How to Disarm a Borderline, Part II

In my Part I post of October 6, I described how a lot of the difficult behavior of patients with borderline personality disorder (BPD) in their intimate relationships is designed to elicit in the observer one of three reactions: anxious helplessness, anxious guilt, and overt hostility.  Furthermore I expressed the view that, even though they will make herculean efforts to induce these reactions, and are very good and finding other folk's vulnerabilities in order to do so, they secretly hope they will fail in their efforts. 

Every time they succeed, they will do more of whatever it was that worked; every time they fail, they will do less of whatever did not work.  They will not give up easily, and if they've known you for a while, if one trick does not work, they will have a whole repertoire of other behaviors from which to choose. They will know how to push all of  your buttons in the most effective way possible.

Last, because of the variable intermittent reinforcent schedule, if you only occasionally react in the "wrong" way to them, that is worse than reacting badly to them all the time, because they will try that much harder and longer to elicit the "desired" response.  I said that in my next post I would start by saying what not to do. 

Here it is.  It's fairly simple, so this will be a relatively short post.  In future posts I will suggest counterstrategies for the most typical BPD strategies for eliciting the three responses, and then finally advise readers about what to do in the inevitable event that they slip up - so that the variable intermittent reinforcement schedule does not kick in.

IMPORTANT CAUTIONS:  Please be advised that sticking to this program is extremely difficult, so the services of a therapist who knows about these patterns are usually necessary.  Also, this section is designed for adults dealing with BPD adults - over 23 years old, actually.  This is not necessarily what you should do if you happen to be raising a teenager with BPD traits.

Without further ado, what not to do:

A. Try to please the unpleasable.  If they put you in a damned if you do, damned if you don't position (a double bind), try to do something to please them anyway.  If they "yes-but" all of your suggestions for solving any problem they present to you (that is, if they reject any and all offered solutions with a sentence that has the structure, "Yes, I could do that, but...), keep offering more solutions.  If they ask you to do something that is clearly impossible, try your best to do it anyway.

They never forget you have a choice

B. Make sacrifices for them.  Stay up all night talking with them and trying to reassure them about their latest emotional debacle when you have to go to work the next day.  Give them thousands of dollars to help get them out of a financial bind that they had put themselves in with profligate spending and irresponsible behavior.  Drop everything you are doing and rearrange your schedule for the entire day so you can do something for them like right now, even though the chances are 50/50 they will not even be there when you get to their abode - and be sure to cancel any planned activity that you've been looking forward to forever.  Drive a hundred miles out of your way to take them somewhere.

C. Get defensive.  Say, in frustrated tones, "You know, I'm only trying to help you" or "Don't you understand that I have other things to do?"

D. Act hostile.

E. Act guilty.  Because you know down deep you should be able to solve impossible dilemmas, and that their behavior is probably all your fault anyway.

F.  Stand there and take it like a (foolish) man.  Are they slapping you around?  Verbally abusing you will a barage of invective?  Impugning everything you stand for?  Screaming at you?  Just stand there and let them.  Maybe they'll stop.
 
G. Return in kind.  I knew a psychiatrist who got so upset with the verbal nastiness of his patient that he told her she was a dog and that she should have consulted a veterinarian.   See if you can stop the BPD person's pain-seeking behavior by inflicting more pain.

H. Lecture them.  Tell them all about how cocaine is harmful, that they should leave an abusive relationship, or that they should not ride their bicycles at midnight through crime-ridden parts of town in a bikini with hundred dollar bills hanging out their bras.  After all, they are just too stupid to figure these things out for themselves.  They'll tell you they think cocaine is good for them.  Argue the point.

I. Try to rescue the help-rejecting complainer.  Go to their house to try to take them away from an abusive romantic partner.  Let them move in with you rent free.  Loan them money that they will never pay back.  Try to mediate their disputes with others (trying to physically get in between two fighting adults is particularly important - maybe they'll both start in on you).  Cuss out the people who they claim have mistreated them.  Go ahead, I dare you.

APA vs. APA

MANAGED CARE SHOCKER!   Imagine my surprise when I opened my mail and found a letter to me from AmeriChoice by UnitedHealthcare managed care insurance company telling me that psychiatrists were not referring enough of their depressed patients for psychotherapy (presumably to psychologists and social workers.  Nothing was said about psychiatrists doing the therapy themselves).

