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A Deeper Understanding of BPD

When treating clients with borderline personality disorder, it’s important for clinicians to see through the stigma and use a more mindful, therapeutic approach.

Estimated watch time: 54 mins 

Available credits: none

Presentation Materials:

Speaker, Allison Johanson, LCSW has over a decade of experience treating people suffering from trauma. She is certified in Eye Movement Desensitization and Reprocessing ( EMDR) and is a Consultant in training with this modality. She is also fully trained in comprehensive Dialectical Behavioral Therapy ( DBT) from Behavioral Tech Institute and worked for many years with a comprehensive DBT program. She currently has a private practice in the DTC and works with clients suffering from both identified and overt trauma as well as those struggling with ineffective behaviors. She utilized EMDR with informed DBT skills to work with people toward meeting their goals.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. 

Candi:
Thanks so much, everybody, for joining us. We really appreciate it, and we are so grateful to have so many people join us on this virtual world we are in — and all the way from the UK. That’s amazing — 7:00 PM at night. 

Welcome. My name is Candi Ader. I am the director of community outreach with The Recovery Village at Palmer Lake. So, our parent company is Advanced Recovery Systems, and we’ve got about nine programs nationally. The Recovery Village at Palmer Lake is here in Colorado. We have a 110-bed facility here; it used to be a resort, so it’s beautiful. We offer a full continuum of care for adults dealing with substance use disorder, so we’ve got a full medical detox, a residential program and then PHP and IOP with housing on-site. Our program here in Colorado is in-network with most major insurance companies, so Blue Cross Blue Shield, United, Cigna, Aetna, Humana, Bright Health, Rocky Mountain Health Plan and then a handful of other local plans. If you’re not familiar with our program and you would like to get some more information, I will be entering in my name and email address in the chatbox. I would love to meet with you. 

Whenever someone comes into our program, they’re meeting with our case managers within the first week to start creating their aftercare plan. So, I’m always up for meeting new clinicians, learning about your specialties and your practice and your insurance in-network contracts or private pay options, whatever it is, so that we can have you as a referral partner when our clients are creating those aftercare plans. We also have some of the other programs that I always mention under our ARS umbrella. One of them is the International Association of Fire Fighters — that’s out in Maryland, and that’s specifically for firefighters that are affiliated with the IAFF union. They can go there for primary trauma, primary mental health, primary substance use, doesn’t matter. Awesome, awesome program. We also have a program in Florida called Next Generation Village. That is for adolescents dealing with substance use disorder so, again, a full medical detox, residential and then day programming and IOP programming, and also in-network with a lot of different insurance companies. Pretty much all over the country, we can help clients out dealing with substance use disorder. And if it’s something else that we can’t help them with, we are always happy to help find them an appropriate referral or resource.

So, we are super excited to have Allison Johanson with us today speaking. Allison is an LCSW and has over a decade of experience treating people suffering from trauma. She is certified in eye movement desensitization and reprocessing, or EMDR. She’s also a consultant in training with that modality. She is also fully trained in comprehensive dialectal behavioral therapy, or DBT, from Behavioral Tech Institute and worked for many years with a comprehensive DBT program. She currently has a private practice in the Denver Tech Center here in Colorado and works with clients suffering from both identified and overt trauma, as well as those struggling with ineffective behaviors. She utilizes EMDR with informed DBT skills to work with people towards meeting their goals.

So, I will pass it over to Allison and let her take over. Also, sorry — couple more things before I do that. If you guys would stay muted during the presentation, just so we don’t have any background noise, and then also, if you — in the chatbox — wouldn’t mind putting your name and the organization that you work with and where you’re located, we would love to just kind of get an idea from where everyone’s at. And then if you have questions throughout the presentation, feel free to enter those in the chatbox. Allison can either try to answer those as she goes, if she happens to see them, or else Ashley can address those at the end of the presentation as well. So, thanks so much for being here, everybody. And Allison, it’s all yours. 

Allison:
Perfect, thank you so much. Yes, I will take some time periodically throughout the presentation to just check the chatbox. If you’re anything like me, you’ll forget your question if you don’t just type it in, so just throw it in there and then I can address those as we go along and so I just give myself some space with that. Today, I’m going to talk about working with borderline personality disorder. I have a lot of experience with it when I was working with DBT. That’s the population that kind of filters through DBT programs, and it’s also become sort of a bad guy in our field. A lot of people have these, like, scary thoughts when they say or when people say something about borderline personality disorder, and so I really like kind of breaking that stigma. 

I still work with a lot of borderline clients who have symptoms of borderline personality disorder, both with the EMDR modality. I don’t do a comprehensive DBT, although because I did it for so many years, some of those concepts trickle in. But in private practice, it became just people. A lot of people needed a full program, and that’s not where I am, so that’s what we’re going to be talking about today. Like I said, ask questions as we go along. I just sort of allow for space to just sort of check in periodically, and then at the end, I’ll also open it up again. Some people prefer to just ask it out loud, and so I’ll allow for that space for people to unmute and ask at the very end if they need to.

I’m going to go ahead and share my screen and we will get — one second. So, we already talked about that. There’s me. For those of you who don’t know the criteria for borderline personality disorder, here’s just the DSM stuff. The thing about it is I have clients take a quick survey online, and pretty much anyone who’s experienced a trauma and has symptoms of it could say they have some of this, but the biggest pieces are when it becomes that behavioral piece — when it becomes something so intense than it is a trauma-based diagnosis. And I talk a lot about the trauma-informed approach to working with this population. So, frantic efforts to avoid real or imagined abandonment, that “I hate you, don’t leave me” sort of idea, a pattern of it, unstable and intense interpersonal relationships. An instability with self-image and sense of self-impulsivity with two of these areas, suicidal gestures, reactive mood, emptiness, anger, stress-related paranoid ideations. 

So, just sort of a quick idea of that, but what I hear from a lot of people are these things that really make me cringe. I hear clients come in and say, “Well, I have borderline personality disorder. I’ve been told that’s untreatable,” or, you know, “This person’s just doing it for attention.” When I worked in agency work, I’d heard that a lot from other people. “Oh, ignore them. They’re doing it for attention, or they’re just manipulating you,” or, “Oh, that’s just another borderline.” Really changing our framework of talking about this is essential, as this became stigmatized because of this. Instead of recognizing it as responses to trauma, it can be really powerful for your work and your motivation to work with this population as well, as they’re going to receive that really well. I have many clients that I consider now BPD in remission, similar to substance abuse in remission. So, their behaviors have become this thing that is always sort of here instead of grasping them. But they have that distance from it, and that can happen through DBT work.

Now, there’s more different things that can work with it as well, and the fact that people have learned about this from their invalidating environments. From that, they learned how to validate their emotions through ineffective behaviors. So, if I’m looking at someone’s behavior that they’re coming into my office with — not as a form to get attention or manipulate, but more as an idea of this is the only way that they can validate what they need and what they’re feeling — I’m able to sit in that a little bit more and able to meet them where they are. So, I have less people explosive at my office, and I have less people feeling threatened because I’m sitting in this with them from their perspective. When a person has not seen or heard, their system develops this, and so a lot of times, they’re not doing it; it’s outside of their window of tolerance. People are not doing this intentionally. Also, seeing the person in a lot of pain when they meet the criteria for borderline personality disorder, but when we start labeling people as borderline, that becomes icky. There’s such a yuck to it, and so please catch it if you say that — “borderline client” — even if it’s meant with the best intentions. Because clients start receiving that and start identifying with that as opposed to their core identity, which they’re already really struggling with. That’s one of the markers for the DSM, and so if you don’t have a sense of identity and then someone gives you an identity, it’s really easy to make that your identity as opposed to forming a really healthy identity. 

So, even if you’re not saying it to clients’ faces, I really believe clients start to receive that. So, I always talk about these because — I’ve even given talks and people have said, they raise their hand and they have a question and they say, “So, I have this borderline client.” And I’m like, “Alright,” because it’s so easy for people to do. But just sort of watching that as you’re talking to people can be really helpful, not just for the client. But do you see how if you’re sitting in the office with this yuck around this person, how easy it’s going to be to burn out around that? So, it also allows for us to have the space to work with this population as they come in. And I always say, I know this is crude, but assuming — it makes an ass out of you and me — so, we’d make these big assumptions about people. “Oh, here comes that borderline,” or “I guess they’re doing this.” Instead of slowing down, that’s what I always check in on: Am I ever assuming something? So, I just like to add that in. 

We’re gonna look at the DBT model. They talk about it from a biosocial model, and if you’re one of those science-minded people, this might be more helpful. So, if I’m looking at the fact that some people are genetically predisposed to a higher intensity of emotions, or they were born with an existing mental health disorder. The struggle is if they do not have that really core system within that, they’re more prone to some of these other behaviors, but just the biological factor in itself doesn’t mean anything. There’s a lot of very healthy people that have that. So, then you add into that some personality and temperament, and then some people say some really nasty things to you that create negative beliefs and self-defeating beliefs, and then you add into that stressful or traumatic events in your life — culture, media, school, so much school trauma, both educationally and socially, and then that invalidating environment. “Get rid of those intense emotions you were born with. They’re bad. These are the bad guys.”

