Embracing Borderline Personality Disorder - Dr Keith Gaynor

good evening ladies and gentlemen with rollin can hear me and that's the main thing my name is Keith Gaynor a material psychologist and I work in st. John the gods and in many ways I'm a bit of a quirky choice to do this lecture in that I work primarily with depression my old job job I used to do last year was with borderline personality disorder and it's not anymore and in many ways that story is a little bit there alter the story of borderline treatment in Ireland and we're going to touch on that throughout the whole lecture and what it means so what are we talking about when we talk about borderline when you begin to look at the name alone it starts getting confusing so some people would say borderline other people would say BPD other people would say EU PD other people would say developmental trauma other people would say long-term complex developmental trauma people say emotional dysregulation people would say affect dysregulation people would say go on and on and on it's very easy to hear a clinician have a conversation are we going to have CBT or DBT for this person with BPD or in UPD of course that just brings total sense it makes everyone very relaxed so when you're looking at the research in this area there isn't five terms there isn't 15 terms there is in 25 terms there is in fact 40 terms to cover this general area which leads everyone feeling a little like this a million words all over the place thrown at you and it's very hard to discern what they mean and you meet one doctor will say one thing you meet someone else will say something else and you meet someone else would say something else again and so when we're even trying to understand what are we talking about we get a little lost and I hope if we can do anything this evening is to bring a little bit of clarity not total clarity but a little bit of clarity to this area so when we're thinking of people sorry just to say I'm going to refer it for clarity sake to BPD through the whole lecture I'm just going to use that one term and I'm going to use that one term for two reasons it's the term people are most likely to hear from a doctor in Ireland it's still so if you go to your GP if you go to your consultant if you receive a diagnosis that is the diagnosis you're most likely to hear I also use it because that's what Marsha Linehan uses we're going to talk a lot about Marsha and she is the leading DBT expert in the world and that's the term she uses so we could use a lot of terms but I'm going to use that one when we're talking about BPD it's very important to understand who we're talking about because this is everyone knows someone with depression but probably nobody knows anybody who would BPD even though it's quite common it exists widely in Ireland and affects a lot of people so somewhere you can see BPD is at the moment in the gate theatre and it's this character here and that's Blanche DuBois in streetcar named desire and at the moment in the gate there's a fantastic performance of this character it's reasonable feeling it's a fictional character but it's reasonable to say that if Blanche walked into a psychiatrist's clinic she would come out with a diagnosis of BPD there's something very interesting about Blanche in that she's based on a real person and the person she's based on is Tennessee Williams a gay white man in the southern States of America in the 1930s and that he based his ownself on his experiences and created this character but obviously he couldn't make it a gay male character for the time so he made it a female character who else might we be talking about Marilyn Monroe one of the most famous women of all time when a most beautiful women of all time when we look back to our history would have met a lot of the criteria that we'd now understand as BPD if we're looking for more modern aspect I didn't know who this was but somebody told me this is Lady gaga apparently I'm reliably informed and again it's very hard to say about someone you've never met and you don't know when you only see the media and a media manipulation but again a lot of her behavior and a lot of her presentation would meet those Sakana criteria and this lady who's it only bit less glamorous than maybe some of the others but it may be more important because this is marshal linen and marshal linen is probably the leading expert in BPD in the world today she developed dialectical behavioral therapy they were going to speak a little bit about DBT the other through that the only other three-letter acronym I'm going to use and she works in the States and has worked in the states for about 30 years on BPD and about two years ago Marcia came out and informed the world that she herself had borderline personality disorder and so she has all the randomized control trials she is all the evidence she is all the efficacy they studies what the first person she tested everything on was herself and did it work for her so a lot of the tone of this lecture a lot of the point of this lecture is to try and differentiate BPD from depression obviously everyone knows what depression is we all know someone with depression we've experienced periods of depression perhaps and yet BPD is this thing that's sort of silent that sort of isn't talked about there only happens over there to other people that we don't really know and so when we're thinking about what BPD is we're thinking a pervasive disorder of emotional regulation so something long-term that affects how we regulate our emotional system so for people with BPD it encompasses all emotions not just one or two it feels overwhelming and it's associated with a wide variety of behaviors and generally when we're looking at depression we're seeing something that stops and starts its relapsing and remitting people have long periods