The letter went on to say that "evidenced-based medicine" has shown that the combination of antidepressants and psychotherapy is more effective than either alone.  This letter was almost as bizarre as another letter I had received not long ago from another managed care company telling me that Abilify or any other atypical antipsychotic medication is not the first choice in augmentation medicine for patients with major depression who do not respond to an antidepressant alone.  No sh*t, Sherlock!

The letter about psychotherapy, as well as the one about about misuse of certain brand-named drugs, is a sick joke coming from managed care, which joined forces with the pharmaceutical companies in the late nineties to try to destroy psychotherapy as we know it.  As I describe in my new book, managed care companies routinely paid psychiatrists a lot more for doing med checks than for doing psychotherapy. In response, psychiatrists stopped doing therapy for the most part, and they began to see medication as a cure all for everything and appropriate for everybody.

Then, mangled care companies started lying to their subscribers about how much psychotherapy was covered under their insurance plan.  In their reading materials, the companies might say that 20 sessions per year were covered, but then they would only certify 4 or 5 sessions as "medically necessary" and refuse to cover any more.  Therapists would then have to spend hours on the phone arguing with clerks about what treatments were medically necessary.  The clerks would try to intimidate the therapists.  Why, the therapist must not be very competent if he or she could not cure the patient in four or five sessions!

For the record, 20 sessions in most mainstream psychotherapy models is itself considered brief therapy, which is most appropriate for patients who are relatively high functioning, have at least some good relationships, and have a single, very well-circumscribed conflict to manage. Diagnositically, they would have only one disorder (no co-morbidity).  This type of case is today rather unusual because patients with anxiety or depression generally have behavioral and relationship issues as well.

In other words, brief psychotherapy works best for the so-called "YAVIS."  YAVIS means young, attractive, verbal, intelligent, and successful.  One might ask why such an individual would even need therapy in the first place.  And, of course, they tend to get better no matter what the therapist does.  For patients who are the most in need of psychotherapy - such as those with serious personality disorders, alcohol and drug abuse, and/or long term repetitive self destructive behavior - brief therapy accomplishes very litle.

After a while, mangled care insurance companies found out that it was not cost effective to hire clerks to argue with therapists, and they were also getting a bad name with employers who are the primary ones purchasing insurance.  I recall a managed care group losing a contract with Matel Toymakers in Southern California because they did not certify as medically necessary psychotherapy for patients who were referred for treatment by the company's own Employee Assistance Program (EAP)! 

So insurance companies quit that strategy and merely racheted down fees for ALL psychotherapists. 

This practice, they found, had a side effect that was just perfect for their ultimate bottom line. Suddenly, psychologists who never before had the slightest interest in prescribing psychiatric medication wanted prescribing privileges.  It was all an issue of money, and little else really. 

(The problem with psychologist prescribers, from this psychiatrist's point of view, is that psychiatric medications not only affect the brain, but may interact with all other organ systems, diseases, and non-psychiatric medications.  If you want to do it, IMO you should go to medical school.  Of four psychologists first trained in psychopharm by the Armed Services, two of them decided to do just that).

Instead of banding together to fight for their patients' needed access to psychotherapy, as well as for their own need to all get paid at rates comparable to other highly trained professionals, the American Psychiatric Association and the American Psychiatric Association got into a turf war over prescribing privileges.  I have come to believe that mangled care has devised a strategy to divide and conquer.  If they did, they were successful beyond their wildest dreams. 
                                                                                                                        

And now they have the audacity to complain about psychiatrists and psychologists not working together, because it would actually save them money? This may seem self-serving coming from a physician, but it is true: Your friendly neighborhood health insurance carrier does not give a good God damn about their patients' mental health.                

Teacher, Teacher, I Declare...

After I posted Preying on Human Misery on May 3, which was critical of the way the Child and Adolescent Bipolar Foundation often  unwittingly supports the labeling of acting-out kids as having brain disorders, one of the people associated with the organization wrote me an angry e-mail.  It took note of the question I had posed, "Why would any parent want their child to be labeled with a brian disorder?"   I was told in no uncertain terms that no parent would ever want this, just as no parent wants their child to be labeled with a life threatening illness. 