Then you’re going to learn to shove it down, which can create those eating disorders, substance abuse, intense behaviors, cutting, suicidal acts, like, anything that you can do to get rid of the emotion that’s been labeled as bad because it was too much at some point in your life for somebody. So, looking at it from this mindset can be a little bit more effective for people who like that science-minded piece. This is coming from somewhere, these aren’t bad people — they’re people who have formed these ways of working that are different than what is effective in our lives. And reteaching that, sometimes people say, “Well, DBT is so basic,” and it is. But for many people, it’s earth-shatteringly new, and the same with EMDR. For some people, it’s like, “Well, yeah, we work through the trauma.” Well, we have to do it slow with this population if they’re a little bit more volatile, and there’s some other things that we can do to make that safe, but that’s for another day. But I’m looking at this and saying, “If I reduce that social vulnerability, this person can have their intense emotions and they’re not bad anymore, and then they don’t have to cover them up.” And then you probably all have your own modalities that fit into that as well. Those are the ones I know that the best.

So, if a person’s trying to tell their parents that they’re hurt and the parent’s distracted by their own stuff or values or trauma or whatever, and they don’t hear “get hurt,” they get louder. I see that with my kids. If I’m distracted, that’s how kids get hurt, but in a healthy environment, that good thing gets repaired. What happens if the parent says they just want attention and punishes the kid, then that kid learns that emotions are not okay. I’m not allowed to be heard and they’re not allowed to be heard, so I should get rid of them. Then emotion becomes more intense, kind of like a small child pulling on your pant legs that needs that attention. That emotion becomes less manageable because it’s become invalid. Things become so intense that the person responds with intensity because they don’t have any more control. That emotion becomes so big. And then as time gets on, they get older and that becomes really scary to a parent sometimes.

Then what can happen is there’s reinforcing behaviors that come into this. I don’t want my kids to react this way, so I’m going to intermittently reinforce it with attention. Then the person hears, “Oh, that really did get me hurt, this person’s worried about me. They’re showing me that they care.” And now, they come into our office. Something happens where they don’t feel validated or heard. They might have a big reaction to that because that’s how they felt heard in the past, and then the therapist feels threatened and then everything’s yucky because now, the therapist is responding to threatening. If instead, the therapist responds to this validation of, “God, did I not hear you correctly?” the person learns, “Oh my gosh. That’s not the way that this works.” So, as we’re looking at this from a different lens, we’re coming at the person from a different angle. 

I’m going to stop sharing and look at comments just to make sure there’s no question. I see that there’s a question about the PowerPoint being shared. Ashley or Candi, do you know if that’s going to be available for folks or if I can send it out to them or whatever would be helpful? So, the event’s going to be hosted on TheRecoveryVillage.com. So I just put the link in the chat of where this will live. Is there a paper copy of the PowerPoint as well? So, if anybody on the website — they’ll have the download to the PDF as well as the video from today. But if anyone wants it prior, I’m going to put my email in the chat and then just email me, letting me know that you would like either the PowerPoint or the video. I can send you those as well. 

So, I have a colleague who did his dissertation on why people leave therapy and don’t come back, which is a pretty important thing. What he found is almost 100% of the time it comes from feeling invalidated or invalidation from the therapist. So, this is something that is incredibly important to me — to review this idea of validation, especially from someone who’s coming from an invalidating environment, which is oftentimes that precursor to borderline personality disorder. When I say validation, I’m talking about listening and observing from that mindset of a trauma-based approach. This person is coming from a trauma response more than anything else. If I’m listening to that room, an unbiased thing, and I’m checking in on myself — if I’m noticing a yuck in myself, then I’m going to stay awake. I’m going to listen. Things are going to feel a lot better, and then I can accurately reflect, “Hey, you said this what’s happening.” Or, being able to articulate the unprovoked.

“Gosh, you look like you’re kind of mad at me right now, or you’re pretty frustrated.” Or, you know, “It actually crosses my boundaries when you throw your book. I bet people around you feel really threatened by that.” And that feels a lot better than, “I’m outta here,” or a scared feeling or whatever. So, articulating that as a behavioral pattern or emotions or thoughts becomes more validating. Also, just giving that biosocial model is important. If you’re not broken, this is because of a system of things that feel so much better to people. And then also, like, yeah, you probably do get your voice heard, and yeah, this is hard. You know, I think the level of validation within the land of COVID is that much stronger because we’re all living it.

So, if we can look at things after this is over, sort of looking at it from that same lens of, like, “I get it,” I think that natural validation is going to come. But how do I do this? I listen and pay attention. I reflect and acknowledge their point of view. I don’t have to be a leader in this room. The other person can have a viewpoint. That’s important. Sometimes, that viewpoint is, “I think what you’re saying is dumb.” And I’m, frankly, okay with that and welcome that because then there’s conversation. And I think that feels very validating for people, as opposed to, “This is what you should do.” What works is working to understand and ask questions, make a hypothesis, check in again, taking our stuff off that pedestal even though I know that this might be true, saying, “Hey, I’m just wondering, is A and B linked or am I off?” as opposed to saying, “Well, A and B equals C and that’s the way it is.”

For a lot of people who have had especially authoritarian people in their life that have been less than supportive, that feels really invalidating and it pulls up that invalidating environment — becomes a trauma response. And then normalizing things when they’re normal — I think that is huge, right? If someone is normalizing something that isn’t true, all we’re doing is feeding that behavior because we’re reinforcing that behavior. If I’m normalizing something that is normal, like, “Yeah, we’re all in this. This really sucks,” or, “You know what? That would be hard for anybody,” that’s different. And sometimes, even extending and matching my own vulnerability. Sometimes, that means saying, “Hey, when you do that, that makes me a little bit uncomfortable. It’s not working for the therapeutic environment when you yell at me; can we use skills before you yell next time? And do you need help with that?” That’s vulnerable for a therapist to say, but that also matches this level of, “I’m human too.” It doesn’t have to be a huge amount of sharing, and as we’ve all heard in school — many of us, I’m sure — sharing your own experiences can be helpful, but making sure it’s minimal. But sometimes, sharing your own experience of even the little things in life can be really helpful.

I used to have a video up on my website that talked about, like, “Gosh, it’s taken me a long time to make a video because my hair was never right.” And a lot of people were like, “Yeah, you know what?” Like, I’m always looking for that little piece of, you know, “You’re human too.”

And sometimes, someone goes off on this huge tangent, and you’re like, “Oh, I cannot find anything to validate in this because they are off on the next page,” and finding that kernel of truth is really important — you know, “What you were saying is valid and true.” But what it’s not is just being positive and warm and agreeing, validating things that are invalid.

So, what happens sometimes is that I hone in on this validation. Validation is so important for the safety and the therapeutic environment, and then someone is only positive, warm — that Pollyanna doll — like, everything you say is correct. Like, “You know what? You don’t like homework? Don’t do homework.” That feels valid, yes, but it’s not effective. So, we’re always wanting to stop and say, “What is effective? What works so I’m not just repeating everything they’re saying?” I’m not saying I like their behavior. If someone comes in and they say — I’ll be over the top — “I drink a six-pack an hour.” And you’re like, “That probably does help things,” and then you stop there. Yeah, it helps things, but how is that? Is that impacting your life in a negative way? Now, we’re having more conversation, but I also validated — not implying or reinforcing these behaviors, not just being warm and positive, although warmth is really important. It is, but it’s not just that. Sometimes, we need to be a little like, “Hey, look, this isn’t working.” We got to stop, but we have to do it in a way that makes sense for our personality and their personality and knowing our clients. 

So, the way that I like to boil validation down is sitting in my own skin and saying, “What does this bring up for me?” Because if I don’t, then it’s going to come off wrong. I don’t have to address that now, but just knowing it. But more importantly, listening to what the client is not saying, listening to where their behaviors are coming from. From their history — more than from a place of malice or being broken or something wrong with them. And I think we all know this, but it gets pushed under the rug, especially with this idea of there’s another borderline client or these borderline people are too exhausting for me, or they’re just trying to wear me out — instead of recognizing, “How can I slow this down so that it is more about how can I understand you?” How can I get where you’re coming from? How can I validate to you so that it’s less exhausting for me? It’s not about me anymore — it is fully about you. And then behaviors tend to go down. We’re able to shift them and move them and mold them in a different way, and things become a lot more manageable for everybody. We learn this feels good and it works from the therapeutic environment, and then people start to expand that out into the world. 

So, just checking in, any questions about validation? No questions in the chat yet, but if you want to unmute yourself, you can always ask them as well. I don’t care how good you are at therapy — there are going to be times when you don’t validate a client because we have our own life and things are hard sometimes. And so, I want to acknowledge this: It isn’t about perfection. It’s about acknowledging it. And sometimes, repairs are just as validating as any of the validation. So, putting yourself in the other person’s shoes and walking with them for a moment so that things feel a little less yucky.

