way to both be hyper Vigilant and disorganized by others but also feel like the responsibility of organizing and taking care of others so when he goes into his own independent process of researching writing about himself communicating just for the sake of clarity I think that's where he does Best But I think that when you introduce another person into the situation like a therapist or a partner or someone who's aiming to be helpful and supportive towards him I think he actually gets activated in this very disorganized attachment style so that you see him actually trying so hard to take care of the other person and delivering what he feels like they want to keep them in a non-threatening position that he can't simultaneously keep track of his own independent position so sometimes therapies that allow people who have these sensitivities to the presence of others will give the patient a lot of work to do outside of the session independently to think about their problems and what they're learning in the treatment in their own time and space and I think that is actually really vital because at the end of the day I think his realization that he has to take care of himself first and figure out a plan for himself independent of others I think that is the right starting point for someone who's had such instability at other people's hands so that he can feel a greater sense of control and predictability in his own life so I would encourage him to continue to do his writing and telling his story in a way that's a bit independent and maybe a step removed from his own experience before he starts to clarify for himself how he's going to actually tell his story in more emotionally present authentic way with another person who is trying to take care of him and like his experience is very inextricably linked to trauma you know the capital T drama and um you know because there's always this debate of right is is BPD really complex PTSD or is it just people with PTSD who are expressing in this way but could you help me parse out the relationship with trauma Jacob's story really illustrates the common clinical presentation that people who have had serious and repeated traumas in their upbringing largely in the context of neglect and inconsistent parental availability they're not only prone to have post-traumatic sequelae but they're also prone to having trouble developing a well-functioning and stable personality and the two components are these is that any overwhelming situation that causes a feeling of powerlessness will induce these symptoms of dissociation or escape and avoidance in order to kind of help that person maintain a feeling of being in control and one of the things we see in Jacob is that his need to control himself as the source of the problem whether it's his fault or he's causing someone else a problem is keeping him very isolated and stuck on the other hand the fact that he didn't have the kind of interpersonal and reliable support he needed to gain a sense of managing for himself and relying on others that has led him to have a very underdeveloped personality Style so I think his early experiences have contributed both having PTSD and not knowing how to use relationships to manage emotional needs as well as having problems of a personality disorder which he feels really explains the difficulties that he continues to have and so in a situation like Jacob's um what is the trajectory to start to build what you didn't have you know I I think that for him trying to have a new story for his future is really all he can do to move his life forward so he has clearly done a lot of work thinking about his past either through his writing or through his treatment and while it has been incomplete he's come to the conclusion that he did not get his needs met early in childhood that there are a number of figures that really failed him and not only did they fail him they initially promised protection that he was so vulnerable to want to kind of attach to but then ended up being so damagingly disappointing that then he kind of um would just withdraw and give up on both himself and others so if he can actually think more about what he wants from the future and then understand that his reactions in the moment to new relationships have something to do with his programming from the past if he can separate himself from his kind of instincts or urges and try to do something more constructively in the moment I think he can actually really have some experiences that correct his expectations that everyone's going to be harmful so that he comes to the conclusion not that people are harmful but that they're inherently disappointed pointing and again that comes to this issue of self-reliance when you've been so sensitized to the failings of others and their self-interest which has been quite damaging to Jacob over time then having some self-control has to do with being able to know that it's your job to manage the vulnerabilities you have which I think he's constructively conveyed as problems of borderline personality disorder and then he has to actually be responsible for interacting with others in a way so that it promotes the responses he needs I see so he's not lashing out or testing or pushing people away he's more aware of those Tendencies and he notes them but then he tries to do something differently got it so it's this kind of more mature sense that he's developing of both being self-reliant for his vulnerabilities that come from his past that nobody can change and then doing the things he needs to do in current relationships to