In my e-mail reply, I said: "Of course many parents resist the drugs, thank goodness, but other parents we see everyday in our clinics demand both the diagnosis of bipolar disorder and the drugs, and when told their children do not need drugs, they go elsewhere.  Are you aware of this?  It’s also happening all over the country.  Your statement that there are no parents who want their children to be diagnosed with a brain disorder is demonstrably incorrect.  And I am not even including the parents who coach their children to act certain ways in order to get what are known as 'crazy checks' from the government." 

Parents who insist that their children are diseased in this manner, often with the backing of a mental health professional, tend to want to blame all of their family's problems on everything and anything but themselves. 

We are seeing another example in schools, in which today's parents may blame "bad teachers" for all of the academic and disciplinary failings of their children.  Stories abound about how teachers, when they send home notes describing problematic behavior in one of their students, are met with irate parents who defend their child, verbally attack the teacher, and are willing to complain about the teacher's "outrageous prejudice" against their darling child to the school principal or even to the district superintendent.  Several commentators have pointed out that, in the good old days, such a child would be punished at school and then later again at home.  The parents believed the teacher's side of the story, and never became so damn defensive.

Frighteningly,  the theme of never holding parents to account for their children's behavior has been picked up by politicians of both political parties, as they attempt to "fix" our "broken down" educational system.  In the case of politicians, however, there may be a second motive behind just catering to the prejudices of the electorate.  One must wonder if the "blame the teacher" movement is designed to destroy public schools.  This issue was covered nicely in a recent op-ed column by Bill Maxwell (http://scrippsnews.com/content/maxwell-dont-turn-teachers-scapegoats):

"No Child Left Behind, for all intents and purposes, is a blueprint for blaming teachers and making the privatization of our public schools more palatable by offering charter schools as the panacea.  Now President Barack Obama has succumbed to the Blame the Teacher Syndrome with his Race to the Top program. A mainstay of the program is improving public education by rewarding or punishing teachers when their schools do or do not close the so-called achievement gap...'Whenever data is generated by any credible source, the correlation between poverty and educational achievement is so strong it is impossible for any unbiased individual to ignore,' writes Jack Random of dissidentvoice.org, an online newsletter. 'When schools are ranked according to quality, those on the top of the list are invariably wealthy and predominantly white while those at the bottom are invariably poor with high proportions of minorities.'"

The politicians' idea is that teachers might actually lose their jobs if their classes' performance on standardized tests does not improve - as if teachers are magically in control of just how motivated to learn the students assigned to them are.  Aside from the lack of wisdom of using standardized tests (which lead to "teaching to the test," a lack of emphasis on teaching critical thinking skills, as well as outright cheating in order to compete), this idea clearly turns teachers into scapegoats.   While there are no doubt incompetent teachers, I highly doubt that they are concentrated in the poorest performing schools.  For that to be true, it would have to have been planned that way. 

Well, come to think of it, maybe it has been planned that way to some degree. The most inexperienced teachers are often sent to work in the most difficult districts, especially in an economic environment in which thousands of teachers have been laid off nationwide - usually with the most senior teachers having, well, seniority. The experienced teachers not only get to keep their jobs, they often have had a chance to land the best school assignments. 

When you combine that process with the way schools are funded using local property taxes, so the schools in the poorest districts have often had the fewest resources, you can see why some minorities get paranoid that the government is conspiring to "keep them in their place."

I propose that we test the proposition that teachers are to blame for the poor performance of their students on standardized tests.  After one year, we should have the schools with the lowest and highest test averages trade faculties.  That way, after a second year, we can see if the supposedly "better" teachers did much better with what are probably the most difficult students, and if the test scores of the students of the supposedly "bad" teachers declined significantly.  Anyone wanna bet on the outcome?

Grandparents Raising Grandchildren

In the last thirty years, a dramatic increase in the numbers of grandparents raising their grandchildren has taken place. Sometimes the parent in the middle also lives in the house, but often not. Between 1990 and 1997, the number of children living in grandparent-headed households increased by a whopping 66 per cent. (Bryson, K., & Casper, L. M. [1999]. Co-resident grandparents and grandchildren. Washington, DC: Current Population Reports, Special Studies, U.S. Department of Commerce, Economics and Statistics Administration, Bureau of the Census).  In 1997, 2.4 million of the nation's families were maintained by grandparents who had one or more of their grandchildren living with them.  This trend seems to be continuing to the present day.

