Archive for June, 2007

This post is a promised follow-up to a post from two weeks ago called, “Do you believe ‘Personality Disorder’ diagnoses are pathologizing?“ I was motivated to finish it this morning when I read a passionate comment posted by Jeana in response to the above mentioned article. The comment can be found here, but for the sake of getting others into the spirit in which I finished this post, I will copy it here:

“I need to rant…I am so tired of therapists and doctors labeling clients PD then in essence giving up on them. I had a recent incident with a client that I have worked with for 6 months. She attempted to get more help by entering a day treatment program for her ED and was told by the MD, who had only read her chart that “with her PD and SI, [she was] too severe for the program.” Of course the client calls after 3 hours of Binging and Purging saying “What PD???” Uggg!! I talked to the MD who was cold, lacked compassion, and in my opinion was irritated by the client! Well, if you think she is PD (x3 BTW) then the last thing you should be is irritated. I can recall working in several inpt. tx centers as a mental health tech before I got my MA and hearing the staff talk poorly about the patients, esp. the BPD ones. If someone walked in with a BPD dx, you might as well hang a target around their neck! Where is the COMPASSION? If BPD is so difficult to manage as a therapist, imaging how hard it is for these people to live with! It is not a choice…neither is bulimia, binge eating or anorexia BTW. If you are burnt out, get out! I love my job!”

Although I don’t know a great deal about the history of psychiatry and psychology, and there are many others more qualified than I to answer this question, I’ll give you my armchair analysis. I believe the “Personality Disorder” label evolved out of the common struggle experienced by early mental health care providers trying to help folks who were deeply wounded and defensive. It’s true that deeply wounded and defensive people can be very difficult to work with, especially when we get our own defenses and wounds triggered. And there is a lot to get triggered by. People with “PD” constellations may self-harm, attempt or feel suicidal, shift from idealizing their therapist to devaluing their therapist, get angry, become overwhelmed by parts of themselves which harbor great emotional needs, expect people to take care of them, quit therapy, and just as quickly beg their therapist to take ‘em back. This is the short list. If we haven’t felt worthless, hopeless, and inadequate prior to working with such a person, it’s likely we will when we do. This highlights the importance of doing our own work so that we can do our best to stay calm, curious, and compassionate in the face of nearly anything.

But because the early history of mental health care was occupied by many people who hadn’t trained in the art of self-soothing, staying calm and compassionate in the face of these kinds of provocations was not the norm. Rather, the first generations of mental health care providers probably felt dumbfounded, confused, at a loss of what to do, and, if some were already harboring burdens, they probably felt powerless and inadequate. Others may have gripped tighter to their theories and preconceptions to avoid feeling powerless and inadequate. I believe that it’s reasonable to believe that a portion of these early pioneers did feel powerlessness, worthlessness, and inadequacy, and protected themselves from falling into the abyss of these feelings by leaning heavily on labeling, judging, and evaluating people, sometimes as hopelessly and fundamentally flawed. Pathologizing, I believe, grew partly out of an attempt to place control over the uncontrollable and reduce feelings of inadequacy, fear, and hopelessness.

Now that new generations of mental health providers have trained and developed in an environment and attitude dominated by the “pathological and deficient model,” the tendency to pathologize is practically unconscious. Many don’t realize the impact of their words, labels, and attitudes, and many know of no alternative.

Thank goodness for my heroes, those brave clinicians, who didn’t take it personally when their clients regressed, raged, rejected, blamed, or insulted them. Those that stayed curious and open eventually learned that even the most wounded, degraded, and abused individuals have the capacity to access their own Self energy and can heal their exiled traumas without relying on years of advice giving, skill building, or high doses of medication. People have the resources needed to transform themselves from within, and healthy therapy helps people to access these resources.

Noah :)

© Copyright 2007 by http://www.GoodTherapy.org Therapist Louisville Bureau - All Rights Reserved.