build a new experience a new way of relating to others and I think that's is really hard about having BPD is doing that all on your own even with good treatment is just a lot of hard work but I think Jacob is doing it with a lot of the resources at hand whether it's treatment work new relationships research writing he's making use of these multiple modalities to revise his experience of the world so that he can feel more comfortable being himself right that makes sense and and so in a way if you have to set up your own essentially treatment facility which is what he's doing I guess someone has to figure out how to in a way do this for themselves to say okay I reacted this way before I responded this way before and I know that it did this so I'm in a really observe how I'm responding and try not to respond that way again despite all the discomfort that that's going to generate I'm going to hold myself steady in that discomfort I guess I say that I say that because so many people don't have the resources of a good therapist so how do they go ahead and do this if they're motivated and driven to do it without that well I don't want to undervalue the kind of importance of good therapy as a very reliable structured um sanctioned and supervised space where people can do this but I think what you're saying about Jacob is ultimately the path that many people if not most will have to take and I think it's not only what you've described with developing some self-awareness and a capacity to change your habits so that you follow a different train of behavior than the one you recognize is causing you problems but I think what Jacob has done so beautifully is really reconcile himself with failures within his own life that he actually takes a lot of responsibility for so for example the relationship with the partner that was actually really good to him he actually tells that story with a sense of remorse which is fairly mature and it's different than this self-critical component that we saw when he's managing himself and kind of criticizing himself for not being more comfortable or not being coherent he managed to say well at the time I was really in a lot of pain why wouldn't you be after what he had been through with his family and with this relationship that was very controlling with a power differential he was really vulnerable and hurting and he met someone who actually was providing a bit of what he needed and that is experienced with a lot of conflict that on the one hand you need that and you're so desperate to maintain it but on the other hand you don't trust it and you constantly need to push it away to prove to yourself that there was a reason you didn't get it all along right and he seems to have somehow independently resolved that it wasn't that other person it was his own limitation in being able to be settled enough to let that person stay in its life right so it's these recognitions of his own Tendencies to obstruct his own growth yeah that I think is most encouraging about Jacob yeah and that's where I think his kind of self-assessment of his own self-reliance as a key to the beginning of his self-discovery is really accurate it's not so much about being independent in the ways in which I think he could change like he's too unable to let people in or lean on others at the moment but he is able to take responsibility of the things he's doing now that may not be his fault because he's had to adapt to a lot of traumatic events but it is his responsibility to work on in order to get a different outcome in life and that's where I think he's used the BPD diagnosis really constructively BPD is not a diagnosis that has any evaluation or judgment about why a person has become that way right whereas trauma is embedded in the notion that something very damaging overwhelming and life-threatening has happened to you BPD is an outcome yeah that really indicates one's capacity for self-direction a positive and stable sense of self and a mutually satisfying and realistic way of relating to others if that's damaged then that's what's really perpetuating a sense of limitation and futility in life and what Jacob really shows is a ability to embrace that as his current problem which is really um promising because a it's empowering because you had some you had something to do with it you you exactly you know you can also change that but it is like it's the opening to possibility absolutely and I think that's a misconception about BPD is that when you tell someone that their current problems are generated from the way they're managing themselves in others it feels like they're blaming them but what you're saying is I think the other side of that the other reframe that is really constructive is saying actually it's something within you that you can control right and rely on yourself to make decisions about even though you can't always predict or influence what other people do or the Fate that the world has for you so it does Center you and gives you a focus of what you can do about your life and in that sense it's empowering yeah but what I'll also say about this kind of combination of trauma-related factors and personality factors that I think Jacob nicely expressed and articulated and demonstrated to us is where they overlap is that there is this kind of painful recurrent situation that Jacob is experiencing in the world of being all alone overwhelmed with some sort of challenging stress of the day and unable to lean on other people that kind of Triad of factors causes him to really panic and in that panic I think for any of us it's