The numbers were rising way before an even bigger spike in this number in 2008, which was widely attributed to economic factors stemming from the deep recession. 

When the situation is not due to external factors such as the sudden unemployment of the parents, military parents being deployed to Iraq, or the untimely death or serious illness of the child's parents, the persons in the middle  – the mother and father of the child – often fall into one of three categories:

       1.  Individuals with borderline personality disorder (BPD) who neglect, abuse or otherwise endanger their children.
       2.  Individuals with antisocial traits who end up in jail (antisocial personality disorder is also a "Cluster B" personality disorder just like BPD).
       3.  Addicts or alcoholics. Many of them may also exhibit significant Cluster B personality traits at one time or another, although in addicts the traits may disappear if and when the addict cleans up.

Courtney Love lost custody of her daughter Frances Bean Cobain to the child's paternal grandmother

These types of parents may literally give their children drugs or alcohol, leave them unattended, or hang out with unsavory characters who are bad influences on the children.  Because the grandchildren appear to be in such danger, the grandparents feel that they simply must take over the rearing of the child, and of course there is a lot of truth to their viewpoint.

When the cluster B parents starts to open up in psychotherapy about what they think is going on, however, a completely different point of view emerges.  They believe that their parents want to take control of the grandchildren, and are just looking for an excuse to do so. They interpret their parents' frequent attacks on them for their bad parenting skills as a coded instruction to become or to continue to be bad parents - so that the grandparents can have the excuse they are looking for to take the kids away. 

The child's parents then abdicate their parental role in order to give the grandparents what they seem to want.  The parents are, in a sense, offering up their own children as gifts to their parents.  The more the grandparents criticize their behavior, the more they think the grandparents are looking for such an excuse, and the worse parents they become.  The worse parents they become, the more the grandparents feel obligated to take over the care of children.  And it's not just a vicious circle - although it is that - because both the parents and the grandparents are simultaneously giving each other double messages.  I refer to this problem as cross motive reading.

A few years ago there was a TV newsmagazine story about grandparents raising grandchildren that illustrated what other family members may be reacting to.  Several of the grandmas who were interviewed waxed eloquently about how their grandchild was the center of their universe and how raising their grandchild was such a joy and how it gave their lives new meaning.  At other times during the same interview, however, they complained bitterly about how, as elderly women, chasing after their grandkids made them soooo tired.  Not that both of these statements cannot be true simultaneously, but I suspect that both the parents of the grandkids and the grandchildren themselves would find the two sentiments somewhat contradictory.  If these women expressed them so readily to a TV news reporter, one can confidently wager that their children and grandchildren had heard them ad nauseum as well.


I strongly suspect that one of the main reasons behind the large increases in the number of grandparents raising grandchildren has been the increasing frequency of Cluster B family dynamics in American culture.

Freddy the Freeloader and Minnie the Moocher Part II: the Hidden Agendas

In my post of August 10, I wrote about how I have been seeing more and more twenty-somethings (and, I might add, thirty- and sometimes forty-somethings) who are freeloading off of their parents with their parents' almost compulsive cooperation.  The parents may complain a lot, but cooperate they do.  The parents' enabling behavior, as time goes on, produces and then reinforces the "incompetent" behavior of the future Freddy the Freeloaders and Minnie the Moochers.  If the parents compulsively do everything for their "kids" and expect nothing from them, their kids get the idea that providing for children is an extremely vital activity for their parents, and continue to offer up themselves so that the parents can continue with the role they seem to want to play so desperately.

But what's going on with the parents?  Often you can show these parents reams of expert opinion from all kinds of opposing camps that all almost unanimously say something to the effect that, "If you don't let kids do for themselves, they never learn how."  If you quote these experts, said parents will, more often than not, get extremely defensive.  All the while, they will completely ignore the "evidence."  The fact that the expert opinion is in a sense proved to them every day that their children act helplessly seems to go in one head and out the other. 

The parents may rush their kid to some horrid psychiatrist who will assert that the kids' failures are really due to some sort of brain pathology, and immediately put the offspring on medication that obviously does not change the kids' overall behavior one bit.  Nonetheless,the parents will then hurry off to join the Child and Adolescent Bipolar Foundation instead of looking at their own seemingly counter-productive behavior, in order to have their bizarre views reinforced by like-minded parents.