Now, moving from the DBT model, this polyvagal response can be really seen in a person with borderline personality disorder. The idea that the vagus system has three different parts: Our connected part that lives in her head, our active fight or flight — the simple way of putting it, but I think it has a lot more stuff in it than there — and then at the bottom part. You can’t see me, but I’m looking at my abdominal region where that shut-down response lives. And that’s a simple version, but looking at the body from the social. If you were thinking about this, someone is out of their window of tolerance — when they’re responding to things, they’re really responding to this vagus system response. If you think about that life-threatening passive protection piece right here that holds itself very much in the person’s abdomen — that looks like depression. And what’s really, really sad is, a lot of times, that is your body preparing to die when you look at it from an adaptive approach, because the body has said, “I can’t tolerate this anymore.” Looking at that from that painful piece can be helpful for us to see the client where they are. People with BPD often have some of these sites.

And then if it were in the danger place, that often holds itself very much so in this chest area, into our arms. Like, I want to punch something. I want to kick something. I feel it. If I have all of this happening — if I feel this rage, this aggression — my body needs to get it out, and our system is very good at doing that. But if it doesn’t learn how to do it well, then it doesn’t work. So, people learn to throw something or yell at someone because it allows that system to give some safety to that dangerous system and has kept them safe. So, even just giving knowledge about this can be really helpful. Like, shake your hands. They need to move or punch a wall, or don’t punch a wall. Jeez, punch a pillow, pushing up against a wall as hard as you can just to get all of that stuff out of your system and allowing your system to run — it can sometimes be really, really effective stuff. But we have to understand that polyvagal thing and then the safety place for many people with BPD. This idea of social engagement and actually connecting to people is as if you’re speaking a completely different language — someone making eye contact, reading people’s facial expressions, being able to connect to people when you don’t have that sense of self can be really, really hard. So, just sitting with people in those small moments of connection, even the connection with you or connection to nature or connection to something they enjoy can start to build that safety network. So, it’s safe to be safe. If you live in a trauma land, it isn’t always safe to be safe. These parts of us need to run their course.

So really, if you want to dive more into Stephen Porges’ work, Deb Dana has some really nice work if you’ve never seen it, and I like hers cause it’s pretty real and reasonable. But if you can also look at this — in the same idea, many of us have heard about this idea of the window of tolerance. If you look at that, if you think about that last slide, my window of tolerance is here with a trauma response. A person with BPD’s comfort level — it’s not this big of a square. It’s maybe a half of that, maybe a quarter of it. So, it’s very easy to get into this hyper-aroused, which is that activated place in the polyvagal system, which is going to come with compulsively doing some behaviors, doing addictive behaviors, being impulsive because the system wants to protect itself and it has learned over time, “This emotion is going to hurt me.” So, being able to even teach people, “How do I get back into my window of tolerance through mindfulness?” Through grounding exercises, through, you know, putting ice on my forehead or my cheeks, and holding my breath is going to allow for that. And if I’m able to see it from this lens, then I’m able to help clients. 

If you’ve ever been trained in a behavioral chain analysis, being able to say, “Where does this happen, and how do we get to a place where we can do stuff before you jump out? The same with that hyper- or hypo-arousal?” You know that’s that shut-down place, and being able to acknowledge that this is where the person’s coming from can be less frustrating when we’re looking at it from a scientific method. So, if you’re looking at these behaviors that come up for the criteria for being, it makes a lot of sense. “I don’t want you to abandon me, so I need to frantically keep you together,” is very fast and it comes from that really activated place. These interpersonal relationships — again, that’s that protective place, that identity disturbance. If I can’t connect to people, how do I know who I am? Impulsivity with self-damage, spending, sex, substance abuse, reckless driving, binge eating — all of those things are coming from this lens of, “I have to use this energy on something in order to make it go away.” And that’s what the system does really well, but for these people, that’s done too well and it works too fast, and so it’s about slowing it down.

Suicidal behaviors, gestures or threats. Suicide is the ultimate avoider, so if I’m completely shut down, I want to avoid reactive moods — if you look at those, those can fit very nicely into that. Feelings of emptiness — again, if I don’t have that connection, I don’t have that. The anger is going to come through their system, their body more than their mind. Dissociative symptoms, that’s shut-down at its T — at the most level. So, being able to see that can be really, really, really important.

I’m going to check if there are any questions. How do we validate someone with BPD without reinforcing negative behavior? So, that’s where that “what not to validate” is really important. If I am validating, I’m not reinforcing. If I’m saying, “This is hard, I get it,” and then I’m stopping and saying, “Let’s slow down and see where this is coming from,” then we’re problem-solving as well but with validation — instead of, “We’ve got to get this under control, it’s bad,” which isn’t validating. So, being able to mix the two, that balance is what’s going to keep it from being reinforcing. So Grace, does that answer your question or is there still more to it that you have questions about? I would give the same advice to a family member with BPD. I can share the quick online assessment you use with clients. I’m not sure what you mean by that, the quick online assessment. Could you clarify, please, to Neil? But going back to Donna, Donna asks, “Would you give the same advice to a family member?”

I would; it’s hard for family members, though, because if someone’s saying they’re going to kill themselves, where’s my line? It takes that extra support from that family, from us, to be able to help them sit in that. So, I recommend to family members to understand the diagnosis so that they can validate. “I Hate You, Don’t Leave Me” is a great book, or “Walking on Eggshells.” Both are really wonderful books for family members so that they can start to understand BPD from a different lens and can start to validate without reinforcing. Any other questions? Did that answer your question? 

Relations are a struggle for me. No one seems to understand why my mood switches so quickly, and I’m constantly wanting reassurance. I just feel, since I was diagnosed around 17, it was just sort of most of my life. Yeah, Vicky, because people have a hard time. So, what I would recommend is getting into some places; you can learn some skills and gain validation for yourself. DBT is a wonderful, wonderful — sorry, I got distracted by the questions — it’s a wonderful, wonderful resource so that it doesn’t have to destroy your life. And you can start to make those shifts and become that BPD in remission. I don’t use a quick assessment for BPD — that was just the DSM, the Diagnostic Statistical Manual. That might be what you were talking about, Neil. I go off of what the person’s coming in with. And if a person’s coming in with a lot of these behavioral things that seem trauma-based to me, then we have that conversation about BPD. So, it’s not necessarily an assessment for me, although there are some really, like — you can find them if you just Google search. 

I’m going to go back to sharing and I’ll come back to this again, but the question is: When I get out of these windows of tolerance, what do I do and how do I teach people? The big thing to teach them is safety. You hear me say validation a million times ‘cause it’s so freaking important, grounding, and then sometimes, a kind irreverence with caution. That’s why I put that slide about making an ass out of you and me. People tend to be taken out by cussing, like, there’s kind of a, “That person cussed, they’re supposed to be a therapist and really well.” So sometimes, that little piece of irreverence of, like, “This effing sucks.” I say effing, but I won’t today. It takes someone by surprise and it helps me become human, and that’s who I am naturally. If you’re not that way naturally, it’s not going to come off very well, but sort of allowing for some of that natural piece to come in can be super-duper important. How do I say, “You know what, that’s just not working,” in a kind way? Or kind of having those really where-angels-fear-to-tread conversations of, “If you’re coming in 15 minutes late for every appointment, are you late to everything in your life? Do we need to work on that? Does that need to be something we’re tracking and working on?” Which doesn’t feel great but can be helpful. So, that irreverence — as you start to do that stuff, people see you as more human and more stuff, and so that irreverence becomes very natural, but if you are not irreverent, if irreverence doesn’t come naturally to you, you might not come off so well. So, I say that with caution.

But the things that I think are most important when someone is outside of their window of tolerance are the TIPP skills, which is temperature. So, that means ice packs or ice water on your cheeks for 30 seconds while you’re holding your breath — unless you have an eating disorder, in which case it’s not great because of heart problems. Like, we don’t want people to have medical conditions intensify, but for someone who is safe to do it, it is a really great reset for the body because it pulls the blood away from those responses within this vagus system into survival and then resets it. Intense exercises. That means doing burpees or jumping jacks to a point where you aren’t thinking about it anymore; you’re essentially just wanting to reset in order to come back to it. Paced breathing is the idea that, throughout the day, we inhale to activate and exhale to relax. And we do that throughout the entire day. But if we’re very activated, we start inhaling more than we’re exhaling in order to run from saber-toothed tigers, essentially. That’s the way our system’s designed. So, when you start to exhale longer than you’re inhaling, it tells your body you’re safe. And then paired breathing, which is the idea of tensing every muscle in your body in an inhale, and then releasing it on an exhale. Now, all of these, if you’ll notice, don’t come from the brain. Because when we’re not in the window of tolerance, that frontal cortex that makes these decisions is not available.

So, I’m trying to do some things that allow my body to know I’m safe because my mind can’t, but then I have to back that up with other things, other skills that will build safety. If I’m backing that up with those other skills that build safety, then I can stay safe within it. I might still have a little anxiety in my chest — and that’s okay because that’s linked to something — but now, I’m able to manage it within that window instead of feeling like I’m impulsively acting out on these behaviors. The other things are those self-soothing with senses that can be easy and quick to get people back. Having some intense smells in your office or around you — lemon, lavender, orange, all kind of big smells. And when people smell, they’re coming back into the room to ground themselves, “This is where I am right now.” Same with intense taste, so sour — those lemon candies or those fire candies that are kind of spicy and sort of shock your mouth can be really helpful. 