of depression and then have long periods their wellness and then long periods of depression again it's generally associated with low mood as the primary emotion that's with an associate with a reduction in behavior people do less they struggle to get out of bed they struggle to engage in their everyday activities so when I say regulated emotion what I mean what I mean is what we feel every day we have good mornings and bad afternoons we have stressful Friday's and good Monday mornings in fact we probably reverse that we have stress good Fridays and stressful Monday mornings we have ups and downs and we experience that all the time we have a very stressful afternoon we have a cup of coffee and a bar of chocolate and we get through it and we get into the traffic and we go home and we get on to do another day and so normal mood and normal emotion isn't a flatline it's a series of ups and downs and that's how we get along and if we're thinking here that our very best day the very best day we've ever had were probably out of 10 and the very worst day we ever had is probably at a zero most the time we're moving along between six and four it's never too bad it's sometimes good but it never becomes too awful for us well we think about depression it's moving there between six and four and then it crushes out and it's low and low and low and low and it stays low for weeks and months at a time and people with depression will tell you how hard it is to shift out of us to make that first step to move at at that point and then at some point if treatment works and things go well they do come out of it and they go back to six to four to six to four and so on well we think a bipolar depression it's a whole period of weeks and months of a high where everything is fantastic and the best I've ever felt everything is going to go right absolutely wonderful and then the weeks and months of the crash where everything is awful and I can't move again when we think of emotional dysregulation it's a little bit different if we're thinking that a regular emotion is going between six and four a lot of people with BPD BPD will say their regular emotion is moving between seven and three or the rest of the world is a little bit German they're a little bit Spanish and that's just their normal thing they're just a bit bigger a bit louder a bit more creative maybe giving a bit more holding back a bit less and that's their everyday and then some we're moving along there a crisis happens and it can be a big thing or a small thing but it knocks them off kilter and their mood starts moving much more exaggeratedly so it's much more much wider and much more frequent they'll experience those mood changes so we're not talking about being depressed for a month we're talking about a crush a depression at 9 o'clock in the morning an elation at 10 and a crash a depression again at 11 we're to have a huge rapid frequent change in emotion that often doesn't have to have a huge trigger it doesn't have to be a car crash or agree for a loss of work for this to happen it just hits and the person has a sudden overwhelm of emotion and I get any of us can imagine that's incredibly hard to deal with that you're sitting there you're in the office somebody says something to you and suddenly your emotions are ping-ponging up and down and up and down and up and down so when we think of the type of emotions it might be ping ping ping pong they're a little bit different for different people for some people at those peaks it may be all about anger you get huge overwhelms of anger for the people it may be anxiety for other people it may be kind of being hyper or being hyper manic or it's just excitement and fun and bulls and people will then tell you about what it's like at the other end the sadness or the hopelessness or the guilt or the shame or the low mood that comes very quickly after that and so there's one a good afternoon feeling great by evening it's turned and it's dropped and it's awful it comes around again and it goes down again and it just builds and builds and builds until there's too many emotions and rather than feel too many or from the person will know mate and they'll move from a place of norm to a place of too much to a place of norm to a place of too much and they can find it very hard to get themselves back in sync again to where they were moving along fairly happy when we think of the behavior that goes with this because often BPD the conversational BVD starts with behavior and specifically didn't do that because everyone sees what the person with BPD does they see the self-harm or they see the addictive behavior or they see the huge fight so they see though the acting out or they see that you know the bigness but they don't see the emotion underneath and that's why it's very important why we started with the emotion but the behavior that goes with those emotions is often interpersonal so it'll be an interpersonal clash the huge rep if you're feeling anger and anxiety and rage who's going to get it the person who's closest to you the person who's standing in the room so the person goes would you like some tea or will you pick up that plate or you know who's there they're going to catch it and slowly then there's a rail you're always doing this you never settle down you're the one and it becomes this bigger and bigger interpersonal conflict there's the impulsivity that people would recognize with BPD so doing things on the spur of the moment things that people don't mean and often that can become sex drugs in rock and roll or other self-harm behaviors or other addictive behaviors or the risky behaviors or just a very long impulsive streak self-harm all the things that go with depression the lack of activity the difficulty getting off the difficulty going to work the difficulty acting difficulty doing is on