Actually, in a way I disagree with the experts who believe that offspring growing up in this environment "never learn" to take care of themselves.  What dysfunctional individuals are and are not able to do, and what knowledge they do or do not possess, is not something they are necessarily going to admit to for fear of not being able to continue in their role of "losers who are totally dependent on their parents."  Quite often they are secretly very capable individuals indeed.  How do I know this if they will not demonstrate competence nor admit to any if they have it?  Simple.  If they learn to trust a therapist, and if the therapist knows how to ask the right questions, they will then admit to said competence and then demonstrate it in order to remove all doubt.

So again, what's going on with the parents?  I find that there are several possibilities, but the most common are three in number. 

The first is sort of a pathological empty nest syndrome.  These parents are so wrapped up in taking care of children that they would literally have an existential crisis if the kids left, and not know what to do with themselves any more.  They might become extremely depressed.  If they are covertly conflicted over the very role of being a parent and feel guilty about those feelings, they may also have a compulsive need to parent and yet constantly be angry with their children for continuing to be around.  This is the situation that is most frequently seen in offspring who develop borderline personality disorder (BPD).   "Don't leave me - I hate you." 

Sometimes the offspring who develops BPD has a child out of wedlock and then acts too incompetent to take care of the child. The child then must be raised by its grandparents.  The child becomes a sort of gift to the parents.  This is one of the major reasons for the huge spike in the number of grandparents raising grandchildren in the US seen over the last couple of decades.  But that's a matter for another post.

The second family dynamic in which a Freddie or a Minnie results is when the child is triangulated into the parents' relationship.  They parents do not get along with each other but remain so focussed on the alledged inadequancies of their hapless offspring that there is almost no time left for them to get on each others' nerves.  If the child "grows up" and moves away, they then start fighting with each other more and more. 

In a milder version of this dynamic, an adult child moves nearby and is "on call" for the parents to mediate disputes.  Usually it's a daughter but not always.  Mom will come over and say things like, "Your father won't do [such and such] for me. But he'll do it if you ask!"

Said daughter will often not marry because when she asks Mom why she does not ask for help from the daughter's brother or sister, Mom says, "Well, she has a family and I don't want to bother her."  In other words, "She has a family and you don't."  Since Mom seems to need someone to do this, daughter takes Mom's statement as an instruction for her to remain single. Otherwise Mom is in trouble.  The daughter will accomplish this feat in a number of ways.  She might choose to stay celibate, but if this is unsatisfactory, she may instead date - but nothing but a series of commitment-phobic or married men.  At least then she gets to have sex and companionship.  Silver lining.

The third common family dynamic is the most interesting.  To the outside world as well as to the family, the parents appear to be taking care of their incompetent child, but underneath the surface, the child is actually taking care of the parents’ emotional or physical needs. I refer to this shell game as Who is Taking Care of Whom? because the answer depends on the answer to another question: exactly which needs are we talking about here?

In my new book, How Dysfunctional Families Spur Mental Disorders, I describe an interesting example of this.  It is the story of a man in his late thirties who still lived with his parents. He would rarely keep a job for long, often stole money from them, and ran up significant bills on their credit card without permission.

Oddly, the parents always left money lying around the house in plain view, and never once called the credit card company to make sure he could not use the card any longer. They never once suggested that he move out. In fact, whenever he offered to, they would tell him that he was too incompetent to make it on his own. Of course, they certainly had reason to believe that such was the case, but from the patient’s point of view, they did this because they secretly wanted him to stay there and continue his seemingly outrageous behavior.

During his therapy, the other side of the Who is Taking Care of Whom shell game gradually emerged. As they used to say on the great TV show Pushing Daisies, the facts were these: the parents were elderly and lived in an extremely crime-ridden and dangerous neighborhood. Several other elderly residents had been burglarized and in some cases assaulted and almost killed. Almost all of the original inhabitants of the block on which they lived had moved out because of the escalating crime rate, but the patient’s parents refused to budge. Furthermore, they were developing physical infirmities which made them easy targets, and would act in careless ways that almost invited victimization.