Touch — right now, a lot of people are doing work from their houses, so they might have a pet right beside them that they can just — you know what? Just grab your pet, your dog or your cat, and give them a quick scratch. Or do you have a blanket around that you can put over top of you? Even just touching your skin, can you just sort of rub your hands to just be in the room? I like to have people see if they can feel their fingerprints. Hearing — for some people, this means music, safe music, music that reminds them of safety for some people. It simply means I just want you to see if you hear anything in the room right now and then see the same idea. What do you see that you’ve never noticed before? Can you pick out one red thing in the room that you see? All of those self-soothing things are things to get someone into the room so they’re not responding to all of their past trauma and all of the yuck in their life. And they’re responding to what is happening in the room right now, able to ground so that we can even talk about skills — that we can even talk about, How do I get through this in a really strong, effective way?” 

There’s just some tangible, really nice skills that we can use to get us through those moments. And then we can build safety, because if I’m not safe, I’m not going to be in that window of tolerance. Most schooling for counselors talks about this safety, but I don’t think we spend enough time really remembering what that means for a client. For a client, that means consistency. People want to know what to expect when they walk into your office or into your virtual sessions. I can have people be really thrown off if the furniture changes, and so I let them know, “Hey, just so you know, I moved my furniture.” If I need to, or if every time they come in, I ask them to give an idea of the behaviors that they did that week and, all of a sudden, I stopped doing that — people don’t do well, whether they realize it or not. 

Getting just a little bit of background noise. If there’s anyone who’s not muted, would you mind to just mute yourself? And then there’s also just coming in with that compassion, putting yourself in the other person’s shoes and sort of making sure you’re not coming from a place of, “How do I fix this person?” because people are naturally coming into therapy feeling like they need to be fixed. That’s just sort of the nature of our job, as gross as that is. So, making sure with yourself, “I’m not working on fixing this person; I’m working on sharing in their journey so that they can build the skills and the effectiveness in their life and be the person that they already are in a more effective way.” And that’s going to come off with natural compassion and natural empathy.

And I have to check in on myself. I think it is very easy for therapists to get into that trap of, “How do I? Like, I really want to.” This person’s desperate, and I’m gonna feel that desperation with them, and really, I want them to get through this and I want them to get through it quickly and I want them to feel better ‘cause I care about them. And slowing that down — sometimes, it is a slow process. I don’t have to rush it, and I don’t have to fix. Sometimes, just sitting in is more important than anything else, and feeling safe in your emotions comes from sitting in. So, making sure that we’re alive — sitting in can build that safety within the room, whatever that means, so that people can gain safety in their emotions. 

And then expressing your own limits — if someone sends me 14 emails in between sessions, I’m gonna bring that up in the session and say, “Hey, what’s that about? What do you think you’re getting from that?” And I’ll say, “I really care about you and I really want to respond, and it’s really pushing on my limits. It’s making me a little exhausted. Can we reduce it down? Is there any way you could make notes on that and know that that’s something we can spend the first 10 minutes of the session talking about?” Because that’s going to build that safety because I’m not going to get burnt out. I’m not going to get there and say, “Oh, here comes Mary Sue, that borderline. She exhausts me.” It’s going to be more of this, like, they are understanding where our boundaries are and where our limits are. And then you hear me say it a million times: Validation is going to build safety. The more I can encourage someone, the better they’re going to be. The more I put myself in their shoes, the more I see it as a trauma response, the better off both of us are going to do with the whole thing. And taking myself off the pedestal and really seeing this as teamwork: “Hey, let’s figure this out together. Let’s work through this together. How do we make this work?” 

And then the other thing that is important for building safety — I talk about just commitment strategies, and a lot of that comes from that teamwork. And so I’ll say, “Okay, they drink a six-pack an hour.” I know that’s crazy, but it’s easy to say something absurd as an example. I might say, “Can you reduce that? Do you think you could reduce that to a beer an hour? Or five beers an hour?” I don’t know — It’s so absurd now I’m struggling. Or, that door in the face: “I need you to stop drinking.” Well, I can’t do that. “Okay. What can you do?” So, if I give them the most absurd thing possible, they can come back with solutions for me, or I give them just that little bit. And sometimes, a lot of times, people say, “I can do more than that.” Okay, I just want you to practice 10 seconds of mindfulness a day. “Well, Allison, I could do 10 seconds — I just can’t do 30 minutes.” 

“Okay, what can you do?” That builds up safety ‘cause they get to make decisions and it becomes that mutual piece. Or, turning the tables — “I hate these skills. I hate them. I don’t know why we have to talk about this. I don’t want to talk about my trauma either. I just want to feel better.” Okay, what do you think we should do that? Turns it back a little bit so that they become mutual, and people tend to then feel empowered and most people are able to find that balance. That’s different if someone’s court-ordered and they’re like, “I really just don’t even want to be here,” or is forced for another reason, which adds a whole ‘nother layer. And some of that stuff doesn’t work, but you can say, “Alright, you know what, though? We have to be here, so what are we going to do with this time? This is what I’m not willing to do, but I am willing to do that.” So, making it teamwork and making it mutual is going to be what builds that safety so that people are less reactive in your space. And you have more space to do work when people are not reacting within the space of therapy. And then you feel less burnt out and you feel like the person is less mean and yucky and all of the stuff that goes with it. 

Any questions that are in there? No questions. Alright, so we’re looking at these dialectics. DBT is my background, and a lot of people hear DBT and they think of these, like, four modules of skills. It’s a lot more than that, and so I like to talk about this idea of dialectics because someone with BPD often tends to pendulate back and forth between extremes. If I’m talking about a balance versus a swing, and I’m doing that for myself and I’m teaching my clients how to do that, it becomes more comfortable to be in this middle area. So, if I’m looking at, “I can either be flexible or rigid and there’s no in-between,” well, if a client comes in and they really need that structure, my flexibility is not going to work for them.

If I am 110% Marsha Linehan DBT, all we are doing is ABCD. Which — Marsha Linehan teaches flexible rigidity, but some people get lost in the rigidity part. Sometimes, someone might come in with something different and they’re not feeling validated by that, and so I talk about this flexible rigidity. I always have an evidence-based practice that is my safety net — that I can always fall back on the basic protocol of EMDR or DBT, depending on which we are focusing on primarily at that time. But sometimes, there’s some flexibility in that. And sometimes, they start to intertwine and intermix. Being able to teach our clients that same idea and telling them what we’re doing and being able to find that balance is going to start to look a little different, like, “Oh, that can happen and it might not be comfortable. And how do I sit in this discomfort?”

Acceptance and change. When I talk about acceptance — I’m a big person of acceptance, if you haven’t caught on to that yet. What happens is people say, “Does that mean I should just be this way?” No, because I also need to change, but I have to accept to change. If I’m only in “change,” then I get in that fix-it mentality. If I’m only in “accept,” I get in that sitting-on-my-hands mentality. But if I accept in order to change, I’m not fixing — I’m allowing for this flow and this balance. I think, sometimes, our BPD clients can fluctuate in some level between apparent confidence in between, like, “I’m fine. I’m good. Everything’s good. We’re good. I’m fine,” which tends to be a little bit of an avoider, to this active passivity. “Nothing’s going to work. I can’t do anything. I’m not doing anything.” So, finding that piece of, “You can do something, and what can you do?” It’s not bad to be fallible, and being accepting within this can be that push and pull — that dialectic. 

How do I move when the only validation I get is from emotional outbursts, which feel very validating? It feels like my only option is to either invalidate myself or gain validation from these emotions — these intense emotions. So, how does the validation feel in that middle ground that’s neither? I talked about a lot of normalizing that pathological behavior and then also pathologizing normative behavior — that idea of, like, “I don’t want to reinforce those behaviors and both can be true.” How do I gain autonomy while allowing people to be a little bit dependent? I don’t want someone to be codependent on their therapist. I always tell people, like, “I do not want you to need me. I want you to be autonomous, and yet I have these really great skills that can get you to where you want to be.” 

So, constantly checking in on, “Am I too far on an end of any of these dialectics? And then that same idea, excessive leniency. “Well, it’s fine that you’re 20 minutes late. We’ll still get a 40-minute session. You missed last week? No big deal.” Versus authoritarian control — “I don’t care if you’ve gotten a car accident; you weren’t on time for your session.” Those are extreme examples, but you sort of get this idea, and this flow can start to add a little bit of that consistency I talked about earlier. So, knowing what a dialectic is — two extreme things happening at the same time — is a really important piece, and then knowing what that means from a therapeutic standpoint so that we can start to show our clients what that looks like. And start to point out when they’re on one end of the dialectic or the other and what it looks like for both to exist.

As people start to see me for a long time, a lot of my clients are like, “There you go again. That’s one of those dialectics you were talking about.” Or a lot of times, people say, “I was accidentally mindful,” just as they talk about it. So, just sort of slowing down a little bit and seeing about extra questions as we end the slides. I will pull up my information actually again, and I’ll put it in the chats. If anybody has any questions, please feel free to ask them. I am available via email. I’m pretty good at answering emails and things like that. 

Thank you for watching this video. We hope you enjoyed the presentation.

Objectives and Summary:

Working with clients who have borderline personality disorder (BPD) can be somewhat tricky for a number of reasons. However, if clinicians can adjust their approach and way of thinking slightly, they can find the task of treatment to be easier and more effective. In this presentation, Allison Johanson, LCSW, provides insight into BPD, explains the stigmas surrounding BPD and shares how health providers can work toward better treatment outcomes.

