BPD & Trauma: One and the Same? | Dr Frank Yeomans

we often get comments on the channel where people say there is no such thing as bpd it is all trauma and my very anecdotal response to that is i personally have no capital t trauma in my history yet i met diagnostic criteria for bpd but i'm just one person maybe everyone else has trauma and bpd is not really a thing so i'm curious for you to address well that debate goes back a long time in the 1990s there was a very strong movement that took the position that bpd was a misconception and an unfair characterization of patients that all patients with bpd were actually trauma patients should be recognized as such and that the treatment should focus on helping them move beyond their ptsd status studies show that 70 or so percent of people diagnosed with bpd have a history of some form of trauma there are different forms of trauma within that 70 but let's leave it at that for now that certainly would support to some degree the idea that bpd is a post-traumatic condition but what most people aren't aware of is that studies have been done or at least one study that took a series of subjects from the general population in society and the criterion for being in the study was do you have a history of trauma but only a minority of those people with a history of trauma had any form of psychiatric or mental health problem so that would make it hard to say that the experience of trauma and having bpd were one of the same and it leads us to wonder what is it within the psychological makeup of the individual that leads some people who've experienced trauma to wind up with the psychological organization of borderline personality and others to not and we don't know all the answers to that but we think it does have to do with the psychological vulnerability the tendency to have that splitting that i described in the paranoid schizoid position in contrast to a more integrated frame of mind in the more integrated frame of mind a person takes any particular experience and embeds it in a broader foundation a broader base of what their life has been if you can't take an individual experience and weave it into a broader fabric it has more impact and more power as you move forward if you're treating someone who clearly does have a trauma history for which they have some kind of ptsd and they also have an access to diagnosis how do you handle it as a clinician and well if it's a simple case of ptsd and i don't mean to make it sound like that's not serious but if it's does not include a personality disorder because ptsd certainly exists with the symptoms that are discussed in the dsm you know flashbacks and anxiety and so on you know that's a different kind of a treatment and it's more symptom focused but if you have ptsd combined with a personality disorder we find that the treatment for the personality disorder carries along with it treatment of the ptsd even including dissociative identity disorder which is probably the most extreme form of ptsd so does ptsd when it integrates with a personality disorder mean that a person can't tolerate a certain spectrum of emotion whereas exclusively ptsd that doesn't happen is that how someone would begin to sort of sniff out the path of am i both am i one versus the other well i think i think that the distinction is in how pervasively the ptsd or the true the impact of the trauma affects a person's involvement in life how pervasively it affects their ability to get close with others how pervasively it affects their ability to invest in and progress in meaningful work so somebody might have ptsd as a more isolated set of symptoms but be able to engage more fully in relationships and work activities but if the personality disorder is part of the picture the ability to have those deep investments in relations and work isn't present i mean ptsd symptoms are severe but they don't invade if they let me put it this way if they invade every aspect of the person's life i would wonder about a personality disorder there have been some cases i've supervised with pretty horrific trauma in the patient's history really disturbing upsetting trauma breaks your heart and then in the person's adult life they go into these fugue states they lose awareness in one case they would run away and helicopters would be sent to chase them and then once that episode was over no memory so it's very hard to work when the material that needs to be there in the session is so dissociated but with patience and the ability of the therapist to show that they're open to any and all intense affect helps the person get in touch with the emotions the affect states in themselves that are too scary to have conscious awareness of ultimately in my experience it has to do with the ability of the patient to acknowledge their own aggression we all have aggressive drives when your own aggressive drives get hijacked by images of monsters who are unbelievably abusive then you can't experience your own aggression without thinking you yourself are a monster so we have to kind of detoxify what the experience of aggression is and show that that's part of you as a healthy human being it doesn't make you a monster it's very gratifying to see these cases when ultimately they get better they have relationships they might have children but it's a long haul can i just get back to the case of the dissociative disorder that i mentioned where the person had these fugue states would run away and do dangerous things i think it's interesting to see how the integration of a person's aggression evolves in the initial stages of therapy the patient was extremely frightening to her therapist and the therapist had to contain that the nature of the patient's actions were pretty terrifying as the patient began to be able to think about what she was doing and from my point of view the best therapy starts in the interaction with the therapist where the emotions are felt intensely so what happened was the patient could begin to see oh yeah i can be aggressive i can be frightening that's not just something i'm the victim of it's something i can be the source of she began to have a fuller life this took a number of years she married her husband had a couple of kids who became her stepchildren and she was thinking at one point about how open to be with her husband and stepchildren about her traumatic past now the really awful details were that when she was a child her mother prostituted her and you can i mean this little that we find more offensive than child prostitution so in one session the patient said to the therapist what am i going to do tell my husband my step-children that when i was eight years old i had sex with every sailor who passed through the port of san francisco and what the therapist could help the patient see was that there was an aggressive impulse in that idea that on the surface might look like confiding and openness but the measure of aggression that a few years before had manifested itself in these few states and violent suicide attempts was now channeled into a thought an idea of a possible action and then the therapist could help the patient see well let's look at this i can see your wish for openness and honesty but can you think of the impact can you think of how that might be experienced so what we're trying to do is take an aggression that's almost limitless and unleashed without boundaries and how it becomes more contained and can be reflected upon together what was the resolution for that is my question yeah the therapist took the position let's look at your uh your whole range of motivations for thinking about telling your family this and the patient said well you know i just want to get it off my chest and i want to be open and honest then the therapist said that's understandable and laudable but can we think about and here again observing ego mentalization reflection coming can we think about what it might be to be on the receiving end of that what impact it might have do you think you might say it to your husband maybe not to the step-children so it was to help the patients see that watch the actions she was considering included a mix of motivations some positive some not positive and to help her make a better informed choice about the right thing to do in the context of an intimate relationship what we try to do is help the person be as clear as they can be about the distinction between their internal world the images they have in their mind and the current more objective reality of their life so in this case when we helped the patient see that there was an aggressive urge in that idea the question then became who are you really angry at is it your husband or is it some of the people you've internalized from the past that you have not ever felt you've come to terms with but let's distinguish who's who if you want to get back at somebody that's not the guy you're living with right now it's not the guy you're married to i can understand you're wanting to get back at somebody but don't get back at somebody who's not the person who is appropriate for you to get back at i could see how she would feel wrongly maybe misunderstood or not fully seen by her husband for not knowing this huge piece of herself well that that is possible but let's let's go back to the way the patient phrased it the patient didn't say i've been thinking about telling my husband to tell stepchildren about some of the awful trauma i experienced when i was young that would be much she literally said what am i supposed to do tell my husband stepchildren i was screwed by every sailor who went through the port of san francisco when i was now you see the difference there she might well want her husband to know the full extent of her traumatic past but then the therapist helped her approach that from a very different tone of voice and kind of way of communicating it's like you know are you really interested in some of the difficult and awful experiences i've had in the past so you see she might feel like she's harboring and she very well in fact did feel that if my husband really knew who i was he wouldn't stay with me and that's an awful insecurity with which to live so we could understand her wanting to go over this information we just didn't want her to hit him over the head with it

Channel: BorderlinerNotes

Views: 25,680

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Id: 4p2pFb4dFpQ

Length: 14min 25sec (865 seconds)

Published: Tue May 11 2021