The patient originally presented to me as a very angry and potentially explosive individual. Many of my office staff was fearful of him. In his neighborhood, he acted like a dangerous and possibly crazy fellow in many different and very public ways that communicated a strong message that he might go postal at a moment’s notice. His behavior said, “Do not mess with me.” In all probability, because of this behavior, his parents and their house were never touched by crime. Despite his angry appearance, he was in fact a highly fearful and non-violent person. His false self had the effect of protecting his parents from crime while at the same time making it appear to everyone else that he was abusing them and seemed to most others to be completely dependent on them. His apparent “abuse” of his parents took place with their full cooperation.

How to Disarm a Borderline, Part I

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If you are an adult in a relationship with another adult, either through blood or through a romantic liaison, who fits the description of a patient diagnosed with borderline personality disorder (BPD), then you already know that you have your hands full.  A New York Times blog post about BPD drew 470 rather contentious comments (http://well.blogs.nytimes.com/2009/06/16/understanding-borderline-personality-disorder/?apage=1#comments) from people who were dealing with BPD relatives and other people who themselves have the disorder.  Although I am in neither category (hopefully), I wrote a few posts myself. 

I wrote about some of the ideas that I describe below.  A couple of people who said they were dealing with BPD parents did not like what I wrote, but showed that they had adopted some of the very behavior they were complaining about in their parents, as evidenced by their responses to me (more on why this might happen shortly).  I was being nice, so I didn't point that out to them.

Some people say that the only way that you will surely survive a relationship with someone with BPD is by cutting all contact with the "toxic" individual.  Some therapists even say this.

If you are in a romantic relationship with a person with BPD, that might indeed be the best course.  Has the relationship already been going on for quite a while?  You won't like hearing this, but this means you: you need to ask yourself why you are attracted to such a difficult person in the first place.  Please don't give me the usual crap like, "I didn't know what (he or she) was like that at first, but now I'm involved and I can't get out.  (He or she) was so charming at the beginning of the relationship!" 

Puh -leeeze!  You are like the wife who insists her husband is not having an affair while she looks for the stain remover to get the lipstick off her husband's shirt collar. Sorry, but most people run at the first sign of BPD behavior.  It is not subtle, and one does not often have to wait very long before one first sees it.

Well, you might object, the person threatens suicide if I tell them I'm going to leave them!  So, let me get this straight.  You're planning to sacrifice your whole life because someone might stab themselves in the heart in front of you and then quickly hand the knife to you before they die so your fingerprints are all over it?  If you feel so responsible for other people that you respond to this kind of threat by caving in to it, please, get some therapy.

When it comes to parents with BPD, however, the strategy of divorcing one's family, while better than remaining in a toxic relationship with them, creates other problems.  First of all, it's kind of lonely to have no family.  You will be faced with a cavernous hole in your life. 

Second, you came from them.  If they are monsters, what does that make you?  You undoubtedly share at least some of their toxic behaviors whether you like to admit to it or not, because one can not grow up in a toxic household without adapting to it in ways that are both problematic themselves and very hard to stop later on in other social contexts. 

Especially with your own children.  Attachment studies clearly show that the best predictor of one's relationship with one's children is......one's relationship with one's parents or other primary caretakers.  Some people from abusive households wisely decide not to have children for fear that they, too, might become abusive.  But is that what you really want to do?

Besides, you cannot completely divorce yourself from your family, because you carry them around with you in your head. Literally. We in the biz call these mental representations schemas.

Your choices are not just limited to these two:
1) To either to continue to be mistreated, or
2) to cut off all contact with your family.

A third choice is to change the nature of your relationship with your parents so that you are not being mistreated but are still in contact with them.  Impossible, you say?  I disagree.  While you do not have the power to "fix" your parents, you do have the power to fix your relationship with them.  If you change your approach to them in a consistent manner, that will force them to change their approach to you. 

However, there is a big problem that you will face in doing this: since you have been in a relationship with them your whole life, they have developed a whole repertoire of behaviors, include recruiting other family members, to give you the powerful message, "You're wrong.  Go back to responding the way you used to."  If one strategy does not work, no worry.  There are plenty more where that came from. Scary to be sure, but not insurmountable if  you can enlist a therapist who knows something about the family dynamics in people with BPD.