Important Announcements 6-19-07

June 19th, 2007  |  

Dear Members & Newsletter Subscribers:

We’re writing with some important announcements:

1. Last week we posted a new Blog article titled, “Do you believe “Personality Disorder” diagnoses are pathologizing?  We’d really appreciate your ideas and responses.  Please have a look at the article by clicking here and feel free to post your comments by clicking on the “Comments” link near the bottom of the article.  All feedback and suggestions are welcome.

2. An exiting new update has been added to all GoodTherapy.org listings: Optional Video Introductions!  You can now add a video greeting or introduction to your listing to share with potential new clients. To upload a video log into your listing.  Please note, at this time only Windows Media Video (WMV) files are accepted.

3. We’ve listened to all of your suggestions and have again made some changes to the licensure designation question. During the sign up process members will now have a choice to select (or not select) any or all of the 5 licensure designations.  These are the options:

A. I’m a licensed mental health professional.
B. I’m a certified mental health professional.
C. I’m an accredited mental health professional
D. I’m a registered mental health professional
E. Other (see explanation below).

If you need to change your designation feel free to log back in and update your profile.  Click here if you can’t remember your password.

4. Lastly, we ask you to please help us by putting a link to GoodTherapy.org on your website.  Even if it’s in a place on your site where people don’t see it, the search engines (such as Google) will see it and that will help us go higher in search engine rankings.

Thanks to all of you,

Noah Rubinstein, LMFT and The GoodTherapy.org Team  :)

www.GoodTherapy.org

© Copyright 2007 by http://www.GoodTherapy.org Therapist Encino Bureau - All Rights Reserved.

Recently, someone asked GoodTherapy.org to include Personality Disorders within our list of Concerns Addressed (this is the list of concerns that people can select when searching for therapists and the list that all members select from when creating their listing). Our decision was a unanimous “no” and we thought it would be fair to explain why and to give our members the chance to make an argument for the use of the “Personality Disorder” diagnosis. I should say that we do support the inclusion of “personality disorder” symptoms in our list of concerns and we are currently working on translating these to fit into our list…. Please feel free to add your comments to this discussion below by clicking on the comments link directly below this post.

The following is our reasoning: We believe that by labeling a person as personality disordered or, in its more gentle form, stating that a person has a personality disorder, we are essentially claiming one’s personality, their person-hood, their essence, is fundamentally flawed. What else are we, other than our personality? Such a diagnosis is very likely, if not absolutely, to produce more shame, worthlessness, and rejection in a person who probably has enough of it already. I don’t care how it is framed, normalized, or expressed: having a diagnosis called “Personality Disorder” says one thing: you are fundamentally flawed.

Please don’t get me wrong, I’m not saying I’ve never worked with people who’s inner systems fit the criteria for the DSM categories of Borderline, Narcissism, and others. The difference is that I don’t use the categorical and shaming word “Personality Disorder” to describe a person’s experience and I don’t view people as fundamentally flawed. Deeply wounded, yes, powerfully protected, yes, but fundamentally and irreparably flawed, no.

It’s at this stage in the debate that some people will say to me, “well what about sociopaths like Ted Bundy, Charles Manson, and others?” My reply to this is to say a few things: 1) I don’t have evidence to conclude that “sociopaths” are born without the capacity for remorse and empathy or that sociopaths are the result of their environment – such as lack of attachment, etc. I think the jury is still out on this and until I have evidence sociopaths are a product of nature, I’m going to give them the benefit of the doubt and assume most sociopaths are a product of their early childhood relationships, one without a healthy emotional attachment to a primary caregiver, among other things. 2) The odds of an adult without remorse and empathy ever developing the capacity to attach is probably very low. But, I think it’s better to stay open to the possibility that adults can develop attachment. The latest research from the field of interpersonal neurobiology demonstrates that the adult brain can develop new neural connections and can even grow new neurons; this offers tremendous hope. 3) We’re talking about people in the context of psychotherapy and “sociopaths” generally don’t go to therapy, unless they’re mandated by the law or their significant other. So, humbly, my experience and beliefs about the nature and etiology of personality wounds comes from my clinical experience, however limited, and leads me to believe that most people classified as “personality disordered” are just deeply wounded, but not irreparably flawed… Sure, many folks with personality wounds may not heal in this lifetime. But this should not preclude us from treating such folks with dignity; recognizing that they too were born as lovable, vulnerable, and helpless babies, rather than evil and irreparably damaged.