After watching this presentation, the viewer will:

  • Understand unique approaches to treating BPD 
  • Know how clinicians can manage their own expectations and beliefs when treating BPD clients
  • Be aware of how DBT and EMDR can be used effectively in BPD treatment

Presentation Materials:

Speaker, Allison Johanson, LCSW has over a decade of experience treating people suffering from trauma. She is certified in Eye Movement Desensitization and Reprocessing ( EMDR) and is a Consultant in training with this modality. She is also fully trained in comprehensive Dialectical Behavioral Therapy ( DBT) from Behavioral Tech Institute and worked for many years with a comprehensive DBT program. She currently has a private practice in the DTC and works with clients suffering from both identified and overt trauma as well as those struggling with ineffective behaviors. She utilized EMDR with informed DBT skills to work with people toward meeting their goals.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. 

Candi:
Thanks so much, everybody, for joining us. We really appreciate it, and we are so grateful to have so many people join us on this virtual world we are in — and all the way from the UK. That’s amazing — 7:00 PM at night. 

Welcome. My name is Candi Ader. I am the director of community outreach with The Recovery Village at Palmer Lake. So, our parent company is Advanced Recovery Systems, and we’ve got about nine programs nationally. The Recovery Village at Palmer Lake is here in Colorado. We have a 110-bed facility here; it used to be a resort, so it’s beautiful. We offer a full continuum of care for adults dealing with substance use disorder, so we’ve got a full medical detox, a residential program and then PHP and IOP with housing on-site. Our program here in Colorado is in-network with most major insurance companies, so Blue Cross Blue Shield, United, Cigna, Aetna, Humana, Bright Health, Rocky Mountain Health Plan and then a handful of other local plans. If you’re not familiar with our program and you would like to get some more information, I will be entering in my name and email address in the chatbox. I would love to meet with you. 

Whenever someone comes into our program, they’re meeting with our case managers within the first week to start creating their aftercare plan. So, I’m always up for meeting new clinicians, learning about your specialties and your practice and your insurance in-network contracts or private pay options, whatever it is, so that we can have you as a referral partner when our clients are creating those aftercare plans. We also have some of the other programs that I always mention under our ARS umbrella. One of them is the International Association of Fire Fighters — that’s out in Maryland, and that’s specifically for firefighters that are affiliated with the IAFF union. They can go there for primary trauma, primary mental health, primary substance use, doesn’t matter. Awesome, awesome program. We also have a program in Florida called Next Generation Village. That is for adolescents dealing with substance use disorder so, again, a full medical detox, residential and then day programming and IOP programming, and also in-network with a lot of different insurance companies. Pretty much all over the country, we can help clients out dealing with substance use disorder. And if it’s something else that we can’t help them with, we are always happy to help find them an appropriate referral or resource.

So, we are super excited to have Allison Johanson with us today speaking. Allison is an LCSW and has over a decade of experience treating people suffering from trauma. She is certified in eye movement desensitization and reprocessing, or EMDR. She’s also a consultant in training with that modality. She is also fully trained in comprehensive dialectal behavioral therapy, or DBT, from Behavioral Tech Institute and worked for many years with a comprehensive DBT program. She currently has a private practice in the Denver Tech Center here in Colorado and works with clients suffering from both identified and overt trauma, as well as those struggling with ineffective behaviors. She utilizes EMDR with informed DBT skills to work with people towards meeting their goals.

So, I will pass it over to Allison and let her take over. Also, sorry — couple more things before I do that. If you guys would stay muted during the presentation, just so we don’t have any background noise, and then also, if you — in the chatbox — wouldn’t mind putting your name and the organization that you work with and where you’re located, we would love to just kind of get an idea from where everyone’s at. And then if you have questions throughout the presentation, feel free to enter those in the chatbox. Allison can either try to answer those as she goes, if she happens to see them, or else Ashley can address those at the end of the presentation as well. So, thanks so much for being here, everybody. And Allison, it’s all yours. 

Allison:
Perfect, thank you so much. Yes, I will take some time periodically throughout the presentation to just check the chatbox. If you’re anything like me, you’ll forget your question if you don’t just type it in, so just throw it in there and then I can address those as we go along and so I just give myself some space with that. Today, I’m going to talk about working with borderline personality disorder. I have a lot of experience with it when I was working with DBT. That’s the population that kind of filters through DBT programs, and it’s also become sort of a bad guy in our field. A lot of people have these, like, scary thoughts when they say or when people say something about borderline personality disorder, and so I really like kind of breaking that stigma. 

I still work with a lot of borderline clients who have symptoms of borderline personality disorder, both with the EMDR modality. I don’t do a comprehensive DBT, although because I did it for so many years, some of those concepts trickle in. But in private practice, it became just people. A lot of people needed a full program, and that’s not where I am, so that’s what we’re going to be talking about today. Like I said, ask questions as we go along. I just sort of allow for space to just sort of check in periodically, and then at the end, I’ll also open it up again. Some people prefer to just ask it out loud, and so I’ll allow for that space for people to unmute and ask at the very end if they need to.

I’m going to go ahead and share my screen and we will get — one second. So, we already talked about that. There’s me. For those of you who don’t know the criteria for borderline personality disorder, here’s just the DSM stuff. The thing about it is I have clients take a quick survey online, and pretty much anyone who’s experienced a trauma and has symptoms of it could say they have some of this, but the biggest pieces are when it becomes that behavioral piece — when it becomes something so intense than it is a trauma-based diagnosis. And I talk a lot about the trauma-informed approach to working with this population. So, frantic efforts to avoid real or imagined abandonment, that “I hate you, don’t leave me” sort of idea, a pattern of it, unstable and intense interpersonal relationships. An instability with self-image and sense of self-impulsivity with two of these areas, suicidal gestures, reactive mood, emptiness, anger, stress-related paranoid ideations. 

So, just sort of a quick idea of that, but what I hear from a lot of people are these things that really make me cringe. I hear clients come in and say, “Well, I have borderline personality disorder. I’ve been told that’s untreatable,” or, you know, “This person’s just doing it for attention.” When I worked in agency work, I’d heard that a lot from other people. “Oh, ignore them. They’re doing it for attention, or they’re just manipulating you,” or, “Oh, that’s just another borderline.” Really changing our framework of talking about this is essential, as this became stigmatized because of this. Instead of recognizing it as responses to trauma, it can be really powerful for your work and your motivation to work with this population as well, as they’re going to receive that really well. I have many clients that I consider now BPD in remission, similar to substance abuse in remission. So, their behaviors have become this thing that is always sort of here instead of grasping them. But they have that distance from it, and that can happen through DBT work.

Now, there’s more different things that can work with it as well, and the fact that people have learned about this from their invalidating environments. From that, they learned how to validate their emotions through ineffective behaviors. So, if I’m looking at someone’s behavior that they’re coming into my office with — not as a form to get attention or manipulate, but more as an idea of this is the only way that they can validate what they need and what they’re feeling — I’m able to sit in that a little bit more and able to meet them where they are. So, I have less people explosive at my office, and I have less people feeling threatened because I’m sitting in this with them from their perspective. When a person has not seen or heard, their system develops this, and so a lot of times, they’re not doing it; it’s outside of their window of tolerance. People are not doing this intentionally. Also, seeing the person in a lot of pain when they meet the criteria for borderline personality disorder, but when we start labeling people as borderline, that becomes icky. There’s such a yuck to it, and so please catch it if you say that — “borderline client” — even if it’s meant with the best intentions. Because clients start receiving that and start identifying with that as opposed to their core identity, which they’re already really struggling with. That’s one of the markers for the DSM, and so if you don’t have a sense of identity and then someone gives you an identity, it’s really easy to make that your identity as opposed to forming a really healthy identity. 

So, even if you’re not saying it to clients’ faces, I really believe clients start to receive that. So, I always talk about these because — I’ve even given talks and people have said, they raise their hand and they have a question and they say, “So, I have this borderline client.” And I’m like, “Alright,” because it’s so easy for people to do. But just sort of watching that as you’re talking to people can be really helpful, not just for the client. But do you see how if you’re sitting in the office with this yuck around this person, how easy it’s going to be to burn out around that? So, it also allows for us to have the space to work with this population as they come in. And I always say, I know this is crude, but assuming — it makes an ass out of you and me — so, we’d make these big assumptions about people. “Oh, here comes that borderline,” or “I guess they’re doing this.” Instead of slowing down, that’s what I always check in on: Am I ever assuming something? So, I just like to add that in. 

We’re gonna look at the DBT model. They talk about it from a biosocial model, and if you’re one of those science-minded people, this might be more helpful. So, if I’m looking at the fact that some people are genetically predisposed to a higher intensity of emotions, or they were born with an existing mental health disorder. The struggle is if they do not have that really core system within that, they’re more prone to some of these other behaviors, but just the biological factor in itself doesn’t mean anything. There’s a lot of very healthy people that have that. So, then you add into that some personality and temperament, and then some people say some really nasty things to you that create negative beliefs and self-defeating beliefs, and then you add into that stressful or traumatic events in your life — culture, media, school, so much school trauma, both educationally and socially, and then that invalidating environment. “Get rid of those intense emotions you were born with. They’re bad. These are the bad guys.”