the flip side of that and so when somebody numbs out where is the motivation to get up and go to college when someone crashes to a low where is the will to go and you know get back in and do another is 9:00 to 5:00 and work that's extraordinarily hard and we think of the cognitions when we think of the thoughts that go with this often they're along the line if I can't cope I can't manage this this is too much because it is too much what's it's just a perfectly good description it is too much to experience and then the thing is you go with that the self blame and the criticism this is my fault I'm doing this wrong I should do this better the self phase and the self hurt that go with that so although we often see the behaviors and doctors and hospitals and parents and family see the behaviors our understanding is about the underlying emotion that that's where we need to aim and that's what we need to work on to change the behaviors and we see the behaviors as a natural consequence of intense emotion so I'm shouting at you because I'm angry it's not because I don't like you and it's not because I don't like me it's because I have this overwhelming feeling of anger or it's an attempt by the individual to regulate their emotion and people often regulate like the rest of the community through not the most healthful ways so most of Ireland regulates its emotion by pints on a Friday they have a stressful week they go for drinks and so we see in BPD we see addictive behaviors we see self-harming behaviors we see other addictive addictive engagements and they're there to try and control and reduce that emotion that emotional overwhelm and the thing is those things work eight points in a Friday worries for that Friday but it doesn't work on Saturday morning it doesn't work on Sunday morning and it gets worse and worse and worse and soon the addiction is the overwhelming problem equally self-harm works for that moment for that five minutes it releases the tension but it doesn't work ten minutes later it doesn't work thirty minutes later and it doesn't work as a lifetime as it becomes an addictive behavior and frequent sexual engagement having risky partners having partners that you don't really like being around people you don't really like but keeping them there anyway all of those behaviors are there to try and manage that sense of low mood or manage that are over so there's a good question as to why have we not been talking about BPD more why isn't this something on that everyone is aware of so if you talk to somebody on the list you're not you know if you talk to somebody on the street you're not going to know what BPD is you go well I have BPD they're not going to tell you they know that and they understand that they've met somebody with it that's because that is varying emotions so some people will be more depressed some people will be more anxious some people with more hypomanic different people will have different behaviors so one person may self-harm another person may have an addiction or another person may just struggle in relationships or completing college so you can have two people with BPD who sit beside each other who don't have any two things in common except for their overwhelming emotion and one of the key things that affects professionals is that their people have different presentations at different times so you'll see somebody on a Friday and they'll be one way and you'll see them on a Monday and they're present in completely different way and so that becomes very hard to diagnose and to treat and all the other things that will go with it so one of the questions we might ask is why does it develop at all where does it come from why is it there and this is the DBT understanding of it firstly but some people we all have emotional variation so we'll surger 'men some moves they're Spanish you'll know people who don't smile on their wedding day have half a glass of cocoa and go to bed at 10:30 and you'll know other people who are up till 4:00 in the morning they're the last in the hotel bar and they have to be kicked out of the room and that's just normal we all know when we look around our streets that emotional variation is there and so we know that some people have bigger expressions of emotion and that's just there and some kids when they're this big are noisier kids there's colicky kids there's kids who cry more those kids who are more Placid and that's just there or when you combine that with traumatic experiences difficult emotional experiences and especially traumatic experiences in childhood that can often lead to emotional dysregulation there's no one path no more there's any one person with BPD there's only one presentation of BPD but in general you will find that there's someone who had long-term emotional sensitivity combined with a traumatic experience and when that happened emotions started to dis regulate and it became very difficult to manage and all the other things that we know about BPD started to happen so people have an inability to think clearly or flexibly we see the impulsivity and deliberate self-harm people start developing an unstable sense of self since they can be a different person on a Friday than they are in a Saturday how does anyone have a core sense of self who am I am I this person am i that person I'm very hard for the person themselves to know who they are and it leads a course to tempestuous relationships so if you don't know who you are how does your partner know how does your boyfriend how does your girlfriend head is your boss head to your parents and it leads to huge tempestuous relationships because they'll someone will see you on a Monday and it's great and fantastic and wonderful and they'll come back Monday evening and it's not and of course that's going to lead to options so what are the effective treatments there