My experience teaches me that people are not fundamentally nor irreparably flawed:We are all born loving, lovable little babies. As far as I can tell, all of us come into the world fully equipped to experience peace, self-acceptance, forgiveness, calm, compassion, confidence, satisfaction, and other positive qualities. Sure, we have many temperamental differences based on genetics, but no child is born prewounded, predefended, closed-hearted, nor do we have evidence that people are born sociopathic. If the caregivers and peers of our youth can nurture us adequately, we flourish; we experience joy, satisfaction, and connection to others. But because there is suffering and danger in life, because things happen to us and around us which burden us with extreme body-feelings and extreme beliefs, few of us mature into adulthood without some wounds and/ or protection. So, nearly all of us, to some degree, are part of the walking wounded. Each of us has developed different strategies, depending on how we suffered, to survive, to cope, to self soothe, to numb the pain, to escape, and to never be hurt again. For those of us, who have experienced a lot of hurt, our protective parts have a big job to do and work very hard to help us survive. For those of us fortunate enough to not have suffered too many wounds, our protectors work less intensely or frequently. Regardless of whether our protectors come in the form of addiction, self-criticism, anger, depression, anxiety, avoidance, or others, these strategies or protectors are just parts of us with survival strategies, not the true Self. The true Self is the indelible core that lies unharmed behind all of our defenses and wounds. And yes, this true Self exists within all of us, even folks labeled as “Personality Disordered.”

A person labeled as Borderline, for example, does not start out with such a polarized and fragile inner system, he or she was born a loving and lovable person, equipped to develop healthy self-esteem, confidence, self-soothing, and other positive qualities. But significant things happened (abuse, trauma, neglect) or did not happen (attachment, connection, love, soothing) to or in proximity of such a person. The results of this are extreme feelings and beliefs which cover over and hinder access to the qualities of the true Self.

Richard Schwartz, a pioneer in the field of psychotherapy and the developer of Internal Family Systems®, a model of therapy I practice and a model of therapy which teaches therapists how to heal trauma safely, describes the Self as the “I” within the storm. I love this analogy. Imagine a hurricane. In a hurricane the outer winds reach over a hundred miles per hour and cause great destruction. This is analogous to how people feel when overtaken by their protective parts (such as anger, self criticism, addictions) or their wounds (rejection, shame, fear, abandonment, worthlessness). It’s how any of us can feel at the end of a long and stressful day when there are too many things to do and not enough time to do them all. However, just as a hurricane has a calm center where the sun shines and the winds are calm, so to do all people. Richard Schwartz and other IFS therapists have demonstrated that even the most heavily traumatized, burdened, abused, and wounded folks, with all kinds of protective and destructive behaviors, can with a bit of guidance, access the calm, curious, reflective, and compassionate core Self. When someone, even someone diagnosed with the label “personality disorder,” can shift into the state of Self, he or she has the potential to heal their wounds and in turn the defenses, which are attempting to keep the person from ever experiencing the overwhelming, awful, trauma they once did.

More curiosity and compassion helps us to see the pain beneath the protection.