tempting to either avoid the thing that becomes overwhelming which is in and of itself life limiting or to escape through some sort of crisis through episodes of self-harm or addiction or relationships that are volatile these become um escapes that generate a different kind of adversity but nonetheless interrupt or distract away from these intrusive memories of past trauma so the avoidance and Escape that we see as an outcome of PTSD is also very Central to emotionally and interpersonally overwhelming situations that people with BPD find themselves in and use shutting down and blowing up to manage Jacob's situation it seems like the two are so linked fused or fused yes so if someone was treating him is there is there a way you handle that differently than you would handle a quote unquote classic BPD case that is without that kind of capital T history of trauma I I think one one of the things I've changed my mind about is that I don't think it's so cut and dry I do think that for Jacob he's done a lot of independent work on establishing a life now that feels somewhat stable predictable and manageable he is a job that he's good at he has this other pursuit in writing that brings him a lot of meaning and um clarification about himself and his future as well as a sense of self-esteem and he has some good relationships right now so one of the things I think that um I would say about him because he's stabilized his personality functioning um is that he would be ready for something that's a more trauma-focused treatment a lot of trials for trauma focused treatments have excluded people in their studies who have serious suicidality or self-destructive papers AKA those with borderline personality disorders so we're not always sure how well those treatments will work for people who have comorbid or co-occurring BPD so once someone can stabilize their BPD symptoms they may be able to go back and do something like exposure therapy which reintroduces elements of their traumatic situation so that they relive that experience with the benefit of being able to tell their story coherently as a memory instead of as something that keeps happening to them interesting and in processing the trauma through exposure they actually get a handle on the experience of the trauma not that it was a good thing or something that wasn't damaging but it allows them to process the emotions so that it doesn't lead to such a feeling of helplessness and powerlessness I see and then this allows them to feel like the trauma was in the past rather than recurring and then they can move on from it and not experience every interaction that becomes overwhelming as another trauma interesting interesting so I think that he could benefit from a trauma-focused treatment if he could find one and if that's what he wants to do it seems that he's almost ready to do that and my sense is it might be easier to find a trauma-focused treatment in this world than it is to find a BPD treat her in this world and so that if he was to focus his task of searching for a therapist he might want to look for a trauma therapist actually I think that nowadays there are a lot of people who are trained in evidence-based treatments for BPD there are actually more people trained in things like DBT MBT and tfp than before and the problem is while there are a lot of therapists who are really good at treating trauma they're training and treating it in the presence of BPD is pretty Limited so when trauma therapists are working with the patient like Jacob who clearly has so much interpersonal hypersensitivity related to BPD the desire to people please but also to feel frightened by care combined with this self-destructive element that interrupts the the trauma therapist's ability to push the patient forward with very emotionally charged work so I think that the trauma therapy in a self activates a very BPD focused dilemma interpersonally in the Therapeutic Alliance which is it becomes very difficult to tell if what you're doing is helpful or harmful and that's the very dilemma that Jacob has is this confusion over whether or not care is damaging or genuinely supportive and so when you enter into a moment in the therapy where there's an emotionally overwhelming memory of something that was has scarred you for the kind of remainder of your life it's hard to not reactivate that inherent way of relating to others in a time of need so the therapist just has to be equipped to manage that relational element which some trauma therapists are and others may not feel as comfortable with especially in the context of suicidality or self-harm I think the work of Martin bojas and the creation of dialectical behavioral therapy for PTSD it's a treatment that he specifically tailored to people who have problems of both borderline personality disorder and severe early complex trauma yeah and so what he's done in this treatment that really honors the fact that there are these overlaps in the disorder where there's avoidance and escape to overwhelming situations and also an incapacity to build one's life forward in a satisfying sense he's really packaged resources together for the patient to be able to work somewhat independently at times with worksheets and homework and exercises on their own where they don't have to rely on the therapist and then he combines that with an exposure therapy so that the treatment can help patients appreciate that the trauma is a memory that's controllable what rather than an intrusive recurrent memory that becomes activated in the present what I had read with mentalization one of