Therapists like myself who work primarily with patients with BPD, regardless of their "school" of psychotherapy or their theoretical ideas about the causes and cures for the condition, all have independently developed some ways of getting BPD patients to be more cooperative with them.  (That is, cooperative just with the the therapist. Unfortunately, not with anyone else). We seem to have all come up with these little tricks of the trade independently, yet they are all very similar, as I described in a paper called, "Techniques for Reducing Therapy-Interfering Behavior in Patients with Borderline Personality Disorders: Similarities in Four Diverse Treatment Paradigms" (Journal of Psychotherapy Practice and Research 1997; 6:25-35). 

Marsha Linehan of DBT fame, Otto Kernberg of psychoanalysis fame, Lorna Smith Benjamin of interpersonal therapy fame, and myself (with my not-at-all famous treatment paradigm called Unified Therapy) all do pretty much the same things at the beginning of treatment.  (We then start to diverge considerably).  These strategies are survival skills for us.  Therapists used to come up to me all the time and ask me how I could stand to work with several patients with BPD at the same time, but it really is not a big problem if you know the "tricks."  I had to devise them a long time ago because I built up a private practice by taking referrals of these patients whom no one else wanted to treat.

As I mentioned, it is much harder for someone who is already enmeshed with a relative with BPD than it is for a therapist who has just met a patient with BPD.  One reason is the aforementioned repertoire of behaviors they have designed over many year specifically with you (the enmeshee) in mind.  They know all of your weaknesses and exactly how to take advantage of them.   Second, as a therapist, I do not have to deal directly with a bunch of interfering relatives like the enmeshee does.

The third reason has to do with something behaviorists call a variable intermittent reinforcement schedule.  This schedule is why slot machines in casinos are so successful.  You never know when the damn thing is going to pay off, and it pays off just often enough, so you keep pulling the lever until you lose your shirt.

I should mention that, as John Rosemond is fond of saying, people are not lab rats that blindly respond to rewards and punishments. However, if a person has a goal, and their behavior helps them to reach it, reinforcement schedules kick into play. It is not the person being "rewarded," but the behavior. It is not rewarding to have people hate you.

The goals of the worst of the behavior exhibited by people with BPD, for reasons I will not discuss here, is to cause in their targets one of three reactions.  The first two of these invariably lead to the third.  The three reactions they shoot for in their targets are a sense of anxious helplessness, a sense of anxious guilt, and overt hostility. 

The great big secret, however, is that folks with BPD are often highly ambivalent about getting these reactions.  They will try like hell to get them - and believe me, they are real professionals at it - but they secretly wish to fail. (How do I know this?  Experience.  But I can not prove it - because there is literally no way to set up an "empirical" experiment that would fill the bill - so readers can call this highly speculative if they wish).

If the persons with BPD succeeds at getting one of three reactions, they will continue to draw for it.  Pull out all the stops in order to get them, in fact.  If they fail at getting the reactions, however, they will suddenly become more conciliatory.  However, because of the variable reinforcement schedule, if they only occasionally succeed in getting one of the reactions with a person with whom they have already been interacting for a long time, they will keep trying much longer. 

Therefore, if you already have a history with them, and they have a track record of making you react in any or all of the three ways, their behavior will get much worse before it gets better.  If you can not keep your cool and occasionally react the wrong way, it becomes even harder to get the BPD's to change their behavior toward you than if you react the wrong way all the time!

In later posts, I will share with readers the therapist's tricks for avoiding "rewarding" the bad behavior of persons with BPD, but most people who are already enmeshed with a BPD family member will find it nearly impossible to employ them successfully without the help of a therapist who understands the family dynamics of those who suffer with the BPD traits, and who can prepare them for your "adversary's" formidable defenses.  I will start in an upcoming post with what not to do.

Yet Another Pharmaceutical Company Develops Mania

Six!!!   In a blogpost on April 30, I noted, "Five drug companies so far have been proven to have a vested interest in expanding the diagnosis of bipolar disorder for their own profit."  This statement followed a series of posts in which I had described settlements that five different companies had made with the U.S. Department of Justice (DOJ) for the illegal marketing of one of their drugs that had been FDA-approved for something other than bipolar disorder, and not for use in mania (off-label marketing).  They ain't supposed to do that.