are three fairly well evidence-based treatments they are all difficult to find the one we're going to talk most about today and has the greatest level of evidence is DBT which was developed by Marshall in and first published in 1993 it combines weekly group skills where people learn skills to manage their emotions with weekly individual work where people look at bringing those skills into their specific situations so how do I bring that into college how do I bring that into my marriage how do I bring that into what I want to do and Plus 24/7 phone contact availability so that when the crisis is happening you're able to contact somebody who's going to talk you through the crisis the schema therapy developed by Jeff young in in New York and that's primarily individual and again it also has 24-hour phone contact a mention ization which was developed in London more recently which is long-term inpatient combined with individual therapy each of these has some common factors the therapy lasts between one two and three years not one of them is it shorter than one year they're all structured so if the person's difficulty is ell that their emotions are everywhere you're going to need a therapy that works in the opposite direction and so they're structured and that there's a system to fit into the first person can buy into and they know what it's going to be the core of each of them is a reliable consistent therapeutic relationship that lasts over a long period of time and if you want to see the evidence and go through it I think it's well worth people do if you go to noise or UK and look at BPD there's a very good summary of all the available evidence open till I think that reviewers last year so what's their evidence for and have a look one of the things to save from a therapy point of view from from being a therapist is DBT is done by a team it's not done by an individual mentalization is done by an entire ward it's not done by an individual and schema therapy even though you're seeing an individual actually that individual is in their own support group and there's a reason for that that as a therapist if the person that you're seeing their emotions are moving X & Y and Zed and you're seeing them in crisis after crisis after crisis the therapist Burnett is really common and so unless you who are working in a team with the team around you you won't last as a BPD therapist and so when services are being set up you set up a team and not not one person so we're going to talk a little bit about DBT because it is the the therapy that's most common that's most accessible in Ireland at the moment and there's two key bits to it and that's group which happens once a week for about a year and these are where you learn skills and it's it's simply a psycho education group it's not a psychotherapy group it's a group where you learn skills and if they're in four different sets so mindfulness skills interpersonal skills distress tolerance so how do I manage my distress when it becomes overwhelming and long-term how do I manage my mood emotional regulation skills and then individual therapy to help the individual manage their emotions day to day and to when and where to use those skills appropriately and it's about understanding their particular triggers we're going to talk a little bit at the D in DBT and then working on actual responses in the moment so not about general things but how do I bring that to the workplace on Monday how do I bring that to my marriage how do I bring that to the relationship with my parents and that also goes on in general DBT will be two years well of twice-weekly one group one individual and so when we're thinking about what sort of treatment do we want where do we want to see this when the crisis happens and the emotional dysregulation starts we want to put skills in there there there and there and that's not saying that people won't feel emotion but we don't want it to reach the peaks that are husband reaching and we don't want it to changes frequently as it has been changing best of all we want the skills to happen before and that's that understanding the triggers what sets me off and it doesn't have to be something huge it isn't the loss of a job or a car crash it can be simply a word or a phrase or a memory or a thought and that understanding what they are from me and recognizing them and dealing with them in advance so one of the triggers that we know that happens a lot for people with borderline is they get caught and dialectics this is the D in DBT and a dialectic is an extreme where I get caught between one side and another and it has no middle ground so I may get caught on the one hand I hate being with this person they're abusive they're not nice I don't like being with them they make me feel worse about myself it's a nightmare but on the other hand I can't be alone so I can't leave and the person gets caught between these two things the intolerance of being able to be alone and the entire ability of being in this situation and what will happen is being caught in between those two things will make the person dysregulated it will set their emotion off it's a trigger it's not something it seems to be solvable and therefore my only response is emotional equally people may have very common dialectic will be between my own self-hatred I hate myself so much but I also don't want to hurt anybody else so I get trapped between not liking myself at all and also trying to protect the people around me because I do love them and not seeing any solution between those two things the sense of when my emotions do become overwhelming getting caught between that huge wave that overwhelm and being known and everyone hates being known it's not a pleasant place to be no one enjoys my matter the gentleman but I met him yesterday I said I don't feel anything and it wasn't