Then you’re going to learn to shove it down, which can create those eating disorders, substance abuse, intense behaviors, cutting, suicidal acts, like, anything that you can do to get rid of the emotion that’s been labeled as bad because it was too much at some point in your life for somebody. So, looking at it from this mindset can be a little bit more effective for people who like that science-minded piece. This is coming from somewhere, these aren’t bad people — they’re people who have formed these ways of working that are different than what is effective in our lives. And reteaching that, sometimes people say, “Well, DBT is so basic,” and it is. But for many people, it’s earth-shatteringly new, and the same with EMDR. For some people, it’s like, “Well, yeah, we work through the trauma.” Well, we have to do it slow with this population if they’re a little bit more volatile, and there’s some other things that we can do to make that safe, but that’s for another day. But I’m looking at this and saying, “If I reduce that social vulnerability, this person can have their intense emotions and they’re not bad anymore, and then they don’t have to cover them up.” And then you probably all have your own modalities that fit into that as well. Those are the ones I know that the best.

So, if a person’s trying to tell their parents that they’re hurt and the parent’s distracted by their own stuff or values or trauma or whatever, and they don’t hear “get hurt,” they get louder. I see that with my kids. If I’m distracted, that’s how kids get hurt, but in a healthy environment, that good thing gets repaired. What happens if the parent says they just want attention and punishes the kid, then that kid learns that emotions are not okay. I’m not allowed to be heard and they’re not allowed to be heard, so I should get rid of them. Then emotion becomes more intense, kind of like a small child pulling on your pant legs that needs that attention. That emotion becomes less manageable because it’s become invalid. Things become so intense that the person responds with intensity because they don’t have any more control. That emotion becomes so big. And then as time gets on, they get older and that becomes really scary to a parent sometimes.

Then what can happen is there’s reinforcing behaviors that come into this. I don’t want my kids to react this way, so I’m going to intermittently reinforce it with attention. Then the person hears, “Oh, that really did get me hurt, this person’s worried about me. They’re showing me that they care.” And now, they come into our office. Something happens where they don’t feel validated or heard. They might have a big reaction to that because that’s how they felt heard in the past, and then the therapist feels threatened and then everything’s yucky because now, the therapist is responding to threatening. If instead, the therapist responds to this validation of, “God, did I not hear you correctly?” the person learns, “Oh my gosh. That’s not the way that this works.” So, as we’re looking at this from a different lens, we’re coming at the person from a different angle. 

I’m going to stop sharing and look at comments just to make sure there’s no question. I see that there’s a question about the PowerPoint being shared. Ashley or Candi, do you know if that’s going to be available for folks or if I can send it out to them or whatever would be helpful? So, the event’s going to be hosted on TheRecoveryVillage.com. So I just put the link in the chat of where this will live. Is there a paper copy of the PowerPoint as well? So, if anybody on the website — they’ll have the download to the PDF as well as the video from today. But if anyone wants it prior, I’m going to put my email in the chat and then just email me, letting me know that you would like either the PowerPoint or the video. I can send you those as well. 

So, I have a colleague who did his dissertation on why people leave therapy and don’t come back, which is a pretty important thing. What he found is almost 100% of the time it comes from feeling invalidated or invalidation from the therapist. So, this is something that is incredibly important to me — to review this idea of validation, especially from someone who’s coming from an invalidating environment, which is oftentimes that precursor to borderline personality disorder. When I say validation, I’m talking about listening and observing from that mindset of a trauma-based approach. This person is coming from a trauma response more than anything else. If I’m listening to that room, an unbiased thing, and I’m checking in on myself — if I’m noticing a yuck in myself, then I’m going to stay awake. I’m going to listen. Things are going to feel a lot better, and then I can accurately reflect, “Hey, you said this what’s happening.” Or, being able to articulate the unprovoked.

“Gosh, you look like you’re kind of mad at me right now, or you’re pretty frustrated.” Or, you know, “It actually crosses my boundaries when you throw your book. I bet people around you feel really threatened by that.” And that feels a lot better than, “I’m outta here,” or a scared feeling or whatever. So, articulating that as a behavioral pattern or emotions or thoughts becomes more validating. Also, just giving that biosocial model is important. If you’re not broken, this is because of a system of things that feel so much better to people. And then also, like, yeah, you probably do get your voice heard, and yeah, this is hard. You know, I think the level of validation within the land of COVID is that much stronger because we’re all living it.

So, if we can look at things after this is over, sort of looking at it from that same lens of, like, “I get it,” I think that natural validation is going to come. But how do I do this? I listen and pay attention. I reflect and acknowledge their point of view. I don’t have to be a leader in this room. The other person can have a viewpoint. That’s important. Sometimes, that viewpoint is, “I think what you’re saying is dumb.” And I’m, frankly, okay with that and welcome that because then there’s conversation. And I think that feels very validating for people, as opposed to, “This is what you should do.” What works is working to understand and ask questions, make a hypothesis, check in again, taking our stuff off that pedestal even though I know that this might be true, saying, “Hey, I’m just wondering, is A and B linked or am I off?” as opposed to saying, “Well, A and B equals C and that’s the way it is.”

For a lot of people who have had especially authoritarian people in their life that have been less than supportive, that feels really invalidating and it pulls up that invalidating environment — becomes a trauma response. And then normalizing things when they’re normal — I think that is huge, right? If someone is normalizing something that isn’t true, all we’re doing is feeding that behavior because we’re reinforcing that behavior. If I’m normalizing something that is normal, like, “Yeah, we’re all in this. This really sucks,” or, “You know what? That would be hard for anybody,” that’s different. And sometimes, even extending and matching my own vulnerability. Sometimes, that means saying, “Hey, when you do that, that makes me a little bit uncomfortable. It’s not working for the therapeutic environment when you yell at me; can we use skills before you yell next time? And do you need help with that?” That’s vulnerable for a therapist to say, but that also matches this level of, “I’m human too.” It doesn’t have to be a huge amount of sharing, and as we’ve all heard in school — many of us, I’m sure — sharing your own experiences can be helpful, but making sure it’s minimal. But sometimes, sharing your own experience of even the little things in life can be really helpful.

I used to have a video up on my website that talked about, like, “Gosh, it’s taken me a long time to make a video because my hair was never right.” And a lot of people were like, “Yeah, you know what?” Like, I’m always looking for that little piece of, you know, “You’re human too.”

And sometimes, someone goes off on this huge tangent, and you’re like, “Oh, I cannot find anything to validate in this because they are off on the next page,” and finding that kernel of truth is really important — you know, “What you were saying is valid and true.” But what it’s not is just being positive and warm and agreeing, validating things that are invalid.

So, what happens sometimes is that I hone in on this validation. Validation is so important for the safety and the therapeutic environment, and then someone is only positive, warm — that Pollyanna doll — like, everything you say is correct. Like, “You know what? You don’t like homework? Don’t do homework.” That feels valid, yes, but it’s not effective. So, we’re always wanting to stop and say, “What is effective? What works so I’m not just repeating everything they’re saying?” I’m not saying I like their behavior. If someone comes in and they say — I’ll be over the top — “I drink a six-pack an hour.” And you’re like, “That probably does help things,” and then you stop there. Yeah, it helps things, but how is that? Is that impacting your life in a negative way? Now, we’re having more conversation, but I also validated — not implying or reinforcing these behaviors, not just being warm and positive, although warmth is really important. It is, but it’s not just that. Sometimes, we need to be a little like, “Hey, look, this isn’t working.” We got to stop, but we have to do it in a way that makes sense for our personality and their personality and knowing our clients. 

So, the way that I like to boil validation down is sitting in my own skin and saying, “What does this bring up for me?” Because if I don’t, then it’s going to come off wrong. I don’t have to address that now, but just knowing it. But more importantly, listening to what the client is not saying, listening to where their behaviors are coming from. From their history — more than from a place of malice or being broken or something wrong with them. And I think we all know this, but it gets pushed under the rug, especially with this idea of there’s another borderline client or these borderline people are too exhausting for me, or they’re just trying to wear me out — instead of recognizing, “How can I slow this down so that it is more about how can I understand you?” How can I get where you’re coming from? How can I validate to you so that it’s less exhausting for me? It’s not about me anymore — it is fully about you. And then behaviors tend to go down. We’re able to shift them and move them and mold them in a different way, and things become a lot more manageable for everybody. We learn this feels good and it works from the therapeutic environment, and then people start to expand that out into the world. 

So, just checking in, any questions about validation? No questions in the chat yet, but if you want to unmute yourself, you can always ask them as well. I don’t care how good you are at therapy — there are going to be times when you don’t validate a client because we have our own life and things are hard sometimes. And so, I want to acknowledge this: It isn’t about perfection. It’s about acknowledging it. And sometimes, repairs are just as validating as any of the validation. So, putting yourself in the other person’s shoes and walking with them for a moment so that things feel a little less yucky.