The marketing was directed at doctors, not at the general public, and included the usual wide variety of amazingly clever manuevers big PhARMA has created over the years to trick physicians into prescribing drugs off-label. I describe many of their tricks in my new book.  As part of the settlements, the companies were fined big bucks. Of course, as I shall show shortly, the amount of the fines paled in comparison to the amount of money the companies made doing their nefarious business (see also my August 17 post, So Sue Me).

Readers may not know that once a drug is approved by the FDA for any indication, doctors may then prescribe the drug for anything that they want to.  It is all perfectly legal.  It is illegal for the drug companies, however, to discuss possible off-label uses with doctors.  Not that the law ever really stopped them.

I'd like to thank reader Duane Sherry (even if he thinks I'm just a lowlife psychiatrist) for alerting me to the sixth Department of Justice judgment against a big pharmaceutical company for off-label marketing a drug for bipolar disorder.  According to a DOJ press release just yesterday:

"WASHINGTON – Novartis Pharmaceuticals Corporation has agreed to pay $422.5 million to resolve criminal and civil liability arising from the illegal marketing of certain pharmaceutical products, the Justice Department announced today.

According to the agreement reached with the government, the East Hanover, N.J.-based company will plead guilty to a misdemeanor and pay a $185 million combined criminal fine and forfeiture for the off-label promotion of Trileptal in violation of the Food, Drug and Cosmetic Act. The Food and Drug Administration (FDA) approved Trileptal as an anti-epileptic drug, for the treatment of partial seizures, but not for any psychiatric, pain or other uses. Once a pharmaceutical is approved by the FDA, a manufacturer may not market or promote it for any use not specified in its new drug application. The unauthorized uses are also known as "unapproved" or "off-label" uses.

In addition to the criminal fine and forfeiture, Novartis has agreed to pay $237.5 million to resolve civil allegations under the False Claims Act that the company unlawfully marketed Trileptal and five other drugs, and thereby caused false claims to be submitted to government health care programs. Specifically, the civil settlement resolves allegations that Novartis illegally promoted Trileptal for a variety of uses, including psychiatric and pain uses, which were not medically accepted indications and therefore not covered by those programs. In addition, the agreement resolves allegations that the company paid kickbacks to health care professionals to induce them to prescribe Trileptal..."

The government's memorandum,  published on line (http://www.justice.gov/usao/pae/News/Pr/2010/Sept/novartis_entryofplea.pdf), stated, "The information alleges that NPC misbranded Trileptal by marketing it for off-label uses from July 2000 through at least June 2004. (Information, par. 17). In January 2000, the FDA had approved Trileptal for the treatment of partial seizures in persons with epilepsy...When sales of Trileptal did not meet expectations, NPC re-launched the drug to market Trileptal for the unapproved uses of neuropathic pain and bipolar disease, and profited from this off-label campaign by hundreds of millions of dollars."

Hmmm.   A $422.5 million fine on profits of hundreds of millions of dollars.  And one "biological" psychiatrist I had a debate with on line said the DOJ were "thugs" for going after these ever-so-honest companies.

The Novartis case was not quite as bad for patients with actual bipolar disorder (as opposed to the patients given a phony bipolar diagnosis according to some new criteria that were literally pulled out of the asses of certain "experts") as the previous five cases, because there is some reason to believe that Trileptal may actually have some efficacy for mania prevention. It is a molecule nearly identical to another drug called Tegretol.  Tegretol and Trileptal are both medicines used for epilepsy.  Tegretol was the first anticonvulsant, as well as the first drug of any sort other than lithium, that was used for prevention of mania in manic-depressive illness, now called bipolar disorder.

There were not a lot of studies done on Tegretol for use in mania prevention, and the ones that were done were somewhat equivocal.  Still, it was widely prescribed by psychiatrists back in the 1980's to bipolar patients who were not able to tolerate lithium, and clinically it seemed to be fairly effective.  Back in those days, there were no good alternatives to lithium other than antipsychotic drugs, which had a lot of problems.  It was also a time when patients had to have actual manic episodes and not "mood swings" in order to qualify for the diagnosis.  The drug company that manufactured Tegretol never did any large-scale studies to see if the clinicians' opinion was justified.

Trileptal, as mentioned, is only slightly different than Tegretol, and works just as well for epilepsy with fewer side effects.  Of course, that does not mean that it will also work just as well for mania prevention.  The fact that Novartis did not do the necessary studies makes me wonder if they really believed that it might work.