AAPEL
Interview of Mr Robin Day Lpc granted on november 16th 2002

Q: Could you first of all talk a little about you and your experience in the BDP treatment?

I starting treating BPD in a community mental health center 7 years ago 3 months after graduating from the university. [In the USA, poor people go to public mental health centers. The vast majority of clients at these public mental health centers have either personality disorders or psychotic illnesses, esp. schizophrenia.] Most masters degree programs donít teach anything about BPD except that therapists should "put on their seat belts." No change or improvement is expected. Not surprisingly, I didnít see much change or improvement in the clients I treated.

I found out about Dialectical Behavioral Therapy [visit www.behavioraltech.com] 3 years ago while employed at a public day treatment program. I started teaching a DBT skills class. Iíve been in private practice for 3 years now doing DBT almost exclusively. Two months ago I quit my job and went full time.

In a few words very simple to everyone
Q: "What is the Borderline personality disorder ?"
If you have BPD, you have a problem with emotional intensity. Itís like youíre in the back seat of the car and your emotions are driving.

Q: What differentiates it from other diseases and personality disorders?
I only have experience working with severe and persistent mental illnesses (SPMIís). I think of people with SPMIís as falling into one of two "pools."

Psychotic or biology-based disorders include illnesses such as schizophrenia, obsessive-compulsive disorder, uncomplicated bi-polar disorder, uncomplicated severe and recurrent depression, uncomplicated schizoaffective disorder. (By "uncomplicated" I mean that the person doesnít really have borderline personality disorder which is then creating the symptoms of mood disorders!) Psychiatric care and medications compliance are the basis of recovery for people with these illnesses. Social skills training, stress reduction training, etc. can also be very helpful to improving the quality of their lives. The cause of these illnesses is biology alone. Lastly, most of these unfortunate victims will never be able to return to their pre-illness levels of functioning.

The other pool includes BPD and illnesses that are secondary to BPD and like personality disorders and childhood trauma. Illnesses in this pool include: BPD; histrionic and dependent personality disorder; sometimes depression; bi-polar, and schizoaffective disorder; dissociative disorders including dissociative identity disorder; post traumatic stress disorder with prolonged onset and duration, trauma related obsessive compulsive disorder; substance dependence and abuse which is related to emotional intensity. While psychiatric medications are often necessary, they work less well than with the other "pool" of illnesses. The key to recovery is therapy. While it takes a lot of effort and good luck in finding the right therapist, recovery is possible. These people can obtain a significantly higher level of functioning. The illnesses are not by their nature permanent.

Q: Is the "childish" side of the adult borderline totally essential in the illness?
No. I have clients who donít seem childish at all.

Q: Same comment about the sudden rage ?
No. Sometimes anxiety or despair are much more out of control than anger.

Q: How to be sure that it is borderline disorder and not another mental illness ?

...

When we are in the circle of one person potentially borderline.
Q: What are the behaviors, the alert signs to tell "this time it is not normal, it would be necessary to him/her to consult a therapist"
Anything that looks "crazy." Impulsive behaviors, intense relationships, etc.

Q: At which age can we start to see the first signs and worry about ?
Donít know. I donít have much experience with children.

The people having this disorder "used to be" like this from all their life and it is "the way they are"
Q: why in that case don't leave them and let them continuing to live their life ?
Itís painful as hell. Thatís why so many are suicidal. (Of course, if someone with any mental illness declines treatment, that is their right.)

Precisely about this illness
Q: "is there a cure ?"
Research indicates that Dialectical Behavioral Therapy [visit www.behavioraltech.com] decreases Sx of BPD. A full cure?óThatís a good question.

Q: Is using medication (almost during a time) necessary or a "simple" therapy can be enough ?
A few of my clients are not on medications because they choose not to have the side effects. I donít press the issue because they are not actively suicidal. I think they might have an easier time of it if they took medications.

Q: Same question but only medication without therapy
Sure. They wonít get better on meds, but it can make life more bearable.

Q: is that mean that only a psychiatrist therapist doctor is able to cure a borderline patient ?
Probably. But medications, the 12-step groups (Al-anon, Overeaters Anonymous, etc.), and maybe other self-help groups can help make life better for people with BPD.