that he's not depressed he doesn't feel anything and that's about him norming out in order not to feel too much and he can't find any point between not feeling anything and they utterly overwhelmed he just doesn't have that middle ground and the a lot of the individual therapy Don and DBT is about finding that middle ground it's about finding the person helping the person to find their dialectical dilemmas the ones that are specific to them finding where they crop up when they crop up and then looking at solutions practical solutions to get it so if it's about ending a relationship it's about how do you end this relationship if it's about making a relationship more tolerable it's about how do you do that if it's about changing job moving job if it's a managing emotion it's about doing that and finding practical ways to get out of impossible situations so where is their DBT in Ireland not very much and there's a few spots and and as far as I'm aware though I don't really know there's about 200 HSE training places on the way but again when and where and how that's going to be distributed and how people are going to access them and how the people are going to manage waiting lists and all the rest I don't know the long and short of it is that there isn't very much so what I wanted what I wanted to call this lecture was eat the damn orange but more people turned off than I expected so some people have oranges and some people don't have oranges and some people ate their oranges because it's a very BPD cred and I bought as many oranges as tesco Hart if you are meant to hold on to a key part of DBT the first person to bring mindfulness into psychology obviously mindfulness is a 3,000 year old Buddhist technique the first person to bring it into psychology was Marshall in it and mindfulness is an absolutely key part of DBT and getting good at mindfulness is an absolutely key part of DBT because it is one of the ways to manage emotion it is one of the ways to manage that overwhelm so people there's been a huge interest in mindfulness and it can be summed up what it is in one sentence to pay attention non-judgmentally in the moment that's all it is and will only take you the rest of your life to learn how to do that and I've been doing it 10 years and I love it but I'm not particularly good at it nobody is something that isn't particularly easy but all we have to do is pay attention in the moment and not bring judgment to it so if something is negative its negative if something is positive it's positive and we just experienced that and letter pass so this is exactly it the man is there and he's overwhelmed and all his thoughts and all his stuff and everything and the dog is there and he's just seeing the park and wondered one of them is mentally healthy and the other one isn't let's be a dark and this is about okay if I'm walking in the park and walk in the park it may be a cold day it might be a perfect day I might have forgotten my jacket and mayor got caught out in the rain maybe all the things that happen in Ireland on autumns day but let's be in the park and that for those ten minutes that's all I'm going to experience and actually if you can manage ten minutes of just experiencing what's happening that's extraordinary that's really really good what I'm hoping or we'll try and do it's not easy with a big crowd is to eat an orange so how many oranges have we got can anyone who still has an orange lifted up in the air okay so how many people would like to share their orange with somebody who doesn't have an arch well what I'd like to do is two minutes of mindfulness with the orange or with a segment of orange you only need a segment so obviously eating is tricky for some people and some people don't like sharing and touching things is difficult so don't worry about it I know we should have done this at the beginning so what I'm going to do I'm going to hang on to some of the orange if you want to take a piece of orange and pass it on so - at least some people have our okay so what I'd like you to do is take one segment of origin and just have this don't put in your mouth yet I'd like you just to begin to notice the orange notice the feel of the orange notice the smell of orange in the room now that we've opened fifty oranges the room is actually full of orange I'd like you to put it to your ear and I'd like you to notice the sound of orange I'd like you to notice the texture of orange I'd like you to look at it and see the difference between the orangey bits and the pithy bits and the veins in it and the white bits and how white the bit in the middle is and now I'd like you to take a small bite just the top and feel orange on your teeth feel the spray of orange feel is a bitter or is it sweet is it Pleasant or is it unpleasant feel the flesh as the juice flows out of it feel it being less and less and less and then feel that orange as a ghost and your throat it ends I'm going to try it one more time we're going to take another bite I'll feel what this bit of ours tastes like we're going to take this route is there anything about it what do you notice does it sting a little cut in your mat do you feel it on the back your teeth can you hear the noise of the room eating oranges that's extraordinarily noisy and the sensation of just eating okay we should almost be down to the last bit of orange now you take the last for the second and just slowly shoot will George and what we did there for about two minutes was two minutes of mindfully eating an orange all we paid attention to was the orange it had no function other than eating an orange it had no purpose other than just a taste and smell and experience orange and why we were doing it our mind was engaged with orange it wasn't somewhere else it wasn't about traffic and cars and homework and work and bus stops and trams and all