Now, moving from the DBT model, this polyvagal response can be really seen in a person with borderline personality disorder. The idea that the vagus system has three different parts: Our connected part that lives in her head, our active fight or flight — the simple way of putting it, but I think it has a lot more stuff in it than there — and then at the bottom part. You can’t see me, but I’m looking at my abdominal region where that shut-down response lives. And that’s a simple version, but looking at the body from the social. If you were thinking about this, someone is out of their window of tolerance — when they’re responding to things, they’re really responding to this vagus system response. If you think about that life-threatening passive protection piece right here that holds itself very much in the person’s abdomen — that looks like depression. And what’s really, really sad is, a lot of times, that is your body preparing to die when you look at it from an adaptive approach, because the body has said, “I can’t tolerate this anymore.” Looking at that from that painful piece can be helpful for us to see the client where they are. People with BPD often have some of these sites.

And then if it were in the danger place, that often holds itself very much so in this chest area, into our arms. Like, I want to punch something. I want to kick something. I feel it. If I have all of this happening — if I feel this rage, this aggression — my body needs to get it out, and our system is very good at doing that. But if it doesn’t learn how to do it well, then it doesn’t work. So, people learn to throw something or yell at someone because it allows that system to give some safety to that dangerous system and has kept them safe. So, even just giving knowledge about this can be really helpful. Like, shake your hands. They need to move or punch a wall, or don’t punch a wall. Jeez, punch a pillow, pushing up against a wall as hard as you can just to get all of that stuff out of your system and allowing your system to run — it can sometimes be really, really effective stuff. But we have to understand that polyvagal thing and then the safety place for many people with BPD. This idea of social engagement and actually connecting to people is as if you’re speaking a completely different language — someone making eye contact, reading people’s facial expressions, being able to connect to people when you don’t have that sense of self can be really, really hard. So, just sitting with people in those small moments of connection, even the connection with you or connection to nature or connection to something they enjoy can start to build that safety network. So, it’s safe to be safe. If you live in a trauma land, it isn’t always safe to be safe. These parts of us need to run their course.

So really, if you want to dive more into Stephen Porges’ work, Deb Dana has some really nice work if you’ve never seen it, and I like hers cause it’s pretty real and reasonable. But if you can also look at this — in the same idea, many of us have heard about this idea of the window of tolerance. If you look at that, if you think about that last slide, my window of tolerance is here with a trauma response. A person with BPD’s comfort level — it’s not this big of a square. It’s maybe a half of that, maybe a quarter of it. So, it’s very easy to get into this hyper-aroused, which is that activated place in the polyvagal system, which is going to come with compulsively doing some behaviors, doing addictive behaviors, being impulsive because the system wants to protect itself and it has learned over time, “This emotion is going to hurt me.” So, being able to even teach people, “How do I get back into my window of tolerance through mindfulness?” Through grounding exercises, through, you know, putting ice on my forehead or my cheeks, and holding my breath is going to allow for that. And if I’m able to see it from this lens, then I’m able to help clients. 

If you’ve ever been trained in a behavioral chain analysis, being able to say, “Where does this happen, and how do we get to a place where we can do stuff before you jump out? The same with that hyper- or hypo-arousal?” You know that’s that shut-down place, and being able to acknowledge that this is where the person’s coming from can be less frustrating when we’re looking at it from a scientific method. So, if you’re looking at these behaviors that come up for the criteria for being, it makes a lot of sense. “I don’t want you to abandon me, so I need to frantically keep you together,” is very fast and it comes from that really activated place. These interpersonal relationships — again, that’s that protective place, that identity disturbance. If I can’t connect to people, how do I know who I am? Impulsivity with self-damage, spending, sex, substance abuse, reckless driving, binge eating — all of those things are coming from this lens of, “I have to use this energy on something in order to make it go away.” And that’s what the system does really well, but for these people, that’s done too well and it works too fast, and so it’s about slowing it down.

Suicidal behaviors, gestures or threats. Suicide is the ultimate avoider, so if I’m completely shut down, I want to avoid reactive moods — if you look at those, those can fit very nicely into that. Feelings of emptiness — again, if I don’t have that connection, I don’t have that. The anger is going to come through their system, their body more than their mind. Dissociative symptoms, that’s shut-down at its T — at the most level. So, being able to see that can be really, really, really important.

I’m going to check if there are any questions. How do we validate someone with BPD without reinforcing negative behavior? So, that’s where that “what not to validate” is really important. If I am validating, I’m not reinforcing. If I’m saying, “This is hard, I get it,” and then I’m stopping and saying, “Let’s slow down and see where this is coming from,” then we’re problem-solving as well but with validation — instead of, “We’ve got to get this under control, it’s bad,” which isn’t validating. So, being able to mix the two, that balance is what’s going to keep it from being reinforcing. So Grace, does that answer your question or is there still more to it that you have questions about? I would give the same advice to a family member with BPD. I can share the quick online assessment you use with clients. I’m not sure what you mean by that, the quick online assessment. Could you clarify, please, to Neil? But going back to Donna, Donna asks, “Would you give the same advice to a family member?”

I would; it’s hard for family members, though, because if someone’s saying they’re going to kill themselves, where’s my line? It takes that extra support from that family, from us, to be able to help them sit in that. So, I recommend to family members to understand the diagnosis so that they can validate. “I Hate You, Don’t Leave Me” is a great book, or “Walking on Eggshells.” Both are really wonderful books for family members so that they can start to understand BPD from a different lens and can start to validate without reinforcing. Any other questions? Did that answer your question? 

Relations are a struggle for me. No one seems to understand why my mood switches so quickly, and I’m constantly wanting reassurance. I just feel, since I was diagnosed around 17, it was just sort of most of my life. Yeah, Vicky, because people have a hard time. So, what I would recommend is getting into some places; you can learn some skills and gain validation for yourself. DBT is a wonderful, wonderful — sorry, I got distracted by the questions — it’s a wonderful, wonderful resource so that it doesn’t have to destroy your life. And you can start to make those shifts and become that BPD in remission. I don’t use a quick assessment for BPD — that was just the DSM, the Diagnostic Statistical Manual. That might be what you were talking about, Neil. I go off of what the person’s coming in with. And if a person’s coming in with a lot of these behavioral things that seem trauma-based to me, then we have that conversation about BPD. So, it’s not necessarily an assessment for me, although there are some really, like — you can find them if you just Google search. 

I’m going to go back to sharing and I’ll come back to this again, but the question is: When I get out of these windows of tolerance, what do I do and how do I teach people? The big thing to teach them is safety. You hear me say validation a million times ‘cause it’s so freaking important, grounding, and then sometimes, a kind irreverence with caution. That’s why I put that slide about making an ass out of you and me. People tend to be taken out by cussing, like, there’s kind of a, “That person cussed, they’re supposed to be a therapist and really well.” So sometimes, that little piece of irreverence of, like, “This effing sucks.” I say effing, but I won’t today. It takes someone by surprise and it helps me become human, and that’s who I am naturally. If you’re not that way naturally, it’s not going to come off very well, but sort of allowing for some of that natural piece to come in can be super-duper important. How do I say, “You know what, that’s just not working,” in a kind way? Or kind of having those really where-angels-fear-to-tread conversations of, “If you’re coming in 15 minutes late for every appointment, are you late to everything in your life? Do we need to work on that? Does that need to be something we’re tracking and working on?” Which doesn’t feel great but can be helpful. So, that irreverence — as you start to do that stuff, people see you as more human and more stuff, and so that irreverence becomes very natural, but if you are not irreverent, if irreverence doesn’t come naturally to you, you might not come off so well. So, I say that with caution.

But the things that I think are most important when someone is outside of their window of tolerance are the TIPP skills, which is temperature. So, that means ice packs or ice water on your cheeks for 30 seconds while you’re holding your breath — unless you have an eating disorder, in which case it’s not great because of heart problems. Like, we don’t want people to have medical conditions intensify, but for someone who is safe to do it, it is a really great reset for the body because it pulls the blood away from those responses within this vagus system into survival and then resets it. Intense exercises. That means doing burpees or jumping jacks to a point where you aren’t thinking about it anymore; you’re essentially just wanting to reset in order to come back to it. Paced breathing is the idea that, throughout the day, we inhale to activate and exhale to relax. And we do that throughout the entire day. But if we’re very activated, we start inhaling more than we’re exhaling in order to run from saber-toothed tigers, essentially. That’s the way our system’s designed. So, when you start to exhale longer than you’re inhaling, it tells your body you’re safe. And then paired breathing, which is the idea of tensing every muscle in your body in an inhale, and then releasing it on an exhale. Now, all of these, if you’ll notice, don’t come from the brain. Because when we’re not in the window of tolerance, that frontal cortex that makes these decisions is not available.

So, I’m trying to do some things that allow my body to know I’m safe because my mind can’t, but then I have to back that up with other things, other skills that will build safety. If I’m backing that up with those other skills that build safety, then I can stay safe within it. I might still have a little anxiety in my chest — and that’s okay because that’s linked to something — but now, I’m able to manage it within that window instead of feeling like I’m impulsively acting out on these behaviors. The other things are those self-soothing with senses that can be easy and quick to get people back. Having some intense smells in your office or around you — lemon, lavender, orange, all kind of big smells. And when people smell, they’re coming back into the room to ground themselves, “This is where I am right now.” Same with intense taste, so sour — those lemon candies or those fire candies that are kind of spicy and sort of shock your mouth can be really helpful. 