Let me be more specific about how some of the protective parts of a person labeled with a “personality disorder” try to help the person to survive and avoid their exiled feelings. So for example, imagine a person named Mary who’s been diagnosed with borderline personality disorder by her mental health provider. Mary tends to “split” people in a way that people with a “borderline” constellation experience, she shifts between states of idealizing and devaluing. The devaluing part of Mary, when activated, views others as “all bad.” So, if Mary’s boyfriend does something which triggers her vulnerability, say by choosing to spend time with someone else or perhaps by expressing a criticism of her, Mary’s devaluing part, in an effort to protect her from feeling rejected, worthless, shameful, or unloved, hijacks her and manifests as anger, criticism, and perhaps even hatred toward her boyfriend. The act of lashing out at the external trigger of the suffering serves the purpose of automatically and powerfully numbing Mary to those vulnerable exiled feelings, which are the real source of her suffering.

This devaluing part of Mary which vilifies her boyfriend and other “people/love objects” in her life has an enormous and important job to do, it’s trying to help her from feeling old feelings she’s exiled. If Mary’s devaluing part were to fail to vilify and blame others who trigger her, there would be a risk of being overwhelmed with worthlessness, shame, and other vulnerable feelings. This is why people with this sort of internal constellation have a reputation for self-harm and suicide, they’re not always successful at keeping the overwhelming and hopeless feelings out of consciousness. If you or I were burdened with as much shame and worthlessness as someone like Mary, it’s likely we’d feel suicidal too.

The second protective ego state that forms the other end of the splitting polarization is a part which idealizes her boyfriend or other “people/love objects” as “all good.” The idealizing part helps Mary’s young exiled ego states, the ones that are harboring the shame & worthlessness, to have hope for redemption. If Mary’s idealizing part can worship her boyfriend and view him as the manifestation of perfection, her young parts which carry the wounds and burdens can maintain hope that someone exists who will finally love them and care for them in away they’ve always wanted; essentially redeeming the young parts inside which have felt so rejected and worthless.

What we see in the example above are protective ego states/parts in existence because there are vulnerable ego states/parts harboring and experiencing, consciously or unconsciously, some kind of old suffering, danger, or hurt. Mary is so livid and hateful toward her boyfriend at times because the power and intensity of a person’s protection is equal to the power and intensity of their hurt. She has deeply wounded parts which harbor intolerable amounts of pain which occasionally get re-triggered by events.

I’ve used one symptom of the “Borderline” constellation, splitting, to demonstrate this, but I believe it’s the same with most constellations which include protection: there is not fundamental and irreparable flaw, there are deep wounds. The whole reason someone with a personality disorder is so protective and dysfunctional is because they harbor parts that are so wounded.

Original sin? I know this term may trigger my Catholic friends, but my answer is “Absolutely not.”

If you’ve worked long enough helping people to grow and heal, you see that these wounds are not something one is born with, as I explained above, they are wounds suffered and experienced in the course of development. So, if it is true that “flaws” are the result of protective and wounded parts; true that protective parts arise in response to our wounded parts; true that wounds are not inborn but a result of experience, then we can only conclude that people are not fundamentally and irreparably flawed, but rather deeply impacted by the thing that happen. Furthermore, if you have witnessed the healing process in someone so deeply wounded you realize that, the wounds and defenses are not destined to be permanent. With the sufficient amount of time, attention, and enough Self in the room, anyone is capable of healing. Developmental psychology, as Richard Schwartz points out, was wrong to ever hold that if a person didn’t get what they needed (love, attention, etc.) from a caregiver by a certain age they were destined to suffer incomplete and deficient. Advances in modern psychotherapy have proven this once strongly held belief to be false. Because people are generally whole from birth and have what they need inside for optimal health and happiness, healing is not about giving someone something they don’t have: be it wisdom, social skills, self soothing skills. It’s about releasing the constraints that inhibit access to the true Self. This is what good psychotherapy helps people to do.~

Stay Tuned for the upcoming posts:

“Why do we use ‘personality disorder’ diagnoses anyway?”
“What’s an alternative to the current diagnostic & classification system?”

© Copyright 2007 by http://www.GoodTherapy.org Therapist Anchorage Bureau - All Rights Reserved.

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