the things that they have worked on but maybe this is standard trauma therapy you actually choose to bring the trauma thought into your you know into your conscious orbit in a moment when it's not circulating if you can do that then you can also level some command over the thought when it comes in intrusively without your choosing well I think that what mentalization-based treatment and dialectical behavioral therapy for PTSD have in common is the kind of acknowledgment that compassionate validation of the suffering of the person who's been through what they've been through that's really the therapeutic ingredient that can help someone see this as a part of their past that they've lived through that's impacted them but is in the past and is no longer what's going on right why is that though why compassionate validation what does that do to the person that allows them to see it as their passages because they were so not validated so it sort of shakes them or jolts them into the present I mean what is it if there's something like mechanical almost happening it sounds like you're saying I think it's about that interpersonal backboard that I discussed with Jacob is that everybody when they've experienced a difficult situation where there's confusing emotional reactions it's very containing and um helpful to have someone acknowledge what you've been through so even having someone just say this is terrible that this happened to you and you didn't deserve it it's not your fault that in and of itself contextualizes the problem so that the person recognizes that they've been hurt and that they need support to move forward from that injury and so that compassionate validation of their suffering and experience helps to contain that part of it so that they don't attribute that to them being bad and the source of why this thing has happened to them or the world being dangerous and that they can never be okay or out of thread in the future moving forward so that compassionate validation provides some definition to where the problem was that something happened in the past that was very hurtful to them and that's why they are struggling in the ways they are struggling now but there is a way to move forward that you can understand things differently and then see yourself and others in a way that might help you have a different experience in the present so part of how um treatment works is to help a person refocus their way of managing themselves and making decisions about their lives based on goals and what they want or values and it seems like Jacob is already doing that he's defining the things that are important to him and he's trying to make decisions based on what's going to promote that and this kind of combination of resolving things from the past as in the past not the person's fault and having caused a lot of suffering and adaptive reactions that made sense for their survival then but aren't helping them with their goals and values that kind of combination of factors whether it's in a dialectical behavior therapy or mentalization-based treatment I think can help people who both have been very damaged by traumatic events in terms of being really restricted in their ability to live in the world and also having personality problems and very limited in their ability to manage themselves and create fulfilling relationships with others thing do you have anything to add Beyond I mean is there anything more you would want to debrief on for well the one thing I would say about Jacob vis-a-vis the avoidance and Escape is that the thing I found very um painful what for him was that as he was opening up about things that were generating some painful emotions for him I think all he could do was either kind of distract himself by being entertaining or humorous or avoid the topic and switch gears and I think that's what was leading to kind of a bit of indirect conversation or tangentiality but I saw that as a real effort for him to manage the moment and I think it's getting in the way of him feeling more clear about himself and more clearly understood by others but it's an adaptation to not having anyone else to rely on so he's constantly short circuiting his emotional experience in the moment to stay grounded but that in and of itself is not helping him gain the Mastery over his own story and his life moving forward and his ability to connect with others so I think if he can become more aware of his tendency to avoid and divert in the face of emotions that he finds vulnerable I think he's going to actually do much better in terms of overcoming all of this trauma in his life and having a more steady way of managing himself in relationships with others and I think as his life feels more like a safe container for him to genuinely experience the emotions he has then I think this will all fall in place with him it will never be easy because he's had a over investment of trauma and an under investment in his own developmental trajectory of building capacities to manage so this will never be easy for him but he is doing what I think all people need to do to set up their life in a way that they feel good enough to Bear the painful emotions they have about what they've been through and so I think he'll get there but I think now it's still really like a like he said a moment-to-moment effort for him to survive yeah thank you so much thank you for your time and wisdom as always anytime

Channel: BorderlinerNotes

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Id: 49CndcLdKzk

Length: 32min 12sec (1932 seconds)

Published: Tue May 23 2023