Q: Is the word "Borderline" suitable, borderline means "not really"
Dr. Marsha Linehan, who developed DBT Tx, suggests the label "Emotional Dysregulation Disorder."

In France, some peoples, and even psychiatrist are saying, "we are all borderline", to be clear that this illness doesn't exist
Q: what is your opinion about this point of view ?
Everyone has times of emotional intensity. I have emotional intensity in the morning if I got less that 6 hours of sleep the night before and coffee is not readily available. However, people with BPD have emotional intensity a lot more than the average person.

The question is certainly not but I ask
Q: Is each / every psychiatrist has the training and experience to treat borderline patient ?
No, No, Hell no.

Q: Do you think that there is actually some deficiency in this domain ?
Do you mean that more training and education is needed for mental health providers? Yes.

In France, mental illness is a taboo like cancer was some years ago
In everybody mind, someone going to consult a psychiatrist is "mad" or "retarded"
Q: what could you say about this ?
Not too much different here in the USA.

About this subject, we often associate the "cure" with the "willing" to
"Please stop to do, act like this and do what it is necessary !"
A kind of "if you want, you can" and "if you are not doing, that's mean that you don't want"
Q: what is your opinion ?
My clients with BPD are pretty smart and in a lot of pain. If they could think their way out of this disorder, they would have done it already.

Q: What do you think about the idea to create an association to promote knowledge of this illness and help peoples ?
Good. Some of the BPD people who contact me have just found out about their illness and that there is hopeóbecause they heard it briefly mentioned by a mental health provider, and then they looked it up on the internet.

Q: What do you think about the principle of "diagnosis obligation" when we know that all over the world there are thousands of sick peoples, which don't know that they are sick, and which think that it is the "way they are" to suffer
Itís good to let people know what illnesses they do or might have. In the USA, however, insurance companies usually wonít pay for BPD Tx. So, itís important not to document on paper too much.

Question without answer I suppose
Q: "how to convince the patient to consult a specialist ?"
Talk about emotional intensity. People with BPD are used to being criticized for their behaviors. Recognizing aloud that their inner experience is full of uncontrollable emotions seems to give them hope. Recommend a few good websites. Thatís all one can do, I think.

The denigration campaign. The fact that the patient accuse the "non" the one which know the truth to be the sick one
Q: is it a common data ?
I donít understand this question

Q: how to react against this ?
?

The borderline seems to have a childish emotional IQ
Q: Is it "sensible" to ask a "children like" to take such a decision ?
(consult or not, treat or not)
They might have a low emotional IQ, but they are still adults. Trying to force someone with BPD into treatment never works.

Q: Is it not totally utopian and even cruel ?
See above

Q: What is your experience about this ?
How borderline people "come to you" ?
Other therapists refer clients to me because I have sent out a lot of fliers to them. Some find me on the internet.

The origin of the illness seems to be really complicated when we talk about borderline disorder, but it seems that trauma during early age are the main reason
Q: What do you think about this?
I think that the illness starts early, but it is not necessarily due to trauma (physical and sexual abuse). Contributing factors include

The family could be a great help to support the patient.
But when one of the parents has some part of "responsibility" (even not conscious) in the illness of her own children,
Q : How is it conceivable for this parent to open yes about the reality of the situation ?
I donít do family therapy much with my adult patients. My only adolescent patient has parents who really arenít responsible. I wouldnít talk about how the parents contributed to the illness, even if it is clearly true. Whatís the point? The client has to get better to feel better, not the parents.

It seems that mental illness is passed down through generations like a child of an alcoholic would become alcoholic at the adult age
Q: Is it true ?
Seems to be.

Q: Is it the same with borderline disorder ?
The borderline mother is going to make her daughter borderline ?
The risk is high.

Q: How to break this infernal circle ?
Make good treatment available to people with BPD.

Latest questions
Q: Is there one question you would like to answer and I didn't ask ?
no

Q: Is the last word "hope" ?
People with BPD can feel better if they can get hold of and utilize effective treatments.

Questions answered with the kindness of Mr Robin Day LPC, therapist - Atlanta

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