the rest it was about orange and mindfulness is simply about engaging with the things around us gauging actually with the world that's here and not the world that's open our head and not the world that were feeling in our chest just experiencing what it is and experiencing is non-judgmentally and it's one of the key skills in DBT and DV t spends babe for months on us and we spent about four minutes on it but in that four minutes I hope you got a sense of what it's like just to pay attention we could have even a whole bag of oranges in those four minutes we often our lunch time we'll eat something and it's gone we don't even notice its taste you'll have a cup of tea while you're still running out the door to do the thing to do the thing and this is actually about slowing the whole process down and just experiencing every now and again the thing that we're experiencing so I'm going to finish up because I know people probably have a lot of questions and so it's a little recap on what we understand BPD to be and that it's a problem of emotional dysregulation the key bit understand isn't the behavior isn't personality isn't about the person it's about what happens when emotion becomes dysregulated and what a person does when they're trying to manage that and sometimes they do things that work and oftentimes they do things that don't work for them and that's the bit we see that one of the best ways to understand this is there's a mismatch between the emotion the person has and the skills the person has to deal with them now you would need to be a wizard to have been born with the skills you would need to manage BPD but the whole point of therapy like DBT is to give those persons the person those extra skills so that they have emotion that's this big and skills that are this big and it's about getting the skills to match that most importantly it's not just about what you do because when you look at DBT it's not there's nothing magical in any of the skills they're not extraordinary they're very common-sense practical skills where they're putting them in at the right time that after a crisis after everything has gone wrong after the blue lights have come is a difficult time to put it all back together again and if you can get in ahead of that you can get in the day before the minute before the crisis hits then that's much better and so it's very long-term planning it's about understanding triggers as we're putting in those skills early when we look at what treatments work generally it's about slow treatments it's by consistent treatments there are treatments with strong therapeutic relationship so for instance I do a lot of CBT and I do a lot of CBT for depression and so an effective treatment of CBT for depression might be anything between 12 and 20 sessions so you might see somebody for 3-4 months that it's going to be ineffective and in fact it's going to be unhelpful for BPD you see somebody nice like me and then it's cut off three months later you get a bit of what you need just enough time to open up and then it's taken away and you're moved on and you go to somewhere else or something else and so often people's experiences of services is chopped and change and different and we did something here and something there and a bit of something else and it's not that any one of those things is wrong it's just wasn't long enough good enough and consistent enough over time people often with BPD will often talk about experiencing things for decades I felt like this since I was this tall I felt like this for the last 20 years the thought that a treatment can do something in 20 weeks that's been going for 20 years just simply isn't practical there is without a doubt a significant shortage of evidence-based treatments in art as far as I'm aware there are some plans to address it but we've yet to see how that's going to play it and what that is and that one of the extraordinary things that's happened in Ireland over 10 years is that people have started to talk about mental health in a way they never did that process is only starting but it is starting I really believe it was anything worth campaigning for I know is world suicide prevention day yesterday and we talked about suicide in Ireland a lot we don't talk about BPD at all and that if there's anything worth campaigning for there will be proper services for BPD and an actual understanding what BPD is and this is one of these things are actually the people with the power on over there the you guys have much more power than therapists do to provide the services that are necessary because you have access to TDS you have access to your local community you have access to people in the HSE that you the people of our if they want it can make it happen and you see when they want something happen it happens on the other side we work in a service that tries to provide what I can when it can within diminishing funds and so I think if there's anything that people would like to campaign or I think this will be a very worried thing and that's me

Channel: Aware

Views: 711,312

Rating: 4.8505683 out of 5

Keywords: Borderline Personality Disorder, DBT, Aware Lectures, BPD

Id: fhOotNCqg2E

Length: 40min 2sec (2402 seconds)

Published: Wed Oct 23 2013

Reddit Comments

[u/nannaruh]

I apologize ahead of time if this is a repost. I find that researching this disorder brings me comfort in knowing that it is continually being studied and recognized. My hope is that appropriate treatment and diagnosis become more relevant and easier to access for all that suffer and wish to recover.

[u/barbiekitsune]

Thanks, I'll watch that later. Sorry to hear you lost your father, I did too a few years ago. Lots of love.

[u/travellust101]

This was so great! I'm so glad you shared this. There are so many people this video can help considering we are so varied.