Touch — right now, a lot of people are doing work from their houses, so they might have a pet right beside them that they can just — you know what? Just grab your pet, your dog or your cat, and give them a quick scratch. Or do you have a blanket around that you can put over top of you? Even just touching your skin, can you just sort of rub your hands to just be in the room? I like to have people see if they can feel their fingerprints. Hearing — for some people, this means music, safe music, music that reminds them of safety for some people. It simply means I just want you to see if you hear anything in the room right now and then see the same idea. What do you see that you’ve never noticed before? Can you pick out one red thing in the room that you see? All of those self-soothing things are things to get someone into the room so they’re not responding to all of their past trauma and all of the yuck in their life. And they’re responding to what is happening in the room right now, able to ground so that we can even talk about skills — that we can even talk about, How do I get through this in a really strong, effective way?” 

There’s just some tangible, really nice skills that we can use to get us through those moments. And then we can build safety, because if I’m not safe, I’m not going to be in that window of tolerance. Most schooling for counselors talks about this safety, but I don’t think we spend enough time really remembering what that means for a client. For a client, that means consistency. People want to know what to expect when they walk into your office or into your virtual sessions. I can have people be really thrown off if the furniture changes, and so I let them know, “Hey, just so you know, I moved my furniture.” If I need to, or if every time they come in, I ask them to give an idea of the behaviors that they did that week and, all of a sudden, I stopped doing that — people don’t do well, whether they realize it or not. 

Getting just a little bit of background noise. If there’s anyone who’s not muted, would you mind to just mute yourself? And then there’s also just coming in with that compassion, putting yourself in the other person’s shoes and sort of making sure you’re not coming from a place of, “How do I fix this person?” because people are naturally coming into therapy feeling like they need to be fixed. That’s just sort of the nature of our job, as gross as that is. So, making sure with yourself, “I’m not working on fixing this person; I’m working on sharing in their journey so that they can build the skills and the effectiveness in their life and be the person that they already are in a more effective way.” And that’s going to come off with natural compassion and natural empathy.

And I have to check in on myself. I think it is very easy for therapists to get into that trap of, “How do I? Like, I really want to.” This person’s desperate, and I’m gonna feel that desperation with them, and really, I want them to get through this and I want them to get through it quickly and I want them to feel better ‘cause I care about them. And slowing that down — sometimes, it is a slow process. I don’t have to rush it, and I don’t have to fix. Sometimes, just sitting in is more important than anything else, and feeling safe in your emotions comes from sitting in. So, making sure that we’re alive — sitting in can build that safety within the room, whatever that means, so that people can gain safety in their emotions. 

And then expressing your own limits — if someone sends me 14 emails in between sessions, I’m gonna bring that up in the session and say, “Hey, what’s that about? What do you think you’re getting from that?” And I’ll say, “I really care about you and I really want to respond, and it’s really pushing on my limits. It’s making me a little exhausted. Can we reduce it down? Is there any way you could make notes on that and know that that’s something we can spend the first 10 minutes of the session talking about?” Because that’s going to build that safety because I’m not going to get burnt out. I’m not going to get there and say, “Oh, here comes Mary Sue, that borderline. She exhausts me.” It’s going to be more of this, like, they are understanding where our boundaries are and where our limits are. And then you hear me say it a million times: Validation is going to build safety. The more I can encourage someone, the better they’re going to be. The more I put myself in their shoes, the more I see it as a trauma response, the better off both of us are going to do with the whole thing. And taking myself off the pedestal and really seeing this as teamwork: “Hey, let’s figure this out together. Let’s work through this together. How do we make this work?” 

And then the other thing that is important for building safety — I talk about just commitment strategies, and a lot of that comes from that teamwork. And so I’ll say, “Okay, they drink a six-pack an hour.” I know that’s crazy, but it’s easy to say something absurd as an example. I might say, “Can you reduce that? Do you think you could reduce that to a beer an hour? Or five beers an hour?” I don’t know — It’s so absurd now I’m struggling. Or, that door in the face: “I need you to stop drinking.” Well, I can’t do that. “Okay. What can you do?” So, if I give them the most absurd thing possible, they can come back with solutions for me, or I give them just that little bit. And sometimes, a lot of times, people say, “I can do more than that.” Okay, I just want you to practice 10 seconds of mindfulness a day. “Well, Allison, I could do 10 seconds — I just can’t do 30 minutes.” 

“Okay, what can you do?” That builds up safety ‘cause they get to make decisions and it becomes that mutual piece. Or, turning the tables — “I hate these skills. I hate them. I don’t know why we have to talk about this. I don’t want to talk about my trauma either. I just want to feel better.” Okay, what do you think we should do that? Turns it back a little bit so that they become mutual, and people tend to then feel empowered and most people are able to find that balance. That’s different if someone’s court-ordered and they’re like, “I really just don’t even want to be here,” or is forced for another reason, which adds a whole ‘nother layer. And some of that stuff doesn’t work, but you can say, “Alright, you know what, though? We have to be here, so what are we going to do with this time? This is what I’m not willing to do, but I am willing to do that.” So, making it teamwork and making it mutual is going to be what builds that safety so that people are less reactive in your space. And you have more space to do work when people are not reacting within the space of therapy. And then you feel less burnt out and you feel like the person is less mean and yucky and all of the stuff that goes with it. 

Any questions that are in there? No questions. Alright, so we’re looking at these dialectics. DBT is my background, and a lot of people hear DBT and they think of these, like, four modules of skills. It’s a lot more than that, and so I like to talk about this idea of dialectics because someone with BPD often tends to pendulate back and forth between extremes. If I’m talking about a balance versus a swing, and I’m doing that for myself and I’m teaching my clients how to do that, it becomes more comfortable to be in this middle area. So, if I’m looking at, “I can either be flexible or rigid and there’s no in-between,” well, if a client comes in and they really need that structure, my flexibility is not going to work for them.

If I am 110% Marsha Linehan DBT, all we are doing is ABCD. Which — Marsha Linehan teaches flexible rigidity, but some people get lost in the rigidity part. Sometimes, someone might come in with something different and they’re not feeling validated by that, and so I talk about this flexible rigidity. I always have an evidence-based practice that is my safety net — that I can always fall back on the basic protocol of EMDR or DBT, depending on which we are focusing on primarily at that time. But sometimes, there’s some flexibility in that. And sometimes, they start to intertwine and intermix. Being able to teach our clients that same idea and telling them what we’re doing and being able to find that balance is going to start to look a little different, like, “Oh, that can happen and it might not be comfortable. And how do I sit in this discomfort?”

Acceptance and change. When I talk about acceptance — I’m a big person of acceptance, if you haven’t caught on to that yet. What happens is people say, “Does that mean I should just be this way?” No, because I also need to change, but I have to accept to change. If I’m only in “change,” then I get in that fix-it mentality. If I’m only in “accept,” I get in that sitting-on-my-hands mentality. But if I accept in order to change, I’m not fixing — I’m allowing for this flow and this balance. I think, sometimes, our BPD clients can fluctuate in some level between apparent confidence in between, like, “I’m fine. I’m good. Everything’s good. We’re good. I’m fine,” which tends to be a little bit of an avoider, to this active passivity. “Nothing’s going to work. I can’t do anything. I’m not doing anything.” So, finding that piece of, “You can do something, and what can you do?” It’s not bad to be fallible, and being accepting within this can be that push and pull — that dialectic. 

How do I move when the only validation I get is from emotional outbursts, which feel very validating? It feels like my only option is to either invalidate myself or gain validation from these emotions — these intense emotions. So, how does the validation feel in that middle ground that’s neither? I talked about a lot of normalizing that pathological behavior and then also pathologizing normative behavior — that idea of, like, “I don’t want to reinforce those behaviors and both can be true.” How do I gain autonomy while allowing people to be a little bit dependent? I don’t want someone to be codependent on their therapist. I always tell people, like, “I do not want you to need me. I want you to be autonomous, and yet I have these really great skills that can get you to where you want to be.” 

So, constantly checking in on, “Am I too far on an end of any of these dialectics? And then that same idea, excessive leniency. “Well, it’s fine that you’re 20 minutes late. We’ll still get a 40-minute session. You missed last week? No big deal.” Versus authoritarian control — “I don’t care if you’ve gotten a car accident; you weren’t on time for your session.” Those are extreme examples, but you sort of get this idea, and this flow can start to add a little bit of that consistency I talked about earlier. So, knowing what a dialectic is — two extreme things happening at the same time — is a really important piece, and then knowing what that means from a therapeutic standpoint so that we can start to show our clients what that looks like. And start to point out when they’re on one end of the dialectic or the other and what it looks like for both to exist.

As people start to see me for a long time, a lot of my clients are like, “There you go again. That’s one of those dialectics you were talking about.” Or a lot of times, people say, “I was accidentally mindful,” just as they talk about it. So, just sort of slowing down a little bit and seeing about extra questions as we end the slides. I will pull up my information actually again, and I’ll put it in the chats. If anybody has any questions, please feel free to ask them. I am available via email. I’m pretty good at answering emails and things like that. 

Thank you for watching this video. We hope you enjoyed the presentation.

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